Author: LBodnarchuk

HHS released the 2027 Payment Notice Proposed Rule on February 9, signaling meaningful shifts for Health Insurance Exchanges, Issuers, brokers and agents. This annual notice sets the stage for potential changes and additions to the standards governing marketplace operations, plan design and compliance oversight.

As anticipated, the Proposed Rule seeks to reintroduce several requirements previously included in the 2025 Marketplace Integrity and Affordability Final Rule that were subsequently stayed by the courts prior to PY2026. These provisions include the elimination of certain Special Enrollment Periods (SEP), enhanced verification requirements for SEPs, restrictions on APTC eligibility for  undocumented individuals and stringent income verification prior to receiving APTCs.

The Proposed Rule also takes several steps to increase state authority and autonomy by removing barriers to the creation of State-Based Exchanges and shifting network adequacy requirements and reviews to the states.

Lastly, the Rule looks to ease the administrative burden on Issuers by removing duplicative certification reviews, eliminating the Standard Plan Design Requirement, relaxing Essential Community Provider (ECP) contracting thresholds and discouraging additional state-mandated Essential Health Benefits (EHBs).

Why this Matters

While states and plans may experience autonomy and procedural relief, CMS has made it clear that compliance with federal regulations remains mandatory and that non-compliance will carry consequences.

What Should Plans Do Now?

• Submit comments on the Proposed Rule by March 11
• Complete a rapid compliance assessment of all impacted operational activities, assuming the rule is codified as proposed
• Collaborate with state insurance departments to understand implications for the upcoming certification cycle
• Re-design processes and procedures to align with codified requirements
• Develop a compliance roadmap, including scheduled mock audits to proactively identify and mitigate risks

Why the first MA-guidance in decades signals a new era of scrutiny and execution.

On February 3rd, the Office of the Inspector General (OIG) released a Medicare Advantage Industry Segment-Specific Compliance Program Guidance. This marks the first time since 1999 that the OIG has issued formal, MA-specific guidance outlining its compliance expectations for Medicare Advantage plans.

This guidance clarifies OIG’s priorities and reinforces a clear message: compliance must be fully embedded into day-to-day operations. The document emphasizes strong governance, efficient and documented workflows, accountability across first-tier, downstream entities and proactive risk identification and management.

The OIG identified several areas that warrant focused and sustained attention, including:

• Access to Care (Network Adequacy and Prior Authorization)
• Marketing and Enrollment
• Risk Adjustment
• Quality of Care (Stars)
• Oversight of Third Parties
• Compliance Programs Within Vertically Integrated Organizations and Other Ownership Structures
• Submission of Accurate Claims

Why this Matters: Reinforced and Sustained Scrutiny

Medicare Advantage has been under increasing scrutiny for several years and this guidance reinforces that heightened oversight is not temporary. Recent actions by Centers for Medicare & Medicare Services (CMS), including expansion of RADV audits to all MA contracts, updated compliance protocols and a growing number of lawsuits addressing fraudulent or non-compliant behavior, signal a sustained regulatory focus on program integrity.

What Should Plans Do Now

Plans should view the OIG’s MA Compliance Guidance as a roadmap for strengthening compliance and operational risk by:

• Assessing organizational strengths and gaps to identify and prioritize key compliance and operational risks
• Establishing strong governance and accountability across all internal, delegated and downstream entities
• Implementing targeted risk assessments, auditing and monitoring to proactively identify, mitigate and manage compliance risks
• Aligning compliance strategy with quality outcomes and enterprise-wide risk management through an actionable, ongoing compliance plan

For years, ACA Risk Adjustment was treated as a technical requirement—important, but largely operational and retrospective in nature. That framing no longer holds.​

​In today’s environment of margin compression, RADV pressure and performance volatility, Risk Adjustment has become one of the few controllable levers plans still have.​

When Risk Adjustment is managed as a siloed, back-office function, plans expose themselves to preventable financial risk and downstream disruption.​

​Leading organizations are reframing Risk Adjustment as an enterprise capability. They connect data, clinical documentation, analytics, finance and operations into a coordinated model—one that supports both accuracy and sustainability.​

​This Shift Changes the Conversation:​

• From retrospective reconciliation to proactive margin protection​
• From isolated technical work to cross-functional accountability​
• From “getting it done” to getting it right​

In 2026, Risk Adjustment performance is not just a technical success factor.​ It is a strategic one.

