In our previous blog, we focused on the new implementation demands of the One Big Beautiful Bill Act (OBBBA) facing states and MCOs. These demands and operational shifts directly affect how members move between Medicaid and Marketplace coverage. To further explore this ripple effect, read below on how eligibility and verification changes are likely to drive membership shifts, coverage churn, and heightened IT requirements for payers.
Specifically, coverage churn is not just a technical problem; it’s a member experience problem. HealthAxis has the capabilities to equip payers with the tools and services needed to make coverage transitions seamless and compliant.
Why churn will rise
Tighter Medicaid eligibility processes (semiannual redeterminations, community engagement verification) and enhanced Marketplace verification for premium tax credits (PTCs) will increase “boundary movement” between coverage programs. H.R. 1 directs exchanges to verify income, family size, lawful presence, residence, and coverage status and expands recapture of excess advance PTCs, with changes taking effect as early as 2028. Plans serving both Medicaid and Marketplace populations should expect more frequent transitions, terminations, appeals, and reconciliation events.
Individuals who disagree with Marketplace eligibility decisions continue to retain formal appeal rights (generally 90 days from the notice date), underscoring the need for well-orchestrated member communications and documentation. Plans that help members navigate appeals and special enrollment periods (SEPs) can reduce abrasion and speed of time to coverage.
Roadmap to Alignment
AxisConnect BPO for Marketplace Operations:
- Appeals & Grievances Support: Intake, evidence-gathering, and submission support aligned with federal timelines.
- Member Communications Using Marketplace Systems: Proactive campaigns to explain PTC verification, documentation checklists, and SEP triggers when Medicaid ends.
- Enrollment Support Using Marketplace Systems: Hands-on assistance with plan selection, binder payments, and 834 issue resolution to minimize gaps.
AxisCore Automation & Reconciliation:
- Eligibility Reconciliation: Automated nightly jobs to match Marketplace decisions with plan systems and resolve discrepancies.
- Grace Period Customization: Custom build rules around grace periods to ensure accurate communication and processing for members resolving outstanding premium bills.
- Cross-Program Transitions: Event-driven workflows that create seamless disenroll/re-enroll sequences when members move between Medicaid and Marketplace.
Strategic benefit
Plans that harden the seams between programs, technologically and operationally, will keep members covered and costs predictable despite higher churn. AxisCore and AxisConnect together provide the rails and the operational muscle to make that happen.
HealthAxis partners with plans to build resilience so that, even in times of change, members experience continuity, compliance remains strong, and operations remain sustainable. Our scalable, modular approach delivers enterprise-grade technology and service without complexity or fixed cost. With a single partner for both technology and operations, plans are implemented faster, support is more responsive, and solutions are designed around their unique size and growth ambitions.
Author:
President and CEO of HealthAxis
