On June 9th, CMS published a draft of new regulatory reporting requirements1 that enhance oversight of initial organization determinations (ODs) and reconsiderations.
This follows the direction set in the 2026 Medicare Advantage Final Rule, which introduced regulations to reinforce prior authorization and utilization management (UM) safeguards. The proposed reporting requirements strengthen CMS’s commitment to taking meaningful action to control inappropriate prior authorization and UM practices that create unnecessary barriers to care access. This new administration has made it abundantly clear that wasteful spend, fraud, abuse and inefficiency will not be tolerated.
Reporting Requirement Details
These new reporting requirements will require plans to submit significantly more detailed information on a quarterly basis than what is currently required by CMS, moving from the existing aggregate reporting of cumulative totals and outcome categories (fully favorable, dismissed, adverse, etc.) to comprehensive details on every individual organizational determination and reconsideration they receive.
Actions for Medicare Advantage Plans
These new requirements could cause operational and compliance challenges for Medicare Advantage plans. The granular requirements will provide CMS with a new level of visibility into plan decision-making processes to identify inappropriate denials, processing delays and inconsistent application of coverage criteria. Given this enhanced level of oversight, it’s essential that plans develop robust capabilities to produce the required reporting elements accurately and on time, with plans maintaining high denial rates likely facing intensified regulatory scrutiny.
How to Prepare for the CMS Changes
To prepare for these requirements, plans should:
Review Internal Documentation: Conduct a review of current policies and procedures to ensure that they capture OD and reconsideration compliance requirements
Establish Quality Validations: Create monitoring processes to track key metrics such as processing timelines and outcomes, denial and adverse decision rates and validity to curb any issues that would raise concern to CMS
Evaluate Reporting Capabilities: Ensure your OD and reconsideration systems and infrastructure are capable of capturing, storing and reporting detailed case-level data
Produce Test Reporting: Generating example/test reports sooner rather than later will help plans achieve accuracy in reporting details to ensure CMS timelines are met for report submission requirements and level of accuracy needed
Plans that proactively address these operational and regulatory changes now will be better positioned to demonstrate compliant utilization management practices and avoid potential regulatory consequences such as corrective action plans and financial penalties.
How ProspHire Can Help
Do you need support navigating these new regulatory requirements? ProspHire can help with a comprehensive compliance readiness review to ensure your organization is prepared. Let’s have a conversation.
HPMS Memo released by CMS on 06/09/2025, “Technical Specifications for the Service Level Data Collection for Initial Determinations and Appeals (CMS-10905, OMB: 0938-New)” ↩︎
A quick look at CMS’s key proposed updates for Play Year 2026:
Key Proposed Changes
1. Measure Removals
CMS proposes removing the International Normalized Ratio Monitoring for Individuals on Warfarin (INR) and Annual Monitoring for Persons on Long-Term Opioid Therapy (AMO) measures.
The Social Need Screening and Intervention (SNS-E) measure is also proposed for removal.
Impacts:
INR: Current clinical guidelines strongly recommend the use of Direct-Acting-Anticoagulants (DOACs) over Warfarin because DOACs demonstrate comparable efficacy for several indications and do not need frequent international normalized ratio monitoring and dietary restrictions. Since the emergence of DOACs in the last two decades, the utilization of Warfarin has steadily decreased across demographics (Navar et. al., JAHA 2022).
However, studies and previous years’ QRS results indicate that despite the decreasing trend in Warfarin utilization, many providers continue to prescribe the drug. Removal of the INR measure, therefore, may impact patient safety for individuals that are still on said drug regimens. QRS results for 2024 indicate that 20,000 beneficiaries across the country received Warfarin therapy and 48% of plans qualified for scoring for this measure. Given these numbers, we agree with the proposal to remove the measure from a quality benchmarking standpoint. However, we urge health plans with members on Warfarin therapy to rollout provider steering strategies to facilitate adoption of DOACs in accordance with clinical best practices.
