Author: LBodnarchuk

SY2024 Data Insights

The Centers for Medicare & Medicaid Services (CMS) released the 2024 Star Ratings for Medicare Advantage plans on October 13th, 2023.

The 2024 Star Ratings incorporated several changes to the methodology, including the introduction of the cut point modifying statistical technique – Tukey outlier deletion. The realized outcomes of Tukey were just as significant as expected. The MAPD average dropped from the 2023 level of 3.76 to 3.62 in 2024, making this the lowest performance within the last six Star Years. Of the plans that received a star rating in 2023, 64% of health plans saw a decrease in rating in Star Year 2024.

The ratings also showed that 42% of MAPD plans earned an overall rating of 4 stars or higher for Star Year 2024, down slightly from 51% in Star Year 2023. However, when weighted by enrollment, 74% of MAPD enrollees are currently in 4+ star plans for Star Year 2024 which is in line with industry trends.

Thirty-one MAPD contracts earned 5 stars, marking them as highest quality “high performing” plans. CMS highlighted these plans on the Medicare Plan Finder website to help beneficiaries identify top-rated options. 

A further breakdown of the data shows that performance varies significantly by profit vs non-profit plans. Non-profit MAPDs plans were almost twice as likely to receive 4+ Stars compared to those for-profit plans (~56% vs. ~36%). Also, in line with industry trends, the MAPD plans with longer tenure also scored higher relative to newer plans.

Our team put together Phase 1 of our SY2024 Insights and Analysis to begin to “tell the story” for SY2024.

Rating Swing Distribution from Prior Year1

Average Star Rating Year Over Year1

Distribution of Star Rating SY2023 and SY20241

In SY2024, CMS continued the emphasis on Member experience by continuing to utilize the 4x weighted for the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey measures and health plan operations measures.

Using the data presented in the tables below, our team conducted an analysis on the distribution of overall plan ratings in correlation with a plan’s performance in five domains. We aggregated performance measures within each domain to create a comprehensive domain score. This assessment allowed us to gain insights into what aspects health plans prioritize to achieve high performance in the 4- to 5-star range, considering health plan performance in CAHPS, HEDIS, Pharmacy, Operations, and HOS.

Key Highlights:

  • The Operations domain demonstrated a more concentrated performance range for high-performing plans, with 82% of 4.0+ star plans achieving a score of 4.0 or higher in the designated measures.
  • In order to achieve 4.0+ Stars, plans were required to succeed in CAHPS. Of the 147 plans that received a 4.0+ star, 88% of them had a minimum CAHPS scoring average of 3.5 stars.
  • In line with CMS methodology weighting, HEDIS, Pharmacy, and HOS showed a more expected spread in overall health plan performance based on the domain’s average rating.

In summary, the health plan operations domain stands out as a consistent and influential factor driving higher Star ratings for health plans. Thus, it should remain a focal point for health plans aiming to achieve a 4- to 5-star overall rating. Additionally, while CAHPS carries significant weight, strong performance in other domain areas can compensate for subpar survey results, specifically HEDIS being a large driver.

As we enter the final stretch of the performance year SY2025, it is essential to place significant emphasis on the efforts of Q4. Health plans should arrange all available resources and make every effort, giving special attention to driving improvements in HEDIS performance. This Q4 push can act as an additional safeguard prior to the CAHPS survey distribution in March 2024.

Looking forward to the arrival of CY2024 (SY2026), health plans must be attentive to an upcoming CMS methodology adjustment. Starting from the performance year 2024, CMS will assign similar weight to CAHPS, Operations, HEDIS and Pharmacy measures (CAHPS and Operations measures shifting from 4x weight to 2x weight). This signifies a shift away from over-reliance on member experience as primary performance drivers. Instead, it requires a strategic approach to enhance performance across all areas.

Plan Count by Overall Rating & Average CAHPS Rating1,2,3

Plan Count by Overall Rating & Average HEDIS Rating1,2,3

Plan Count by Overall Rating & Average Pharmacy Rating1,2,3

Plan Count by Overall Rating & Average Operations Rating1,2,3

Plan Count by Overall Rating & Average HOS Rating1,2,3

If you have any questions or are curious to speak about your plans Star Rating and how we can help improve, submit the form on the right.

