More than a decade after being signed into law, the Affordable Care Act (ACA) continues to set new records for enrollment.
During the 2024 plan year, a record 21.3 million people enrolled in health insurance coverage through the federal marketplace (Healthcare.gov) or through the 19 State Based Marketplaces (SBMs), also known as exchanges, an increase of more than 30 percent compared to last year. In 2024, plan selections in SBMs increased by 22 percent to 5.1 million.
These results mean millions of Americans have enrolled in health insurance coverage with the overall benefit of reducing the number of the uninsured. With so many consumers enrolling through an SBM for their 2024 coverage, there is a new trend emerging as states consider, or even plan, to establish their own SBM.
Under the ACA, states must either operate their own SBM or use the federal marketplace. Currently, 32 states use the federal marketplace platform while 18 states and the District of Columbia currently operate their own eligibility and enrollment platform or SBM.
What drives these states to consider joining the other independent SBMs? For starters, greater autonomy, and control. For states contemplating the move to an SBM, here are five essential considerations for a successful transition with the aim of boosting enrollment.
1) Procure customer service and technology solutions independently.
It is critically important that solutions are implemented that improve services for the public, and a key way to ensure that is by allowing vendors to focus solely on their area of expertise while still confirming technology and service solutions can work together. Customer service vendors excel at providing consumer-centric solutions that optimize for speed and customer support. Make sure you select one that has the demonstrated experience.
2) Meet (or exceed) the federal platform’s user experience.
If your state is transitioning from the federal platform, there is an expected level of service from users. That means a new SBM must deliver superior customer service experience through a well-run customer contact center. Contract with proven vendors that bring you demonstrated experience in analyzing historical trends, identifying potential call drivers, and accurately forecasting call/chat volumes to manage seasonality and fluctuations in staffing levels—and have the technological and operational capacity to quickly scale (up and down) in response.
Quality user experience also means having customer service representatives (CSRs) who are properly trained with skillsets that include empathy, a dedication to providing excellent customer service, and technical and policy awareness. Require the inclusion of bilingual CSRs and professional interpretation services to match the diverse needs of the people in your state.
Another important facet to remember is the importance of ensuring all customer services are accessible to all people. While the accessibility of an SBM website is generally the responsibility of the state’s technology vendor, your customer assistance vendor plays an equally critical role.
3) Establish systems that allow for efficient coordination between programs.
Bring the “no wrong door” approach to government service provision through your SBM. The unwinding of the Medicaid continuous enrollment provision has highlighted the need for disenrolled people to enroll in other health insurance coverage, quickly and seamlessly. An SBM that supports consumers — regardless of the initial plan they sought — helps minimize the number of people who might fall through the cracks.
4) Commit to eligibility modernization.
A transition to an SBM also requires a new mindset, and states should adopt a modernized consumer application approach that allows for more accurate, timely, and efficient eligibility determinations. This requires a partner that brings a proven combination of resources and technology to scan, upload and extract data, manually confirm, and match data to an existing record — as well demonstrated experience conducting outreach for missing or incomplete information.
5) Invest in a marketing strategy alongside outreach and education efforts.
Remember that diverse populations interact with SBMs. They bring different understanding, motivations, and previous experience with health insurance. They have varying education levels, language needs, and cultural considerations that influence how they perceive and comprehend health insurance.
For a successful transition, the state’s outreach and education strategies must reach everyone—including those who are chronically uninsured or face multiple barriers. Make sure the strategic use of advertising and social media to communicate important program changes and enrollment deadlines is a fundamental part of any strategy.
With the right investments, carefully coordinated efforts to increase coverage, and an ongoing commitment to consumers, states can successfully make the transition to SBMs.
This transition has the potential to shape the future of a consumer-centric marketplace where people can access quality, affordable health insurance coverage to help improve overall health outcomes.
Photo: zimmytws, Getty Images
Donna Frescatore brings 40 years of experience in health insurance program administration and management. She has dedicated her career to the healthcare field, with an emphasis on developing and implementing health policy and financing strategies to expand access to care and improve quality.
Donna joined Maximus in July 2022 as Senior Vice President of Strategic Initiatives. In this role, she oversees the market strategy for U.S. Services and assesses emerging policy, legislation, and trends to enhance the service offerings Maximus provides to its state partners.
Prior to joining Maximus, Donna had a distinguished career in state government. She twice served as New York State’s Medicaid Director overseeing the Medicaid program and was responsible for the health coverage of more than 8 million low-income New Yorkers.
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