Lessons From 2026 Enrollment

Enrollment for 2026 brought major shifts for health plans, driven by new CMS rules, rising consumer expectations, and the growing pressure to modernize operations. This episode explores how plans are rethinking enrollment integrity, broker oversight, digital shopping, data quality, and how emerging interoperability requirements will reshape eligibility, provider data, and automation in the seasons ahead.

Tune in to understand how these changes affect the future of enrollment, and how leading plans are preparing now.

Host: Welcome. Today, we’re talking with Alex Loera. Alex oversees the enrollment and billing operations part of the BPaaS ecosystem. He specializes in scaling enrollment and billing operations, improving data integrity, and strengthening compliance in high-growth, regulated environments. Welcome Alex. 

Alex: Hey it’s great to be here. 

Host: Alex, we’ve got a number of things affecting the future of enrollment that started with the most recent Payment Year 2026 enrollment. NBPP 2026 final rule and the CMS-0057-F Interoperability, to name a few. This Final Rule applies to ACA Marketplace plans and enforces stronger safeguards against unauthorized enrollments and plan switches, which tightened processes for broker oversight and consumer disclosures. The idea was to enhance consumer understanding during the shopping and enrollment period. For plans that rely on brokers and agents as a distribution channel, what do you think went well this past enrollment period, and what should they be evaluating in their current enrollment solutions for next time? 
 

Alex: CMS observed a rising number of situations where consumers were enrolled in plans or switched to new plans without their knowledge or consent. ACA Marketplace plans need to increase their due diligence in contracting, auditing, compliance monitoring of agents, and require enhanced attestations or training around consent and application accuracy. The consumer’s knowledge and consent need to be documented. 
 

Host: While this final rule applies to ACA, if you’re a plan with multiple lines of business, like Medicare Advantage or Medicaid, wouldn’t this policy still provide direction for where CMS is likely to go?

Alex: Yes, CMS often pilots standards in ACA first, and regardless, CMS expects a consistent compliance culture and member protection practices across all plans.

Host: That makes sense to apply the same standards across multiple lines of business. How did plans safeguard against unauthorized or duplicate enrollments this season?

Alex: During enrollment season, beneficiaries are bombarded with mail, ads, and online offers, which can easily confuse them and cause them to sign up for more than one plan. Sending out identity verification correspondence is a valuable step. Also, plans need to invest in training for their brokers to provide guidelines and raise awareness of the importance of checking for eligibility, duplicates, completeness, and data accuracy. This is important for reducing duplicate enrollments or preventing enrollment delays with something as small as transposing member numbers or confusing U's and V’s. It’s also an important side note: providing robust broker training communicates the plan’s expectations for how the brokers represent the health plan, including communication expectations and when the member ID cards will be received, as well as a basic understanding of turnaround times.

Host: Good point. Brokers are an extension of the health plan in the eyes of beneficiaries. Going back to how enrollments are processed, from a technology perspective, what guardrails can be implemented to flag enrollments that don’t meet the criteria for whatever reason: duplicates, incomplete, eligibility, or plan requirements? And in the industry, is this process generally automated?

Alex: When we talk about the industry's technology, there are certainly some enrollment platforms that are more automated than others. Some require manual intervention, some quite a bit less. There’s so much value in auto-adjudicating health plan enrollment. Instead of staff reviewing each application, the system checks in real time for identity confirmation, eligibility rules, plan-specific requirements, file completeness, and data accuracy, ensuring there’s no contradictory data. For example, mismatched Social Security numbers, dates, and similar details. If everything meets the rules, the system auto-approves the enrollment and posts it directly to the membership system. This reduces bottlenecks, backlogs, and enrollment errors.

Host: What are the important factors in how you determine the configuration rules?

Alex: For the plans we service, first, we address simple data rules and scrubbing to ensure the data is clean. Second, the data is loaded into the system and put through validation and eligibility rules, including things like checking age range limits, disability qualifiers, dependents up to age 26, spouse benefits, and plan dates for the coverage period.

Host: It’s my understanding that configuration rules need to be actively monitored throughout the entire enrollment period. Is that right?

