August 13, 2025 • 16 mins
The ACA Open Enrollment Period is changing—are you ready?
Millions of members typically enroll after December 15, but that window is now gone.
In this episode of Regulatory Joe, Joe Boyle breaks down what health plans need to do to protect enrollment, adjust crosswalk strategies, and seize growth opportunities heading into Plan Year 2026.
You'll learn why revalidating assumptions, preparing ops early, and acting on competitive intel is more important than ever.
▶️ Don’t miss a key update—subscribe for more insights: https://www.regulatoryjoe.com
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Hey everybody.
(00:00):
Welcome to Regulatory Joe.
I'm Joe Boyle, president of ClearFile,and on today's episode we'll be discussing
plan year 2026 enrollment strategies.
Plan year 2026 open enrollmentis shaping up to be one of the
most condensed and competitiveyears in the history of the ACA.
Harnessing the changes for plan year2026, issuers will have to be very aware
on not just retaining their existingmembership base, but also planning
(00:21):
strategically on how to grow theirmembership through a year of carrier
decisions to enter net new markets andalso withdraw from existing markets.
So here's what's changingfor Plan Year 2026.
Looking back in time, this is thefirst time in the history of the
ACA that the core annual cyclicalenrollment period has ever changed.
In all historic years leading upinto plan year 2026, members across
(00:43):
the country enrolling on exchangeon healthcare.gov have always been
afforded the opportunity to enrollfrom November 1st through January 15th.
The only exception to the rule inthe past 10 years of the ACA that
changed the annual cyclical windowof enrollment was the COVID pandemic.
AEP now runs one month shorter thanit ever has in the history of the ACA.
(01:04):
Members will have an opportunitythis year to enroll into coverage
from November 1st to December 15th.
While the change in enrollment is avery disruptive change to members,
issuers have to be very mindful aboutthe impact of what this means in terms
of their plan portfolio strategy, andtheir overall enrollment strategy.
Looking into plan year 2026, we encourageall issuers and payers to take a hard
(01:25):
look at their previous historic enrollmenttrends and understand on a weekly basis
how members have historically enrolledinto your product, starting November
1st, all the way through January 15th.
What you'll need to absolutely dois understand, in that latter four
weeks between December 15th andJanuary 15th, the percentage of your
(01:45):
overall ACA membership that actuallyeffectuated during that period of time.
If you're a smaller, more regionalcarrier, we estimate that this
could make up about three to 5% ofyour overall total ACA membership.
If you're a larger carrier, thiscould make up to over 10% of
your overall total membership.
Understanding the type of memberand understanding their behavior
and why they're enrolling thislate into the AEP period is going
(02:08):
to be very important as well.
Understanding if the member doesn'thave correct access to technology
to simply navigate the enrollmentor reconciliation process.
Maybe there is a language barrier or aliteracy barrier to actually understanding
the application for healthcare.gov.
Maybe a member simply doesn't havethe time because they're too busy
working multiple part-time jobs andthey simply don't have a navigator
(02:30):
or somebody supporting them, likea broker to help them enroll.
So that being said, when you trulyunderstand the percentage of membership
that has historically enrolled in thatlatter four week period of the annual
AEP cycle, that's really going toempower you as an issuer, as a payer,
regardless if you're a regional payer, asmaller payer in one or multiple states
to alter and augment your strategyto be proactive and not reactive to
(02:55):
do what's best for your business.
So we understand this is a year ofdisruption, a year of change, and a
year of reactiveness in some cases.
So being able to get ahead of your planstrategy will be critical and also very
timely because we know enrollment'sright around the corner and plans have
definitely competing priorities aswe've just completed the filing season
and have entered the review period.
(03:16):
Make sure you're prioritizingAEP strategy against the change
and against the new timeline.
And we can talk all day about what thismeans on a strategic level from an AEP
perspective, but it'll even be moreimportant to talk about the tactical
execution of the crosswalk hierarchy.