AMO: According to the 2024 QRS data, 114K beneficiaries received long-term opioid therapy across the country and 76% of plans were scored for this measure. Recent studies have indicated a decrease in opioid prescription for treatment of chronic non-cancer pain, down to 30% in 2019 (Bandara et. al., Plos One, 2019). However, given the significant risks associated with long-term opioid use and that the majority of plans continue to score for this measure, we recommend delaying the exclusion of this measure. This would allow time for more current assessments of clinical trends in long-term opioid utilization and further decrease in utilization among beneficiaries.
SNS-E: Health plans may inadvertently overlook critical non-medical factors that significantly impact patient health, such as housing instability, food insecurity and access to transportation. Without this measure, health plans may also have fewer incentives to develop and implement targeted programs that address these social determinants of health. This could potentially exacerbate existing health disparities and widen inequities in care, particularly among vulnerable populations who are already at a higher risk for poor health outcomes.
2. Measure Addition:
A new “Enrollee Experience with Cost” measure is proposed to assess enrollees’ perspectives on healthcare costs.
Impact:
The introduction of the “Enrollee Experience with Cost” measure could drive health plans to focus more on affordability, transparency and consumer satisfaction. It will likely influence plan ratings, consumer choices and health equity initiatives while pushing insurers to improve cost control mechanisms. The measure has the potential to create a more transparent, consumer-centric healthcare environment where cost is a key factor in both plan selection and patient satisfaction.
3. Measure Transition:
The existing Controlling High Blood Pressure (CBP) measure may transition to the Blood Pressure Control for Patients with Hypertension (BPC-E) measure.
Impact:
This change may enhance health equity by targeting vulnerable populations, promoting a more patient-centered approach and encourage long-term, comprehensive care. Health plans and providers will need to adjust their practices and reporting systems to align with this more focused measure, which could lead to better quality ratings in the QRS and improved care for high-risk individuals
4. Measure Refinements:
Proposed refinements include updates to the Breast Cancer Screening (BCS-E) and Adult Immunization Status (AIS-E) measures.
Impact
These updates may enhance preventative care efforts by expanding the eligible population and addressing age-related disparities. Lowering the BCS-E screening age to 40 encourages earlier detection for younger women, who historically have lower screening rates. Health plans and providers will need to implement age-targeted outreach, adjust clinical workflows and enhance provider communications to support this change. Stratified reporting by age bands may also help to identify gaps in care and inform quality improvement strategies.
The additional indicator for Hepatitis B vaccine in adults 19-59 supports increased vaccine uptake and aligns with NCQA. However, capturing data from sources such as pharmacies and public clinics may present interoperability challenges. Health plans may need to strengthen data-sharing capabilities and implement targeted member and provider engagement strategies to raise awareness and improve vaccination rates.
Electronic Clinical Data System (ECDS) Reporting Expansion:
CMS plans to transition certain measures, such as Cervical Cancer Screening (CCS-E), Immunizations for Adolescents (IMA-E) and Childhood Immunization Status (CIS-E), to ECDS-only reporting.
Impact:
The shift to ECDS-only reporting for Cervical Cancer Screening, Immunizations for Adolescents, Childhood Immunization Status and Blood Pressure Control could accelerate the adoption of more integrated, data-driven care. Health plans may be pushed to strengthen partnerships with providers and invest in better clinical data exchange to ensure accurate reporting. This move could improve care visibility and lead to more timely interventions, but it may also challenge plans with limited access to EHR or HIE data. Ultimately, this transition supports a more holistic and proactive approach to quality measurement, but readiness and infrastructure will play a key role in performance success.
QHP Enrollee Survey Sample Frame Revisions:
Revisions are proposed for the QHP Enrollee Survey sample frame variables to enhance data accuracy.
Impact:
The revisions to the QHP Enrollee Survey may improve the comparability of QHPs, identify areas for improvement and promote better health equity by ensuring that underserved populations are adequately represented. Adjustments to data collection and reporting processes may be necessary, while consumers could benefit from more trustworthy quality ratings to guide their healthcare decisions.
How ProspHire Can Help
Our team at ProspHire is closely tracking these developments to help you stay compliant, competitive and ahead of industry shifts.