Breast Cancer Awareness Month

October is Breast Cancer Awareness Month, which serves as an important reminder to schedule regular wellness visits with your healthcare practitioner. According to the National Cancer Institute, one in eight women will develop breast cancer during their lifetimes1. When we take a closer look and consider the demographic data surrounding breast cancer outcomes, worrying disparities emerge between rates of diagnosis and mortality between different groups.  

For example, while white women are more likely to be diagnosed with breast cancer, black women are more likely to die from the disease. Race and discrimination are an example of a social determinant of health (SDOH), which are the non-medical factors which influence health outcomes2. We will further address race and other SDOH factors which contribute to disparities in health outcomes and assess ways these disparities can be addressed.  

Establishing the SDOH-Driven Disparities in Breast Cancer Outcomes  

When assessing causes of cancer, generally more attention is paid to genetics and individual health behaviors than SDOH influences. However, there is strong evidence that breast cancer outcomes are influenced by SDOH factors, which emphasizes the importance of at-risk groups obtaining regular breast cancer screenings from their doctor.  

Race has emerged as a main contributing SDOH factor to breast cancer health outcomes. White women are more likely than black women to be diagnosed with breast cancer, but black women are 40% more likely to die from the disease3. A research study conducted by the University of Illinois-Chicago concluded that social determinants of health are the roots of these racial disparities in breast cancer outcomes4. Specifically, the study cited neighborhood disadvantage and insurance status as contributors of 19% of this outcome disparity5. Addressing these barriers on a large scale will require wider public policy changes, but the key is to identify short-term interventions to fix such disparities.  

Lack of insurance is correlated with poorer health outcomes. There is evidence that state expansion of Medicaid enrollment contributes to improved breast cancer health outcomes. Women from economically disadvantaged backgrounds, who might normally avoid the doctor due to cost or burden of access, are able to obtain breast cancer screenings (mammography) through Medicaid. Prior to the Affordable Care Act, this is evidenced by overall higher rates of mammogram screenings in states which have expanded Medicaid6. For example, incidence rates of black women being diagnosed with breast cancer decreased from 24.6% to 21.6% in states which expanded access to Medicaid compared to states that did not expand access, which sit at about 27%7.   

Closing the Gap 

Consistently throughout this analysis, lack of health insurance access, for both the uninsured and underinsured, has emerged as a driving factor for disparities in breast cancer health outcomes. This is especially the case when a lack of insurance is coupled with socioeconomic disadvantage. Whether you are a health plan, accountable care organization or breast cancer awareness organization- what can be done to close this gap?  

Specialized health interventions are often the most effective short-term method to address SDOH-driven health disparities. For breast cancer, findings by the Community Preventative Services Task Force (CPSTF) recommend engaging community health workers (CHWs) to increase mammography screenings8. Often, there is a wedge driven between healthcare workers and the public which can be attributed to factors such as community mistrust or lack of health literacy. CHWs serve to bridge this gap, working in tandem with healthcare professionals or on their own. CHWs can assist in making screening services more accessible than a typical doctor’s visit, by assisting with interventions such as group education, 1-to-1 education, client reminders or newsletters9.  

How ProspHire Can Help 

ProspHire can assist in breast cancer screening adherence improvement strategies and community-based partnership development to support health plans engage members in preventive care. Our practitioners support the strategy and execution to drive improved outcomes for plan members with a focus on health equity. 

Soaring to New Health – Bonus Episode, Who the Health is ProspHire

Welcome to Season 1, the Bonus Episode of the Soaring to New Health Podcast.  

This episode is Who the Health is ProspHire. Our hosts, Chris Miladinovich and Dan Crogan are talking with Lauren Miladinovich, CEO, Managing Principal and Co-founder of ProspHire about the history of the Firm, why the focus is 100% on healthcare and why relationships are the number one core value. 

Lauren and Chris started the Firm in 2015. Within a year they opened the first office space on the North Shore of the city of Pittsburgh. By year three they determined the focus to be 100% on healthcare, earned a woman in business certification and expanded the headquarters to a new location in the Pittsburgh Power Building in downtown Pittsburgh. As ProspHire was about to hit a milestone five-year anniversary in 2020, COVID cases spiked and we all found ourselves in the midst of a global pandemic. Small but mighty, ProspHire took an agile approach and adapted, pivoted and succeeded in a rapidly changing, ambiguous, turbulent environment. The leadership team is already looking forward to its 10-year anniversary in 2025. 

