Author: LBodnarchuk

Andrew Bell with blurred background

Q&A with Andrew Bell: Empowering Health Plans to Excel in Medicare Advantage Performance

Written by LBodnarchuk on . Posted in Insights.

Medicare Advantage (MA) continues to be one of the most competitive and highly regulated sectors in healthcare. With shifting CMS requirements, evolving member expectations and an increased focus on quality outcomes, health plans face growing pressure to balance compliance, cost and performance. ProspHire’s Medicare Advantage Practice helps health plans thrive in this complex environment, bringing hands-on execution experience across Stars performance, risk adjustment, cost savings initiatives, member engagement and operational improvement.
 
In this Q&A, we sit down with Andrew Bell, Medicare Advantage Practice Leader, to explore the trends shaping MA today, the evolving market and how ProspHire partners with clients to deliver measurable impact.Medicare Stars landscape.

Section 1: Inside the Medicare Advantage Market

What are some of the biggest challenges facing Medicare Advantage health plans today?

The Medicare Advantage space remains amid massive and fundamental change. Over the past 15 years, the MA industry has experienced nothing but tremendous growth, a favorable regulatory environment, steadily increasing payments and reimbursements and growing membership. As the industry emerges from the unusually favorable conditions of the past few years, plans now face a fundamentally new operating environment. This Medicare Advantage reset is happening at a time when several major pressures are converging.

  • Margin compression + utilization volatility: Higher unit costs, post-COVID acuity and site-of-care shifts are outpacing bid assumptions.
  • Regulatory whiplash: Rapid measure changes, audit intensity (RADV), supplemental benefit scrutiny and DSNP alignment rules tighten the screws.
  • Stars headwinds: Cut points drifting upward, measure redefinitions and reduced cushions (e.g., fewer “easy” lifts), reward factor removal.
  • Data fragmentation: Clinical data liquidity is still uneven; FHIR maturity varies by partner; Internal ops aren’t fully digital-first.
  • Distribution + retention pressure: Benefit resets strain retention; Broker dynamics and member friction affect mix and persistency.

These market pressures, combined with outdated models for success, will be the reason many Medicare Advantage plans will struggle in the near term.

What opportunities exist for plans to differentiate themselves in an increasingly saturated MA market?

In terms of “real” market differentiation, recent years have shown that Medicare Advantage plans have had little “true” differentiation. Plan benefit packages, supplemental benefits and provider networks were nearly identical across markets and carriers. Now, in the age of the Medicare Advantage reset, plans have the tremendous opportunity to truly differentiate themselves not only to members but to providers and regulators.

  • Member experience in the modern age: The adage of Medicare Advantage members was that they were primarily baby boomers with little to zero interest in digital engagement and experience. Snail mail, direct to consumer outreach and traditional outreach models worked until they didn’t. In fact, this demographic is more tech savvy than ever, not to mention that in five years the first Gen X’er will be Medicare eligible. This means that plans have the true opportunity to treat member experience and engagement like banking and retail and bring it into the modern age, frictionless onboarding, proactive outreach and next-best-action at scale.
  • Clinical data advantage: CMS and other regulating agencies continue to push for new and innovative advances in interoperability and digital quality measurement. This top-down approach to innovation can only move as fast as the regulators care to move and the moment is ripe for forward thinking plans to move fast and truly embrace this digital future. Plans should focus on superior ECDS/digital data capture that closes gaps faster (and cheaper) than competitors and FHIR based interoperable data exchanges to further democratize data and place the member at the center.
  • Reimagined product strategy: Every plan must do more with less. The age of overly rich benefit packages ripe with all the bells and whistles is gone. Plans need to really consider their market, their specific membership needs and right-size benefits and PBPs around segments (e.g., DSNP, chronic cohorts) rather than trying to be everything to everyone. This reimagined product strategy will certainly be “less rich” than previous benefit cycles but will be a better reflection of the current reality and ultimately will be more sensible and practical as a matter of financial prudence.