Want to talk through how these changes may impact your quality strategy or operational planning? We’re here to help, so contact us today.
Healthcare is an industry that touches every one of our lives yet few are privy to the behind-the-scenes work that keeps the wheels turning. Healthcare organizations must balance servicing their member’s needs today while also planning for their needs 10 years from now. ProspHire’s Caitlin Nicklow sheds light on the rising demand for project delivery and how successful execution can position healthcare organizations for both short and long terms success.
Can you provide an overview of ProspHire’s Project Delivery practice and its role within healthcare consulting?
ProspHire’s Delivery Practice first and foremost is focused on the desired outcomes of our clients and providing the right level of expertise in terms of talent and experience. When a client engages ProspHire, we seek to understand their most pressing needs and then design a tailored support solution. ProspHire specializes in a variety of types of projects including Large Scale System Implementations, Health Plan Integrations, Establishing/Enhancing EPMO capabilities, as well as Program and Project Management. Our team consists of certified Project Management Professionals (PMP), Six Sigma Green Belt Certified Scrum Masters and Certified Product Managers who offer industry expertise in the payer and provider sectors.
What are some key challenges that healthcare organizations typically face when it comes to project delivery and how does ProspHire address these challenges?
The major challenges healthcare organizations must consider when approaching project delivery are time, resources, and cost. Many projects are time bound by operational urgencies, compliance mandates, and other factors. Project delivery also requires time from the same resources that are already fully allocated to a day job. Many organizations manage these two constraints at the expense of the overall budget. Our goal is to provide our clients with relief. We do this by supplementing their teams with highly skilled resources to give them time back in their day while keeping projects on time and on budget. We also use our decade of industry expertise to find efficiencies and streamline project delivery.
Could you share a success story that highlights the impact of the Project Delivery practice on a healthcare client’s operations or outcomes?
One of our clients is currently going through rapid growth and transformation. With that comes the need to connect business and technical process/decision making and manage decisions/dependencies. The client engaged ProspHire to manage several of those programs. We were able to utilize our strong execution skills, industry and process knowledge and our strong relationships to act as an extension of our stakeholder, identify risk, and implement mitigation plans to keep the project on track. At the end of the project, our client stakeholders remarked that they can’t tell the difference between our ProspHire teams and their full-time employees due to our seamless integration into their work and alignment with their organizational mission.
In the rapidly evolving healthcare landscape, how does ProspHire stay ahead of the curve in terms of project management methodologies and industry best practices?
ProspHire practitioners are experts in operating in a variety of different project management methodologies including agile, hybrid, and waterfall approaches. We also take the time to understand the methodologies utilized by our clients. ProspHire collaborates with some of the largest healthcare organizations in the country and that entails many customized ways to deliver projects. Several factors contribute to selecting the right delivery methodology for a specific client and initiative, including understanding the organization’s current capabilities, the evolving implementation journey, complexity, scale, speed and specific goals of the company. To keep up with the ever-changing delivery landscape, ProspHire invests in our employees through continuing education and certifications through ProspHire University (PMP, Agile, etc.).
What role does technology play in optimizing project delivery within healthcare organizations and how does ProspHire leverage technology in its consulting services?
Technology always plays a critical role in project delivery. From a macro level, this starts with an organization’s ability to manage strategic portfolios of projects that align to the long-term vision and goals. It’s key to keeping leadership informed on desired outcomes by continually tracking the demand, the portfolios, the capacity to support them as well as accurate KPIs to overall performance. At the project level, we utilize various Project Portfolio Management (PPM) applications to manage project status, risk mitigation strategies and financials for our clients.
Collaboration is crucial in project delivery. How does ProspHire develop collaboration among cross-functional teams within healthcare organizations to ensure successful project outcomes?
Working in any sized organization, project execution rarely impacts a single business area and with that highlights the importance of building trust and relationships. It is critical to understand how people like to communicate and their leadership styles and set clear expectations for the team’s relationship. Projects are not all filled with good news as dependencies, resource constraints and competing priorities also become a factor. Setting clear expectations, communicating frequently and building a strong relationship up-front goes a long way to staying aligned and gaining respect with our clients.
