On November 4th, CMS released the Notice of Intent to Apply (NOIA) applications calendar year 2027 for Medicare Advantage Prescription Drug (MAPD) plans. While often viewed as an administrative first step, the NOIA represents a plan’s formal commitment to participate in the upcoming contract year. More importantly, before the NOIA is even submitted, plans must use this moment to articulate their strategic intent by identifying which products to sustain, where to innovate and what new opportunities to pursue in the year ahead.
This is especially critical amid the Medicare Advantage Reset we are experiencing today. Medicare Advantage headwinds are broad and big, such as shifting regulatory targets, potential policy changes under a new administration, heightened audit scrutiny, increased political pressure and increased need to improve and maintain strong Stars and quality performance.
For plans, the CY2027 NOIA cannot be viewed as business as usual. It needs to be treated as a strategic checkpoint. It’s the moment to define your plan’s Medicare Advantage roadmap, reaffirm market goals and set the tone for the entire bid season.
Some key focus areas for this year’s NOIA cycle include:
Product Realignment: The NOIA enables plans to reassess offerings, retire underperforming products and refine benefits to stay competitive while balancing market appeal with cost containment for long-term sustainability.
Special Needs Plan (SNP) Penetration: SNP plans continue to see steady growth, as reflected in the October CMS landscape files. MAPDs that excel in care coordination and member outcomes are well positioned to capitalize on this trend and benefit from the higher rebate margins these plan types offer.
Market Expansion or Retraction: The NOIA period allows plans to evaluate where to grow their footprint and where to scale back, ensuring data-driven decisions on market participation ahead of bid development.
Organizational Readiness: Before committing to a strategic roadmap, plans should carefully evaluate their existing infrastructure and capabilities to ensure they can operationally support future goals. A sound strategy requires not only vision, but the processes, systems and resources to bring it to life.
As the MAPD landscape continues to evolve, the CY2027 NOIA marks more than the start of another bid cycle. MAPD plans that make the time now to realign, innovate and set a clear goal for 2027 will be well positioned when bids are submitted.
At ProspHire, we have been partnering with health plans for over a decade, navigating this critical period with clarity and confidence by helping organizations strategically plan for sustainable growth, operational readiness and long-term success in the evolving Medicare Advantage landscape. If you are prepared to chart a new path forward, embracing the Medicare Advantage Reset and exploring new models for success, not anchored to the past but positioned for the future, let’s have a conversation.
Season 3 of Soaring to New Health, ProspHire’s original podcast series, brought together healthcare leaders, innovators and changemakers to explore one central idea: how insight becomes impact.
Across five powerful episodes, the conversations spanned cybersecurity, Medicaid transformation, equity and performance improvement. Each one focused on solving real-world challenges in today’s healthcare environment.
Highlights from Season 3
Cybersecurity Challenges in Healthcare Guests: Chris Vermilya | Loom Security and Joe Wynn | Seiso Digital transformation has made patient data more vulnerable than ever. This two-part discussion unpacks how protecting information is no longer just an IT concern, it’s a patient-safety priority.
Medicaid Momentum: Managing Change in a Shifting System Guest: Brendan Harris | UPMC for You As Medicaid programs evolve post-pandemic, adaptability is becoming the new advantage. This episode explores how health plans can balance compliance, cost and care quality in a rapidly changing landscape.
Equity at Life’s Edges Guests: Dr. Joe Sanfilippo and Arnie Burchianti From access to IVF treatments to end-of-life care, this conversation shines a light on where innovation and empathy intersect and how true equity means designing care for everyone.
Medicaid Matters Guests: Jim Burgess | Highmark Wholecare and Julie Evans | ProspHire Policy, technology and operational best practices come together in this deep-dive series on how Medicaid plans can modernize, perform and sustain success through data-driven execution.
Listen. Learn. Lead.
Season 3 of Soaring to New Health captures what ProspHire stands for: transforming healthcare through expert delivery and execution. Whether it’s securing patient data, strengthening Medicaid performance or driving equity in care, every episode offers practical insights leaders can act on today.
Stream all episodes and explore the Season 3 infographic at prosphire.com/podcast or wherever you download your podcasts.