And for any filer out there listening,you know well and clear that CMS
required all issuer crosswalks tobe submitted in alignment with the
(03:39):
June 11th deadline of this year.
So going into AEP we already knowour issuers have made prospective
determinations of where they have theircurrent membership today, in calendar year
2025, and where they propose to crosswalkthese members on the hierarchy into
their net new plans in plan year 2026.
So if you've already made yourcrosswalk determinations in your initial
(04:02):
6/11 submission, those assumptionsare probably based on not just the
shortening of the AEP period, butthose crosswalks and those hierarchies
that you submitted has probably beenbased on other strategic initiatives
driven by the change of the ACA.
On a normal year, you're goingto be crosswalking a one-to-one,
one-hundred percent renewal.
(04:22):
What we've seen very quickly thisyear is we've seen issuers scramble
where they may have had a one-to-onerenewal strategy a month ago, but due
to the looming extension, issuers thatwere historically HMO issuers, we're
actually seeing create new PPO products.
Issuers who are historically a PPO issuer,we're seeing create new EPO products.
(04:42):
We're even seeing issuers drivingtheir products outside the exchange
to file off exchange only portfolios,ICHRA portfolios, or even products
outside of the ACA entirely.
So all to say the crosswalk hierarchy,CMS will be reviewing these up until
11/1 and issuers need to be a hundredpercent sure and confident of where their
members are currently and where they'recrosswalking them from the next plan year.
(05:04):
So that being said, we encourage allissuers between now and 11/1 to take
a real hard look and a historic lookabout how your product team or your
benefits team have set up the currentstructure with how you're planning to
map your members into plan year 2026.
So taking a look and split itinto two or three categories.
We would recommend, standard planoptions, non-standard plan options, your
(05:26):
off exchange business and any non-coreACA products, on your product shelf
to truly understand a few criteria.
The number of membership in your plans byHIOS ID and by product id, that's going to
actually tell you what your top performingplan is and quite frankly why members
are so attracted to that plan design.
Why is a member needing that coverage?
(05:47):
Are there certain benefits thatare more desirable than your top
competitors' plans or top comparableplan by your top competitor?
Drilling down, not just with membership,but then by metallic tier type.
So understanding that issuers thisyear have not just crosswalk by
different products, but the number ofplans by metallic tiers has changed.
So we're actually seeing, in some cases,members who have historically enrolled
(06:11):
into gold plans now being crosswalkedon the hierarchy to a silver plan.
And is that allowed?
Understanding your plan AVs are goingto be very, very, very critical, down
to the decimal or the 0.01% to makingsure you're following your five UBM or
uniform benefit modification criteria.
Make sure your plans are within plusor minus 0.2 or 2% of your actuarial
(06:34):
value so that if you choose to crosswalkplans across metallic tier, gold to
silver, silver to bronze, bronze tosilver, silver to gold, that you're
actually doing it in a compliant way.
So run that AV calculator, firstlook to see if there's a new
version of the AV calculator.
Download it on the CMS application page.
Run your plans even ifit's already submitted.
(06:55):
All plan crosswalks, if you intendto participate on the marketplace,
have already been submitted on 6/11.
Even though you're in the review period,go back and still complete this review.
And it's really important to talk aboutthis right now because as this is a
year of disruption and change for theACA specifically for crosswalk and
enrollment, the decision you make forplan year 2026 will carry forward through
(07:18):
plan year 2027, 2028, 2029 and so on.
The message here is just tobe absolutely sure of your
crosswalk strategy for this year.
so that you can retain, your existingmembership like we talked about, and
that you can grow your business andalso spend time strategically, obtaining
business from your top competitors.
(07:38):
While you're actually lookingat your crosswalks, you can
pull, even your competitorcrosswalks, use the CMS PUF files.
The public use files should berefreshed on a monthly, or at
this point, a quarterly basis.
