Payer Market Planning Report: Key Regulations Impacting Health Plans in 2025
For healthcare payers, complying with shifting regulations can be a challenge. Increasingly, state and federal guidelines focus on improving cost transparency while improving patient data safety. Key regulations impacting health plans include the Health Insurance Portability and Accountability Act (HIPAA), the No Surprises Act, the Interoperability and Patient Access Rule, and the Affordable Care Act (ACA). Many payers are reinvesting in their technology ecosystems to increase regulatory compliance through workflow efficiency and streamlined data sharing.
In this article, we highlight four regulations impacting health plans and actionable strategies payers can use to ensure compliance, improve patient satisfaction, and remain competitive.
4 Regulations Impacting Health Plans
The healthcare regulatory landscape is growing more complex, with frequent updates and new laws requiring constant flexibility. Some changes, like the No Surprises Act and recent HIPAA amendments, urge health plans to make regular updates to their policies and procedures. The sheer volume and pace of these changes are unprecedented, underscoring health plans’ need for dedicated resources and specialized expertise to maintain compliance effectively.
The Health Insurance Portability and Accountability Act (HIPAA) Updates
HIPAA is undergoing significant revisions, particularly within the Privacy and Security Rules. By 2024, provisions will streamline patient access to Protected Health Information (PHI), reducing the maximum response time for requests from 30 days to 15 days. This update prioritizes administrative efficiency while maintaining robust privacy and security standards, improving care coordination and patient access to health information.
What it Means for Health Plans
- Accelerated timelines require faster administrative processes.
- Enhanced privacy and security frameworks are critical to safeguard patient information.
- Investment in advanced data management systems like HealthRules® Payer can streamline compliance with these new requirements.
No Surprises Act
As of June 30, 2024, the Centers for Medicare & Medicaid Services (CMS) received over 16,000 complaints from payers related to the No Surprises Act. Many of the complaints highlighted difficulties payers had adhering to guidelines regarding billing transparency and surprise billing provisions. The issued complaints also demonstrate the challenges many payers face in improving organizational transparency and data sharing with their current workflows.
What it Means for Health Plans
- Transparent cost-sharing policies must become a priority for healthcare payers.
- Enhanced member education and digital tools are crucial for addressing transparency concerns.
- Solutions like GuidingCare®, which help manage member engagement and care coordination, can assist in adhering to regulatory mandates.
Interoperability and Patient Access Rule
By 2027, health plans must implement Fast Healthcare Interoperability Resources (FHIR) APIs to facilitate seamless, secure sharing of health records. This rule aims to drive operational efficiency, reduce manual processes, and improve data accessibility for both providers and patients. For health plans, this means balancing short-term adjustments with long-term opportunities to innovate and drive operational improvements.
What it Means for Health Plans
- Short-term adjustments are required to integrate FHIR-compliant APIs.
- Long-term opportunities exist for innovation in member service delivery.
- Updates to existing technology solutions can enhance interoperability while ensuring compliance.
Affordable Care Act (ACA)
Extended open enrollment periods and enhanced subsidies under the ACA have created new opportunities for member growth. However, success depends on payers reassessing their pricing structures and benefit designs to attract a variety of consumer groups. Diversifying plan options can help payers appeal to evolving member needs and stay competitive in a crowded market. It’s also valuable for health plans to communicate any changes in their offerings to members in a clear and timely way—and, ideally, across multiple channels to increase visibility.
What it Means for Health Plans
- Clear communication of benefits through digital platforms is essential.
- Personalized customer service and tailored plan options improve engagement and retention.
- Strategic investments in member experience technologies can ensure competitiveness and improved outcomes.
3 Challenges in Regulatory Compliance
1. Agility and Market Responsiveness
Keeping up with regulatory changes demands agility and responsiveness from payers and their administrative solutions. Yet 55% of health plan executives identify managing fee schedules as a major challenge, according to the Annual Payer Market Planning Report from HealthEdge. Outdated and legacy systems often can’t handle the complexity, update frequency, and data sharing requirements of new regulations—increasing the risk of non-compliance.
2. Resource Shortages & Compliance Gaps
Health plans face pressing operational challenges, including a lack of in-house IT expertise to address regulatory requirements. According to the same Market Planning Report, 50% of health plan executives highlighted “insufficient staffing and resources” as barriers to regulatory compliance. This shortage can hinder a health plan’s ability to implement changes swiftly, leaving organizations vulnerable to penalties.
By leveraging the expertise and knowledge of vendor resources, like the HealthEdge Professional Services team, health plans can minimize disruption, maintain the integrity and efficiency of their contracts, and streamline business functions.
3. Cybersecurity Risks
With escalating cyber threats, protecting sensitive patient data has become a top priority for healthcare organizations. Compliance with HIPAA and other cybersecurity-focused regulations is essential to reduce the risk of breaches that could lead to financial and reputational damage. Many payer technologies lag behind in implementing modern data security features. HealthEdge solutions leverage artificial intelligence (AI) and other tools to help payers achieve enterprise cybersecurity transformation.
4 Strategies to Help Ensure Health Plan Regulatory Compliance
To keep pace with these challenges, health plans can implement the following strategies:
1. Invest in Modern Technology
Modern Core Administrative Processing Systems (CAPS) solutions can empower health plans to adapt swiftly to regulatory changes without compromising operational efficiency. Platforms like HealthRules® Payer can help streamline administrative workflows, reduce manual errors, and enhance data access, ensuring compliance with minimal disruption.
2. Form Strategic Partnerships
Collaborating with technology vendors experienced in compliance and change management can lighten internal resource requirements and provide specialized expertise. These partnerships offer cutting-edge tools and insights to keep health plans ahead of regulatory shifts.
3. Conduct Regular Compliance Audits
Regular compliance audits are the safety net every health plan needs. They can identify compliance gaps, highlight areas for improvement, and help avoid costly penalties. Audits can also uncover billing inconsistencies, allowing time for corrections before regulators step in. Beyond risk mitigation, audits foster a culture of accountability and continuous improvement within health plans.
4. Engage Key Stakeholders
Effective compliance strategies extend beyond internal initiatives. Engaging stakeholders—including providers, members, and regulators—helps establish transparency and trust. Open communication about regulatory changes fosters collaboration and ensures compliance responsibilities are shared instead of siloed.
By integrating these strategies, health plans can build a resilient compliance framework that both meets current regulatory demand and allows for future growth. Investing in advanced technology solutions can empower health plans to scale their operations through seamless integrations, data sharing, and automation. HealthEdge’s suite of solutions, including HealthRules® Payer, HealthEdge Source
, GuidingCare®, and Wellframe, are designed to support health plans in navigating regulatory complexities and achieve success.
Want to dive deeper into these insights and discover strategies from top health plan executives? Download our HealthEdge Annual Payer Market Planning Report 2025 for an exclusive look at trends, challenges, and solutions shaping the industry. Get actionable strategies to strengthen compliance, improve patient satisfaction, and drive success.
