The upcoming Affordable Care Act (ACA) Open Enrollment (OE) period presents at least three major challenges for health plans: Legislative changes, double-digit premium increases, and potentially expiring subsidies. To maintain membership and a positive user experience, health plans must carefully evaluate their approach to enrollment, engagement, and retention.
New rules are reshaping OE workflows, while price increases create affordability concerns for members. It’s difficult for health plans to manage these challenges effectively — even with the help of AI — as long as they rely on fragmented data and manual operations. Payers will need a robust, integrated ecosystem to support their members through this transition.
Major Changes Pending for ACA Coverage in 2026
Obtaining or maintaining health coverage in 2026 will require more member action and complicated enrollment processes. Health plans must contend with:
- Enrollment changes
The One Big Beautiful Bill Act (OBBBA) requires certain consumers to submit additional documentation for eligibility confirmation and removes the 60-day extension to resolve income inconsistencies. These changes will significantly increase the verification burden for members, plans, and technology vendors during OE26.
- Increased premiums
For 2026, nationwide premiums for ACA marketplace plans are expected to increase by 23.4%, the second-largest rate change since 2014.
- Potential subsidy expiration
Complicating the situation, enhanced subsidies are set to expire at the end of the year if Congress does not act. Without these supports, net premiums would spike beyond the proposed increases. Lawmakers are still debating the future of the tax credits, adding more uncertainty for both plan members and carriers.
In light of these changes, some members will reassess their plan choices and may even be forced to drop coverage. Experts warn that expired subsidies will result in millions of people losing access to coverage. LifeWise Health Plan of Washington President Kristin Meadows said, “The loss of these credits would not only disrupt individual lives, it would also weaken our local health care system and economy.”
To avoid coverage disruption, plans need systems that can absorb policy shifts while supporting member needs.
Integration is essential for successful Open Enrollment
For OE2026, health plans face greater operational pressure — more member actions, more verification steps, and more paperwork to manage. The key to navigating this complexity is integration.
By connecting enrollment, eligibility verification, billing, payments, and communications on one platform, plans can automate workflows and keep members at the center of every interaction. A unified infrastructure allows teams to reconfigure eligibility and enrollment logic across multiple lines of business at once, applying new rules consistently On- and Off-Exchange.
Integrated platforms also streamline verification and reconciliation. Instead of manually reviewing documentation, plans can automate approvals and payments, ensuring accuracy, speed, and compliance. Members receive consistent information and real-time status updates across all touchpoints, from the Exchange to direct enrollment and broker portals, building trust through transparency.
Integration doesn’t just simplify operations; it protects coverage continuity. Members can enroll and renew digitally without toggling between platforms, repeatedly filling out forms, and uploading documents multiple times. That means fewer delays in subsidy determinations and less confusion as rates and plan options change.
Managing member relationships amid the change
Integration of systems supports another crucial piece of OE: Member communication. This OE period requires clear, personalized outreach, especially as automatic renewals phase out. Members will need multiple reminders, timely explanations, and reassurance about what’s changing.
Integrated systems enable personalized, AI-driven communication that adapts to each member’s situation. Plans can automatically trigger messages based on the person’s current status and financial profile, providing tailored guidance and timely reminders. AI-powered tools support plan selection by making recommendations based on health needs, subsidy eligibility, and budget. These suggestions will be especially important as people reevaluate their coverage.
Of course, members will have questions about the changes. Health plans must support customer service teams in managing the influx of inquiries. With consolidated enrollment, billing, and eligibility data, AI-powered chatbots can handle simple requests, and employees have the information — and the time — to give members accurate guidance and meaningful support.
Preparing for the future
This year is just the start. The OBBBA will further alter next year’s OE, including a shortened enrollment window and the elimination of automatic re-enrollment for all subsidy-eligible members. Additional legislative changes are likely between now and then.
Integrated technology gives health plans the agility to adapt. By linking enrollment, eligibility, billing, and communication systems, plans can leverage automation and AI to simplify complexity, reduce administrative strain, and improve member experience.
About Kevin Deutsch
Kevin Deutsch is the General Manager and Senior Vice President of Health Plan Solutions at Softheon, a leading cloud-based shopping, eligibility, enrollment, billing, and member management solution for health plans, brokers and government agencies. Kevin aids health plans across the country in their mission to expand and retain coverage by providing a streamlined and efficient shopping, enrollment and billing experience.
