• Hypertrophic Cardiomyopathy (HCM)
  • Vaccines: 2023 Year in Review
  • Eyecare
  • Urothelial Carcinoma
  • Hemophilia
  • Heart Failure
  • Vaccines
  • Neonatal Care
  • Type II Inflammation
  • Substance Use Disorder
  • Gene Therapy
  • Lung Cancer
  • Spinal Muscular Atrophy
  • HIV
  • Post-Acute Care
  • Liver Disease
  • Asthma
  • Atrial Fibrillation
  • COVID-19
  • Cardiovascular Diseases
  • Prescription Digital Therapeutics
  • Reproductive Health
  • The Improving Patient Access Podcast
  • Blood Cancer
  • Ulcerative Colitis
  • Respiratory Conditions
  • Multiple Sclerosis
  • Digital Health
  • Population Health
  • Sleep Disorders
  • Biosimilars
  • Plaque Psoriasis
  • Leukemia and Lymphoma
  • Oncology
  • Pediatrics
  • Urology
  • Obstetrics-Gynecology & Women's Health
  • Opioids
  • Solid Tumors
  • Autoimmune Diseases
  • Dermatology
  • Diabetes
  • Mental Health

How Health Agencies Can Navigate the Newly Proposed ACA Marketplace Rules


The Centers for Medicare and Medicaid Services and the Treasury Department recently proposed a new rule intending to expand access to health coverage for individuals currently in or interested in entering the Marketplace.

There have been many uncertainties in the healthcare industry lately, however, there have been steady transformations across the board from 2020 into 2021. One area where this can continue to be seen is within the Affordable Care Act (ACA) Marketplaces. A recent Kaiser Family Foundation report found insurer participation on the ACA Marketplaces in 2021 increased for the third straight year, with companies both entering the market or expanding their footprints within states.

In an effort to increase demand with eligible populations and increase supply with newly participating health plans, The Centers for Medicare and Medicaid Services (CMS) and the Treasury Department recently proposed a new rule intending to expand access to health coverage for individuals currently in or interested in entering the Marketplace.

Key proposals within this new rule are expected to significantly impact both Exchanges and members. How can health agencies scale their current operations to meet these shifting demands and be prepared for future changes? First, we must examine key differences that this new Rule is bringing about.

The Rule represents the third installment of the Health & Human Services (HHS) Notice of Benefit and Payment Parameters for 2022 and differs from its predecessors in its efforts to reverse policies enacted during the Trump Administration and implement a range of new ones.

Among the proposed changes are:

  • Expansions to enrollment periods – In an effort to expand access to coverage for all individuals on or interested in the Marketplace, the Rule proposes extending the individual market open enrollment period starting in 2022. While the ultimate goal of aligning health plan enrollment with tax-filing through April 15th (in order to select a health insurance with tax subsidies) may be a tall order, the newly suggested open enrollment period for the upcoming benefit year is a good start, spanning from November 1st, 2021 to January 15th, 2022. This would extend open enrollment permanently to lengths similar to those during the COVID-19 pandemic and the early years of the ACA, giving members another month to enroll compared to the 2019 open enrollment period.
  • Increasing user support – The Rule aims to reduce health disparities by educating individuals at an increased risk of being provided misinformation. Specifically, it would reinstate requirements surrounding the enrollment information and assistance activities that Federally Facilitated Marketplace Navigators must provide. After all, an educated health insurance consumer is the best consumer to bend the ever-increasing cost curve.
  • Addressing healthcare inequality through expanded coverage access – Proposed measures in the Rule aim to increase access to affordable and comprehensive coverage, reducing the burden for both issuers and consumers. Efforts center around improving access for uninsured people who are affected by health disparities, which COVID-19 has further exacerbated.

These changes are anticipated to bring about a number of shifts:

  1. A substantial portion of individuals that qualified for Medicaid during the Public Health Emergency will soon no longer be eligible for those benefits. States will need to run specialized Medicaid reassessments for their recipient populations.
  2. New and returning members are expected to flock to the Marketplace to capitalize on the increased savings brought about by the American Rescue Plan. Payers who already feel the strain of growth in the ACA marketplace will need to ensure their systems can continue to scale.
  3. Exchanges can expect to see increased enrollment numbers from low-income individuals affected by Medicaid redeterminations. Those new shoppers will need frictionless experiences such as what exists with Amazon, eBay, Expedia, and other eCommerce solutions, with timely reconciliation between premium payments, exchange subsidies, and payer core administration systems.
  4. In order to address the limited supply of health insurance companies, increased eligibility along with risk capitation through Cost Share Reduction (reinsurance) will attract not only existing but also a new generation of health insurance providers. Companies like Oscar, Bright Health, and many others can provide new choices to consumers, hence the competition for affordable, accessible, and plentiful care.

All of this translates to massive movements within enrollment numbers. How can Exchanges best prepare for this outcome to ensure a seamless experience?

As for the states that are operating or considering designing, building, and operating a State- based Marketplace solution, the $20 million in grants available through the American Rescue Plan should be used for first principle reasoning to address not only current, but future challenges now that the ACA is here to stay. Among the questions for states to consider: should we own or partner? Should we build on-premise or move to cloud? Are we using the right technology stack?

Investing in an adaptable and configurable technology solution will allow issuers and Exchanges to meet ever-changing regulations with ease while reducing processing time, administrative overhead, and human error. However, it’s important to note that the timeframe for effective implementation of a technology solution is closing for SBMs and the payers that wish to connect with them – considerations must be made now if organizations want to ensure timely adaptation to the changing ACA requirements.

Shifting legislation and changing market demands mean health plans needs to remain prepared to confront any situation. By understanding where key changes will be made and choosing a technology solution that can support frequent adjustments, health agencies will be well-prepared for both the short and long term.

Eugene Sayan is CEO and founder of Softheon.

Related Videos
Related Content
© 2023 MJH Life Sciences

All rights reserved.