Top 3 Health Insurance Marketplace Myths (Part 1 of 3)

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MYTH #1: Operations is the most important function to mature.

 

THE FACT: Technology is the backbone of a health insurance marketplace without which it would become unmanageable and unsustainable operationally. 

 

Technology and operational processes united is the foundation of a successful state-based marketplace. One does not work without the other.

 

There are 18 core functions required to stand up a health insurance marketplace, all require technology.  This doesn’t mean technology has a role, it specifically means without working technology the essential functions will not operate. It is that simple.

 

The macro requirements for business enablement of the minimum regulatory requirements are listed below.  There are 18 essential functions. Let me know which functions do not heavily rely on technology to function.  Most functions apply to SHOP and Individual Markets.

 

  1. APTC, CSR, Medicaid and CHIP Eligibility Determination
  2. Comparison Shopping
  3. Enrollment, Disenrollment and Change of Circumstance, Carrier 834 setup
  4. Operational of a toll-free hotline (SHOP and Individual Call centers)
  5. Presentment of plans on website, Anonymous Shopping
  6. Create Worker Portal/Dashboard (Documentation Management, scanning of paper applications)
  7. Setup Secondary Data Sharing Interfaces
  8. QHP Certification, Recertification and decertification (Manual or SERFF etc.)
  9. Plan Price and Quality Ratings (Quality Rate Sources Loaded)
  10. Plan Account Management (Carrier Setup SHOP and Individual, Carrier self-serve)
  11. Plan Publishing (Load, Validate, and Publish)
  12. Establish Essential Business Reports (CMS, CCIIO, EDI, 1095, general applications submitted)
  13. Financial Management & Notices, 820 transactions, notices (Enrollment and Eligibility) (Billing, Collections and Remits from Carriers)
  14. Create Master Person Index Solution
  15. Operate a Small Business Health Option Programs (SHOP)
  16. Legacy Eligibility Management System Interfaces changes
    • My account
    • IVR (system)
    • Document imaging Workflow
    • Benefit Center (Call Center) – Operational
    • Applications
    • Redets/changes (online, not batch)
  17. External Application Changes (Pre-screening and Applications)
  18. Other Interfaces Required

 

There are 18 essential functions that must be operational and working before the Authority to Connect is awarded.  This is the formal conditional approval mandatory to connect to the Federal Data Services hub (FDSH).  FDSH is the service that responds to confirm that a subscriber or member in the policy is in fact within the income range for qualification for a tax credit like Advance Payment of the Premium Tax Credit (APTC) or a Cost Sharing Reduction (CSR). There are many other services the FDSH provides but this is among the most critical.

 

If technology is not stable as Colorado, Massachusetts, Washington, Maryland and other states discovered in 2013 and 2014 it simply is not possible operationally to cover all the bleeding.  Do not under estimate how critical technology and technology leadership is to a successful state-based marketplace.  The consequences are disastrous.

(Look for Part 2 and Part 3 of this post, later this week)

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Peter is a healthcare business and technology executive, recognized for Digital Innovation by CIO 100, MIT Sloan, Computerworld, and the Project Management Institute. As Managing Director at OROCA Innovations, Peter leads the CXO advisory services practice driving digital strategies.

Peter was honored as an MIT Sloan CIO Leadership Award Finalist in 2015 and is a regular contributor to CIO.com on innovation. As Head of Information Technology, Peter was responsible for Connecticut’s Health Insurance Exchange’s (HIX) industry-leading digital platform transforming consumerism and retail oriented services for the health insurance industry. Peter championed the Connecticut marketplace digital implementation with a transformational cloud-based SaaS platform and mobile application recognized as a 2014 PMI Project of the Year Award finalist, CIO 100, and awards for best digital services, API, and platform. He also received a lifetime achievement award for leadership and digital transformation, honored as a 2016 Computerworld Premier 100 IT Leader.

Peter has a B.S. in C.I.S from Bentley University and an MBA from Quinnipiac University, where he graduated Summa Cum Laude. He earned his PMP® in 2001 and is a certified Six Sigma Master Black Belt, Business Relationship Management Professional (BRMP) and Certified Scrum Master. As a Commercial Rated Aviation Pilot and Master Scuba Diver, Peter understands first hand, how to anticipate change and lead boldly.