hcentive webinsure exchange integration platform

WebInsure Exchange Manager“Solution to Exchange Integration”

Cent ivehTechnology Solutions to Simplify Healthcare

Are you an insurer worried about integrating to state & federal exchanges? Are you worried about cost, technologyinfrastructure, 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 andchanging landscape.

This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosed—in whole or in part—for any purpose other than to evaluate hCentive products or services. This document contains con�dential and proprietary information specific to hCentive, Inc.


Health Insurance Exchange Integration

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IntroductionThe 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.

Currently, insurers work directly with individuals, brokers, and small groups (aka Small Business Health Options Programs or SHOP). Therefore, their processes aren’t 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

Individual

EligibilityDetermination

Coverage Ratingand Quoting

Enrollmentand Renewal

Premium Billing/Reconciliation

MemberManagement

Broker

Small Group(SHOP)

Education andCustomer Service

HealthPlan

BusinessServices

Customer Services

Product & Benefits

Enrollment & Billing

MemberManagement

TechnicalInfrastructure

Customer RelationshipManagement Systems

Membership, Billingand other Systems

General Ledger

Data Warehouse

This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosed—in whole or in part—for any purpose other than to evaluate hCentive products or services. This document contains con dential and proprietary information specific to hCentive, Inc.

incredibly di�cult.


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Evolve with the Change or Wither Away?

infrastructures, which payers do not know if their systems can support.

Unfortunately despite PPACA’s aggressive deadlines, many organizations and agencies have had a “wait and see” attitude and have not taken any meaningful action.

integrate with the newly founded HIX in order to enroll subscribers. If they choose not to integrate with HIX,

This new landscape is forcing insurers to transform but they are struggling with what exactly that means. This

Individual

EligibilityDetermination




MemberManagement

IndividualConsumer

Small Group(SHOP)

Education andCustomer Service

HealthInsuranceExchange

(HIX)

BusinessServices

Customer Services

Product & Benefits

Enrollment & Billing

MemberManagement

TechnicalInfrastructure

Customer RelationshipManagement Systems

Membership, Billingand other Systems

General Ledger

Data Warehouse



MemberManagement

Customer Service


HealthPlan

Self Service Capabilities

Federal Agencies

Bill, Pay, Delinquency and Customer Service

Subsidy Reconciliation


systems and

and, most likely, see a decrease in market share.If they integrate poorly with HIX, they could signi�cantly increase internal costs and o�set newly foundrevenue.


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Implementation ReadinessInsurers 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 manyorganizations had put on hold and are now scrambling to put a plan in place.

Exchange Management and Connectivity SolutionhCentive’s 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.

This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosed—in whole or in part—for 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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End-to-End ProcessinghCentive’s 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:

Collect enrollment information in a variety of formats, such as 834x12, 834 4010 v220, 834 5010 v307, custom XML format, mainframe formats, etc.

Collect billing information and calculate premium

Enrollment/Renewal and Payments1.

Customer Service2.

a.

b.

Allow searching of enrollments using HIX, payer member IDs and other

a.

b.

3.

Integrate with HIOS and SERFF as required

a.

b.c.

Reconcile Enrollments and Membership4.

Provide the ability to generate and distribute invoices, accept online payments, post

payments, manage delinquency and reconcile payments

Provide subsidy reconciliation

Premium Billing and Reconciliation5.a.

b.

Collect and process updates, terminations and re-instatements requestsMember Management6.a.

hCentive’s solution will guide your organization to quickly adapt to the changes that are imminent

due to the reform.


Plan Management & Distribution



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Get Organized, Get Started

Solution Integration

Features and Functions

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

steps.

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 isn’t going to be easy. Since there aren’t 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 WEM’s I/O agnostic nature, your organization’s technical infrastructure does not need to

existing infrastructure and various health insurance exchanges.

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.

Plan Management

WEM acts as a middleware, integrating HIX and your organization's backend systems in the most seamless waypossible.

Ability to generate plan data in appropriate format and upload data to exchanges

Integration with SERFF and HIOS

Other features include:

Product and Rate DataProvider NetworkQuality Data


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The Enrollment Application Management Solution enables the insurer’s 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

Key features include:Membership Reconciliation

Premium & Subsidy reconciliation

Capability to generate actionable work items and feed business process management systems from reconciliation results

Reconciliation

Enrollment Application

In ConclusionhCentive’s 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. hCentive’s WebInsure Exchange Manager enables quick adoption so you can take advantage of these new opportunities.



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For Further Reading & Questions:www.hcentive.com

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