hCentiv e

Technology Solutions to Simplify Healthcare

WebInsure Exchange Manager

Solution to Exchange Integration

Are you an insurer worried about integrating to state & federal exchanges? Are you worried about cost, technology infrastructure, strategy, complexity and deadlines? This white paper addresses these concerns and more. Learn what steps you need to take and what pitfalls to avoid. Let hCentive be your guide through this challenging and changing landscape.

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Technology Solutions to Simplify Healthcare

Health Insurance Exchange Integration

Introduction
The Supreme Court ruling on health reform, released June 28, 2012, upheld the two key elements of the health coverage or pay a penalty; and the massive nationwide Medicaid eligibility expansion, which will extend health coverage to a broader segment of the U.S. population. The U.S. Census Bureau reports that there are approximately 50.7 million uninsured Americans, including 8.7 million children. In the near future, it is According to the healthcare reform, states need to have a Health Insurance Exchange (HIX) operational by Oct. 1, 2013. To comply and take advantage of the opportunity, insurers need to integrate and showcase their products across multiple state exchanges. This integration requires insurers to conform to various PPACA and rollments, life status change requests, billing and many others.
Business Services Technical Infrastructure
Customer Relationship Management Systems

Individual

Education and Customer Service Eligibility Determination Coverage Rating and Quoting

Health Plan

Customer Services

Product & Benefits

Membership, Billing and other Systems

Broker

Enrollment and Renewal Premium Billing/ Reconciliation Member Management

Enrollment & Billing General Ledger Member Management Data Warehouse

Small Group (SHOP)

Currently, insurers work directly with individuals, brokers, and small groups (aka Small Business Health Options Programs or SHOP). Therefore, their processes arent equipped to integrate with HIX. These processes include customer service, eligibility determination, coverage rating, enrollment, renewal, billing, reconciliation, member management and more. Compounding the problem, the majority of these processes are supported by proprietary technical infrastructures, which can make integration incredibly difficult.
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infrastructures, which payers do not know if their systems can support. systems and

Technology Solutions to Simplify Healthcare

Unfortunately despite PPACAs aggressive deadlines, many organizations and agencies have had a wait and see attitude and have not taken any meaningful action.

Evolve with the Change or Wither Away?

integrate with the newly founded HIX in order to enroll subscribers. If they choose not to integrate with HIX, and, most likely, see a decrease in market share. If they integrate poorly with HIX, they could significantly increase internal costs and offset newly found revenue. This new landscape is forcing insurers to transform but they are struggling with what exactly that means. This

Education and Customer Service Eligibility Determination Individual Coverage Rating and Quoting Enrollment and Renewal Premium Billing/ Reconciliation Member Management

Coverage Rating and Quoting Enrollment and Renewal Premium Billing/ Reconciliation

Business Services
Customer Services

Technical Infrastructure
Customer Relationship Management Systems

Health Plan

Product & Benefits

Membership, Billing and other Systems

Small Group (SHOP)

Health Insurance Exchange (HIX)

Member Management Customer Service

Enrollment & Billing General Ledger Member Management Data Warehouse

Subsidy Reconciliation Federal Agencies Bill, Pay, Delinquency and Customer Service
Individual Consumer

Self Service Capabilities

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Implementation Readiness

Technology Solutions to Simplify Healthcare

Insurers need to realign their organizational governance to prepare for the reform. A roadmap needs to be

Operational and Technical Readiness

can avoid extensive costs and not unnecessarily tax resources. Integration with multiple HIX requires a new technical infrastructure. Insurers must be equipped with an automated backend system that seamlessly works with state HIX for eligibility, enrollment, billing and reconciliation transactions. This is a step that many organizations had put on hold and are now scrambling to put a plan in place.

Exchange Management and Connectivity Solution

hCentives WebInsure Exchange Manager (WEM) can lift the burden of adapting to this new landscape. It acts as an integration point between HIX, your organization and other related parties to minimize the impact on existing business services and technical infrastructures.