When cut points tighten and deadlines loom, every day and every data point matters.
In the final stretch of the Stars season, success depends on speed, accuracy and focus. Our dual-track approach delivers both:
Rapid Data Assessment
Health plan reimbursements, compliance and quality outcomes are highly connected to data accuracy. It’s critical to prioritize the integrity of data sources. We can quickly evaluate your data to help identify:
Optimal Stars math and scenario modeling to develop “win strategies” tailored to your plan, your data and your situation
Incomplete or missing supplemental data elements impacting rates for key HEDIS measures
Fragmented and inconsistent member data across pharmacy, claims and clinical systems that lead to inaccurate reporting and missed opportunities
Systematic errors that can lead to member dissatisfaction or service issues
By strengthening the completeness of your data and establishing effective validation processes, we empower your team to make informed, fast decisions.
Stars Recovery Accelerator
Once the data foundation is sound, our team launches precision-driven sprints focused on high-risk measures or contracts. Together with your team, we will identify and prioritize high-impact measures approaching the next cut point or improvement threshold. These short, intensive engagements are designed to deliver measurable lift before it’s too late, protecting your ratings and revenue.
Why ProspHire
When there’s no time to waste, trust ProspHire to move your plan from reactive to ready – transforming data into performance and urgency into results.
The Stars environment has changed and so must the strategy. As CMS continues to tighten cut points, redefine measures and raise the bar for quality outcomes and member experience, maintaining 4+ Stars is no longer about incremental gains. It is about sustained transformation. Success belongs to the plans that pair precision analytics with operational discipline and member-focused engagement.
At ProspHire, we help Medicare Advantage organizations move from reactive firefighting to proactive performance, unlocking sustainable improvements across every dimension of Stars.
ProspHire Impact
Star Year 2026 Market Insights
40% of H-Contracts earned star ratings above 4.0
Over 50 contracts experienced a decline in ratings, dropping from above 4.0 to below, between SY25 and SY26
Approximately 40 contracts saw improved performance, rising to a star rating above 4.0 in SY26
More than 80 H-contracts saw their Part D ratings fall from above 4.0 to below
Medicare Advantage is undergoing a fundamental reset and Stars strategies and programs need to adapt to that new reality. The things that made programs of the past successful won’t yield positive results in today’s changing environment. Plans are balancing evolving regulatory changes, shrinking budgets and member populations with increasingly complex needs. Amid this challenge lies opportunity. With the right structure, data and alignment, your Stars program can become a true driver of quality, retention and growth.
ProspHire’s Approach
At ProspHire, we partner with health plans to design and execute Stars strategies built for your members in today’s environment: measure specific, data-driven and member-centric. Our comprehensive portfolio of Stars services address both immediate recovery needs and long-term transformation:
Delivering Results. Period.
Whether your goal is to become a 4 Star contract or build your roadmap toward 5 Stars, ProspHire brings the precision, partnership and proven results you need to perform.
The Affordable Care Act (ACA) continues to shape the healthcare landscape, influencing access, affordability, quality and compliance for health plans across the U.S. With ongoing regulatory updates and evolving market dynamics, staying compliant and competitive requires careful planning and expert guidance. In this Q&A, ProspHire’s ACA practice leader, Caitlin Nicklow, shares her insights on ACA compliance, key operational requirements, emerging trends and how health plans can successfully navigate the complexities of ACA regulations.
Section 1: Current Trends & Strategic Insights
What are the current challenges for ACA health plans in 2025–2026?
The biggest challenge on everyone’s minds this year is affordability. With the Biden Era Enhanced Premium Tax Credits set to expire at the end of year, consumers will experience a sharp increase in their monthly premium. Some could see an increase as much as 75%. With cost already a top concern for Marketplace members, this kind of rate increase will force many to go uninsured. For Health Plans, this can lead to deteriorating risk pools and higher claims costs, both effecting profitability.
How are ACA regulations evolving with recent federal or state updates?