You should actually have line of sightinto how your top competitors crosswalked
their plans last year by membership.
Take a couple minutes to look at that,to understand where they're at, and
(07:59):
then also look in SERFF Filing Access.
See what data you can pull fromyour publicly available URRTs.
You can actually track yourtop competitors' projected
membership for this year.
So even if you don't know their actualmembership, even looking at their
projections of what they thoughtthey were going to attain to make
those types of lines of insights.
So with all the changes that carriershave to accommodate for plan year
(08:20):
2026, it's going to be important toalso pause and acknowledge Aetna's
decision to withdraw from themarketplace for this year as well.
So that decision, while creatingopportunity for some regional carriers
or other large carriers in the industryalso causes a lot of change and
disruption for the over million membersthat are impacted by the decision.
Understanding that these millionmembers are dispersed across multiple
(08:41):
different states in a variety ofgeographies, counties and zip codes.
What we would encourage issuers todo, whether you're another large
issuer or a smaller regional issuer,even a hospital health plan, is
to understand the markets that youparticipate in, that also Aetna had
competed with you in in that geography.
If you understand that if there areplans offered within those same zip
(09:04):
codes within those counties, all ofthat can be extracted through public
information requests or downloadsthrough the PUF files or SFA.
You're gonna have a really goodunderstanding of your opportunity for
your carrier and for your issuer abouthow many members were participating
in what types of plans and howthose plans were built and designed.
And I know it may sound verytactical and detail-oriented.
(09:25):
And yes, it will take a lot of time todive into the details and understand
the impact of a Fortune four issuerwithdrawing from the marketplace and
what that means for your business.
But it truly will only helpyou position your issuer for a
better plan strategy beyond planyear 26 into 2027 and into 2028.
And while we see carriers making strategicchanges or proposals to change, it's
(09:48):
really interesting because while someare continuing to consider different
product types or different productsentirely, some have also taken the
opportunity to explore the differencesbetween having a presence on the
exchange as well as off of the exchange.
So if you are considering offeringoff exchange only portfolios or
considering offering mirrored portfoliosfor the individual or small group
(10:09):
markets, also, just be mindful asyou go into this shortened enrollment
period for the first time ever that,also, SEPs may not be guaranteed
for issuers entering plan year 2026.
So what this means is while anything'spossible, we can't guarantee that
members will have an opportunity afterDecember 15th to continue enrollment
into the calendar year of 2026.
(10:31):
Now, that may not be the caseif your strategy is to offer a
standalone off-exchange portfolio.
Outside of the exchange, SEPs maystill be upheld by your respective
state and by your enrollment partners.
But again, just to be very clear,on-exchange is not guaranteed
for the individual marketplace.
Now that we know and are familiarwith all the changes that we're up
against this year, we can talk abouthow to codify your issuer retention
(10:54):
strategy and some other operationalstrategies to tackle ahead of enrollment.
So from a retention strategy perspective,we really break this into two buckets.
What can we control andwhat is out of our control?
So what we'd recommend is there arecontrollable filings that wrap around your
core, major medical submissions that youcan actually submit to a state regulator
your marketing, for your product.
(11:15):
Advertising filings are allowed postsubmission, post 6/11 up until 11/1 and
ongoing through the next calendar year.
So what we'd encourage you to do is towork with your marketing team internally
to understand any new advertisements,campaigns, whether they're posters,
commercials, radio advertisements, orother that your marketing team is putting
(11:38):
together to build their strategy, tocollect as much members as they can and
to retain as many members as they canfrom their current book of business.
Working with your marketing and yourproduct team, you should be able to
develop process to notify your regulatorsthat advertising filings will be on the
way and they should be expecting them.
Once any ad filings are submittedby your product filers and approved,
(11:59):
those can be used to go to market.
And that content can be reusedfor your next year strategy
and the year after that.
Separate from retention strategies, we cantalk about some operational items that you
can execute to be successful to get aheadof AEP, to make sure you're on track.
