Preliminary data indicate that 2023 may prove to be the most volatile year for health plan enrollment in a decade. The convergence of major market disruptions—namely the Inflation Reduction Act (IRA) and the end of the Public Health Emergency (PHE)—is sparking tremendous shifts in the individual and public exchange markets.
For health IT vendors, understanding these enrollment shifts is essential for identifying potential growth areas for clients. Both payers and providers will need to improve the quality and variety of their services to attract and retain patients, who are increasingly focused on accessibility and value. Health IT vendors can assist by leveraging real-time coverage, restriction, and reimbursement data to help payers and providers offer a more seamless care experience.
Each April, MMIT conducts a comprehensive survey of all payers offering commercial risk and ASO (administrative services only) products to confirm and audit their state-filed enrollment data. The results of this research are published in MMIT’s Directory of Health Plans tool and used by AHIP, the health insurance industry trade association, as its definitive source of health insurance enrollment data.
Here’s a peek at our early findings and what they signal for the year ahead.
Understanding the driving forces behind enrollment shifts
While the process is still underway, our preliminary results indicate major enrollment upheavals. Some larger ACA insurers, such as Bright Health, have chosen to leave the exchanges, resulting in millions of members searching for a replacement plan. In the first half of 2023, our research reveals that many regional insurers have seen enrollment increases in the tens of thousands, while national insurers have gained hundreds of thousands of members in the individual market.
To understand why, let’s first look at the impact of the IRA, which extended the ACA subsidies previously expanded through pandemic relief legislation. Suddenly, ACA plans became a much more attractive option for a much broader population. By the close of the extended open enrollment period in January, a record 16.3 million people had signed up for an ACA plan; 22% of these members are first-time participants. Until 2025, premium subsidies for ACA plans will continue to be available even to those with an income four times the federal poverty level.
During the second half of the year, our research indicates that we should also see marked decreases in Medicaid enrollment and an additional uptick in ACA plan and/or commercial enrollment. Given the increase in overall employment rates, many former Medicaid members will likely move to the employer market, although they may also enroll in exchange plans or opt to remain uninsured if their employer coverage is inadequate or non-existent.
To complicate matters, understaffed Medicaid agencies are having a hard time completing redeterminations in a timely manner. Early data shows wide variation in disenrollment rates among states, along with an alarmingly high rate of procedural disenrollments.
How to improve the care journey with data-driven tools
Given this ongoing turbulence, health IT vendors will need access to real-time coverage and enrollment data to track trends and identify areas of opportunity. Health plans and providers will also need digital tools to help patients access care, evaluate their payment and reimbursement options, and pursue diagnosis and treatment.
By leveraging real-time data to inform digital tools, health IT vendors can help their clients offer a seamless healthcare experience that improves both utilization, loyalty and the patient experience. For example, some specialty pharmacies, infusion centers, and providers already import patient coverage, assistance, and reimbursement data into their internal systems, which allows them to educate patients about which therapies are covered, for how much, and at which pharmacies and locations.
The next generation of digital tools might allow patients and physicians to view eligibility and patient assistance data from a shared platform, alongside clinical data and longitudinal care history. Together, they could evaluate various treatment options, pulling up the patient’s health plan data to see which therapies are covered—and under what restrictions—for a particular indication.
By focusing on improving patient access, increasing pricing transparency, and offering convenient digital services, health plans and provider networks will be better equipped to attract and retain patients. During this growth period, healthcare IT vendors will need to leverage market intelligence data to help payers and providers optimize the value of their services.
Visit our website to learn how MMIT’s solutions for Healthcare IT vendors can help you analyze enrollment data, evaluate access and create new applications.
About the author
Erin Trompeter is manager of payer data at MMIT.
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MMIT, a Norstella company, believes that patients who need lifesaving treatments shouldn’t face delays because of barriers to accessing therapies. As the leading provider of market access data, analytics and insights, our expert teams of pharmacists, clinicians, data specialists and market researchers provide clarity and confidence so that our clients can make better decisions.