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End-to-End Processing

Technology Solutions to Simplify Healthcare

hCentives End-to-End Business Service and Technology Solution provides the operational and technology components for a health plan to interact with state HIX and federal and state entities, and members/groups. It includes the following features: 1. Enrollment/Renewal and Payments a. Collect enrollment information in a variety of formats, such as 834x12, 834 4010 v220, 834 5010 v307, custom XML format, mainframe formats, etc. b. Collect billing information and calculate premium 2. Customer Service a. b. Allow searching of enrollments using HIX, payer member IDs and other 3. Plan Management & Distribution a. b. Integrate with HIOS and SERFF as required c. 4. Reconcile Enrollments and Membership 5. Premium Billing and Reconciliation a. Provide the ability to generate and distribute invoices, accept online payments, post payments, manage delinquency and reconcile payments b. Provide subsidy reconciliation 6. Member Management a. Collect and process updates, terminations and re-instatements requests hCentives solution will guide your organization to quickly adapt to the changes that are imminent due to the reform.

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Get Organized, Get Started

Technology Solutions to Simplify Healthcare

new Exchange model. This involves a readiness assessment and road map, gap analysis, requirements steps.

Solution Integration
WEM acts as a middleware, integrating HIX and your organization's backend systems in the most seamless way possible. This allows you to seamlessly integrate existing business services, including revenue reporting, enrollment management, reconciliati on, plan management, customer service and more. While it is necessary for an exchange solution to be able to connect with multiple HIX, it isnt going to be easy. Since there arent set standards and protocols, it is highly probable that various states HIX will not speak same language. The exchange format and protocol will most likely vary from state to state and organization to organization. This is why hCentive developed WebInsure Exchange Manager to be input/output (I/O) agnostic. Due to WEMs I/O agnostic nature, your organizations technical infrastructure does not need to existing infrastructure and various health insurance exchanges.

Features and Functions

Plan Management
many elements that are functions of the state insurance departments. After exchanges are implemented in 2014, states will need to continue to perform these roles to ensure QHPs meet the requirements necessary for participation. Carriers will be responsible for uploading and pushing plan information to HIX and maintaining this information in WEM for data validation.

Other features include:

Ability to generate plan data in appropriate format and upload data to exchanges
Product and Rate Data Provider Network Quality Data

Integration with SERFF and HIOS

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Enrollment Application

Technology Solutions to Simplify Healthcare

The Enrollment Application Management Solution enables the insurers existing enrollment processing system to connect to multiple state HIX without implementing multiple management systems. Key features include: Business Rules based routing Queue and Workload Management SLA Management Integration with back end services, such as letter generation, letter tracking, audit capture, etc. Dashboards and Reporting Customizable Business Process Management Framework

Reconciliation
Key features include: Membership Reconciliation Premium & Subsidy reconciliation Capability to generate actionable work items and feed business process management systems from reconciliation results

In Conclusion
hCentives WebInsure Exchange Manager is designed to adapt to current and future market changes. It is expected that the landscape of public and private health insurance exchanges will continue to evolve in 2014 and beyond. Data models and business processes will continue to change and require insurers to continually realign their business models to adapt. WEM will help you cope with the rapid changes brought by the reform; as well as enable you to stay ahead of the market. existing business services and technical infrastructures. hCentive will leverage your existing IT investments and resources to help reduce your costs. Time is the biggest issue. Insurers need to move quickly in order to adapt to the massive changes in the regulatory environment. hCentives WebInsure Exchange Manager enables quick adoption so you can take advantage of these new opportunities.
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This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosedin whole or in partfor any purpose other than to evaluate hCentive products or services. This document contains con dential and proprietary information specific to hCentive, Inc.

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Technology Solutions to Simplify Healthcare

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-----------------End of White Paper----------------This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosedin whole or in partfor any purpose other than to evaluate hCentive products or services. This document contains con dential and proprietary information specific to hCentive, Inc.