Eight Ways ACA Marketplaces Should Be Leveraging AI to Manage New H.R.1 Requirements

On July 4, the president  budget reconciliation legislation,  into law. Prior to this signing, on June 20, the Centers for Medicare and Medicaid (CMS) released the Marketplace Integrity and Affordability rule. As a result of the final rule and the new budget legislation law, Affordable Care Act (ACA) Marketplaces will face a wave of new federal operational mandates. These include new eligibility, verification and enrollment rules that will deter eligible individuals from getting and keeping coverage. For more information about these specific policies, see .

Marketplaces face immediate to change business processes and systems, retrain staff, educate consumers and partners, and rescope and scale existing and new contractor work, much of it before the November 2025 open enrollment period that is less than four months away.

The combined impact of these changes and the upcoming expiration of enhanced premium tax credits could result in 12 million people losing Marketplace coverage. To attempt to minimize coverage loss and mitigate market instability, Marketplaces need to focus on making the federally mandated changes as frictionless as possible for new and returning consumers—a herculean task.  

Fortunately, we are in a time of significant technological advancements—primarily driven by the advancement of artificial intelligence (AI). While far from a panacea, Marketplaces could explore targeted applications of AI, which, in coordination with expert staff, could prove a useful tool to meet operational needs in the immediate and long term.  

In the immediate term, to prepare for the 2026 open enrollment cycle, AI could help Marketplaces by:

• Processing Eligibility Paperwork. New federal rules surrounding eligibility verification—including income and qualifying life events for special enrollment periods—will dramatically increase the amount of paperwork applicants must submit and have verified before enrollment. Marketplace staff and contractors equipped with AI tools could expedite processing by:  
  • Using intelligent document processing tools. Optical Character Recognition, combined with AI-driven data extraction tools, can extract information from pay stubs, W-2s, immigration and other documents to significantly reduce manual review time and flagging anomalies. For example, has already begun using AI technology to help automate document verification tasks.
  • Outreach assistance. AI can help identify who is likely to miss paperwork steps and send step-by-step digital guides or refer individuals to assisters.
• Releasing New Consumer Communications. Marketplaces will need to invest in outreach and communication efforts to educate consumers and partners about new obligations under the bill and final rule. AI can assist states subject to limited staff bandwidth with:
  • Outreach and micro-segmentation. Rather than requiring staff to manually define and code individual outreach scenarios, AI models can automatically detect, predict and segment individuals at the greatest risk of procrastination or churn and push timed and personalized nudges (short message service, email, in-app) ahead of compressed deadlines.
  • Generating consumer-facing content at scale. AI can assist expert communication staff to produce first drafts of new and updated tools and collateral that explain changes and new requirements. For example, updating frequently asked questions (FAQ) and consumer notices and auto-drafting plain-language materials. AI can also facilitate A/B testing to optimize messaging and engagement to prioritize changes that will improve engagement.  
• Improving User Experience and Customer Support. Marketplaces must develop and provide new training materials for consumer-facing staff and partners—including call center operators, case workers, Navigators, agents, brokers and certified application counselors—to assist consumers under more complex enrollment processes. AI can enhance the effort of Marketplace staff through:
  • Updating training materials. AI can help develop training materials with direction, oversight and quality control from Marketplace staff and can produce interactive simulations for use during training.
  • Deploying AI-driven virtual assistants and chatbots. The chatbots can triage common consumer questions, freeing up human staff to focus on complex cases. For example, became the first state-based marketplace to gain CMS approval to deploy an AI-based Interactive Virtual Agent, which assists customers with basic questions and tasks.
  • Enhancing call center support. For consumers that still need assistance from Marketplace call centers, large-language-models can surface policy answers from official Marketplace FAQ documents and autofill notes, real-time call transcriptions so human reps can clear calls faster during peak days.
  • Monitoring consumer sentiment and proposing corrective action. AI-powered sentiment analysis can help Marketplaces monitor consumer confusion or frustration in real time, allowing for rapid adjustments to messaging strategies and/or additional training for partners.

Beyond the immediate use of AI to prepare for the 2025  Open Enrollment period, longer-term opportunities exist to help Marketplaces streamline operations and address persistent challenges. As new federal requirements continue to roll out, Marketplaces will face ongoing resource constraints, making AI an important tool to support sustainable, efficient operations. Some promising areas for AI-driven improvements to efficiency and user experience include:

• Network Adequacy Oversight. Marketplaces, Departments of Insurance and Medicaid agencies often receive consumer complaints and provider grievances related to inadequate health plan networks. AI tools can help proactively oversee and enforce network adequacy requirements to ensure providers are accessible to enrollees using AI-powered tools to analyze patterns in claims denials and grievances to detect systemic access barriers, conduct secret shopper analysis at scale with AI voice agents and work with qualified health plans to maintain provider directory data accuracy.
• Consumer Enrollment. New requirements will make successful applications take longer to complete and, in many cases, will require additional back and forth with the Marketplace to verify information, potentially deterring consumers and discouraging participation from agents and brokers who currently support a significant share of Marketplace enrollment. AI can ease these challenges for both consumers and enrollment partners with additional tools to support the application process and integration for enrollees coming from other types of coverage.
• Plan Selection. AI-powered tools can modernize plan-selection algorithms and hyper-personalize recommendations to support navigators, agents and brokers, and individuals directly. These tools can also forecast spending scenarios based on consumer-provided information and make financial predictions or highlight tradeoffs between different levels of coverage and premium and cost share subsidies.
• Enhanced Verification Sources. As data sharing capacity evolves, AI-powered data integrations can connect to and scan additional and new third-party data sources to auto verify income or qualifying life events more proactively, reducing the need for individuals to manually gather and upload paper sources. For example, interfacing with state vital records systems (e.g., NAPHSIS Electronic Verification of Vital Events), the Postal Service National Change of Address database or expanded payroll system sources (e.g., ADP, Paychex, Intuit, Argyle). Anticipating the end of automatic reenrollment in 2028, AI models could help collect and present information for the applicant to review and confirm during the newly established pre-enrollment verification window and limit reenrollment burden and mitigate erroneous coverage disruptions.
• Fraud and Waste. AI offers additional tools to further constrain bad actors. AI is known for its ability to quickly identify patterns and recognize irregularities within large sets of data. Machine learning models can continuously scan enrollment transactions and detect anomalies or suspicious account activity. This allows Marketplaces to target investigations more efficiently and limit exposure to fraud.

New federal requirements make it harder for eligible individuals to enroll in Marketplace coverage. However, policymakers and Marketplaces have many opportunities to deploy tools and technologies that help protect recent enrollment gains and smartly and precisely weave AI into the enrollment, verification, and consumer-support stack. Wise leaders will adapt in the face of a crisis—doing so quickly and responsibly will be essential to help blunt enrollment friction and coverage losses while simultaneously enhancing the consumer and partner experience.

For information on AI use and implications for payor systems, including Marketplaces, please contact , , or .

Manatt Health estimates based on Urban Institute analysis of  and  using the Urban Institute’s Health Insurance Policy Simulation Model (HIPSM). Note not all people using Marketplace coverage will become uninsured.