Page 1

hCen ti v e

Technology Solutions to Simplify Healthcare

WebInsure State

Overview of hCentive’s State Exchange Solution


hCent iv e

Technology Solutions to Simplify Healthcare

Table of Contents Introduction

3

Eligibility & Enrollment

5

Rules Engine

6

Eligibility Screening

6

Quotes & Subsidy

7

Evidence Management

8

Enrollment & Renewals

8

Life Status Change Management

9

Benefits Management

9

SHOP Exchange

9

Employer Portal

10

Employee Portal

10

Billing & Payments

11

Customer Billing

12

Health Plan Payments

12

Broker Payments

12

Employer Billing

12

Accounting Integration

13

Exchange Portals

13

Broker Portal

13

Navigator Portal

14

Carrier Portal

14

Customer Support

14

Analytics & Reports

15

Technology Overview

16

Security

17

Integration

17

Rule Engine Support

17

Hosting & Deployment

18

Browser Compatibility

18

System Performance & Fail-over

19

Summary

19


hCent ive

Technology Solutions to Simplify Healthcare

Introduction To comply with the requirements of the Patient Protection and Affordable Care Act, states must launch health insurance exchanges that allow eligible state residents to search for, choose and buy health insurance, and small businesses to pool together their resources to reduce their insurance costs. The Department of Health and Human Services has required that states must meet two deadlines regarding the launch of a state-run health insurance exchange: • "Readiness determination" deadline of January 1, 2013 and • Exchange "Go live" deadline of January 1, 2014. Our WebInsure State solution helps states comply with this requirement and timetable.

We help states launch and operate an Exchange that: Helps state residents determine their eligibility to Exchange, State Medicaid, CHIP, Basic Health Plan and to Federal subsidies on purchase of Qualified Health Plans Helps state residents find and enroll in an affordable Qualified Health Plan that meets their specific needs Helps state residents maintain continuity of coverage Helps small businesses find affordable health plans that meet the needs of their employees in accordance with the Small Business Health Options Program (SHOP) Offers a simple, easy-to-understand experience designed for individuals who possess little or no knowledge of health insurance Operates cost-effectively and eliminates administrative complexity Meets all Federal and State regulations and timetables Connects all entities in the health insurance delivery process - consumer, carriers, state agencies, navigators/brokers etc.

3


hC ent ive

Technology Solutions to Simplify Healthcare

The WebInsure State helps those states seeking to: Design and build an end-to-end Insurance Exchange Incorporate Exchange modules into an existing infrastructure or design plan

The WebInsure State consists of following modules and sub-modules:

y Eligibilit g Screenin

Enr ollm ent Ren & ew als

B an ene ag fit em s en t

les Ru ine g En

Evidence Managem ent

M

M

SHOP Exchange

Cu st Sup omer po rt

Billing & Payment Reports

WebInsure State

Acc Int ounti egr n atio g n

m Po r

g

e

ay

an

r ato vig Na ortal P

ch

en

Ex

ts

Employee Portal

Analytics & Reports

er Employ Portal

s& ote y Qu bsid Su

Eligibility & Enro llm en t

L S ife C ta an han tus ag ge em en t

s

B

g illi n

&

P

er ok l Br orta P

Em Bi plo llin ye g r

tal

Ca rr Po ier rta l

Custome r Billing

Health Plan ts Paymen

ker Bro ents m Pay

4


hC ent ive

Technology Solutions to Simplify Healthcare

Eligibility & Enrollment The WebInsure State Eligibility & Enrollment module is a complete Eligibility & Enrollment solution for individual, families, small employers and employees.

Using WebInsure Eligibility & Enrollment Portal, Individuals & Families can: Determine their eligibility to Medicaid, CHIP, Basic health plan, Exchange plans and Federal subsidies Determine their eligibility to exemption from individual mandate Save eligibility information and complete eligibility process later Search and compare health plans Enroll self and family through filing an electronic application with the health insurer or state agency Submit applicants’ verification documents online e-App ‘Save and complete later’ E-sign the application Track the status of application online Complete semi-filled application by printing & fill it in by hand to submit it offline Submit paper application via e-mail or fax Pay via credit card, bank transfer, PayPal, check, or Health Reimbursement Accounts (HRAs) File for life status changes and re-determine their eligibility Manage renewals & terminations

Using WebInsure Eligibility & Enrollment Portal, Small Employers can: Determine their eligibility to purchase health insurance in the Exchange Determine their eligibility for federal tax credits Set up employee enrollments Manage employee eligibility Decide cost sharing between employee and employer Configure related products (dental, vision, life, etc.) a business may want to offer its employees Manage renewals & terminations Manage employee information and benefits Make changes to enrollments if required Track enrollments by employees Brand employee enrollment portal with employer logo, company name, contact details, etc. Manage bills & payments

5


hCentive

Technology Solutions to Simplify Healthcare

Using WebInsure Eligibility & Enrollment Portal, Employees can: Enroll themselves and their family members in plans for which they are eligible Track their enrollment status online Add/Remove family members upon life changing events such as marriage, child birth, death, adoption, etc. Make changes to their enrollments during annual enrollment periods Manage terminations and renewals Pay via credit card, bank transfer, PayPal, check, Health Reimbursement Accounts (HRAs) or Health Savings Accounts (HSAs)

Rules Engine WebInsure State Rules Engine maintains the rules repository for calculation of premiums and for eligibility determination and enrollment. It allows processing of individual’s household information through the rules repository to come up with premium amounts and eligibility results.

