Month: September 2025

CEO Series with Suraya Yahaya: How the OBBBA Drives Increased Demand for Eligibility and Redetermination Services

What changed and why it matters now 

The One Big Beautiful Bill Act (H.R. 1), which was ratified on July 4th, 2025, has changed how states verify and maintain Medicaid eligibility. HealthAxis is committed to helping payers, managed care organizations (MCOs), and states understand these changes and prepare their operations to remain compliant, efficient, and member-centric. 

Among the most consequential shifts are the shortening of retroactive coverage windows for new applicants beginning in 2027 and that states must redetermine eligibility for the ACA expansion population every six months starting with the first quarter after December 31, 2026. States must also adopt a centralized CMS process for cross-state duplicate enrollment checks and they must run regular checks against the Social Security Administration’s Death Master File to prevent improper payments.  

Additionally, states will also be required to begin reporting enrollees’ Social Security numbers and address data to CMS on a recurring cadence to support multi-state matching. These data-sharing and verification requirements compound system complexity (eligibility logic, data pipelines, privacy and security controls) and place a premium on audit-ready processes. Further, they collectively elevate operational volume and compliance exposure for Medicaid managed care organizations (MCOs) well beyond typical year-over-year cycles.¹

Implications for Medicaid plans 

For plans administering Medicaid, this means more frequent verifications, more back-and-forth with state systems, and significantly more notices, documentation intake, and member outreach.  

Front-end workflows (applications, renewals, changes in circumstance) will need to capture evidence at new checkpoints.  

Back-end processes must prove that every eligibility decision aligns to federal and state rules, including new data-matching obligations. Even small gaps, like a missing quarterly data feed, can escalate into payment disallowances or corrective action plans.²

How HealthAxis helps 

  • AxisCore™ (CAPS): Our core administrative processing platform is designed to handle complex eligibility and enrollment logic, including configurable rules that reflect federal and state program specifics. AxisCore integrates with required data exchanges and supports robust documentation and audit trails, making redeterminations and evidence tracking systematic rather than manual.
  • AxisConnect™ (BPaaS/BPO & Consulting): We stand up rapid-response intake, verification, and member-contact teams to absorb redetermination surges, resolve evidence gaps, and standardize compliance documentation. Our teams help health plans optimize letters, scripts, and renewal campaigns that reduce avoidable churn, while aligning to new statutory cadence and verification steps.

Why act now  

Eligibility operations often appear to be in order until new rules are introduced all at once. The six-month redetermination cycle and data-matching mandates will strain legacy queues and brittle integrations. We help MCOs conduct readiness assessments, map new verification touchpoints, and deploy AxisCore configuration updates and AxisConnect operational capacity ahead of deadlines. That means fewer backlogs, fewer compliance findings, and fewer members slipping through the cracks during renewal.  

Navigating these changes requires more than just compliance; it calls for agile systems and experienced partners. HealthAxis stands ready with AxisCore and AxisConnect to keep your eligibility operations ahead of federal deadlines. 

 

Author

Suraya Yahaya, President and Chief Executive Officer

 

Sources:

1 and 2, Congress.gov 

How Modular Workflows Help TPAs Deliver Differentiated Services

The challenge TPAs face today 

Third-party administrators must stand up and maintain a wide range of client-specific benefit designs, each with its own eligibility rules, cost-sharing structures, accumulators, prior authorization requirements, provider networks, and funding models. Traditional plan-build processes often rely on one-off spreadsheets, custom code, and tribal knowledge. The result is slow onboarding, inconsistent quality, and operational risk every time a new client arrives or an existing one changes benefits mid-year. 

What “modular workflows” mean in practice 

A modular approach breaks a plan into reusable building blocks, benefit components, rules, and templates, that can be assembled into client-specific configurations without writing new code. Instead of recreating the wheel for every employer or payer partner, you select and combine pre-vetted modules (e.g., deductible options, tiered copay schedules, network rules, specialty carve-outs), then apply client-specific parameters. 

With AxisCore, HealthAxis provides rules-driven workflows that make this modular approach practical for busy operations teams: 

  • Rules-driven configuration. Plan logic is captured as human-readable rules that determine eligibility, cost-share, and adjudication behaviors. 
  • Templates and libraries. Common plan patterns become templates that can be cloned and parameterized across contracts. 
  • Non-technical usability. Operations and product staff can configure and update plans through guided workflows with no heavy development cycles. 
  • Change control. Versioning and approvals enforce governance, so every change is tracked and auditable. 