The regulatory environment around the ACA is undergoing a notable shift. While past administrations have taken efforts to increase access and affordability of plans, the Marketplace Integrity & Affordability Final Rule (2025) takes us in a different direction. Some elements of this Rule are facing opposition, but if implemented, it will greatly restrict who can enroll in the Marketplace and how. This rule enhances eligibility requirements, including stricter and more frequent verification. It also reduces opportunities for members to enroll but eliminating income-based special enrollment periods. Coupled with the rising cost, these enrollment burdens may dissuade members from the Marketplace.
What strategies can health plans use to optimize enrollment and member retention?
To combat these headwinds, it is more important now than ever for Health Plans to engage with current and potential members. To do this, Health Plans should use targeted outreach including social determinants and demographic data to reach consumers most at risk. Health Plans also need to make it easy for Members to use the plan by simplifying enrollment processes, making plan information easy to understand and leveraging broker partners where possible.
How can health plans ensure ongoing compliance post-launch?
A strong governance structure is key to ensuring long term compliance success. Clear owners and roles must be identified, with cross collaboration across all functions. Compliance is everyone’s job. Real time regulatory tracking will also be crucial in the new environment. Plans must proactively prepare for impacts of proposals and partner with lobbyists and legislators to make these impacts known. Lastly, routine auditing and monitoring will ensure Health Plans always have a current picture of their compliance risk and identify potential risks before they become a problem.
What trends are shaping the future of ACA health plans?
With pressures on rates, membershi, and claims costs, Health Plans will be forced to find ways to remain profitable. Successful plans will double down on Risk Adjustment strategies to make sure their risk pool is accurately reflected and reimbursed. Plans must also continue to look for Administrative cost reductions. Leveraging automation, AI and streamlined processes will be essential to claw back tight operating margins.
Section 2: ACA Compliance Fundamentals
How does the ACA impact healthcare today?
The Affordable Care Act (ACA) includes several provisions that have important implications for public health:
Increased Access to Health Insurance: The ACA has expanded access to health insurance by creating marketplaces where individuals can purchase affordable health insurance plans and by expanding eligibility for Medicaid. As a result, millions of previously uninsured Americans gained access to health insurance.
Prohibiting Insurance Discrimination: The ACA prohibits health insurance providers from discriminating against individuals with pre-existing conditions and it also prohibits health insurance providers from charging higher premiums based on factors such as gender or health status.
Enhancing Preventative Care: The ACA has emphasized the importance of preventative care and it requires most health insurance providers to cover preventative services such as cancer screenings and immunizations without cost-sharing.
Lowering Healthcare Costs: The ACA includes provisions that aim to lower healthcare costs, including measures to reduce waste, fraud and abuse in the healthcare system and initiatives to encourage more efficient and coordinated care. Many individuals are also eligible for financial assistance in the form of subsidies and cost sharing reductions.
Improving Healthcare Quality: Insurers offering Plans on the ACA Marketplace receive a Quality Rating Score (QRS). This score not only measures the quality of healthcare received by members, but also the administration of the Health Plan. Members can compare scores when shopping for the best Plan.
Is there a mandate that all health insurance providers need to provide ACA-compliant health plans?
Yes, under the Affordable Care Act (ACA), also known as Obamacare, all health insurance providers are required to offer ACA-compliant health plans in the individual and small group markets. ACA-compliant health plans must meet certain requirements, such as covering essential health benefits, not discriminating against individuals with pre-existing conditions and capping out-of-pocket costs for covered services.
The individual mandate, which required most Americans to have health insurance or pay a penalty, was repealed in 2017. However, the requirement for health insurance providers to offer ACA-compliant plans remains in place.
It is worth noting that certain types of health insurance plans, such as short-term health plans and health care sharing ministries, are not required to comply with the ACA’s regulations. These plans may offer lower premiums but may not provide the same level of coverage or consumer protections as ACA-compliant plans.
What are the rules once you are an ACA-compliant provider?
Once a health insurance provider offers an ACA-compliant health plan, they must adhere to certain rules and regulations. Here are some of the key rules for ACA-compliant providers:
Cover Essential Health Benefits: ACA-compliant health providers must cover ten essential health benefits, which include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services.