Starting with, just because your filingis still under review by your regulator
doesn't mean that you can't startconfiguration processes inside of your
(12:20):
internal database to make sure you couldadminister the plans and administer the
claims when a member actually enrolls.
There is an ongoing annual argumentbetween product and IT, generally
speaking, with payers and issuers acrossthe country, and it goes like this.
Why would we configure our products ifthe filing hasn't been approved yet?
What if something changes?
Product will always respond andsay, well, we need to because
(12:42):
we don't have enough time.
We need to be prepared for 11/1 AEP,regardless if there's a product change.
We are big believers thatconfiguration can never wait.
There is never too soon to startcoding your benefits into your claims
adjudication system because the last thingyou want to do is a mad scramble push
and missing a sink window where a memberwill enroll into a plan, receive coverage
(13:03):
and receive care, and their claim is notadministered and their claim is not paid.
That's the last situation you'dever want to be in with a member,
especially a new member, that'sjoining your plan for the first time.
So understanding you'regetting ahead of config.
you know, under the notion thatmaking a few changes at the end of
the line is, better than the whole andbuilding a business process in place.
So being operationally ready iscritical this year more than any year
(13:26):
in the ACA because of the substantialchange, that's being pushed on issuers.
Amongst the year of AEP shortening,hierarchy of enrollment, don't let that
distract you from other operationalexecution strategies, as well as retention
strategies that you need to get ahead of.
And even right on the heels ofconfiguration and retention, planning
for your new members will be crucial.
(13:47):
Just because you can now accept theminto your claims adjudication system
and enrollment platform seamlessly,you need to make sure that your
members are welcomed within yoursales and service team, and that your
internal operations are actually ableto ingest an influx of membership.
So it's not uncommon to start hiringclassrooms of call center representatives,
beginning your training programs andtraining platforms, making sure that
(14:10):
these agents and call reps understand yourbrand product portfolio, so that they can
understand the questions when the membercalls in to ask why was I crosswalked,
or why was I enrolled into a plan.
So making sure that you're armed withthe tools in your toolkit to serve the
members, that are paying their premiums.
This will only prepare you fora very successful retention
strategy year over year.
(14:30):
At the end of the day, it's reallyimportant just to remember to pause, step
back and say, not one individual issuerhas been siloed with these changes.
Everybody across the countrywho participates in the ACA
has been impacted by theseregulations and mandated decisions.
Executing these changes and beingcompliant and serving our members
with a quality product will take alot of time, material, and resources.
(14:54):
Set the time aside now for atthe end of the year, prior to
planning for your plan year 2027strategy, conduct a lessons learned.
Carve out the time, whether it's a fullday session, two half day sessions,
virtual or in person with your core staff.
Get members or leaders from your productteam, your benefits team, your actuarial
pricing team, even down to your claimsteam and even your product strategists.
(15:17):
It'll be worth the time to documentthe changes that were executed
this year to build your repository.
Establish one if you don't have one, andthen build your repository year over year.
Harnessing the impact of whatthe decisions you've made this
year and what that means for yourmembership next year, because the
clock starts ticking January 1st.
you should be measuring, I mean,if you can on a daily basis,
(15:38):
membership activity, but that'snot always feasible, unfortunately.
Track your membership weekly andcheck in from your lessons learned
on a monthly basis throughout yourproduct strategy timeline next year.
Generally speaking, and we'll just giveyou a rule of thumb, all issuers should
have their plan portfolio strategiescompleted by the end of February annually.
(15:59):
So really you're thinking you've got thesecond half of December minus holidays
and weekends to the middle of February.
Really it's not that much time.
And with all the work that we're executingthis year, it will be very easy to
deprioritize lessons learned and actuallynot do the diligence that's needed for
your business and for your members.