Healthcare projects often involve complex regulatory and compliance requirements. How does ProspHire ensure that its clients navigate these challenges effectively?
Regulatory and compliance projects always start with an understanding of the requirements and how these requirements impact the current processes, workflow and technology. Even the smallest change impacts the business and with the heightened compliance or regulatory impact it’s critically important to establish strong collaborative governance models that hold people accountable, communicate an accurate status, empower the right people to make decisions and share a transparent risk assessment with clear mitigation strategies.
Can you share some insights into the skills and expertise that your Project Delivery practice team brings to the table to make a difference in healthcare projects?
At ProspHire, our practitioners have experience in Payor, Provider, Dental and even post-acute projects. That experience helps us work side by side with our business, technical and regulatory compliance stakeholders to inform decision making, provide recommendations and ultimately give our clients time back to focus on the business. In no way are we replacing our stakeholders but rather allowing our experience to build the trust they seek when delivering projects. Our clients seek a partner with a proven reputation for delivering complex and priority initiatives, effectively planning and managing progress and risks and understanding implications to processes, technology and regulatory demands.
Risk management is vital in any industry. How does the PMO identify and mitigate potential risks that could impact the success of healthcare consulting projects?
Risk management and communication are critical to managing a program/project and building trust with your clients. Risk is going to happen on every project and how that is documented and communicated is vitally important. Risk is not about calling teams or individuals out but rather a way to communicate what is causing the risk, the impact and the mitigation options to manage the risk. By not sharing or communicating risks, it is likely going to grow into something more unmanageable thus further impacting the project and resources supporting the desired outcome. At ProspHire, we run towards the risk and aim to understand the root cause, the impact of the project and defining a clear strategy for managing the risk.
Looking ahead, what trends and innovations do you foresee shaping the future of project delivery in healthcare and how is ProspHire preparing to adapt to these changes?
Digital transformation, data analytics and AI and process automation are all new trends and innovations that are now impacting project delivery in healthcare. It is important that we understand the needs and capabilities of every organization we work with to gauge their ability to evolve. And as important in understanding the technology, equal importance is understanding how operational processes may need to be examined and redesigned to complement and gain further efficiencies and quality gains that technology brings. At ProspHire, we are continuously training and upskilling our practitioners in emerging technologies and healthcare trends and regulations. We collaborate with technology companies and healthcare providers to develop innovative solutions that help to stay current with industry developments and we tailor solutions to the unique needs and challenges of every healthcare client.
ProspHire will work with you to understand your unique circumstances and identify the best methods to achieve your goals. Connect with us today to learn more.
There is a saying in the Medicaid community of “if you know Medicaid in one state, you know Medicaid in one state” given the variation in program eligibility, services and operations across states. While this remains true, there are fundamentals in Medicaid services, quality performance and operations that remain the same nationally.
As health plans seek to differentiate themselves in the market and deliver a member-first program, ProspHire supports health plans in establishing a strategic roadmap that integrates organizational goals and unique regional membership needs. ProspHire is dedicated to a regional approach to product development, quality programs, and member engagement. Demonstrating this commitment, ProspHire leverages and promotes the use of social determinant of health and other publicly available data sources to develop data-driven strategies and identify key steppingstones to appropriately address unique health plan membership needs. Check out our data dashboard!
Medicaid plans seeking to outperform will need to look beyond their bottom line and focus on the successful delivery of care and resulting outcomes for their membership. ProspHire collaborates with health plans to bring vision and strategy to execution and reality as a partner to your organization and your community.
The intent to award Medicaid contracts presents both opportunities and challenges for health plans. Whether you are an incumbent plan seeking to optimize performance or a new entrant preparing for go-live, ProspHire specializes in providing strategic support to drive operational success.
Opportunities in Focus
Operational Readiness
Develop and execute a comprehensive implementation plan to meet state requirements. Establish effective workflows, IT system integration and operational policies.