No Discrimination Based on Pre-Existing Conditions: Health insurance providers cannot discriminate against individuals with pre-existing conditions. This means they cannot deny coverage or charge higher premiums based on an individual’s health status.
Cap Out-of-Pocket Costs: ACA-compliant health insurance providers must cap out-of-pocket costs for covered services. In 2026, out-of-pocket costs are limited to $10,600 for individuals and $21,200 for families.
Cover Preventive Services without Cost-Sharing: Health insurance providers must cover certain preventive services without requiring cost-sharing, such as copays or deductibles. Examples of these services include mammograms, colonoscopies and immunizations.
Provide Coverage for Dependent Children: Health insurance providers must provide coverage for dependent children up to age 26.
Limit Annual and Lifetime Coverage: Health insurance providers cannot impose annual or lifetime dollar limits on essential health benefits.
These are just some of the key rules for ACA-compliant providers. There are additional rules related to network adequacy, rate review and other aspects of health insurance regulation that providers must also follow to maintain compliance with the ACA.
Are there key dates that health insurance providers need to be aware of throughout the year?
Providers should be familiar with several important dates:
Open Enrollment: Open Enrollment is the period when individuals can enroll in or change their health insurance plans for the following year. The dates for Open Enrollment may vary from year to year, but it generally takes place in the fall. For 2026 coverage, Open Enrollment begins November 1, 2025 and ends January 15, 2026, in most states.
Special Enrollment Periods: Special Enrollment Periods (SEPs) allow individuals to enroll in or change their health insurance plans outside of Open Enrollment if they experience certain qualifying life events such as getting married, having a baby or losing their job-based health coverage. SEPs are available throughout the year but individuals typically have a limited amount of time to enroll after their qualifying event.
Tax Season: Health insurance providers need to be aware of the ACA-related tax forms that must be issued to individuals and the IRS during tax season. For example, individuals who received premium tax credits to help pay for their health insurance during the year will need to file Form 8962 to reconcile the amount of the credit they received with their actual income for the year.
Plan Year Renewals: Health insurance providers must renew their ACA-compliant health plans each year. The certification process typically runs May through September.
Regulatory Changes: The ACA is subject to ongoing regulatory changes, which can affect health insurance providers and their customers. Providers should stay up to date on any regulatory changes and be prepared to make changes to their plans or operations as necessary.
What is required to set up an ACA-compliant health plan?
ACA-compliant health plans must follow rules established by the Affordable Care Act.
Obtain Licensure: Health insurance providers must obtain licensure from the state(s) in which they operate. State insurance departments oversee the licensing process and ensure that providers comply with state regulations.
Cover Essential Health Benefits: ACA-compliant health plans must cover ten essential health benefits, which include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services.
Comply with Rate Review Requirements: Health insurance providers must comply with rate review requirements, which vary by state. These requirements typically require providers to submit rate increase requests to state insurance departments for approval.
Comply with Network Adequacy Requirements: Health insurance providers must ensure that their provider networks are adequate to meet the needs of their customers. Network adequacy requirements vary by state and may include minimum provider-to-patient ratios, distance standards and other criteria.
Comply with Reporting Requirements: Health insurance providers must comply with various reporting requirements, including the submission of data on the number of individuals enrolled in their plans, the cost of coverage and the number of claims denied.
What is the timeline to launch an ACA-compliant health plan?
The timeline to launch an ACA-compliant health plan can vary depending on several factors such as the size and complexity of the organization, the state in which it operates and the level of existing infrastructure and resources. However, here are some general steps and timelines that healthcare insurance providers typically follow when launching an ACA-compliant health plan:
Develop a Plan: The first step in launching an ACA-compliant health plan is to develop a business plan that outlines the goals, objectives and strategies for the new plan. This process typically takes several months and may involve market research, competitor analysis and other activities.
Obtain Licensure: Health insurance providers must obtain licensure from the state(s) in which they operate. The licensure process can take several months and may involve completing an application, paying fees and providing documentation such as financial statements, business plans and marketing materials.
Develop Provider Networks: Health insurance providers must develop provider networks that are adequate to meet the needs of their customers. This process can take several months and may involve recruiting new providers, negotiating contracts and setting up systems for provider credentialing and claims processing.