Alex: Yes, we set configuration rules to automate and achieve a high level of efficiency and auto-adjudication, but we also monitor the rules' output to ensure the outcomes aren’t too restrictive or flagging items that should pass through fine. We’re tweaking and optimizing the rules as we go, which is why our auto-adjudication rate is about 98% or up to 98%.

Host: How do you set the rules? Are you working with the client to determine what’s best for their plan?

Alex: That’s exactly right. The first step is working with the client to send the cleanest data possible. It all comes down to the quality of the data. Then we work with the client to develop validation and configuration rules, and spend time on the front end to identify all possible enrollment pitfalls. We determine what should be handled on the front end and what should be handled on the back end. For example, how does a plan want to handle when a dependent turns 26? Maybe they want to handle that on the back end and send out correspondence to determine whether they are disabled, or maybe they want to handle it on the front end at the time of enrollment. Clear rules for configuration are critical so we can auto-adjudicate the record rather than have a human handle it.

Host: Let’s discuss the Interoperability & Prior Authorization rules. There is an industry push for plans to improve auto-adjudication with cleaner identity, eligibility, formulary, and provider data. What did your team learn as you migrated toward the CMS API milestones?

Alex: Yes, so for background, the key payer obligations of this rule begin Jan 1, 2026, such as Patient Access API metrics reporting. Other API builds, such as the Provider Access API, Payer-to-Payer API, and Prior Auth APIs, are due on Jan 1, 2027. We got a jump on this and have been connected to the CMS API interface for a while now.

Host: It sounds like plans should use this regulatory change as an opportunity to review the entire enrollment funnel and the digital shopping experience.
 

Alex: Exactly. Now that enrollment has past, or this season has past, plans need to evaluate the enrollment funnel from pre-shopping and plan selection through application and identity proofing, all the way to onboarding in the first 90 days.
 

Host: What’s the SWOT analysis look like? How are plans reviewing this year’s performance to determine the priorities for next enrollment season?
 

Alex: Plans will look at what worked and what didn’t. Let’s say a plan had a goal of adding 5000 members from specific channels and funneling them into specific plans. If they got 7000, they're happy; if they got 4000, they’re evaluating where they fell short. Maybe they used a broker that didn’t deliver. In many cases, the benefits offered may not have appealed to the consumer.  So, the plan compares its benefits to those of other plans in the marketplace. Plans can use disenrollment data for members who left the plan. We can get reports that show member attrition. What plan did those members choose instead, and what were the attributes of that plan? CMS publishes data files that disclose enrollment membership details. Regional plans should be downloading the files in their market area for insight. Furthermore, we’ve made reporting that allows us to identify the specific health plans members are transitioning from. This level of insight is critical for post-enrollment evaluation, as it helps us to understand the prior coverage environment of the incoming population, anticipate operational compliance considerations, and refine our onboarding and retention strategies based on the characteristics of those source plans.
 

Host: From what you observed this enrollment season, where did plans encounter challenges?
 

Alex: The exchange plans experienced some uncertainty with the shutdown. In the ACA market, several plans dropped out. Of the plans that stayed in the market, they probably had a robust season. Of the government-sponsored health plans, it was really mixed. From a broader perspective, plans need to ensure their enrollment platforms are going through continuous improvement and development to evolve and meet all of the requirements across all the lines of business. Our BPaaS clients don’t have to worry about this because we have subject matter experts who collaborate continuously with the tech teams on enhancements and testing cycles, and then run business operations for the health plan. When you think big picture, the real problem may not be exposed with a simple SWOT of enrollment. Health plans can’t operate in siloes, where each area is fragmented, and data is separated by area of operation. Our most successful clients have our full BPaaS ecosystem, where data is unified across operational areas and member experience is woven in. Plans have to remember that the member experience starts well before the first day of coverage. 
 

Host: That’s a great point. Members are forming their first impressions during enrollment, and a big-picture view of operations is bound to be more successful than a siloed approach. Alex, thanks for the discussion. You provided a valuable framework for plans to use in their 2025 post-enrollment analysis. 
 

Alex: Good. I aim to be helpful, and I enjoyed the conversation.

Host: To our listeners, if you liked this episode, be sure to follow on Apple, Spotify, or your favorite podcast app.