Conduct readiness assessments to mitigate risks prior to go-live.
Provider Network Expansion & Management
Assess and expand provider networks to meet state adequacy standards.Implement contracting strategies to enhance access to care and quality measure performance.
Improve provider relations and streamline credentialing processes.
Regulatory Compliance
Ensure alignment with state Medicaid regulations and reporting requirements. Conduct compliance audits and gap analyses.
Develop policies and procedures to maintain ongoing compliance.
Quality Programs, Performance & Addressing Health Disparities
Optimize HEDIS and Medicaid quality measures to improve performance. Implement care management programs to enhance member health outcomes. Align quality initiatives with state and federal benchmarks. Implement social determinants of health (SDOH) strategies. Develop community engagement initiatives to improve equity in care.
Leverage data analytics to identify and address disparities.
Member Experience
Improve CAHPS and member satisfaction scores through targeted interventions.
Develop data-driven member engagement strategies.
Administrative Cost Savings
Identify cost-containment opportunities to maximize efficiency. Streamline operations to reduce administrative burden through systems integration, process automation and strategic workflow optimization.
Leverage technology to enhance claims processing, contracting and other productive repetitive activities.
ProspHire Can Help
By partnering with us, health plans can confidently navigate the complexities of Medicaid implementation and achieve operational excellence. Contact us today to learn more about how we can support your success.
Welcome to the Healthcare Uncovered Podcast Series– your front-row seat to the future of healthcare. In this exclusive blog series, we spotlight expert insights and real-world strategies from ProspHire’s Soaring to New Health podcast. Each episode takes a deep dive into a distinct area of the healthcare ecosystem, from the rise of cloud-based dental software to unlocking Medicare Stars success, optimizing Medicaid and navigating the ever-changing ACA marketplace. Whether you’re a provider, payer or industry leader, these conversations are designed to inform, inspire and empower you to drive meaningful change. Need a quick overview? Click on the series highlights infographic to the right.
Explore the full series below and uncover the innovation shaping healthcare today.
The Modern Dental Practice – Software to Believe In
Revolutionizing Dental Care Through Technology
The dental industry is evolving, and cloud-based solutions are leading the charge. In this episode, we dive into the future of dental practice management software and how innovations are helping dental organizations scale, optimize operations, and improve patient care.
Our experts discuss the impact of cloud technology, how it enhances workflow efficiency and why leading dental practices are making the switch from legacy systems. If you’re looking to streamline practice management and improve operational outcomes, this episode is a must-listen!
Tune in now to discover how technology is transforming dental care!
How Health Plans Can Improve Quality and Performance
Achieving a 5-Star rating is no small feat, but it’s essential for health plans aiming to deliver high-quality care while maximizing reimbursement. In this episode, we break down the critical factors behind Stars success, from improving member engagement to optimizing HEDIS and CAHPS performance.
Our experts share best practices for navigating CMS guidelines, addressing key challenges in Stars improvement and driving meaningful quality outcomes. If you’re looking to enhance your health plan’s Star rating, this conversation provides actionable insights you won’t want to miss.
Listen now and take your Stars strategy to the next level!
Medicaid Strategy – Enhancing Access and Efficiency
Innovative Approaches to Medicaid Optimization
Medicaid plays a crucial role in providing healthcare access but navigating its complexities requires strategic expertise. In this episode, we explore how health plans and providers can enhance Medicaid quality, control costs and improve member experiences.
We cover key topics like Medicaid HEDIS optimization, addressing health disparities and integrating new technologies to streamline processes. With rising demands on Medicaid programs, this discussion is essential for healthcare leaders looking to drive innovation and efficiency in Medicaid services.
Tune in to explore cutting-edge strategies for Medicaid success!
The Affordable Care Act (ACA) marketplace continues to evolve and insurers must stay ahead of changing regulations, risk adjustment policies and enrollment trends. This episode takes a deep dive into the challenges and opportunities in the ACA landscape.