Coming up with a company name was not a priority at the time but ended up being a big deal.  

Chris had a few requirements: it had to be less than 2-syllables, the domain name had to be available and it had to be easy to say. ProspHire was derived from the first mission statement that ‘clients hire us to help them prosper’. Everyone in Chris’s inner circle said it was great but it didn’t do well when it hit the market. No one could pronounce it, understand what it was or what it meant. The few years that followed included a lot of marketing dollars to create over 1,000 alternative names… all rejected. To this day, they still have fun with mispronunciations. 

Before 2015, Lauren was leading large, complex project management engagements and Chris had experience in health and human services and the consulting industry. Together, they had a passion to do something that helped businesses that helped others. Focusing 100% on the healthcare industry was a natural fit. 

One of their favorite activities is the annual Prosper Together Day. The Firm’s charity of choice is the Boys and Girls Clubs and every year in Pittsburgh and now in Philadelphia the employees spend an entire day in interactive STEAM (Science, Technology, Engineering, Art and Math) activities that teach leadership and life skills, as well as played games with the children of the Clubs. Lauren and Chris’s pet pig Nola sparked the relationship with the Clubs. Nola had her own Facebook page and the Clubs had been following her story when they reached out to propose making her the celebrity for a new Kiss-a-Pig Fundraising Gala.  

For more on the history of ProspHire and why client relationships are so important, download the Soaring to New Health podcast, Who the Health is ProspHire, where you find your podcasts. 

Medicare Stars – SY2024 Cut Point Analysis

Medicare’s Plan Preview Period #2 data is available for Health Plans to review in HPMS. Our Medicare Stars Practice Team has been crunching the numbers to see how cut points moved from year to year. 

The below images walk you through an in-depth analysis across each Stars domain—HEDIS, HOS, CAHPS, Pharmacy, Administrative—to showcase the individual measure cut point movement across each Star level. The cut points displayed in this analysis are from the draft 2024 Technical Notes from CMS. The finalized 2024 Technical Notes will be released with the remaining public data in early October. The bottom line is that Tukey impacts are real. We observed many dramatic cut point changes at the 2- and 3- Star levels across all measure sets. The compression of cut points was stark and only puts greater pressure on Stars Programs to achieve optimal performance in their Star measures. 

We can’t wait for the public data release in early October. At that point we’ll dig into the data and get a real picture of just how dramatic of a role that Tukey Outlier Deletion played on the industry.

If you have any questions about the analysis below or larger questions about how to best achieve and sustain 4.0+ Star performance, connect with our experts today.

HEDIS Cut Point Analysis

Pharmacy Cut Point Analysis

Administrative Cut Point Analysis

HOS Cut Point Analysis

CAHPS Cut Point Analysis

Soaring to New Health Blog – Episode 5, The Glass is Half Healthy

Welcome to Season 1, Episode 5 of the Soaring to New Health Podcast.

This episode is The Glass is Half Healthy. We’re talking with Dan LaVallee, Senior Director of Social Impact from the Insurance Services Division at UPMC Health Plan along with Julie Evans, leader of ProspHire’s Social Determinants of Health (SDOH) service offering.

Social Determinants of Health are coming to the forefront of the healthcare industry for a lot of reasons – and one of those is health equity. Health equity is understanding that different individuals across the country have different health outcomes and a lot of that is determined by the zip code they live in. Part of SDOH is thinking about how we can focus our efforts on healthcare to address those specific needs and therefore address health equity as well. An example is if a child with asthma is growing up in a home with overcrowding and poor air circulation. The child will not be able to address their asthma needs without appropriate social determinants of healthcare in housing.

LaVallee says the Center for Social Impact wants to get ahead of scenarios where the population cannot access healthcare with prevention, support and listening to solutions from within those communities. Data shows that if you can find these members supportive housing for 10 months, it can change the trajectory of their healthcare. It takes a coordinated effort of community organizations that provide jobs, housing, benefits access and food programs to create a circle of member trust. The Center’s Cultivating Health for Success Program aims to get homeless Medicaid recipients in Allegheny County (and now Blair and Lawrence Counties) off the streets and into structured, long-term care by combining the resources of UPMC Health Plan and the housing-focused Community Human Services (CHS). Across the State of Pennsylvania, the Regional Accountable Health Council (RAHC) created forums for strategic health planning that provide a community-led approach to implement the planning and coordination of activities that address social determinants of health needs, reduce health disparities and promote health equity and value in health care.