This approach aligns technical rigor with operational speed, so your business can say “yes” to more nuanced client needs without adding complexity. 

 

How it comes together 

  • Multi-state employer with varied cost-sharing. A TPA needs to launch a PPO with HSA-compatible options in some states and standard PPO cost-sharing elsewhere. Using AxisCore, the team selects an HSA-compliant deductible/coinsurance module for applicable states, applies a copay module for others, and assigns the appropriate network rules, all from established templates. Mid-year adjustments become parameter changes, not custom projects. 
  • Specialty carve-out for high-cost therapies. An employer introduces a specialty drug program with distinct prior authorization logic. The team adds a specialty pharmacy module with pre-defined authorization rules and ties it to the relevant formulary and network settings. The change is governed through approvals, and the updated configuration can be reused when another client requests a similar carve-out. 
  • Union group with unique eligibility windows. A fund requires alternating eligibility periods based on hours worked. The eligibility module is applied with parameters reflecting the client’s hour thresholds and look-back rules, again, without introducing bespoke code. 

These are common TPA patterns that benefit from modular, rules-based assembly and controlled reuse. 

What are the benefits of using a modular approach 

1) Faster commercialization without tech debt
Say “yes” to differentiated RFP requirements by assembling from a trusted catalog rather than coding from scratch. This compresses onboarding timelines and reduces reliance on scarce engineering cycles. 

2) Governance and risk control
Standardized components reduce variance in plan builds. Approvals and versioning ensure changes are intentional, reviewable, and reversible. 

3) Operational scalability
When client growth outpaces engineering headcount, modularity lets operations scale plan setup and maintenance predictably. New hires ramp up faster because they work with guided workflows and repeatable templates. 

4) Lower cost to serve
Reusable modules cut the hidden costs of one-off builds, requirements gathering, development, QA, and convert them into parameter changes handled by the business. 

The bottom line 

AxisCore simplifies the setup of diverse client-specific plans using rules-driven workflows that minimize technical effort. By making plan logic modular, reusable, and governed, TPAs can support dozens of clients with unique plan needs, without heavy dev work or platform complexity. 

Let’s talk 

If you’re ready to reduce onboarding times, expand your catalog of differentiated benefit designs, and scale without expanding technical headcount, HealthAxis can help.
Contact us to see AxisCore’s modular plan setup in action and explore how a rules-driven approach can accelerate your growth while strengthening control. 

What Modular Really Means in Payer Technology

Directors and executives across commercial health plans are under relentless pressure: introduce new employer-specific products faster, keep up with shifting rules, and do it without expanding IT backlogs. “Modular” technology is often pitched as the answer, but the word can become buzzword soup without a concrete definition tied to business outcomes.

At HealthAxis, modular means something very specific: AxisCore uses configurable workflows and a rules-based engine to design, launch, and administer plans with minimal day-to-day IT involvement. The result is a platform that adapts to your business instead of forcing your business to adapt to your software.

 

Why modular matters now

The regulatory bar continues to rise and evolve. For example:

  • Transparency in Coverage (TiC) requires most group and individual plans to publish machine-readable pricing files on public websites and keep them current. Plans also must provide consumer cost-sharing estimates via a self-service tool.
  • Interoperability & Prior Authorization rules mandate FHIR® APIs (Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization) with compliance dates that begin in 2026 for operational provisions and January 1, 2027 for API implementations—plus faster decisions (72 hours expedited; 7 days standard) and public reporting of PA metrics.
  • The annual Notice of Benefit and Payment Parameters (NBPP) continues to refine Marketplace standards (e.g., network adequacy reviews and other plan certification criteria), requiring issuers to adjust designs and processes on tight cycles.

In short, requirements evolve every year. A modular platform lets you respond by reconfiguring, not re-coding.

 

AxisCore, in practice

Configurable. With AxisCore, benefit, enrollment, billing, and adjudication steps are orchestrated as discrete workflow components. You can tailor pathways to your market and regulatory context without breaking other lines of business.

Reusable. Standard functions (e.g., eligibility checks, accumulators, network lookups, PA routing) are pre-built modules. Once approved by governance, they’re reused across products and employer groups to drive consistency and speed.

Scalable. Need to add a new Marketplace product, a carve-out rider, or a specialty network? You extend the workflow with additional modules and experience no disruptive refactors to the core system.