Our discussion highlights risk adjustment transfer payments, how insurers can optimize financial performance and the impact of policy shifts on healthcare access. Whether you’re an insurer, policymaker or healthcare leader, this episode unpacks the latest insights shaping the ACA marketplace.
Listen now to stay informed on the future of ACA and risk adjustment!
Setting the Stage for the 2026 Medicare Advantage Rate Announcement
On April 4th and April 7th, 2025, the Centers for Medicare & Medicaid Services (CMS) released 2026 Medicare Advantage Final Rule and 2026 Final Rate Announcement, respectively. These releases outline critical policy updates and payment adjustments that will shape the present and future of Medicare Advantage plans. The impact of these changes and signals present both a challenge and an opportunity for plans to reassess their strategies and adapt to the new normal.
More than Just the Numbers
CMS finalized a 5.06% increase in Medicare Advantage payments for 2026, amounting to $25 billion in additional plan revenue. Big number. Big headline. But the real story is how CMS continues to evolve its role—not just as a payer but as a regulator, standard-setter and advocate for Medicare enrollees. It’s not just how much CMS is investing in the Medicare program, it’s also about the standards for how the they expect plans to operate.
Star Ratings and Measure Impacts: Few Changes but Signals for What’s to Come
From a Stars perspective, these regulatory updates weren’t the tidal wave that some predicted. There was a notable measure rebrand, formerly the Health Equity Index (HEI). The much-maligned measure has been renamed to Excellent Health Outcomes 4 All (EHO4A). This change is not merely cosmetic but signals CMS’s ongoing commitment to reducing cost to the Medicare Advantage program (the true intention of the Health Equity Index anyway). In addition, the possibility of integrating geography as a social risk factor adds an extra layer of complexity for plans to consider. Plans may soon be required to account for geographic location when measuring and addressing health disparities and outcomes – a major nod to challenges in rural health. This could have a profound impact on how programs are designed and how quality measures are calculated, especially in communities facing systemic health challenges.
Finally, CMS has established official deadlines for plans to review and dispute data:
May 30, 2025 – CTM data review deadline
June 30, 2025 – Appeals data review deadline
May 18, 2026 – Part D Patient Safety data review deadline (SY2027)
March 31, 2026 – Deadline for all contracts to request a review of 2025 CTM data (SY2027)
With these fixed deadlines for data review, last-minute efforts to improve measure performance may be a challenge due to time constraints. Plans need to be much more proactive and diligent when reviewing their own data and searching for improvement opportunities.
A New Normal: The Need for Innovation in the Evolving CMS Landscape
The changes outlined in the 2026 Medicare Advantage announcements are more than just policy adjustments—they are part of a broader shift in the healthcare landscape. With figures like Dr. Oz and RFK Jr. now influencing the conversation, it’s clear that CMS is moving in a direction that prioritizes innovation, positive health outcomes, efficiency and adaptability.
CMS also showed strong interest in AI and operational efficiency, suggesting this administration is open to exploring technology’s role in modernizing Stars and other quality programs. The emphasis on the Universal Foundation of core measures—and the potential removal of many operational-style metrics—means plans will also need to focus on clinical outcomes, data capture/interoperability and measurement strategy in areas that matter most.
Plans must take a hard look at how they operate today and prepare to adjust their strategies under this new lens. The healthcare industry is entering a “new normal,” where the plans that succeed will be those that innovate and respond proactively to emerging trends. Those that fail to adapt risk falling behind in a competitive market. The future of Medicare Advantage will belong to innovators who can navigate this shifting terrain, ensuring that they are providing high-quality, outcomes driven care that meets the evolving needs of beneficiaries.
Conclusion: Building for the Future By Assessing Your Present
The Rate Announcement and Final Rule aren’t just technical documents—they’re a glimpse into CMS’s evolving philosophy: tighter guardrails, enhanced beneficiary protections and a firmer hand on program integrity and efficiency. The takeaway should be about building health plan infrastructure that can keep up with the direction that CMS is heading.
