The Opportunity for MA Plans to Modernize


Medicare Advantage (MA) plans are facing both major opportunities, and significant hurdles. On one side, they are seeing continued growth in Medicare eligibles who have an increased interest in the additional benefits provided by MA[1]. On the other side, chronic diseases are elevating healthcare costs and overall risks for participating health plans. In a market where leading health plans attribute growth to factors such as high Medicare star ratings and expanded benefit offerings[2], now is the time where all other MA plans look to improve their operational processes and enhance their offerings, in order to effectively compete in the highly regulated Medicare markets. 

Fully integrated, end-to-end systems should be designed to accommodate the intense amount of regulations in the government markets. Ideally, these solutions would include customer service-focused workflows and automation to support and strengthen the health plan’s operational structures. Additionally, with the Centers for Medicare and Medicaid Services (CMS) vision of a future with improved member experiences and measurable value on clinical outcomes, plans have begun to address social determinants of health and enrich the conversation around sustainable member health.

Evolving MA Climate 

As technology progresses and the boomer population begins to age-in, the expectations on service has grown in importance more so than for prior generations. The expectation on service excellence is simply one factor. Often, today’s Medicare beneficiaries are also making decisions based on trust and comfort demanding more assurances on security, responsiveness and rewards available from health plans for their loyalty.[3]

As this population is expected to spend and use more health care dollars than ever before, MA plans are investing to prepare for the influx. Over 80% of all Americans over 65 possess multiple chronic conditions, with roughly 5% of MA members having six or more which can lead to a medical loss ratio (MLR) over 190%[4]. These numbers only continue to rise, further securing the need for sustainable member health and efficient member management in an effort to better handle financial stresses and more effectively manage the population.

Common Features and Capabilities that
Elevate Health Plans and Ensure Operational Readiness


While some solutions may work for Medicare, it is best to find a solution built for the Medicare market. No other solution will be equitable in its functionality and efficacy.

End-To-End Functionality:

Whether for benefit administration, or enrollment and billing, end-to-end functionality should facilitate secure data flow, limit the strain on health plan resources, and optimize automation and workflows – all with a lower cost of ownership and maintenance.

Intelligent & Comprehensive Automation:

Not only reducing errors, timeliness and labor, intelligent automation allows for more seamless integration with CMS and management of regulation and requirement changes. Reconciliation rates should be high, and drop-out rates for manual work should be low.

Compliance Safeguards:

Compliance is at the top of the health plan’s mind, and it should also be at the top of the systems’. The solution should be able to compliantly handle CMS, as well as supply reporting and analytics.

Seamless Exchanges & Integrations:

Full integration with CMS and other institutions / solutions when necessary should not be a worry for plans. The plan should feel secure in their system’s ability to successfully integrate and operate in a way that protects and preserves data and further enhances other features.

A Search for the Right Answer

In the quest to enhance operations and satisfy members, and potential members, plans must consider the effectiveness of their legacy systems and point solutions. If the technology solution(s) are not effectively managing benefit administration, enrollment, billing, document processing, and customer services (to name a few) in ways that are appreciated by members, customer services representatives and business owners, then what purpose are they serving? Modernization is a clear choice when looking to move from disservice to streamlined services.

By investing in a purpose-built system, the health plan enjoys reduced operational spending, improved ability to scale and innovate, and streamlined processes to easily support members. These investments ultimately allow the plan to focus on market needs, which will help improve their ability to grow their MA membership. Of course, needs will vary by health plan, but any MA plan that is serious about success in the MA market will develop strategies and identify solutions that meet these needs.


Is Modernization Right for My Plan? Learn More.


[1] HealthScape Advisors, 2018. What Does EGWP Stand For? Untapped Potential!

[2] Mark Farrah Associates, March 19, 2018. Medicare Advantage Plans Cover Over 21 Million Seniors as of February 2018.

[3] HealthPayerIntelligence, June 26, 2018. Customer Satisfaction with Medicare Advantage Health Plans Remain Low.

[4] HealthScape Advisors, 2018. Is Change Good for the Medicare Advantage Market?