The following is a guest article by Lindsey Miller, Program Director of Health Plan Solutions at Softheon
Health plans are bracing for Affordable Care Act (ACA) Open Enrollment (OE), which will test their processes and systems. The last few months have been a rollercoaster of policy changes, including debates over healthcare premium subsidies set to expire at the end of the year. Adding to the challenge: forecasted double-digit premium increases driven by rising healthcare costs.
As plans manage extreme uncertainty, they must also support their members in navigating one of the most complex Open Enrollments in years. The 2027 cycle is likely to bring even more disruption.
Many Marketplace payers are turning to AI and automation for assistance, but this effort will produce limited benefits or even backfire without the necessary underlying infrastructure. Health plans must integrate their systems to build a digital framework that supports quick operational pivots and maintains user experience through the changes.
Premium Increases
Health insurance affordability presents a major challenge for health plans. 2026 ACA premium rates will increase by an average of 22-24% nationwide.
Enhanced premium tax credits are scheduled to expire at the end of the year, unless Congress intervenes. Without the financial support from the subsidies, KFF estimates that annual premiums will more than double what subsidized enrollees currently pay. Lawmakers are still debating a possible extension, creating uncertainty for plans and members.
The increased costs will prompt some members to reassess their plans or even drop coverage. Retention will depend on consistent, supportive engagement with members utilizing brokers, community partners, and health plans.
Legislative Changes
Recent legislation introduced new eligibility and verification requirements, but many are on hold amid legal challenges. This uncertainty shortened timelines; plans had only one day to refile with actuarial values for OE 2026 with CMS, creating an operational bottleneck.
Payers must prepare for additional compliance changes for OE 2027. Federal legislation will likely shorten the enrollment period, shift enrollment eligibility requirements, and end auto-reenrollments.
These changes will make data integration even more critical as plans deal with increased document volume, new verification processes, condensed timelines, and the imperative for member education.
Integrated Data Infrastructure for Plan Management
Siloed systems create the opportunity for errors and delays. Each CMS rule change triggers a chain reaction — exporting lists, reformatting files, re-uploading data, and resending updates across platforms. If enrollment and approval processes take too long or are done improperly, members may experience coverage delays, inaccurate communications, or even lose access to benefits.
Adding AI and automation without integration multiplies potential mistakes, and layering it onto a broken or siloed process will not solve the underlying problem. When data lives in separate systems, automated processes act on gaps and outdated information. As a result, employees must spend time finding and fixing errors while members deal with confusion or even coverage issues.
Under shorter timelines and stricter documentation requirements, these inefficiencies will create additional compliance risks and member frustration.
Health plans with integrated systems have comprehensive, real-time information necessary to automate enrollment, verification, and reconciliation for accurate and timely approvals and payments. With all platforms connected, plans can uniformly update eligibility and enrollment logic while maintaining accurate subsidy and premium calculations as new rules take effect. The result: Members stay covered as they move between plans or eligibility statuses.
Supporting Member Communication with Integrated Systems
With the uncertainty surrounding eligibility rules, premiums, and subsidies, member confusion will be rampant. One renewal reminder won’t be enough. Plans need tools to enable sustained, clear communication. Transparency and consistency throughout the enrollment process help maintain trust.
The more proactive the outreach plan, the less painful the first invoice shock will be. Manually sending messages risks delays, outdated information, or entirely missing an affected member. By connecting eligibility, enrollment, and billing data, plans can trigger AI-powered, status-based outreach personalized to the member.
The new premiums will likely push some people to change their coverage. With access to comprehensive data, AI tools can help these members select a plan that aligns with their health needs and budget. This guidance will reduce drop-off.
The changes will spur many member questions. Customer service teams must be educated and trained so they can properly explain what’s happening. Integrated systems give agents access to a comprehensive view of each member’s status, the latest policy changes, and updated, consistent scripts to provide accurate responses. Health plans can also use AI-powered chatbots, trained on the latest information, to handle simple questions, reducing the call volume for the human team.
Managing Uncertainty and Pending Changes
Right now, health plans are making operational decisions under conditions that could change dramatically with a single vote in Congress. Integration gives them the flexibility to pivot quickly.
Health plans should treat OE 2026 as a stress test. With more dramatic changes coming next year, Open Enrollment will demand even faster processing and dynamic, persistent communication. Learn from this year to build an infrastructure that enables AI and automation to help, not hinder, performance and member experience.
About Lindsey Miller
Lindsey Miller is the Program Director of Health Plan Solutions at Softheon. She leads strategies for health plan solutions (Marketplace, Medicare, ICHRA, and Broker). Prior to this role, she founded Gardens in the Gorge and served as Client Success Lead at NextHealth Technologies before its acquisition by Softheon. Her other experience includes roles in revenue cycle operations at Catholic Health Initiatives (now Common Spirit Health), project management at BlueCross BlueShield of Tennessee, and consulting at Booz Allen Hamilton.