Develop Products and Pricing: Health insurance providers must develop products and pricing that comply with the ACA’s regulations. This process can take several months and may involve developing new products or modifying existing ones, conducting actuarial analyses and setting premiums.
Implement Systems and Processes: Health insurance providers must implement systems and processes to support their new ACA-compliant health plan. This can include developing and implementing new technology systems, hiring staff and establishing procedures for claims processing, customer service and compliance.
Overall, the timeline to launch an ACA-compliant health plan can range from several months to a year or more, depending on the complexity of the organization and the state in which it operates. It is important to work closely with legal and regulatory experts to ensure compliance with all applicable regulations and to allow sufficient time for the licensure and implementation process.
Does ProspHire have experience launching ACA-Compliant plans?
ProspHire has launched fully certified and accredited ACA plans in 6 states, with additional growth in our portfolio of existing clients. We have extensive experience driving end-to-end current state assessments to analyze the regulatory and operational gaps organizations must fulfill in pursuit of an ACA-compliant plan and we have the implementation and change management knowledge to close those gaps in limited timelines. Additionally, our subject matter expertise in guiding organizations to achieve success in medical management and quality care delivery can help to get the plan firmly grounded at launch.
How can ProspHire help you throughout this process?
ProspHire will work with you to understand your unique circumstances and identify the best method to achieve your ACA goals, whether as an extension of your teams or as a completely outsourced program management group while you work to hire the right people to operate the plan at go live. Following an in-depth current state assessment and comparison to State and/or Federal guidelines, you will receive a roadmap and step-by-step project plan to manage the various regulatory, operational and technological requirements necessary for certification and/or accreditation, operational readiness and plan go live. Post go live support can also ensure you are set with a clear plan on maintaining your status as a Qualified Health Plan, helping to develop the tools and practices to ensure your ACA plan is operating at its highest level and help you target and execute on plan expansions for the following years.
The Affordable Care Act (ACA) has transformed the healthcare system, presenting both challenges and opportunities for health plans. Navigating the ACA landscape requires a solid strategy for compliance, competitive positioning and long-term success. ProspHire’s expertise can help health plans adapt to the ever-changing ACA marketplace while maximizing enrollment, improving member care and ensuring compliance with regulatory standards.
1. Ensuring Compliance with ACA Regulations
In order to offer plans in the Marketplace, Issuers must apply for Quality Health Plan Certification annually, meaning compliance with regulations is non-negotiable. ProspHire assists health plans in staying up to date with ACA requirements, including essential health benefits, product design, rate development and reporting obligations. Our solutions ensure that health plans are always prepared for audits and regulatory changes.
2. Achieving Competitive Rates While Maintaining Financial Stability
Actionable Tip: Utilize advanced data analytics to forecast risk, invest in AI and automation, and collaborate with network providers.
ACA members are highly price sensitive, so competitive rates are essential. To achieve these rates, plans must look for maximum efficiency in areas like medical management, claims handling and provider contracting. By offering rates that are not only competitive, but realistic, Plans will attract more members while remaining profitable.
Actionable Tip: Utilize advanced data analytics to forecast risk, invest in AI and automation, and collaborate with network providers.
3. Optimizing Member Engagement and Enrollment
A successful ACA plan requires not only compliance but also high member engagement. ProspHire helps health plans optimize their enrollment processes, ensuring a smooth experience for new members and improving retention through tailored communication strategies.
Contact ProspHire for Health Plan Support
The ACA landscape is complex, but with the right strategies in place, health plans can thrive. ProspHire’s solutions help health plans navigate these challenges and achieve success in the ACA market. Is your health plan prepared for the evolving ACA marketplace? Contact ProspHire for a consultation to learn how we can help.
ProspHire, a leading healthcare consulting firm dedicated to transforming healthcare through expert delivery and execution, is proud to announce its ranking as #14 in the Supplier Group in Modern Healthcare’s 2025 Best Places to Work.
This recognition highlights ProspHire’s commitment to building an inclusive, collaborative and high-performing workplace where employees thrive while delivering exceptional results for clients. The firm’s focus on culture, professional growth and meaningful impact continues to set it apart in the healthcare industry.
