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Health Insurance Exchanges


representatives from participating carriers and legal advisor, as well as a consumer representative. The exchange would serve a broad spectrum of people with a range of income levels, English proficiency and technological savvy. Process: Private exchange needs to define business pro- cesses equivalent to public exchanges (in compliance with ACA), since it has provisions for tax credits and subsidies to attract consumers. Financial modeling should factor all ex- penses while providing subsidized and affordable coverage and generate revenue at the same time. Addressing adverse selec- tion requires appropriate risk management strategies and can be achieved with claims and premium information from core health plan systems. Plan management and related business rules are important, as the flexibility of plan and benefits for consumers can attract them through transparency. Landscape definition for plan management should consider provisions for value-based benefits, dynamic quote generation and rating capabilities, and marketing and CRM for differentiation and profitability of the exchange – a holistic strategy for multi- channel marketing (direct mail, Web, mobile), education, and service and support. Technology: Technology strategy driven by people and process is key to exchange efficiency. Leveraging existing technology infrastructure (e.g., call center/help desk), in- tegration with existing systems (claims processing, rating, quoting, premium processing engines, etc.) and process automation are key factors. Contracting with vendors that provide operational and technology services for customer management, enrollment, billing, premium payments, pay- ment reconciliations, commissions handling, education and outreach, etc., under a single umbrella enables administrative simplicity and efficiency.


HIX set up approach The following features enable carriers to enhance the pri-


vate exchange service landscape and provide a user-friendly, one-stop-shop experience for consumers: • Robust plan selection tools with search filters (e.g., monthly cost, office visits, additional coverage, provid- ers, HSA eligibility) and benefit-level comparison with benefit-level pricing.


• Holistic plan recommendation engine based on demo- graphic and clinical data.


Private exchanges are likely to proliferate, but health plans need to differentiate from the private insurance market and public exchanges through clear strategies for innovative deployment, distinct consumer experience and efficient operation.


• Online quoting and comparison for easy comparison shopping across insurers; robust rating and quoting engine that facilitates “apples-to-apples” comparison of plans and rates.


• Provision for discounts/subsidies. • Integration with claims and premium processing sys- tems for transaction automation and risk management.


• Rich user experience with user training, multi-channel delivery, social media support with plan negotiation capabilities, online education and surveys.


• Integration with broker networking systems. • Security and privacy compliance with robust infra- structure.


• Analytics and reporting to aid real-time business deci- sions based on realized value levers.


Private exchanges:


Driving growth and differentiation Private exchanges are likely to proliferate, but health plans need to differentiate from the private insurance market and public exchanges through clear strategies for innovative deployment, distinct consumer experience and efficient operation. Value-added features are key for each strategy, such as integration with tax-deferred accounts (HSAs, HRAs, etc.), tax credits processing, communities and auctions in implementation, social media networking and support for consumer experience, innovative operating models around plan management and so on. Health plans can broaden their product offerings over time with dental and life insurance or even non-insurance products to best their competition. If thoughtfully planned and systematically executed, private exchanges can help health insurers adapt to the individual market and drive growth, while achieving healthcare reform goals for consumers.


HMT 14 November 2012 HEALTH MANAGEMENT TECHNOLOGY www.healthmgttech.com


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