Creating Competitive ACA Plans: Balancing Costs & Coverage Quality

December 18, 2023

The Affordable Care Act (ACA) — also known as “Obamacare” — is an inclusive healthcare law that aims to make healthcare insurance available to more people. It does this by lowering healthcare costs and mandating several requirements to ensure the plans are inclusive and accessible.

More Americans have enrolled for healthcare through the ACA than ever before — even the White House addressed the record ACA enrollment numbers. An ACA plan is a roadmap for your company to create and offer an affordable insurance plan with adequate coverage. ACA plans are crucial for the individuals who enroll, the healthcare insurance providers and the industry. Creating ACA plans diversifies your organization and lets you enjoy business growth and expansion.

Most importantly, understanding the complex and evolving regulations under the ACA is critical to ensure your plan is compliant. The ACA requires all health plans in the marketplace to offer ACA-compliant programs that meet specific requirements. Of course, creating comprehensive plans that suit your business model is a top priority and balancing affordability and coverage is imperative. This guide outlines the requirements for an ACA-compliant program and how to launch your plan to cover costs and coverage.

What Impact Does ACA Have on Healthcare?

The ACA has had a positive impact on the health sector. The two main benefits of ACA are that it is inclusive and accessible. More Americans have healthcare today than ever before due to the affordability of these Plans for many individuals.

Additional benefits include:

Comprehensive Provider Networks that must meet federal and state adequacy standards.
Under the ACA, health insurance providers can’t deny coverage due to a preexisting health problem.
The ACA prohibits health insurance providers from charging higher premiums based on gender, pre-existing conditions and other factors.
All ACA plans must cover preventative services.
Affordable access to prescription drugs.

As the ACA marketplace continues to evolve, there are still opportunity areas:

Not everyone qualifies for ACA subsidies, so many Americans still find healthcare unaffordable.
In areas with several issuers and product offerings, individuals can struggle to compare plans and navigate enrollment windows.

While these pros and cons affect individuals more than they do your business, it’s essential to be aware of them, as you can consider these points when creating a competitive ACA plan that meets consumer needs.

What You Require to Set Up an ACA-Compliant Health Plan

Creating a compliant health plan that follows the rules established by the ACA is essential:

Cover essential health benefits: Cover the essential health benefits for your state to be ACA-compliant. These benefits include hospital stays, outpatient care, emergency care, maternity and newborn care, pediatric care, mental health coverage, prescription drugs, rehab services, lab resources and accessible options for preventive care.
Rate review requirements: Comply with all state and federal regulations when developing and adjusting rates during annual review.
Cap out-of-pocket expenses: To have an ACA-compliant plan, you must limit out-of-pocket costs for covered services. The out-of-pocket limit doesn’t include monthly premiums, out-of-network care and services, spending on services not covered in the plan and costs that exceed the amount for a service that you, as the provider, charge. This limit is set by the state in which you operate.
Reporting requirements: Comply with reporting requirements by always submitting the required data of your plans, including enrollment numbers, coverage costs and the number of denied claims.
Network adequacy requirements: The provider networks you contract with must be able to meet your customers’ needs adequately. Look into your state requirements for adequacy, including qualitative and quantitative standards.

How to Launch ACA Plans That Balance Affordability and Coverage

The ACA plan you design will meet certain benchmark standards but will also have elements unique to your organization and the portfolio you are building for target and expected populations. These general steps serve as an excellent springboard for launching your plans to make ACA more affordable:

Create an Outline and Goals

Develop a plan that outlines your goals and the strategies you can implement to achieve your objectives. ACA plans can be standardized, so finding various ways to stand out in the market while remaining compliant is vital. You can accomplish this by considering your current and intended market, branding, pricing, provider networks and the plan’s overall design. You want to use your strengths to position yourself in the competitive health insurance market.

The planning stage may take several months of researching the market but it does pay off when you offer a plan customers will gravitate toward.

Get Your Licensure

You must get licensure for the state(s) you operate in. Dive straight into obtaining your licensure as soon as you start the planning phase, as obtaining licensure is a lengthy application process that can take months to finalize and can vary greatly depending on your state. Consider the fees involved so you may add that to your budget. Plan so that you have all the required documents to get your credentials and licensure without a hitch, including but not limited to:

Your National Provider Identifier (NPI)
Certificate of Authority
Financial Documentation
Organizational Structure
Attestations

Establish Provider Networks

Establish contracts with reliable provider networks that meet state requirements and who you trust to meet your customers’ needs. Develop an established provider network over a few months as you recruit and negotiate the terms of each affiliation.

Design Products and Strategize Pricing

The most crucial step is creating products, services and pricing options that comply with ACA’s regulations. Collaboration is the key to ensuring you make the best outline for products and pricing. Bring your financial team on board, your customer services team, your design team and marketing as you brainstorm on implementing new products, tweaking existing services, determining enrollment strategies and developing premiums.

Explore strategies regarding health costs to develop a realistic plan for balancing affordability and coverage that benefits you and your customers.

Submit a Qualified Health Plan Application

This is a yearly process that all health plans must complete to offer plans in any state or federal ACA marketplace. The application process opens in April and is concluded in September each year. Applications include templates and documents that outline your plan’s product offerings, rates, benefits, network and other vital information.

Development Systems

Strategize your options as you design and implement the practical components of your ACA plans. Practical elements include promotions or hiring new staff, choosing the best technology systems to fit your plans, how you will execute claims processing and implementing compliance procedures.

Develop and Grow Your ACA Plans with ProspHire

Having an ACA-compliant plan in your portfolio is crucial and developing the best plan for your business is undoubtedly a top priority. At ProspHire, you have a professional and reliable consulting firm supporting healthcare organizations as you develop and expand your portfolio. Our professional team works alongside you to tailor your ACA plans to your organization while offering expert advice and meaningful strategies to execute successful plans. We also assist you with marketplace accreditation, vendor implementation and business growth. Contact us today to achieve your ACA plan goals and learn more about our ACA plan development and expansion services.

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