Expanding Medicaid and Medicare Health Plan into ACA

This document is a case study detailing the process of a regional health plan's expansion into the Affordable Care Act (ACA) within a State-Based Marketplace (SBM). The health plan, which specializes in Medicaid and Medicare offerings and serves approximately 300,000 members, aimed to tap into a new market and reduce risk by entering the ACA in a state where it already had a presence. The plan established a timeline of under five months to achieve enrollment for Open Enrollment 2024 (OE 24). A comprehensive Marketplace Cloud solution was utilized, which included shopping, eligibility and enrollment, premium billing and payment, and program administration. The results indicated a successful entry into the SBM within the targeted timeframe, leading to plans for further expansion into additional SBM states in 2025. The case study outlines the necessary state-specific expertise and the importance of a technology partner with a proven track record in navigating the complexities of SBMs.