At UPMC Health Plan, the Center for High Value Healthcare evaluates the impact of the programs supported by the Center for Social Impact, like the new Food is Medicine Program. They will help determine what works that is social impact related and then expand on that, all while seeking continual member feedback.

Evans talks about these types of programs helping Stars, HEDIS and CAHPS measures that tie back to the quality health incentives that are so important to health plans for their members. The investment into SDOH programs can show immediate return on investment. The impact of the pandemic is what really highlighted the needs of vulnerable individuals. Today we are seeing an influx of funding to support community-based organizations and health plans to address those needs but the concern is that as the public health emergency lifted the funds will dwindle and programs will not be sustained. That’s a huge barrier to housing and transportation challenges, which are being spotlighted right now. The future will include how to address these needs without funding.

At UPMC Health Plan’s Center for Social Impact, LaVallee says they are doing a good job of staying ahead of these challenges through investment and community partnerships and leveraging a model that can scale in one community and be replicated in others. There is no intention of slowing down.

For more on Social Determinants of Health, why they are important to measure and how they can play a role in more efficient care with better patient outcomes, download the Soaring to New Health podcast, The Glass is Half Healthy, where you find your podcasts.

Healthy Aging Awareness Month

Healthy Aging Month is observed during the month of September. This observance raises awareness on the physical, mental, social and financial wellness of older adults and serves as a reminder that as we age, our minds and bodies change. It is essential to maintain a healthy and positive lifestyle to help deal with those changes and to help prevent common age-related health problems. Even if you have not thought of these changes, it is never too late to consider ways to re-invent yourself.  

No Age Limit to Adopting Healthy Habits

The United States boasts an increasingly aging population; according to the 2020 census, 1 in 6 people are now over the age of 65[1]. This trend is largely driven by the size of the Baby Boomer generation, born 1946-1964. By the 2030’s, it is estimated that older adults (over the age of 65) will outnumber the number of children (under the age of 18)[2]. Figure 1 illustrates this trend over the past century, which further emphasizes the importance of adopting healthy aging habits[3].

What Are Healthy Habits and Behaviors for a Healthy Life?

Embrace a well-rounded approach to your well-being during Healthy Awareness Month and beyond, with a collection of empowering habits and behaviors that build lifelong health and vitality. Try some of these healthy habits and behaviors:

  • Take a proactive health approach by maintaining healthy habits throughout your life
  • Adopt a healthy diet and incorporate moderate physical exercise into your daily routine
  • Monitor your health by receiving regular health screenings from your doctor
  • Volunteer and get involved with local groups to maintain a sense of community
  • Take advantage of rewards & incentives tied to maintaining a healthy lifestyle. Talk to your insurance plan today.

How Can ProspHire Help? 

ProspHire has subject matter experts working closely with Health Plans, Provider Practices and Community Specialists to enhance healthy lifestyle opportunities while optimizing current benefit offerings. The healthcare community can attain an excellent level of insight into outcomes via Quality Measures. It provides a deeper understanding of how various internal and external contributing factors play a critical role in one’s outcome.

ProspHire is continuously working with key stakeholders to leverage data indicated by these contributing factors such as Social Determinants, Health Equity and Geographical Indicators to improve Quality Measures and provide the right resources needed to maintain a healthy lifestyle.

Connect with ProspHire today.


[1] https://www.census.gov/library/stories/2023/05/2020-census-united-states-older-population-grew.html

[2] https://www.census.gov/library/stories/2018/03/graying-america.html

[3] https://www.census.gov/library/stories/2023/05/2020-census-united-states-older-population-grew.html

Dental Management Services

Advancing Your Dental Practice Through Clinical Operations Support

In the rapidly evolving landscape of modern dentistry, staying ahead of the curve requires a comprehensive approach that integrates technological advancements, innovative services and streamlined clinical operations. The key to success lies in embracing these changes and leveraging them to not only enhance patient care but also boost the efficiency and profitability of your practice. Clinical operations support plays a pivotal role in achieving these goals by encompassing various elements such as technology and equipment upgrades, expanded service offerings and continuous education for both clinicians and staff.