Why This Result Matters 

This wasn’t indecision. 
It was a signal. 

When inefficiencies show up equally across people, processes, systems and data, the problem isn’t isolated, it’s systemic. Inefficiency doesn’t live in one department. It travels across the organization, compounding at every handoff and workaround. 

The Cost You Don’t See on the Balance Sheet 

These issues rarely appear as line items.  They show up as:

• Time lost to rework and manual effort
• Momentum lost during team handoffs
• Delayed decisions due to disconnected systems
• Teams operating without real-time visibility

Individually manageable. Collectively expensive. 

Key Takeaway 

Inefficiency isn’t a single problem to fix.  It’s an execution chain to break. 

What High-Performing Organizations Do Differently 

The organizations making progress aren’t chasing one-off improvements. 
They’re strengthening how work moves: aligning people, processes and systems to reduce friction end-to-end. 

Execution doesn’t fail loudly. It slows quietly until the cost is impossible to ignore.  Let’s talk about where inefficiency is slowing execution in your organization. 

The Challenge: Efficiency Matters When Every Chart Counts

Hybrid HEDIS season (aka Retrospective HEDIS project) requires accuracy, speed and coordination across analytics, operations and provider networks… all under intense time pressure. Plans are expected to close gaps at scale while navigating evolving specifications and a growing dependency on chart retrieval and medical record completeness.

Too often, teams are forced into reactive workflows:

• Chasing charts without prioritization
• Manually flagging members
• Relying on inconsistent provider responses

What Successful Plans Are Doing Differently

High-performing plans are shifting away from manual, sprint-based chart hunts to data-driven hybrid strategies. They are:

• Using advanced data analytics to improve their hybrid sample and prioritize high-impact members and providers early
• Automating chart chase workflows to reduce manual effort and enhance retrieval accuracy
• Engaging providers before hybrid season to improve documentation quality and reduce chart volume, not just chase records

These plans recognize that faster chart retrieval alone isn’t optimization. True efficiency comes from reducing avoidable chart work and creating workflows that scale year over year.

They are also:

• Strengthening supplemental data capturethroughout the year
• Improving ETL processes to ensure cleaner, more reliable data
• Making insights accessible through dashboards and self-service reporting for quality, clinical and operational teams

Our Perspective

With upcoming deadlines from NCQA and CMS regarding ECDS measure changes, digital quality measurement and FHIR based APIs, hybrid season as we know it is evolving.

However, the investments plans make now to optimize today’s programs will directly enable success in what comes next. Prospective HEDIS efforts will continue. Improved SDS capture and next-generation tools, such as natural language processing and large language models, will further enhance clinical data capture. At its core, this evolution is about one thing: ensuring plans capture the most accurate, most relevant clinical data to drive better outcomes for members… today and in the future.

Operational readiness determines whether teams adopt new systems or work around them.

What Readiness Really Means

True readiness includes:

• Defined roles and decision authority
• Capacity for teams to absorb change
• Aligned workflows across functions
• Metrics that track adoption and outcomes

The Outcome

When readiness is built into execution:

• Adoption accelerates
• Operational disruption decreases
• Performance improves faster

ProspHire Perspective

We operationalize readiness, embedding it into delivery so systems drive measurable, sustained improvement. Operational readiness determines whether new systems are embraced or quietly worked around. When roles are clear, teams are prepared and workflows are aligned, adoption accelerates and disruption is minimized. Readiness built into execution is what enables health plans to sustain results long after implementation ends.

Connect with Jaspreet Laungia.