Take some time, conduct your lessonslearned, and, believe me, when you can
(16:21):
measure performance or speed to market,reduced downtime, reduced errors for
your members, and have a true retentionstrategy for next year, it'll only,
drive your market growth, new marketentry, or even expansion of your product.
So we covered a lot today.. Best ofluck with enrollment season, everybody.
Give us a like, give us share andwe'll catch you all next time.
Hey everybody.
(00:00):
Welcome to Regulatory Joe.
I'm Joe Boyle, president of ClearFile,and on today's episode we'll be discussing
plan year 2026 enrollment strategies.
Plan year 2026 open enrollmentis shaping up to be one of the
most condensed and competitiveyears in the history of the ACA.
Harnessing the changes for plan year2026, issuers will have to be very aware
on not just retaining their existingmembership base, but also planning
(00:21):
strategically on how to grow theirmembership through a year of carrier
decisions to enter net new markets andalso withdraw from existing markets.
So here's what's changingfor Plan Year 2026.
Looking back in time, this is thefirst time in the history of the
ACA that the core annual cyclicalenrollment period has ever changed.
In all historic years leading upinto plan year 2026, members across
(00:43):
the country enrolling on exchangeon healthcare.gov have always been
afforded the opportunity to enrollfrom November 1st through January 15th.
The only exception to the rule inthe past 10 years of the ACA that
changed the annual cyclical windowof enrollment was the COVID pandemic.
AEP now runs one month shorter thanit ever has in the history of the ACA.
(01:04):
Members will have an opportunitythis year to enroll into coverage
from November 1st to December 15th.
While the change in enrollment is avery disruptive change to members,
issuers have to be very mindful aboutthe impact of what this means in terms
of their plan portfolio strategy, andtheir overall enrollment strategy.
Looking into plan year 2026, we encourageall issuers and payers to take a hard
(01:25):
look at their previous historic enrollmenttrends and understand on a weekly basis
how members have historically enrolledinto your product, starting November
1st, all the way through January 15th.
What you'll need to absolutely dois understand, in that latter four
weeks between December 15th andJanuary 15th, the percentage of your
(01:45):
overall ACA membership that actuallyeffectuated during that period of time.
If you're a smaller, more regionalcarrier, we estimate that this
could make up about three to 5% ofyour overall total ACA membership.
If you're a larger carrier, thiscould make up to over 10% of
your overall total membership.
Understanding the type of memberand understanding their behavior
and why they're enrolling thislate into the AEP period is going
(02:08):
to be very important as well.
Understanding if the member doesn'thave correct access to technology
to simply navigate the enrollmentor reconciliation process.
Maybe there is a language barrier or aliteracy barrier to actually understanding
the application for healthcare.gov.
Maybe a member simply doesn't havethe time because they're too busy
working multiple part-time jobs andthey simply don't have a navigator
(02:30):
or somebody supporting them, likea broker to help them enroll.
So that being said, when you trulyunderstand the percentage of membership
that has historically enrolled in thatlatter four week period of the annual
AEP cycle, that's really going toempower you as an issuer, as a payer,
regardless if you're a regional payer, asmaller payer in one or multiple states
to alter and augment your strategyto be proactive and not reactive to
(02:55):
do what's best for your business.
So we understand this is a year ofdisruption, a year of change, and a
year of reactiveness in some cases.
So being able to get ahead of your planstrategy will be critical and also very
timely because we know enrollment'sright around the corner and plans have
definitely competing priorities aswe've just completed the filing season
and have entered the review period.
(03:16):
Make sure you're prioritizingAEP strategy against the change
and against the new timeline.
And we can talk all day about what thismeans on a strategic level from an AEP
perspective, but it'll even be moreimportant to talk about the tactical
execution of the crosswalk hierarchy.
And for any filer out there listening,you know well and clear that CMS
required all issuer crosswalks tobe submitted in alignment with the
(03:39):
June 11th deadline of this year.