So, what should plans be doing now? We’re entering a summer and fall that will be filled with speculation, potential demonstration programs and policy previews that will shape 2027 and beyond. But 2026 is already defined—and it presents a critical opportunity for health plans to re-evaluate their Stars strategy, challenge current assumptions and reimagine how performance, data and member experience come together. At ProspHire, we’re working with clients to assess Stars readiness from every angle and every function—clinical workflows, data infrastructure, provider engagement and more. In this moment of change, everything should be on the table: new partnerships, new technologies and bold innovations that improve performance and drive sustainable results.
If your team is looking to get ahead of these changes and set the foundation for long-term success, let’s talk. At ProspHire, we have the experience and expertise in the Medicare Advantage and Stars space and the frameworks for evaluating plans capabilities and Stars potential. The way we approach our assessments of plans is comprehensive and wholistic, understanding that Stars success is about the entire health plan not just one team. Gaining a better understanding of your present, in order to prepare for the future will enable long-term success. Change is hard, but the work we do today will define your outcomes of tomorrow.
At ProspHire, social responsibility isn’t just a guiding principle—it’s a fundamental part of who we are. As we work toward our mission to help our clients provide better access to quality healthcare, we recognize that true impact goes beyond our profession. It means actively contributing to the well-being of the communities we serve, particularly those most vulnerable.
One of the most meaningful ways we demonstrate this commitment daily is through our ongoing efforts to improve government programs that provide healthcare to those in greatest need. But our responsibility doesn’t stop there. We understand that healthcare extends beyond policies and programs—it’s about people. That’s why we proudly support the Children’s Hospital of Pittsburgh Child Advocacy Center and its Patient Family Support Fund, which was established and continues to be sustained through ProspHire’s philanthropic support.
During National Child Abuse Prevention Month, we reaffirm our dedication to protecting and advocating for children who have experienced abuse or neglect. The Patient Family Support Fund ensures that the Child Advocacy Center has a dedicated budget to meet the immediate needs of these children—whether it’s providing essential resources, medical care, or emotional support. This initiative reflects our core belief that healthcare is not just about treatment but also about compassion, advocacy and meaningful action.
At ProspHire, social responsibility is not just an obligation, it’s a privilege. It’s the reason we do what we do every day and it’s why we will continue to use our expertise, resources and passion to make a tangible difference in the lives of those who need it most.
Did You Know?
Children living in poverty are significantly more likely to experience abuse or neglect—and over 70% of children involved in child welfare systems are enrolled in Medicaid or CHIP. That’s why our work to strengthen these public programs and support advocacy organizations is so critical to protecting children and ensuring they receive the care and compassion they need.
Social Determinants of Health (SDOH) shape health outcomes more profoundly than clinical care alone, influencing everything from chronic disease prevalence to healthcare utilization. As health plans, providers, and policymakers seek to address health disparities and improve outcomes, the key to success lies in leveraging data to inform targeted, high-impact interventions.
The Data-Driven Imperative
Without reliable data, SDOH interventions risk being broad and inefficient—potentially missing the communities and populations that need support the most. By harnessing robust, localized SDOH data, healthcare stakeholders can design interventions that address specific community needs, ensuring resources are allocated effectively for maximum return on investment (ROI).
The Medicaid Imperative
Medicaid enrollees are disproportionately affected by adverse SDOH, making a data-informed, community-driven strategy particularly critical. With Medicaid managed care organizations (MCOs) increasingly accountable for addressing SDOH, access to granular, zip code-level data—when paired with community input—empowers plans to:
Optimize Resource Allocation: Direct funding to programs with the highest potential for impact, such as housing initiatives or nutrition support.
Enhance Member Engagement: Tailor outreach efforts based on both regional SDOH insights and direct feedback from members about their most pressing needs.
Strengthen Value-Based Care Models: Align interventions with risk-based arrangements, reducing total cost of care while improving quality outcomes.
Pairing Data with Community Engagement
Data alone cannot capture the full context of challenges individuals and communities face. While it provides valuable insights into where disparities exist, it must be combined with community engagement and lived experiences to drive meaningful action. It must be complemented by:
Local Partnerships: Collaborating with community-based organizations (CBOs), faith-based groups and local leaders enables interventions are culturally appropriate and aligned with real needs.