Section 2: Driving Stars Performance Excellence

Stars Ratings continue to be a major performance driver for Medicare Advantage organizations. What trends are you seeing across the industry?

It’s impossible to separate the larger Medicare Advantage reset from the Stars trends and pressures we’re seeing across the industry. In many ways they are inextricably linked. Stars leaders have less discretionary spending at their disposal to throw at late HEDIS blitz’s or that intriguing new vendor to pilot. Leaders will have to scrutinize every dollar spent and focus on what truly delivers value and ROI.

Another area of interest is how plans are navigating the rapidly changing Stars regulatory and rule environment. The industry has seen more change in the past two years than we’ve experienced in the past many years. New measures, new methodologies and new considerations all crashing at the same time is putting pressure to Stars leadership and health plan leadership to maintain the Stars revenue.

Many plans have in the past resorted to large regional or national contracts to concentrate Stars performance on one mega contract. This strategy has yielded great success to those national players by insulating Stars risk and maximizing Stars related revenue. However, the recent Stars regulatory changes are flipping that old model on its head, and many national players are scrambling to understand their exposure (see the most recent Humana Stars loss and the impact to their revenue). I think that this is a big wake up call to health plan leaders who may have taken their prior Stars success for granted. Many plans (even those with consistent 4.0+ success) are taking the time to evaluate their programs and determine whether a new path needs charted, one with less Stars exposure and tighter controls in place.

Last but certainly not least, what remains is the uncertainty on the future of Stars itself. The long-standing program is facing growing criticism from Washington DC policy circles, including groups like the Paragon Institute, as well as from MedPAC, which has repeatedly called for changes to the program and the elimination of quality bonus payments. Wherever the program ends up in the near term, one thing is for sure, changes are coming and plans will be forced to react.

How can plans improve or sustain their Stars Ratings amid regulatory tightening and the new Stars reality?

Plans looking to maintain or grow their Stars Ratings in a period of regulatory tightening and volatile cut points need a dual approach. In the near term, leaders should concentrate on interventions across the sub-set of measures still within reach for the current cycle, focusing on the controllable levers that can meaningfully shift outcomes before submission. Simultaneously, they must begin rebuilding the operating model for the next three years, anticipating the structural realities of future Star Years (SY27–SY29), including digital measure adoption, reward factor removal, the EHO4 all measurement, integration of AI and automation into workflows and finally reduced resources available.

A major driver of Stars success is mastering both the denominator and numerator. Plans must “own the denominator” through eligibility hygiene, attribution accuracy and encounter completeness to minimize avoidable misses and ensure members are correctly represented. Time and time again we see that plans struggle with data capture on the front end, leading to data leakage and numerator devaluing. On the numerator side, success increasingly depends on a reimagination of the vendor stack, standardizing clinical data ingestion, prioritizing FHIR-first architecture, automating evidence capture and compressing cycle times from weeks to days. This operational rigor allows teams to act on near-real-time information rather than retrospective data.

Member experience remains a differentiator. CAHPS performance cannot be treated as a once-a-year campaign. It must be embedded as an operating philosophy that influences every member touchpoint, access, communication and trust. Finally, executive visibility is critical. Weekly Stars reporting at the contract (and potentially PBP) level and the measure level, with a clear path-to-goal and owner accountability, ensures leadership alignment, proactive intervention and real-time decision-making as performance shifts throughout the year.

What practical steps can organizations take to enhance performance and avoid the rush of year end?

Sustained performance comes from embedding Stars management into year-round operations rather than relying on end-of-year surge efforts. A 12-month playbook lays the foundation and helps to maintain momentum: monthly gap sprints to close measurable care opportunities, quarterly CAHPS reviews to monitor member sentiment, biweekly pharmacy adherence scrubs to improve medication persistence and ongoing provider performance huddles to reinforce expectations are a few of the many ongoing efforts that need to be deployed.