So going into AEP we already knowour issuers have made prospective
determinations of where they have theircurrent membership today, in calendar year
2025, and where they propose to crosswalkthese members on the hierarchy into
their net new plans in plan year 2026.
So if you've already made yourcrosswalk determinations in your initial
(04:02):
6/11 submission, those assumptionsare probably based on not just the
shortening of the AEP period, butthose crosswalks and those hierarchies
that you submitted has probably beenbased on other strategic initiatives
driven by the change of the ACA.
On a normal year, you're goingto be crosswalking a one-to-one,
one-hundred percent renewal.
(04:22):
What we've seen very quickly thisyear is we've seen issuers scramble
where they may have had a one-to-onerenewal strategy a month ago, but due
to the looming extension, issuers thatwere historically HMO issuers, we're
actually seeing create new PPO products.
Issuers who are historically a PPO issuer,we're seeing create new EPO products.
(04:42):
We're even seeing issuers drivingtheir products outside the exchange
to file off exchange only portfolios,ICHRA portfolios, or even products
outside of the ACA entirely.
So all to say the crosswalk hierarchy,CMS will be reviewing these up until
11/1 and issuers need to be a hundredpercent sure and confident of where their
members are currently and where they'recrosswalking them from the next plan year.
(05:04):
So that being said, we encourage allissuers between now and 11/1 to take
a real hard look and a historic lookabout how your product team or your
benefits team have set up the currentstructure with how you're planning to
map your members into plan year 2026.
So taking a look and split itinto two or three categories.
We would recommend, standard planoptions, non-standard plan options, your
(05:26):
off exchange business and any non-coreACA products, on your product shelf
to truly understand a few criteria.
The number of membership in your plans byHIOS ID and by product id, that's going to
actually tell you what your top performingplan is and quite frankly why members
are so attracted to that plan design.
Why is a member needing that coverage?
(05:47):
Are there certain benefits thatare more desirable than your top
competitors' plans or top comparableplan by your top competitor?
Drilling down, not just with membership,but then by metallic tier type.
So understanding that issuers thisyear have not just crosswalk by
different products, but the number ofplans by metallic tiers has changed.
So we're actually seeing, in some cases,members who have historically enrolled
(06:11):
into gold plans now being crosswalkedon the hierarchy to a silver plan.
And is that allowed?
Understanding your plan AVs are goingto be very, very, very critical, down
to the decimal or the 0.01% to makingsure you're following your five UBM or
uniform benefit modification criteria.
Make sure your plans are within plusor minus 0.2 or 2% of your actuarial
(06:34):
value so that if you choose to crosswalkplans across metallic tier, gold to
silver, silver to bronze, bronze tosilver, silver to gold, that you're
actually doing it in a compliant way.
So run that AV calculator, firstlook to see if there's a new
version of the AV calculator.
Download it on the CMS application page.
Run your plans even ifit's already submitted.
(06:55):
All plan crosswalks, if you intendto participate on the marketplace,
have already been submitted on 6/11.
Even though you're in the review period,go back and still complete this review.
And it's really important to talk aboutthis right now because as this is a
year of disruption and change for theACA specifically for crosswalk and
enrollment, the decision you make forplan year 2026 will carry forward through
(07:18):
plan year 2027, 2028, 2029 and so on.
The message here is just tobe absolutely sure of your
crosswalk strategy for this year.
so that you can retain, your existingmembership like we talked about, and
that you can grow your business andalso spend time strategically, obtaining
business from your top competitors.
(07:38):
While you're actually lookingat your crosswalks, you can
pull, even your competitorcrosswalks, use the CMS PUF files.
The public use files should berefreshed on a monthly, or at
this point, a quarterly basis.
You should actually have line of sightinto how your top competitors crosswalked
their plans last year by membership.
Take a couple minutes to look at that,to understand where they're at, and
(07:59):
then also look in SERFF Filing Access.
See what data you can pull fromyour publicly available URRTs.
You can actually track yourtop competitors' projected
membership for this year.