Technological Evolution and Dental Equipment Upgrades

Technology has revolutionized nearly every industry and dentistry is no exception. The integration of advanced dental equipment has not only transformed the way procedures are conducted but has also significantly improved patient outcomes and experiences. From digital radiography and intraoral scanners to computer-aided design and manufacturing (CAD/CAM) systems, technology has expedited diagnosis and treatment planning while reducing patient discomfort.

Dentists now have access to state-of-the-art equipment that enhances precision and accuracy. For instance, cone-beam computed tomography (CBCT) provides 3D images that aid in the placement of dental implants and complex procedures, minimizing complications and increasing success rates. Similarly, CAD/CAM systems enable same-day restorations, saving time for both patients and practitioners.

Furthermore, vendor offerings and supplies have adapted to these technological changes. Companies are now providing more customizable solutions, offering dental professionals the flexibility to tailor equipment to their specific needs. This not only improves patient care but also enables practices to optimize their workflows.

Continuous Clinical Education and Staff Training

Staying current in the ever-evolving field of dentistry requires a commitment to continuous learning. Clinical education not only ensures that practitioners are delivering the highest standard of care but also empowers them to integrate new technologies and techniques effectively.

Staff training is equally crucial, as the success of any practice depends on the collaborative efforts of the entire team. Dental assistants, hygienists and front-office staff all play pivotal roles in delivering exceptional patient experiences. Providing ongoing training not only boosts their confidence and skill set but also enhances the overall efficiency of the practice.

Vendor Management and Workflow Optimization

Managing relationships with vendors is a vital aspect of clinical operations support. Partnering with reputable suppliers ensures a steady supply of quality materials and equipment, ultimately contributing to the smooth functioning of the practice. Vendor management involves:

  • Negotiating favorable terms
  • Maintaining clear communication
  • Staying updated on the latest offerings in the market.

Integrating new equipment and software into existing workflows can be a challenging process. However, with proper planning and training, the transition can lead to increased efficiency and reduced room for errors. Workflow optimization includes:

  • Assessing the current processes
  • Identifying bottlenecks and implementing strategies to streamline operations
  • Reconfiguring operatory layouts
  • Standardizing protocols
  • Utilizing software solutions for appointment scheduling, treatment planning and patient communication.
Expanding Service Offerings formula

These three areas of Technological Evolution and Dental Equipment Upgrades, Continuous Clinical Education and Staff Training and Vendor Management and Workflow Optimization are all a part of the process that leads to Expanding Service Offerings. Offering new or enhanced services not only attracts a broader patient base but also positions your practice as a comprehensive solution provider. Implant placement and restoration, orthodontic treatment, sleep apnea therapy, TMJ/TMD management, general muscular pain relief and enhancements to facial aesthetics are areas that have seen significant growth.

ProspHire Helps Dental Practices Through the Process of Expanding Service Offerings

In the dynamic landscape of modern dentistry, advancing your practice through clinical operations support is a multifaceted endeavor. ProspHire’s Dental Management team will collaborate with you and lead you through technological advancements, expansion of service offerings, clinical education, staff training, vendor management and workflow optimization. Our experts will identify potential new offerings or ways to enhance your current services via a detailed assessment process of your current state business and guide you through the implementation processes and activities using best- in-class program and vendor management techniques. For more information, connect with us today.

Soaring to New Health Blog – Episode 4, This is Like Pulling Teeth

Welcome to Season 1, Episode 4 of the Soaring to New Health Podcast.

This episode is This is Like Pulling Teeth. We talk with Paul Reda, CEO, and Armanda Lester, VP of Operations, from North American Dental Group (NADG) – a dental services organization that provides nonclinical administrative services to more than 240 affiliated dental practices across 15 states and continues to expand access to care.

As NADG started to evolve the leaders looked at group dentistry practices and aimed to add best-in-class providers to the organization. Today, NADG is pioneering a new culture of dentistry… to be available to patients when it suits the patient and serve patients in the way they want to be served. It’s about providing the best patient care for every patient at every visit.

A technology that was born out of listening to their patients is a platform called Ask Nicely. The patient receives a text message after each visit that asks for a rating about the recent office visit experience. The question responses scale from one to ten and any response below a nine prompts a call to the patient within 24 hours to discuss. The goal is to ensure every patient is receiving the best care and to continue to improve the patient’s experience.