The Problem

Health plans often declare success at go-live, yet performance improvement remains elusive months later. The issue isn’t the technology. It’s the assumption that implementation equals transformation.

Why Value Breaks Down

After launch, organizations frequently encounter:

• Unchanged workflows layered onto new systems
• Unclear ownership between IT, vendors and operations
• Limited adoption beyond basic functionality
• Metrics focused on completion, not outcomes

Without execution discipline, systems become expensive infrastructure rather than performance drivers.

What Successful Plans Do Differently

High-performing organizations:

• Redesign workflows alongside system changes
• Establish clear operational ownership post-launch
• Invest in adoption, not just training
• Measure outcomes tied to business performance

ProspHire Perspective

ProspHire helps health plans move beyond go-live by leading implementations as business change initiatives, not technical events. When execution changes, outcomes follow.

Implementation success is not defined at go-live. It’s defined by what changes afterward: how work is performed, how decisions are made and how teams adopt new ways of operating. Health plans that treat implementation as a business change, not a technical milestone, are the ones that turn systems into measurable performance improvement.

Connect with Jaspreet Laungia.

The Reality

Most system implementations don’t fail outright. They stall. Timelines stretch. Decisions slow.
Teams burn out managing change alongside daily operations.

Where Execution Breaks Down

Common risk points include:

• Diffuse accountability across teams
• Competing priorities and limited capacity
• Vendor-led timelines disconnected from operations
• Lack of adoption ownership after launch

Why This Matters

When execution falters:

• ROI is delayed or lost
• Teams revert to workarounds
• Leadership confidence erodes

ProspHire Perspective

ProspHire mitigates execution risk by providing:

• Clear ownership and governance
• Disciplined delivery management
• Alignment across IT, operations and leadership

Execution isn’t a phase; it’s the work. When system implementations fall short, the root cause is rarely technology; it’s execution under pressure. Clear ownership, disciplined delivery and operational alignment are what prevent delays, burnout and stalled adoption. Addressing execution risk early is what separates stable implementations from ones that struggle to deliver value.

Connect with Jaspreet Laungia.

The Challenge: You Can’t Improve What You Don’t Understand

In today’s Stars environment, health plans are expected to deliver stronger performance while managing varying contract maturity levels, operational capabilities, geographic variability and diverse member populations. At the same time, regulators continue to refine the program, most recently the proposed CY 2027 rule, adding complexity and volatility to an already high-stakes system.

As pressure mounts, plans must do more than improve outcomes. They must understand whether their contracts are positioned to perform, sustain and scale success.

Without a clear baseline, benchmarking or contract readiness evaluation, plans risk investing in the wrong strategies, duplicating effort or missing meaningful opportunities for improvement.

What High-Performing Plans Are Doing Differently

Leading organizations are pausing before they push forward. Rather than spreading resources evenly across contracts or chasing isolated measure improvements, they begin by gaining a clear picture of where they stand.

This disciplined approach enables targeted improvement, reduces waste and focuses effort where it will generate the greatest return.

Three Priorities for Contract Benchmarking and Readiness

• Contract-Level Benchmarking: Measure competitive standing by contract to identify improvement opportunities, risk exposure and of performance leverage.
• Operational Readiness Assessment: Evaluate the core health plan capabilities that drive Stars performance, including analytics, governance, provider engagement, member experience strategies and vendor accountability.
• Targeted Investment and Strategy Alignment: Use assessment insights to direct resources toward contracts with the strongest opportunity for sustainable performance improvement.

Our Perspective

At ProspHire, we believe the strongest Stars strategies begin with precision, knowing exactly where you are before deciding where to go next. Through Contract insight, operational assessment and focused prioritization, create the clarity plans need to aim higher with confidence and measurable impact.

Measure. Benchmark. Improve with Purpose.

Stars improvement begins with understanding. Let’s redefine how you benchmark performance, assess readiness and elevate contract performance outcomes with a strategy built on clarity, focus and execution.

Connect with ProspHire to learn how a contract-level Stars assessment can position your plan for sustainable success.