“Being named one of the Best Places to Work is a testament to the incredible team at ProspHire,” said Lauren Miladinovich, CEO, Managing Principal and Co-Founder. “Our people are at the heart of everything we do and we are proud to create an environment where they can excel, innovate and grow while making a real difference in healthcare.”
Chris Miladinovich, Co-Founder and Chief Strategy Officer, added, “This recognition reflects the collective effort, dedication and passion of our team. At ProspHire, we strive to create a workplace where strategy, innovation and culture intersect, enabling our people to thrive while delivering meaningful impact for our clients and the healthcare industry.”
ProspHire’s team-driven approach, combined with its dedication to operational excellence, empowers employees to contribute to transformative projects across healthcare, from Medicaid and Medicare Advantage to Dental Practice Management and ACACompliance.
Dental care is an essential aspect of holistic health, yet managing dental practices presents notable challenges for health plans. ProspHire assists health plans in enhancing dental practice management through streamlined workflows, improved patient outcome and reduced operational costs. Effective dental practice administration is crucial to ensuring members receive necessary care efficiently and without undue expense.
1. Streamlining Dental Practice Operations
Health plans frequently encounter inefficiencies in dental practice operations, resulting in delayed treatments and suboptimal patient satisfaction. ProspHire enables health plans to identify areas of operational weakness, optimize scheduling, billing and patient intake procedures and implement solutions that facilitate seamless patient experiences.
Actionable Tip: Establish standardized dental workflows and integrate electronic health records (EHR) systems to expedite patient data entry and minimize administrative delays.
2. Enhancing Patient Care and Satisfaction
Patient satisfaction represents a significant benchmark for health plan success. ProspHire’s methodology encompasses optimizing communication with patients, guaranteeing timely delivery of care and elevating the overall patient experience within dental services. Through ProspHire’s expertise, health plans can achieve higher rates of patient retention and satisfaction by offering more efficient dental services.
3. Reducing Costs in Dental Practices
Dental Practice Management often incurs substantial expenditures and inefficient processes may contribute to considerable waste. ProspHire supports health plans in cost reduction by refining operational workflows, improving billing accuracy and leveraging advanced data analytics for optimal resource management.
Actionable Tip: Utilize predictive analytics to monitor patient appointments and mitigate overbooking, thereby promoting effective allocation of resources.
Ready to Optimize Your Dental Practice Management?
Optimizing Dental Practice Management within health plans is fundamental to advancing care delivery, increasing patient satisfaction and minimizing costs. ProspHire provides tailored solutions that enable health plans to accomplish these objectives.
For comprehensive enhancement of your Dental Practice Management, partner with ProspHire to improve operational efficiency and elevate patient care.
Medicaid health plans face unique challenges, from complex regulatory requirements to managing large volumes and extensive care across diverse populations. ProspHire’s approach helps Medicaid health plans streamline operations, reduce administrative costs and improve care coordination—all while enhancing member outcomes and ensuring compliance with state and federal regulations.
1. Streamlining Administrative Processes
One of the biggest challenges for Medicaid health plans is the complexity of operational and administrative tasks. ProspHire works with health plans to simplify these processes, from claims management to enrollment procedures. By optimizing workflows and leveraging automation, Medicaid health plans can reduce the administrative burden, cut costs and improve operational efficiency.
2. Improving Care Coordination
Effective care coordination is crucial in Medicaid, as members often face multiple health challenges that require coordinated efforts between providers, health plans and community resources. ProspHire helps Medicaid health plans create systems for seamless care coordination, ensuring that members receive the right care at the right time.
3. Driving Compliance with Regulatory Standards
Medicaid is highly regulated, with strict requirements that health plans must meet. ProspHire helps Medicaid health plans stay ahead of compliance requirements by providing expertise on CMS and state regulations, as well as supporting audits and quality reporting initiatives.
Conclusion:
Transforming Medicaid operations requires a focus on efficiency, care coordination and compliance. ProspHire’s solutions empower Medicaid health plans to streamline their processes, reduce costs and improve member outcomes.
