5 keys for the successful implementation of a state-based marketplace

More than a decade after being signed into law, the Affordable Care Act (ACA) continues to set new records for enrollment.

During the 2024 plan year, a record 21.3 million people enrolled in health insurance coverage through the federal marketplace (Healthcare.gov) or the 19 State-Based Marketplaces (SBMs), also known as exchanges, an increase of more than 30 percent compared to last year. In 2024, plan selections in SBMs increased by 22 percent to 5.1 million. (1)

These results mean millions of Americans have enrolled in health insurance coverage, which has the overall benefit of reducing the number of uninsured. With so many consumers enrolling through an SBM for their 2024 coverage, a new trend is emerging as states consider or even plan to establish their own SBMs.

Under the ACA, states must operate their own SBM or use the federal marketplace. Currently, 32 states use the federal marketplace platform, while 18 states and the District of Columbia operate their own eligibility and enrollment platform or SBM.

What drives these states to consider joining the other independent SBMs? For starters, greater autonomy and control. For states contemplating the move to an SBM, here are five essential considerations for a successful transition with the aim of boosting enrollment.

1. Choose contractors with proven experience in their respective areas of expertise.

It is critically important that solutions are implemented to improve services for the public, and the best way to achieve that is by allowing vendors to focus solely on their area of expertise while still ensuring technology and service solutions work together. SBM customer service vendors excel at providing consumer-centric solutions. They have demonstrated experience in analyzing historical trends, identifying potential call drivers, and accurately forecasting call/chat volumes to manage seasonality and fluctuations in staffing levels. They also have the technological and operational capacity to quickly scale (up and down) in response to changes in demand.

2. Create a user experience that meets or exceeds consumers' expectations.

Enrolling in health insurance coverage impacts consumers’ health and financial wellbeing. While standardized benefits and coverage levels have helped simplify the shopping experience, choosing a coverage option can still be a complicated decision. A quality experience means not only having the technology to support the consumer experience but also having customer service representatives (CSRs) who are properly trained with skillsets that include empathy, a dedication to providing exceptional customer service, and technical and program understanding. When designing the customer service experience, it is important to consider the critical role it plays in ensuring equitable access to coverage. All customer services must be accessible to all people. SBMs need to ensure the availability of bilingual CSRs and professional interpretation services to match the diverse needs of residents.

3. Consumers expect a modernized customer service experience.

A transition to an SBM presents an opportunity to adopt a modernized consumer experience that makes applying for and enrolling in coverage easier. Consumer preferences for interaction with an SBM vary. While some people will prefer to speak with a highly trained CSR, others may prefer interactive voice response or chat. Mobile applications and document upload capabilities speed up the process and help achieve the goal of ensuring more people successfully enroll. From initial contact to enrollment, meeting the consumer’s preference requires a partner with a proven combination of technology and human resources.

4. Design your SBM to help consumers easily transition from one type of coverage to another when moving between programs.

Changes in income, family size, and other life circumstances change program eligibility. The unwinding of the Medicaid continuous enrollment provision has highlighted the need for people to be able to transition from one health insurance coverage option to another quickly and seamlessly. Bringing a “no wrong door” approach to your SBM can help address this reality and minimize the number of people who have a gap in coverage or lose coverage entirely.

5. Invest in a marketing strategy alongside outreach and education efforts.

Diverse populations interact with SBMs. They bring different understandings, motivations, and previous experiences with health insurance. They have varying education levels, language needs, and cultural considerations that influence how they perceive and comprehend health insurance. For a successful transition, your state’s outreach and education strategies must reach everyone — including those who are chronically uninsured or face multiple barriers. Strategic use of outreach, including social media to communicate important program changes and enrollment deadlines, is a fundamental part of any strategy.

With the right investments focused on increasing coverage and an ongoing commitment to consumers, states can successfully transition to SBMs.

(1) Source: Health Insurance Marketplaces 2024 Open Enrollment Report, Centers for Medicare & Medicaid Services