In addition, provider engagement should be a crucial component of the 12-month playbook. This goes beyond the table stakes of providing visit “starter kits”, coding education, alert systems embedded into care delivery system and performance incentives. With the growing adoption of near-real-time reporting for quality measures through FHIR-CQL adoption, plans and providers can begin to close the gap that exists between them, and start to have more meaningful, real-time discussions of member care.

Data accountability is equally important. Service-level agreements (SLAs) for both internal teams and vendors must define timeliness, completeness, and reconciliation standards to ensure data reliability. Enforcing these SLAs helps minimize lag, rework and reporting discrepancies, allowing quality and Stars teams to make decisions based on accurate, current information rather than chasing data fixes in Q4.

Section 3: Data, Analytics and Member Engagement

How can data and analytics be better leveraged to drive Stars, Risk Adjustment and Quality Performance?

Accurate, complete and streamlined data sets serve as the cornerstone of high-performing Stars, risk adjustment and quality outcomes. This level of data integrity enables plans to pinpoint opportunities, respond quickly to performance gaps and drive meaningful operational improvements. Plans can no longer rely on the status quo, evolving regulatory expectations and digital quality requirements demand a proactive transformation of data strategy and infrastructure. The most effective organizations are reengineering their data foundations to unify clinical and administrative sources into a single analytics pipeline.

A modern approach leverages FHIR-based ingestion, standardized mapping, CQL-driven measure calculation and near-real-time dashboards to transform raw data into actionable intelligence for Stars, risk adjustment and quality programs. By incorporating opportunity scoring, plans can prioritize high-value data source, such as HIEs, EHRs, labs and retail clinics, based on timeliness, yield and cost-per-closed-gap, while closed-loop analytics drive continuous improvement by triggering next-best actions and measuring hit rates, not just identified gaps.

Where do you see the greatest opportunity for innovation in MA, whether through technology, partnerships or process improvement?

The next wave of innovation in Medicare Advantage will be defined by digital quality measurement, interoperability and artificial intelligence, all buoyed against the changing tides of regulatory or agency action. Transitioning from hybrid to fully digital measurement unlocks faster, lower-cost numerator capture and real-time performance visibility, all supported by the growing need for interoperability that enables seamless clinical and administrative data exchange across Medicare. Paired with this, artificial intelligence will also continue to play an emerging role, not as a replacement for human decision-making but as a prioritization engine that predicts which members are most likely to close gaps, which interventions will be most effective and at what cost.

Section 4: Partnering with ProspHire

How does ProspHire’s Medicare Advantage Practice uniquely support health plans navigating these challenges?

ProspHire’s Medicare Advantage Practice combines deep regulatory expertise with hands-on implementation capability, enabling plans to translate strategy into sustained performance. Our team bridges the gap between CMS rules and operational reality, turning regulatory language into actionable playbooks, KPIs and accountable workflows.  We support clients in building comprehensive Medicare Advantage operating systems that deliver transparency into compliance, benefit administration, care management, member experience and overall operational effectiveness. Our operating systems are complete with clear ownership, measure actions and executive-level dashboards that track progress toward organizational goals.

ProspHire partners with plans to take a forward-looking, proactive stance on regulatory and operational readiness.  Unlike traditional advisory firms, we embed alongside client teams to build and stabilize these capabilities, not just design them. ProspHire’s delivery model ensures plans have the data infrastructure, governance and workflows needed to sustain performance year over year.

Looking ahead, what should health plans be prioritizing as they navigate the Medicare Advantage reset?

As the Medicare Advantage market grows increasingly complex, the key to long-term success lies in aligning compliance, quality, total cost of care and operational effectiveness under one strategy. ProspHire brings deep executional expertise, translating strategy into action and driving results that elevate Stars Ratings, member satisfaction and financial outcomes. With a view across data, delivery and engagement, ProspHire helps health plans not only meet CMS standards but set new benchmarks for excellence in Medicare Advantage.