So even if you don't know their actualmembership, even looking at their
projections of what they thoughtthey were going to attain to make
those types of lines of insights.
So with all the changes that carriershave to accommodate for plan year
(08:20):
2026, it's going to be important toalso pause and acknowledge Aetna's
decision to withdraw from themarketplace for this year as well.
So that decision, while creatingopportunity for some regional carriers
or other large carriers in the industryalso causes a lot of change and
disruption for the over million membersthat are impacted by the decision.
Understanding that these millionmembers are dispersed across multiple
(08:41):
different states in a variety ofgeographies, counties and zip codes.
What we would encourage issuers todo, whether you're another large
issuer or a smaller regional issuer,even a hospital health plan, is
to understand the markets that youparticipate in, that also Aetna had
competed with you in in that geography.
If you understand that if there areplans offered within those same zip
(09:04):
codes within those counties, all ofthat can be extracted through public
information requests or downloadsthrough the PUF files or SFA.
You're gonna have a really goodunderstanding of your opportunity for
your carrier and for your issuer abouthow many members were participating
in what types of plans and howthose plans were built and designed.
And I know it may sound verytactical and detail-oriented.
(09:25):
And yes, it will take a lot of time todive into the details and understand
the impact of a Fortune four issuerwithdrawing from the marketplace and
what that means for your business.
But it truly will only helpyou position your issuer for a
better plan strategy beyond planyear 26 into 2027 and into 2028.
And while we see carriers making strategicchanges or proposals to change, it's
(09:48):
really interesting because while someare continuing to consider different
product types or different productsentirely, some have also taken the
opportunity to explore the differencesbetween having a presence on the
exchange as well as off of the exchange.
So if you are considering offeringoff exchange only portfolios or
considering offering mirrored portfoliosfor the individual or small group
(10:09):
markets, also, just be mindful asyou go into this shortened enrollment
period for the first time ever that,also, SEPs may not be guaranteed
for issuers entering plan year 2026.
So what this means is while anything'spossible, we can't guarantee that
members will have an opportunity afterDecember 15th to continue enrollment
into the calendar year of 2026.
(10:31):
Now, that may not be the caseif your strategy is to offer a
standalone off-exchange portfolio.
Outside of the exchange, SEPs maystill be upheld by your respective
state and by your enrollment partners.
But again, just to be very clear,on-exchange is not guaranteed
for the individual marketplace.
Now that we know and are familiarwith all the changes that we're up
against this year, we can talk abouthow to codify your issuer retention
(10:54):
strategy and some other operationalstrategies to tackle ahead of enrollment.
So from a retention strategy perspective,we really break this into two buckets.
What can we control andwhat is out of our control?
So what we'd recommend is there arecontrollable filings that wrap around your
core, major medical submissions that youcan actually submit to a state regulator
your marketing, for your product.
(11:15):
Advertising filings are allowed postsubmission, post 6/11 up until 11/1 and
ongoing through the next calendar year.
So what we'd encourage you to do is towork with your marketing team internally
to understand any new advertisements,campaigns, whether they're posters,
commercials, radio advertisements, orother that your marketing team is putting
(11:38):
together to build their strategy, tocollect as much members as they can and
to retain as many members as they canfrom their current book of business.
Working with your marketing and yourproduct team, you should be able to
develop process to notify your regulatorsthat advertising filings will be on the
way and they should be expecting them.
Once any ad filings are submittedby your product filers and approved,
(11:59):
those can be used to go to market.
And that content can be reusedfor your next year strategy
and the year after that.
Separate from retention strategies, we cantalk about some operational items that you
can execute to be successful to get aheadof AEP, to make sure you're on track.
Starting with, just because your filingis still under review by your regulator
doesn't mean that you can't startconfiguration processes inside of your
(12:20):
internal database to make sure you couldadminister the plans and administer the
claims when a member actually enrolls.