 

What this unlocks for Commercial plans

1) Launch employer-specific products—fast

Whether it’s a large group with custom riders or a Marketplace offering aligned to standardized options, AxisCore’s rules layer captures plan specifics (deductibles, accumulators, tiering, prior-auth lists) while workflow modules manage eligibility, enrollment, billing, and claims. Your product team can iterate on designs; operations can stand up administration without waiting on bespoke code.

Key message: Easily configure and launch employer-specific plans, from large group to Marketplace products.

2) Compliance by configuration

Transparency in Coverage: Keep machine-readable files and cost-sharing estimates aligned to plan rules by sourcing rates and accumulators from a single rules base, so updates flow to required disclosures on schedule.

Interoperability & Prior Authorization: A modular data and workflow architecture makes it straightforward to route PA requests, capture decision reasons, publish metrics, and support FHIR-based APIs on the mandated timelines.

NBPP updates: When Marketplace standards change (e.g., network adequacy checks or display rules), you adjust the affected modules, provider data validation, plan display attributes, without re-engineering the rest of your stack.

3) Standardize once, scale everywhere

Reusable components (enrollment validations, subsidy logic, SBC generation, PA criteria checks) promote uniformity across employers and markets. Governance teams approve the module; product and operations teams reuse it repeatedly, reducing error rates and accelerating time-to-offer.

4) Evolve without disruption

Because AxisCore’s modules are loosely coupled and policy is expressed in rules, you can swap, add, or version components as your business changes, such as bringing new vendors online, piloting value-based arrangements, or introducing novel benefits, all without halting daily operations.

 

The upside for leaders

CFO: Lower variability in admin processes, clearer unit economics per product line, and fewer one-off builds.

COO: Faster operationalization of benefit changes and employer customizations with built-in controls.

CIO/CTO: A product-centric roadmap where IT enables business configuration, not endless queues of tickets.

Compliance: Evidence trails and rule sets map cleanly to CMS requirements (TiC, Interoperability/PA, NBPP), supporting audits and reporting.

 

The HealthAxis difference

AxisCore was built for payers who need to configure, reuse, and scale. By combining modular workflows with a robust rules engine, we help commercial plans launch employer-specific products rapidly, adapt to regulatory change, and evolve operations without disrupting what already works.

If your next growth target depends on faster product cycles or tighter compliance, with less IT friction, let’s talk about how AxisCore can help.

 

 

 

Sources:

CMS, Interoperability and Prior Authorization Final Rule (CMS-0057-F) (compliance windows, FHIR APIs, decision timeframes). Centers for Medicare & Medicaid Services.

CMS, Transparency in Coverage Final Rule Fact Sheet and Use of Pricing Information Published under TiC (machine-readable files, consumer estimate tools, update cadence). Centers for Medicare & Medicaid Services.

CMS, HHS Notice of Benefit and Payment Parameters for 2025 Final Rule (ongoing Marketplace and plan standards). Centers for Medicare & Medicaid Services.

Workflows Built for Waivers, Carve-Outs, and State-Specific Requirements

Regulatory change isn’t a quarterly event, it’s constant. Each year, CMS releases the Medicare Advantage and Part D Advance Notice followed by the Rate Announcement, setting off plan modeling, benefit updates, and operational changes that can’t wait for long IT projects. 

At the same time, D-SNPs must align with State Medicaid Agency Contracts (SMACs) under 42 CFR §422.107, contracts that spell out exactly how MA organizations and states will coordinate benefits, data, and member communications for dual-eligible populations. Requirements vary by state and evolve over time. 

And modernization pressures continue: CMS’s Interoperability and Prior Authorization final rule adds new expectations for data exchange and prior authorization transparency on a fixed timeline, changes that ripple through intake, review, notification, and reporting processes. 

Bottom line: health plans need operations that can pivot quickly without rebuilding core systems.

How AxisCore Helps

AxisCore uses modular workflows and a rules-based engine so your teams can configure and administer plans with minimal IT involvement. Think building blocks: assemble the steps you need, attach the rules that govern them, and move from policy to production faster, without custom code each time.

