Soaring to New Health Blog-Episode 1, Don’t Be a Pain in the ACA

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

This episode is Don’t be a Pain in the ACA. ProspHire’s Affordable Care Act (ACA) experts, Caitlin Nicklow and Matt Dauffenbach, talk about what it is, why it’s important, the timeline for launching a plan, how to get started and the impact on health plans.

When we’re talking about ACA, we’re normally talking about the individual exchange. This is an insurance marketplace for those who don’t have employer sponsored health care and don’t qualify for Medicaid or Medicare.  To obtain coverage, individuals log on to their state or federal exchange and you shop for health care. It’s as simple as that.

The ACA has benefitted both members and Health Plans. The biggest advantage for members is the essential health benefits that each plan must include. It’s a safeguard for members. When you shop for a plan, you know that each one has, at minimum, the same core benefits, including preventative care and emergency services. Health Plans benefit from launching ACA plans because it’s an opportunity to stay with a member through all the phases of their life. When health plans launch an ACA plan, it keeps that revenue stream within the organization. Those health plans also immediately benefited from the Medicaid Redetermination because those members could move from Medicaid to their ACA plan. If your health plan doesn’t have an ACA plan, there is still an opportunity to launch one because the Medicaid Regermination process is going to take a year to unwind. Open Enrollment for Plan Year 2024 will be key for members who shop around for plans and want to make a switch.

Health plans shouldn’t underestimate the time it takes to set up an ACA Plan. The timeline varies and it depends on whether you are a brand-new plan or a mature plan that has already obtained NCQA or URAC accreditation. That could mean the difference between 12 months and 18 to 24 months. At ProspHire, we tell our clients not to rush… plan out those processes, make sure you have the infrastructure to support the potential number of member growth.

Demographics and competition are important. You could have a plan that launches with 5,000 members and quickly grows to 50,000. Realistic short term and long-term goals are all a part of planning conversations. It’s important to understand what your strengths as a plan are, how strong your brand is and what differentiators will attract members.

Staying on top of ACA compliance and regulations can be a full-time job. At the foundation, the biggest requirement is Qualified Health Plan (QHP) certification. Any plan in the marketplace in any U.S. state must have this certification and you must renew it annually. The process looks at the bones of the operation of the plan, starting in May and wrapping up in September. In addition, every state will have their own specific requirements to operate in that state. Third is a must have – accreditation. That looks at the inside of the plan, the policies and procedures. Beware that NCQA or URAC is very time intensive and involves more than 100 requirements for the plan to be in compliance.

Prioritization is key when launching an ACA plan. During the assessment phase, we talk with you about competing projects and resources. We look for ways to align your priorities and leverage existing projects and resources in your organization to avoid duplication of efforts across multiple programs.

For more details on the challenges and solutions once the plan is established and enrollment period begins, download Soaring to New Health’s episode one, Don’t be a Pain in the ACA here.

Let’s have a conversation

Caitlin Nicklow

Senior Manager