Updated Q&A: Navigating Medicaid in 2025 and Beyond

Written by LBodnarchuk on . Posted in Insights, Medicaid.

The Medicaid market continues to evolve amid shifting regulatory priorities, state-level variations and economic pressures. As health plans, providers and agencies adapt to changes in funding, eligibility and oversight, the need for flexible strategies and expert execution has never been greater. In this updated Q&A, ProspHire’s Medicaid Practice Leader, Julie Evans, discusses the challenges, innovations and forward-looking strategies shaping Medicaid in 2026 and how ProspHire partners with clients to drive meaningful, measurable impact.

Section 1: Current Landscape & Pressing Challenges

What are some of the most pressing challenges that healthcare organizations face in navigating the Medicaid landscape, particularly considering recent regulatory changes?

Recent regulatory changes are most impactful with consideration to Medicaid eligibility, accessibility and sustainability. Looking ahead, as redeterminations become more frequent, work requirements become a reality and marketplace costs increase, the currently or formerly eligible Medicaid population face uncertainty. For healthcare organizations, this translates to coverage gaps, member abrasion and high administrative costs. Payors will seek to support their membership in understanding their eligibility and support in the administrative requirements to maintain coverage, but for those who temporarily lose coverage or go for an extended period without coverage, additional complications arise. The acuity of Medicaid members has increased, particularly as an outcome of the ending of the COVID-19 public health emergency redeterminations. As individuals lose or go without healthcare coverage, preventive care and health issues go unaddressed. Over time, we can expect that this will impact acuity and cost of care further, as preventive care is bypassed and members are faced with more complex health needs.

As financial pressures and administrative complexities continue to grow, how do we keep the member and care delivery at the forefront of Medicaid?

Financial and administrative burdens aren’t going anywhere as Medicaid will continue to face these challenges by nature of the program. Likewise, the pressure to drive improved health outcomes will also continue to exist and to achieve the desired health outcomes with a health plan’s wallet and administrative requirements in mind, there are several opportunities.

  • Improved member engagement in preventive care and care management programs result in improved cost of care; therefore, driving a human-centered strategy will result in improved financial performance.
  • Leveraging administrative data requirements to tell the human story will create added value in regulatory and quality operations.
  • Removing administrative burdens on member-facing roles wherever possible through technology and operational efficiencies will allow the member and human connection to be the focus.
  • Build trust and partnerships with the community and the community-based partners to engage with and improve care delivery. When members are being met where they are and their ample needs outside of medical care are being met, we will see improved engagement, outcomes and satisfaction.

As a reminder, Medicaid looks different not only across states but the needs of Medicaid members can vary down to the zip code level. The strategies are theoretically similar across health plans but execution should be deliberate with consideration to regional membership. Take care of the members to see improved outcomes and improved financial performance, allowing for reinvestment into operational efficiencies, staffing and technology to drive innovation and alleviate the “burden” of administrative and regulatory activities.

Section 2: ProspHire’s Approach & Methodology

How does ProspHire help clients drive innovation and sustainable improvement in Medicaid?

One of ProspHire’s core values is relationships. As we seek to drive innovation and sustainable improvement in Medicaid, our first step is to understand each health plan’s unique population and regional priorities through relationships with Medicaid beneficiaries, customer facing teams and community-based providers.

State regulations and region-specific needs are the foundation of Medicaid services and pose unique guardrails for our clients. While state regulations are rigid and defined, region-specific needs vary and evolve leaving room for innovation. Through a customer-centered approach, we seek to understand, rather than assume, and drive innovations that are inspired by the customer, leading to desirable and sustainable improvement.

ProspHire partners with our clients to amplify the voice of the customer through the ideation and execution of their innovations by means of strategic initiatives in alignment with organizational priorities.

Section 3: Compliance, Technology & Transformation

How does ProspHire stay on top of the evolving Medicaid regulations and policies and how do you ensure your clients remain compliant?