The Voice of the Customer: Engaging directly with Medicaid members and other impacted populations through focus groups, surveys and advisory councils provides firsthand insight into barriers to care and potential solutions.
Flexible, Community-Driven Solutions: A data-informed intervention might indicate a need for increased access to transportation, but without community input, the solution may not be effective—whether due to affordability, scheduling issues or cultural considerations.
Turning Insights into Action
Our newest data insight tool, snapshot shown above, provides health plans, providers and policymakers with the first layer of data and information needed to make strategic, high-impact decisions. By visualizing SDOH indicators at the county level, users can identify gaps and drive toward evidence-based interventions. Success, however, depends on further investigation and the complementing of data insights with strong community partnerships and the voices of those most affected.
At ProspHire we believe we can achieve more equitable health outcomes and drive meaningful change, particularly for those who need it most with our partners.
After the 2026 Final Letter to Issuers was published this January, Issuers likely felt relief that no major changes were in store for the upcoming QHP Certification cycle and 2026 Plan Year. Fast forward to today and the industry is scrambling to digest the 2025 Marketplace Integrity and Affordability Proposed Rule released on March 10th. The proposed rule introduces several changes that could impact ACA Marketplace enrollment and member subsidies.
Barriers to Continued Enrollment
Below are a few of the largest barriers to continued enrollment that members would face under the new Rule:
Satisfying Debt for Past Due Premiums
Today, Issuers are prohibited from taking a member’s current plan year premium and using it to satisfy a previously unpaid premium. In the proposed rule, this direction would be reversed and members could be forced to pay any outstanding debts on top of their new premium prior to receiving coverage.
Eliminating Gross Premium Percentage-Based and Fixed-Dollar Premium Payment Thresholds
Health Plans are allowed to set their own payment thresholds prior to marking a member as “delinquent”. Plans have the autonomy to decide if this threshold is a percentage of the gross premium due (prior to subtracting any government subsidies), percentage of net premium or fixed dollar amount. Under this new rule, Plans would only be able to use a net premium percentage threshold.
For Example:
Gross Premium Percentage Threshold
Member Premium = $1,000
Federal Subsidy = $950
Percentage Threshold = 95% Paid
Member would not become delinquent if they missed a payment as the subsidy would still cover 95% of the bill
Net Premium Percentage Threshold with same premium
Net Premium = $50
Member would have to pay at least $47.50 to avoid delinquency
Shortening Annual Open Enrollment Period
The new rule proposed shortening the annual open enrollment window by a full month, changing the last day to enroll from January 15th to December 15th.
Subsidy Verification
Several measures in the proposed rule aim to increase the difficulty for consumers to obtain and keep federal subsidies. Americans living below 400% Poverty Level currently depend on these subsidies to make ACA Marketplace coverage affordable. Under the new rule, these members would face a higher burden of proof for proving income as well as be required to continually respond to redetermination requests. Failure to comply would result in a reduction or loss in subsidies.
In addition to the barriers consumers will face, this new rule would also put a large administrative burden on Marketplaces and Issuers. Interested to hear how Health Plans will be responding to the request for comments on this Proposal.
How Can ProspHire Help?
At ProspHire, we specialize in navigating complex regulatory changes and optimizing health plan operations. Our team of experts can help your organization:
✅ Assess the Financial and Operational Impact – Understand how these rule changes will affect your enrollment, member retention and subsidy compliance.
✅ Develop Compliance Strategies – Ensure your health plan meets the new regulatory requirements while minimizing disruption to members.
✅ Optimize Member Engagement and Retention – Implement solutions that reduce member churn and improve payment processes under the new thresholds.
✅ Streamline Administrative Processes – Enhance efficiency in handling redeterminations, subsidy verifications, and enrollment period changes.
With our deep expertise in ACA Marketplace strategy, risk adjustment and quality performance, we’re here to help you stay ahead of the curve. Let’s connect to discuss how your health plan can proactively adapt to these changes.