What “modular” looks like in practice

  • Eligibility & program routing – Determine whether members fall under standard MA, D-SNP, or a state-specific arrangement, then route to the right processes.
  • Benefit administration – Apply benefit design differences (e.g., supplemental benefits by county or contract) using rules that reference CMS guidance and state terms.
  • Authorization & notification flows – Orchestrate intake, clinical review, decisioning, and member/provider letters with configurable steps and deadlines.
  • Appeals & grievances – Enable state-specific content, timelines, and tracking alongside standard MA requirements.
  • Data exchange hooks – Drop-in connectors for file-based or API-driven feeds to meet emerging interoperability expectations.

Why This Matters Now

1) State-specific D-SNP expectations keep changing. 
States can impose integration, data-sharing, and notification provisions through the SMAC. When an annual update lands, operations must reflect it quickly (e.g., new notification content or data exchange cadence). Our rules layer isolates those state deltas so operations, not developers, can roll them out safely. 

2) Policy updates arrive on fixed clocks. 
The Advance Notice/Rate Announcement cycle drives yearly recalibration across benefits, bids, and downstream processes. Modular workflows let you model and implement changes earlier, so member communications, producer training, and internal QA aren’t squeezed at the end. 

3) Carve-outs and waivers are operationally real. 
Programs frequently carve out specific benefits to different administrators. A clear example: California’s Medi-Cal Rx moved pharmacy benefits out of managed care to fee-for-service in 2022, a large-scale operational shift that required new routing, data exchange, and member messaging at launch. Our approach treats carve-outs as configuration, not re-engineering. (Medicaid example used to illustrate carve-outs.)

4) Interoperability & prior authorization standards are maturing. 
CMS’s recent rule sets new requirements for how payers exchange data and communicate PA decisions, affecting intake, review, and notification steps. HealthAxis workflows already segment those steps, so updating logic, payloads, and timelines is a targeted change, not a system overhaul.

How AxisCore Delivers

Configurable – Tailor workflows to your organization’s needs and to regulatory specifics:

  • Parameterize timelines, content, and routing by state, contract, or line of business.
  • Reference rule sets (e.g., D-SNP contract terms, MA communications standards) directly in workflow logic to drive consistent outcomes.

Reusable – Leverage pre-built modules across teams to increase efficiency and consistency:

  • Standard steps—eligibility checks, UM review gates, A&G queues, provider/member notifications—are drag-and-drop.
  • Shared components lower training overhead and reduce variance across markets.

Scalable – Evolve and expand workflows without disrupting existing systems:

  • Introduce a new state requirement or benefit carve-out by adding a branch with its own rules, no code freeze, no parallel stack.
  • Version workflows, test safely, then promote to production on your timeline.

Scenarios your Team Can Act on Immediately

  • A state updates its D-SNP SMAC: Add a new notice template and data-sharing cadence; apply only to members in that state and product line through targeting rules.
  • Annual MA changes: Adjust benefit logic following the Rate Announcement while preserving last year’s configuration for audit traceability.
  • Benefit carve-out or vendor change: Reroute pharmacy or behavioral health transactions to a different administrator; update member and provider letters accordingly. (Illustrated by the Medi-Cal Rx carve-out example.)
  • Interoperability/PA updates: Insert new API calls or decision-explanation steps into the existing authorization flow, rather than rewriting it.

Governance you Can Trust

  • Transparent rules: Every decision path is visible and explainable for regulators and auditors.
  • Version control & rollbacks: Promote, compare, and revert workflow versions as needed.
  • Separation of duties: Business owners manage rules; IT governs environments and integrations.

What your Organization Can Gain

  • Speed to market: Convert policy into production changes faster—without monopolizing scarce engineering time.
  • Lower operational risk: Centralized rules reduce one-off exceptions and help ensure consistent compliance.
  • Cost control: Reuse modules across lines of business and states; focus effort where regulations truly differ.

Let’s Make Policy Agility your Competitive Advantage

HealthAxis gives your plan the operational flexibility to adapt quickly to policy or benefit changes across Medicare Advantage, D-SNP, and Medicare programs—without disrupting the systems you rely on every day.

If you’re preparing for state-specific updates, planning for the next Advance Notice/Rate Announcement cycle, or mapping to new interoperability expectations, we’d welcome a conversation about how our modular workflows and rules engine can help. Schedule a discovery call today.

 

 

 

Sources:

CMS Medicare Advantage rate-setting process and timelines; 42 CFR §422.107 D-SNP SMAC requirements; CMS Interoperability and Prior Authorization final rule
DCHS Medi-Cal RX