Read, watch, listen and react. Like many of our clients, we stay up to date on industry changes, trends and discussions to prepare ourselves and others to react to our evolving environment. This includes the ever-changing regulatory requirements and discussions at the federal and state level. Our attention to detail and quality assurance practices help us work in partnership with our clients and their legal and compliance teams to drive results and remain agile and in the case of political shifts, prepare for flexibility and adaptability in response to any sweeping or frequent policy changes.

Technology plays a crucial role in modernizing healthcare delivery. How does ProspHire integrate technology solutions into its Medicaid services to improve efficiency and outcomes?

Technology is continuously increasing in significance across healthcare delivery. Most recently our team supported the integration of a new clinical platform to enhance care management, utilization management and reporting capabilities. From requirements gathering to go-live and post go-live risk management and resolutions, our team has been in the weeds, working alongside the client to deliver a multi-state clinical solution. This tool improves efficiency of workflows, decision making and ultimately the delivery of care to the Medicaid population and those who are most vulnerable to adverse health outcomes.

Artificial Intelligence (AI) is another technological advancement that is buzzing as vendors and healthcare organizations find opportunities to integrate AI in the industry. ProspHire focuses on the business and end user when considering AI implementation, supporting health plans through business case development, user stories, vendor or system implementation and readiness and adoption activities. By preparing our clients to utilize the technology effectively, there is a greater return on investment through improved efficiency and outcomes.

Lastly, as quality improvement measurement transitions to digital quality measures (dQMs), health plans will face unique challenges in technology including application programming interfaces (APIs), coding, vendor integration and more in preparation for regulatory requirements driving this shift. The roadmap exists to embark on this transition but many health plans will require project management and subject matter expertise to drive the tactics and execution of this shift to achieve coordination across the organization, assess dQM readiness, conduct successful parallel reporting and ultimately migrate to the dQM model in a timely manner.

Plans have different technological needs depending on the current state of their operations and we partner with our clients to integrate the solutions that are prioritized in alignment with organizational goals to deliver improved member and operational outcomes.

Section 4: Data-Driven Insights and Equity

Can you talk about the importance of data analytics in Medicaid projects and how you use data-driven insights to inform decision-making and strategy development?

Social Determinants of Health (SDOH) and health equity efforts have led to a shift in the way specific care needs are identified and delivered. A challenge posed by SDOH, and ultimately health equity, is the variation in need based on environmental factors. Through partnerships with community-based organizations and our clients, mutual goals can be achieved by addressing social needs and downstream health outcomes.

To do so, data analytics is crucial. Who is our population of focus? Where do they live? What impact will our intervention have? These are all questions that data can provide insight to. Knowing this, ProspHire has supported population health assessments and data dashboards focused on marrying publicly available data and internal clinical data to support data-driven decision making. These tools support strategic development and inform the who, what and where of many Medicaid projects, specifically those focused on quality.

Section 5: Value-Based Care and Future Outlook

With the rise of Value-Based Care, how do you assist clients in transitioning from fee-for-service to value-based models within Medicaid?

Pay for performance models, shared savings programs, patient centered medical homes, Medicaid ACOs… the many value-based care models, continue to evolve and demonstrate their effectiveness. Our focus is to support the readiness and feasibility of transition followed by the monitoring and controlling of care model commitments. The continuous need to reduce costs and deliver improved quality of care poses a challenge to both providers and payors and leads to the continuous need to reevaluate and refine our reimbursement structures.

Looking ahead, what trends do you anticipate shaping the future of Medicaid consulting and how is ProspHire positioned to address these trends proactively?

As a boutique consultancy with an exclusive focus on healthcare and an emphasis on government programs, ProspHire is well positioned to be adaptive and quickly support our clients in understanding, implementing and monitoring the changes and impacts of regulatory and industry shifts.

One priority in Medicaid that will remain unchanged is the desire to reduce costs and improve quality, an effort that will continue to foundationally drive ProspHire efforts and priorities. As we evaluate the regulatory environment, industry trends and strategies, our goal remains the same – to drive positive change for our clients and the Medicaid population.

