ACA Rate Hikes: What They Teach Us About Premium Billing for TPAs & Health Plans

ACA premiums are climbing sharply. While Mirra Healthcare does not provide ACA products, these shifts highlight broader operational challenges that any health plan or TPA billing team can learn from. Rising premiums whether in ACA, Medicare Advantage, or commercial lines stress billing systems, increase payment failures, and elevate compliance risks. 

Mirra has long focused on simplifying complex operations for health plans through its Medicare Advantage in a Box platform. The automation principles and billing innovations we’ve built for Medicare Advantage and TPA premium billing directly address these types of challenges; helping organizations reduce manual work, stay compliant, and improve member satisfaction, even in the face of rising rates. 

Why Are ACA Premiums Increasing and What Does It Mean for Premium Billing Healthcare

A combination of economic and regulatory forces is fueling premium increases.  

• Medical cost inflation continues to outpace general inflation. National health spending grew 7.5% in 2023, driven by costly specialty drugs, higher utilization, and escalating labor expenses.¹  

• Reinsurance volatility adds to the pressure, with more expensive stop‑loss coverage tied to unpredictable, high‑cost claims.  

• Risk adjustment dynamics under the ACA create uneven financial pressures across plans depending on population health balance. Contributions to the risk pool can be significant for plans with relatively healthier groups.   

• State mandates and regulatory changes further increase administrative costs that ultimately get passed on to members.   

The result: greater billing complexity, larger refund volumes, and higher compliance scrutiny; all challenges Mirra helps plans solve within Medicare Advantage and TPA billing ecosystems. 

What Operational Challenges Do Rising Premiums Create for TPA Premium Billing?

Premium increases are not simply a member affordability issue; they reverberate through the entire billing flow. Rising rates challenge every part of a health plan’s operations:  

Payment Processing 

Larger monthly charges increase the frequency of declined credit cards and bounced ACH payments. What was a $200 monthly deduction might process smoothly; at $280, failures surge.  

Subsidy Reconciliation

Even minor errors in applying APTC subsidies are magnified when the base premium is higher, creating costly over‑ or under‑payments that demand manual correction.  

Member Communication

Without proactive education, members often interpret higher bills as errors, driving a spike in inbound calls and disputes.  

Compliance & Audit

Billing mistakes that were minor previously become material exposures at higher premium levels, attracting scrutiny from regulators.   

Every 1% drop in billing accuracy generates a spike in member calls and disputes. For leaders, this isn’t just an ops issue; it’s a member trust issue. 

Know 6 Strategies to Master & Optimize TPA Premium Billing 

3 Key Challenges in a High‑Rate Environment

Regardless of the market, three friction points dominate premium billing when rates rise: 

1. Data Fragmentation

Eligibility data, rate information, and subsidy records often reside in different systems. Manual extracts and reconciliations inevitably cause mismatches. At higher dollar values, those mismatches become unsustainable.  

2. Grace Period and Termination Rules

ACA grace period rules, particularly for members receiving subsidies, are federally defined but vary in complexity at the state level. Misapplying these rules exposes plans to both compliance risk and member frustration.  

3. Refund and Adjustment Workload

Life changes, retroactive subsidies, and plan switches trigger high refund volumes. With higher premiums, refunds are larger and require tighter documentation and quicker turnaround to prevent dissatisfaction or regulatory inquiry.  

These challenges are painfully similar to what health plans face in TPA and Medicare Advantage billing. Where automation makes the difference between surviving and thriving. 

How Premium Billing Automation Reduces Complexity for Health Plans & TPAs

At Mirra, our automation-first designs (originally built for Medicare Advantage) include capabilities directly applicable to ACA-like scenarios: 

• End‑to‑end invoice management that recalculates instantly based on updated eligibility or subsidy data, eliminating error‑prone spreadsheets.   

• Smart payment posting across multiple rails (ACH, card, SSA, LIS, lockbox) with automatic reconciliation.   

• Exception routing, where failed transactions are classified and routed automatically with corrective actions suggested.  

• Member self‑service tools that enable one‑click autopay enrollment, payment method updates, and grace period transparency, reducing inbound call volume.   

• Compliance automation with system‑generated audit trails that capture every adjustment, ensuring regulators get a clear, defensible record.  

Plans leveraging these tools see fewer payment failures, faster reconciliation, and a measurable drop in member complaints. 

What Immediate Actions Can Strengthen Your Premium Billing Strategy?

Navigating rising ACA premiums requires proactive measures, not reactive fixes. To truly future‑proof your premium billing strategy, consider these three prioritized actions, each with a realistic timeframe:   

1. Conduct a Comprehensive Billing Audit (1–2 weeks)

Evaluate first‑pass payment success rates, average days to settlement, and refund turnaround times. The goal isn’t only to uncover errors; it’s to understand how resilient your systems are under increased complexity.   

2. Pilot Targeted Automation Solutions (30–90 days)

Identify one or two high‑impact processes to automate quickly. Familiar pilots include automated retries for failed payments and intelligent routing for exceptions. These small, contained projects can deliver quick wins while demonstrating ROI.  

3. Refine Member Communication Strategies (2–3 weeks)

Clear communication prevents confusion and deflects unnecessary service calls. Create concise, non‑technical pre‑bill notices explaining what changed and why. Enhance digital portals with grace‑period progress indicators to give members clarity about their status and options.  

For more perspectives on trends shaping healthcare operations, explore Mirra’s Insights hub, which covers emerging strategies in billing, member engagement, and compliance.   

Mirra Healthcare’s Advantage in TPA Premium Billing Operations

When premiums increase, you need more than incremental fixes; you need a partner that has built systems specifically for complexity.  

Mirra’s premium billing platform offers:  

• Automated retroactivity to account for daily enrollment changes, subsidy adjustments, and life events without manual recalculation.   

• Integrated membership + billing data for accurate, real‑time reconciliation.   

• Full payment spectrum support from SSA and LIS to direct member and lockbox payments, with seamless automated posting.   

• Compliance‑ready audit trails with granular user and timestamp records for every transaction.  

 Reported client outcomes:  

• 95% automated payment posting  

• 60% reduction in billing‑related complaints  

• 40% less manual processing  

Mirra’s expertise spans health plans and TPA premium billing operations, ensuring that even the most complex premium billing healthcare challenges are automated and compliant.   

Read our blog post on How a Premium Billing System Improves Cash Flow for Health Insurers 

Conclusion

Premium increases are here to stay. For health plans, the challenge isn’t only processing higher invoices but also sustaining member trust, cash‑flow stability, and strong compliance amidst rising complexity. Lessons from ACA markets underscore a broader truth: health plans need resilient, automated billing systems to thrive.   

See how Mirra transforms TPA and Medicare Advantage premium billing into a growth engine. Explore Premium Billing Solutions

Reference: 

1. AMA: Trend in Healthcare Spending