3 Ways Insurers Can Succeed in Government Markets

As enrollment rates decline in the large-group market and premiums rise for employers and employees alike, health plans are focusing their attention on government-sponsored markets. Ongoing and upcoming policy changes allow for continuous growth in the Affordable Care Act, Medicaid, and Medicare Advantage markets. To capitalize on the significant gains in stability and profitability, health plans must first understand what success looks like in government-sponsored markets.

Thriving in government markets was the focus of a recent Softheon Executive Advisory Council, an invitation-only think tank of senior executives from national and regional health plans. During the two-day meeting, senior executives from 15 carriers and government agency leaders set out to define success in government markets and detail how to achieve their goals. Health plans represented in the council account for more than 50% of the US insured population.

Benchmarking with other health plans

Executives defined success as improved acquisition, retention, and continuity of coverage rates.

In a pre-event survey detailing their definitions of success, council participants shared the following goals that apply to multiple government-sponsored markets:

• On-demand, precision analytics that allows for personalized and frequent outreach
• Repeatable processes and technologies that promote continuity of coverage
• Integrated shopping, eligibility, and enrollment platform & experience

3 keys to success in 2023

Healthcare leaders shared the top nine capabilities their health plan needed to achieve benchmarks they set for 2023. Of those, three were selected as the top shared priorities:

Integrating the shopping, eligibility, and enrollment platform and experience

Competition in government markets is only getting tougher, and eligible individuals are still slipping through the cracks.

With a rise in individuals transferring from employer-sponsored coverage or another government market, there is a demand for a universal access point for coverage. Since government markets underwent various reforms to increase stability and eligibility, there has been a corelated decrease in employer-sponsored enrollment. Between 2018 and 2020, employment-based coverage decreased by 0.7 percentage points. This decline can be expected to continue with the total percent of Americans enrolled in employer-sponsored coverage hitting the lowest point in 10-plus years at 48.5%.

Meanwhile, government markets are experiencing a period of growth:

• More than 16 million people signed up for coverage in the ACA during the 2023 open enrollment period.
• Growth in the Medicaid market parallels the ACA enrollment boom. The states that expanded Medicaid since 2020 have seen largest increases in Medicaid and CHIP enrollments.
• Enrollment in Medicare Advantage plans have more than doubled over the past decade. Enrollment jumped 8.8% increase in 2022. The acceleration exceeded growth estimates made in 2021.

Transition between coverage types is expected to reach a new high beginning April 2023. The Kaiser Family Foundation estimates that between 5.3 million and 14.2 million low-income people could lose Medicaid coverage following the end of the federal continuous enrollment requirement.

According to an EAC participant, health plans in the ACA should aim for a 50% digital engagement rate. The general shift toward e-commerce means health plans must utilize a variety of avenues to target and enroll members in and between government-sponsored markets.

Benefits beyond the immediate financial gain of transferring individuals between different coverage types include a positive user experience that increases retention rates. Health plans can reduce gaps in coverage by prioritizing continuity of coverage through targeted member outreach and a seamless shopping, eligibility, and enrollment interface.

In a live poll, EAC participants unanimously identified a unified shopping, eligibility, and enrollment experience as an initiative worth funding, but only 18% considered it a top priority.

At the conclusion of the conference, participants voted a “no-wrong-door” approach to coverage as a top 3 priority. The goal is to create a single access point to government-sponsored coverage. Ideally, through a single interface, individuals can determine eligibility for and enroll in the coverage type that best suits their needs without being redirected.

Know your customer through data and interoperability

Are you concerned with how an end to the public health emergency and automatic Medicaid redeterminations will affect your health plan? EAC participants were.

Health plans are in danger of a massive wave of Medicaid disenrollments when the public health emergency ends in May. Health plans need to make sure they can assist people transitioning from Medicaid and enrolling in alternative coverage.

Over the last 20 years, banking, financial services, and retailers have adopted “Know Your Customer” to provide a seamless consumer experience while reducing fraud, waste, and abuse.

Using new and existing data sets allows health plans to target members most likely to lose Medicaid coverage, gather up-to-date contact information, and determine eligibility for other forms of government-sponsored coverage.

Health plans have already begun the process of integrating with external data sources. Fast Healthcare Interoperability Resources offers a promising and common set of application programming interfaces for healthcare systems to communicate and collect vital contact data.

Defining a 6-star member experience

A health plan with over 1.5 million members shared that the top reason for voluntary Medicare Advantage disenrollment is members not understanding the product offering.

Members transitioning from a guided coverage shopping, enrollment, and management experience — complete with a dedicated HR department — might get lost in the confusing world of government-sponsored coverage.

To improve retention rates, health plans are simplifying their plan offerings and enrollment journey. Investing in a simplified self-guided member experience helps health plans reduce call center volumes while increasing member satisfaction.

Leaders agreed that collaboration between health plans is needed to define the 6-star member experience.

Too often, health plans approach increasing acquisition and retention rates by actively working against other plans. From divisive (and conflicting) messaging to overloading the markets with low-quality plans, anti-competitive behavior hurts members much faster than the competition.

Plan executives expressed a desire to collaborate with other plans and Government partners to create better outcomes for members.

To learn more contact Matthew Weinstock, Senior Editor, Health and Life Sciences.