Want to improve your Medicaid operations? Contact ProspHire today to schedule a consultation.
Medicare Advantage (MA), since its inception, has been on a meteoric rise. With more than half of all eligible seniors enrolled in the program, it remains a popular choice for consumers. However, the convergence of several factors over the past few years has marked a turning point for the program as we know it. Driven primarily by the COVID pandemic reset, rising utilization, increased regulatory scrutiny and an overinflated market, leading payors are rethinking previous models for success. What we’re seeing now are plans exiting key markets and launching resets of their own, including rethinking benefit designs, reducing administrative costs and considering the role of artificial intelligence in the context of managed cares, “new normal”. What worked yesterday, most certainly, will not work for tomorrow.
To be clear, this is not the end of Medicare Advantage; it is a paradigm shift. Those plans that seize this opportunity to take a hard look in the mirror and prepare themselves for the Medicare Advantage of tomorrow will most certainly be long term winners.
At ProspHire, we see four priorities that will define success for Medicare Advantage organizations in 2025 and beyond:
1. Define Your Goal, Then Recalibrate Portfolios, Products and Markets
The first step in navigating this reset is a strategic one, not an operational one. Too often, plans leap into tactical fixes without clarifying who they want to be. The fundamental question is: what is your goal?
Do you want to be a growth leader, capturing market share and aggressively expanding into new geographies?
Do you want to be a profitability leader, focusing on margin discipline and sustainable operations?
Do you want to specialize in specific populations, such as dual eligibles or chronic condition cohorts?
Once that strategic identity is clear, portfolios and products must be recalibrated accordingly. The right benefits, the right markets and the right member segments should all ladder up to that core purpose. Without alignment, plans risk chasing growth in areas where the economics don’t work or overinvesting in products that don’t match their long-term strategy.
2. Revitalize Member Engagement
Action areas include:
Proactive and personalized outreach, leveraging data to anticipate member needs.
Intuitive tools and digital navigation that reduce confusion.
A true focus on experience equity — meeting members where they are, across geography, culture and socioeconomic status.
Another important note looming in the MA space is that the first Gen X’er will be Medicare eligible in 2030, which is less than 5 years away. This represents an entirely new consumer segment with new expectations that plans will need to meet.
3. Invest in Technology and Infrastructure for Tomorrow
Success in MA is massively dependent on data: how it’s acquired, how it’s managed and how it’s used to make decisions. Many health plans today are still operating with fragmented systems, outdated analytics and cumbersome integrations. That is no longer sustainable.
The reset is the right moment to make serious infrastructure investments:
Build robust IT and analytics capabilities that support real-time decision-making.
Prepare for digital quality measurement and data submission in an ECDS/FHIR world.
Reevaluate vendor relationships to ensure each partnership contributes to a smarter, more integrated tech stack.
The message is simple: technology is a competitive differentiator and plans that invest wisely now will be positioned to outpace competitors for the next decade.
4. Optimize Revenue Drivers: Stars, Quality and Risk
While the regulatory environment continues to shift, the core revenue levers of Medicare Advantage (Stars, quality and risk adjustment) remain central to financial sustainability. Yet these are often not given the investments required or siloed into business-as-usual functions rather than treated with the strategic importance they deserve.
Health plans must:
Prioritize Stars improvement strategies that align with member experience, CAHPS and clinical outcomes.
Consider new, innovative care delivery models, including PACE, neighborhood-driven clinical care delivery and other models to deliver care that members need.
Tighten risk adjustment accuracy to avoid over- or under-coding exposures in a stricter audit environment.
Treat quality not as an end but as a margin enabler, directly tied to reimbursement and member retention.
Even amid change, this truth remains: optimizing Stars, quality and risk is not optional. It is a foundational pillar of Medicare Advantage success.
What’s Next? Embrace the Reset and Seize the Opportunity
At ProspHire, we believe this is a moment for reinvention and a time for plans to confront hard questions, make bold choices and position themselves for long-term success. The Medicare Advantage of tomorrow will not look like yesterday’s version and that is precisely what makes this reset an opportunity worth seizing.