Expert Advisory: Translating Insights into Action

Written by LBodnarchuk on . Posted in Insights.

The Challenge: Navigating a Shifting Stars Landscape

Medicare Advantage plans are entering one of the most complex and high-stakes Stars cycles to date. As cut points tighten, new measures are added and a greater emphasis is placed on outcomes-based measures, plans are faced with the reality that every decision from governance design to resource allocation carries a lasting impact. Plans can no longer rely on reactive strategies or one-off improvement efforts. Sustained performance now requires foresight, alignment and deliberate planning across all levels of the organization.

What Successful Plans Are Doing Differently

Leading Medicare Advantage plans are shifting from short-term fixes to enterprise-wide Stars strategies that aligns product strategy, technology investment strategy and operational efficiency around sustained performance. These organizations focus on building accountability and clarity through governance structures, use predictive analytics to inform decision making and integrate real-time data to drive decision making at all levels.

As plans prepare for the 2026 measurement year, several priorities stand out:

Governance Optimization: Governance is basic but it is everything. Plans need to do more with less and that means they should be re-evaluating their current models. They need to seek transparent, accountable and cross-functional governance models that drive alignment and ownership across teams.

Align Product Strategy and Stars Strategy: This AEP has been one of the most hectic AEPs in MA history, with more plans exiting the market and reducing service areas than ever before. The gradual shift away from PPOs and toward HMOs is also telling. Plans need to take the opportunity to align current and future product strategies to Stars strategies to prepare for what’s coming in MA.

Stars Analytics and Forecasting: Analytics and forecasting capabilities are table stakes at this point in the Stars game. Plans need to apply those data-driven forecasts and existing competitive intelligence to stay ahead of regulatory changes and cut point shifts. Integrating Stars intelligence capabilities into network contracting, member engagement activities and business planning are a few of the many use cases of this type of data.

Performance Planning and Domain Expertise: Each domain from within Stars carries its own unique set of rules, nuances and minutia. Plans need expertise at the domain level to be able to connect what the data is telling them with the reality of operations on the ground.

Successful plans understand that Stars success is not just about closing gaps; it is about translating insights into coordinated action that drives measurable results year after year.

Our Perspective

At ProspHire, we have led Stars programs from the inside. Our advisory approach helps health plans move from reactive to deliberate, aligning leadership and operations around a shared vision for long-term success.

Think Ahead. Plan Differently.

The path to future Stars success begins with informed, strategic action today. Let’s plan differently for 2026, combining insight with execution and experience with results.

Medicare Advantage CY2027 NOIA: Strategic Reset and Charting a Path Forward

Written by LBodnarchuk on . Posted in Insights.

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.

Soaring to New Health, Season 3 Recap

Written by LBodnarchuk on . Posted in Blog.

Season 3 Recap Infographic

Where Insight Meets Action in Healthcare

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.

Stars Rapid Response: From Data to Impact

Written by LBodnarchuk on . Posted in Insights.

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.

Beyond the Stars: Building Sustainable Medicare Advantage Success

Written by LBodnarchuk on . Posted in Insights.

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.

Demystifying the ACA: Insights from ProspHire’s ACA Practice Leader, Caitlin Nicklow

Written by LBodnarchuk on . Posted in Insights.

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.
How does the ACA impact healthcare?

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.

What are the rules once you are an ACA-compliant provider

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.
Providers should be familiar with several important dates

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.

ProspHire seeks to understand your unique circumstances

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.

Navigating the ACA Landscape: Key Strategies for Health Plan Success

Written by LBodnarchuk on . Posted in Insights.

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.

Stay ahead of ACA compliance by conducting internal audits and invest in staff training.

2. Achieving Competitive Rates While Maintaining Financial Stability

Achieving Competitive Health Plan 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.

Use digital platforms to streamline enrollment process and create targeted communications.

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.