There is an ongoing annual argumentbetween product and IT, generally
speaking, with payers and issuers acrossthe country, and it goes like this.
Why would we configure our products ifthe filing hasn't been approved yet?
What if something changes?
Product will always respond andsay, well, we need to because
(12:42):
we don't have enough time.
We need to be prepared for 11/1 AEP,regardless if there's a product change.
We are big believers thatconfiguration can never wait.
There is never too soon to startcoding your benefits into your claims
adjudication system because the last thingyou want to do is a mad scramble push
and missing a sink window where a memberwill enroll into a plan, receive coverage
(13:03):
and receive care, and their claim is notadministered and their claim is not paid.
That's the last situation you'dever want to be in with a member,
especially a new member, that'sjoining your plan for the first time.
So understanding you'regetting ahead of config.
you know, under the notion thatmaking a few changes at the end of
the line is, better than the whole andbuilding a business process in place.
So being operationally ready iscritical this year more than any year
(13:26):
in the ACA because of the substantialchange, that's being pushed on issuers.
Amongst the year of AEP shortening,hierarchy of enrollment, don't let that
distract you from other operationalexecution strategies, as well as retention
strategies that you need to get ahead of.
And even right on the heels ofconfiguration and retention, planning
for your new members will be crucial.
(13:47):
Just because you can now accept theminto your claims adjudication system
and enrollment platform seamlessly,you need to make sure that your
members are welcomed within yoursales and service team, and that your
internal operations are actually ableto ingest an influx of membership.
So it's not uncommon to start hiringclassrooms of call center representatives,
beginning your training programs andtraining platforms, making sure that
(14:10):
these agents and call reps understand yourbrand product portfolio, so that they can
understand the questions when the membercalls in to ask why was I crosswalked,
or why was I enrolled into a plan.
So making sure that you're armed withthe tools in your toolkit to serve the
members, that are paying their premiums.
This will only prepare you fora very successful retention
strategy year over year.
(14:30):
At the end of the day, it's reallyimportant just to remember to pause, step
back and say, not one individual issuerhas been siloed with these changes.
Everybody across the countrywho participates in the ACA
has been impacted by theseregulations and mandated decisions.
Executing these changes and beingcompliant and serving our members
with a quality product will take alot of time, material, and resources.
(14:54):
Set the time aside now for atthe end of the year, prior to
planning for your plan year 2027strategy, conduct a lessons learned.
Carve out the time, whether it's a fullday session, two half day sessions,
virtual or in person with your core staff.
Get members or leaders from your productteam, your benefits team, your actuarial
pricing team, even down to your claimsteam and even your product strategists.
(15:17):
It'll be worth the time to documentthe changes that were executed
this year to build your repository.
Establish one if you don't have one, andthen build your repository year over year.
Harnessing the impact of whatthe decisions you've made this
year and what that means for yourmembership next year, because the
clock starts ticking January 1st.
you should be measuring, I mean,if you can on a daily basis,
(15:38):
membership activity, but that'snot always feasible, unfortunately.
Track your membership weekly andcheck in from your lessons learned
on a monthly basis throughout yourproduct strategy timeline next year.
Generally speaking, and we'll just giveyou a rule of thumb, all issuers should
have their plan portfolio strategiescompleted by the end of February annually.
(15:59):
So really you're thinking you've got thesecond half of December minus holidays
and weekends to the middle of February.
Really it's not that much time.
And with all the work that we're executingthis year, it will be very easy to
deprioritize lessons learned and actuallynot do the diligence that's needed for
your business and for your members.
Take some time, conduct your lessonslearned, and, believe me, when you can
(16:21):
measure performance or speed to market,reduced downtime, reduced errors for
your members, and have a true retentionstrategy for next year, it'll only,
drive your market growth, new marketentry, or even expansion of your product.
So we covered a lot today.. Best ofluck with enrollment season, everybody.
Give us a like, give us share andwe'll catch you all next time.
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