Innovation is a continuous path at NADG. In early 2023, the organization began rolling out an artificial intelligence (AI) platform for dental called Overjet. It is an intelligence support mechanism that involves an overlay of color coding that the dentist or hygienist uses to determine a treatment path and that visual makes it easier to communicate to the patient. Additionally, many of the top insurance companies are making claim decisions with this platform. Reda says, “AI is in its infancy and I think we need to use it responsibly. It’s not a replacement for human beings and it’s certainly not a replacement for a doctor. Patients want to talk to a real person and be treated like a real person rather than an object or a number.”

NADG encourages community service within its practices, participating in events such as Give Kids a Smile or local school training for teaching children how to brush their teeth. It’s a part of the culture and the core values. Every year, Paul Reda acknowledges team members who exemplify community involvement. A select group travels with him to Zurich, Switzerland for a global ceremony for the Chairman’s Award.

For more on innovative dentistry and what it takes to be a strategic partner with NADG, download the Soaring to New Health podcast, This is Like Pulling Teeth, where you find your podcasts.

ProspHire Earns Spot on the Inc. 5000 List for 4th Consecutive Year

PITTSBURGH, PA – ProspHire announced today that it ranks #4307 on Inc. Magazine’s annual list of America’s Fastest-Growing Private Companies – the 2023 Inc. 5000. The rank reveal also put ProspHire at #19 in Pittsburgh, #132 in Pennsylvania and #516 in the nation for business products and services. The list represents a unique look at the most successful companies within the U.S. economy’s most dynamic segment – independent, small businesses. ProspHire, a national healthcare consulting firm, is recognized for its rapid revenue growth while navigating inflationary pressure, the rising costs of capital and hiring challenges. In the history of Inc. 5000, only 5% of companies have made the list 4 times.

“Making the Inc. 5000 list is a huge honor that we credit to our employees,” said Lauren Miladinovich, Managing Principal and CEO of ProspHire. “The hard work and dedication from across all departments is the reason for our success and growth.”

Chris Miladinovich, ProspHire’s Principal and Chief Strategy Officer, said, “Being recognized with innovative and high growth companies across the U.S. for the 4th consecutive year is an accomplishment that we celebrate. This accolade showcases not just our success but demonstrates resilience though the threat of economic downturn, labor shortages and lasting impact of Covid-19.”

“Thank you to all our team members and clients for helping ProspHire reach this incredible milestone,” says Dan Crogan, Principal and SVP of Consulting. “Our dedication to the healthcare industry and our focus on project execution has enabled us to develop and maintain genuine partnerships with our clients where we act as an extension of their team to help them solve their most significant people, process and technology challenges.”

Complete results of the Inc, 5000, including company profiles and an interactive database that can be sorted by industry, region and other criteria can be found at www.inc.com/inc5000.

Q&A with ProspHire’s Caitlin Nicklow on the Affordable Care Act

The Affordable Care Act (ACA) has had a profound impact on the landscape of healthcare in the United States. With provisions aimed at increasing access to health insurance, preventing discrimination by insurance providers enhancing preventive care, lowering healthcare costs and improving healthcare quality, the ACA reshaped how Americans access and receive healthcare services. ProspHire’s ACA practice leader, Caitlin Nicklow delves into the intricacies of ACA compliance and the rules and requirements for health insurance providers, key dates to be aware of and the timeline for launching an ACA-compliant health plan.

How does the ACA impact healthcare? 

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 age, 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: The ACA incentivizes healthcare providers to improve the quality of care they deliver by tying reimbursement to performance on quality measures.
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. For the 2023 plan year, the ceiling for out-of-pocket services is $9,100 for individuals and$18,400 for families. In 2024, these amounts will grow to $9,450 and $18,900, respectively.
  • 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 2024 coverage, Open Enrollment begins November 1, 2023 and ends January 15, 2024, 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.
  • Limit out-of-pocket costs: ACA-compliant health plans must cap out-of-pocket costs for covered services. For the 2023 plan year, the ceiling for out-of-pocket services is $9,100 for individuals and$18,400 for families. In 2024, these amounts will grow to $9,450 and $18,900, respectively.
  • 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 5 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.

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