Rules engine offers the following features: Allows maintaining standardized rate sheets with effective dates Allows maintaining rules for eligibility determination for state programs, exchange plans and subsidies Allows maintaining rules for verification of information provided for eligibility and enrollment Allows premium calculation and verifications of individual/household information and eligibility determination based on rules

Eligibility Screening Eligibility Screening component of Eligibility and Enrollment solution is a shop for individual users to determine their eligibility to Exchange plans, Medicaid, CHIP and Basic health plan. They will also be able to determine their eligibility to premium and cost sharing subsidies. Our solution supports real time eligibility determination and has a standard eligibility process with some configurability at benefit level. Individual is taken through an intuitive and structured eligibility determination process.

Eligibility Screening allows the following: Eligibility determination to Medicaid, CHIP, Basic Health Plan, Exchange plans and Federal subsidies (Premium and Cost sharing) Seamless integration with enrollment process Internal and External verification of eligibility information MAGI calculation and interface with IRS for income information based on taxes filed Real time eligibility determination

6


hCent ive

Technology Solutions to Simplify Healthcare

Consistent customer experience Transmission of eligibility information to/from State agencies through HIPAA 270 Eligibility determination for exemption from individual mandate Navigator/Broker access to eligibility determination module Process appeals to eligibility decisions Eligibility determination for other public programs like food support, cash assistance, child care assistance and child support with minimal configuration/customization

Quotes & Subsidy The WebInsure Quotes aims to enable consumers and small businesses to search, compare, decide, apply and enroll for state exchange insurance programs. This engine helps eligible state residents (individuals, families and small businesses) find and purchase the insurance plan that best meets their coverage and financial needs taking into account any federal premium subsidies that they are eligible for. It provides a unique, user-friendly online experience that has been specifically designed to be understandable by individuals who possess little or no health insurance knowledge or experience.

Connecting Individuals with the Plan that Best Meets Their Needs Finding a health insurance plan isn't very hard to do. But finding the right health insurance plan is. Though there are hundreds of plans available, they are complex and very hard to understand. it is difficult to compare plans side-by-side, and health plan terminology is confusing. You never know if you have asked all the right questions, and you cannot be certain about the answers. That's why we have created a unique Web destination that goes beyond today's "health plan search engines." Our health insurance exchange platform contains intuitive comparison and filter tools and a state-of-the-art hCentive Health Insurance Decision Engine to help individuals select and purchase the health plan that best meets their needs.

Individuals & Employers can: Research available health plans under various benefit levels Platinum, Gold, Silver, Bronze Generate quotes based on various parameters, e.g. DOB, smoker, pregnant etc. Review and understand health plans, options and costs View and compare plan details Download and e-mail plan details to third parties Compare plans on key benefit and cost parameters

7


hCent ive

Technology Solutions to Simplify Healthcare

Get plan recommendations based on projected medical and health needs Sort & filter by various parameters, e.g. Deductible, Co-pay, Co-insurance, Out-of-pocket maximum, Premium, in-network doctors, etc. Connect instantly to a customer help line or licensed insurance brokers for assistance

Evidence Management Evidence Management helps state residents and employers upload and maintain evidence for verification by state personnel during the enrollment or life status change process. State residents or employers will be able to upload acceptable documents as evidence to support theinformation provided by them. State personnel can then access the documents online and verify information provided and accept/reject applications or request for additional evidencve.

Evidence Management allows the following: Seamless integration with enrollment, life status change process Upload evidence saved in user account for later use State personnel can review documents online, download them, and add comments to them which can also be viewed by the individual who submitted the document

Enrollment & Renewals Using Eligibility and Enrollment solution State residents can enroll themselves into Medicaid, CHIP, Basic Health Plan or in Exchange individual or group plans. Our solution has a standardized enrollment process for individual enrollments, which is configurable to some extent at benefit program level. Residents can also renew their enrollments for upcoming plan years through a user friendly and intuitive renewal process.

Enrollment & Renewals cover the following: Selection of health benefit plans Decision support tools to assist in plan selection Enrollment in health benefit plans for which eligibility is established Transmission of enrollment information to/from carriers and state agencies through HIPAA 834 Enrollment status updates based on verifications and actions by carriers and state agencies Process renewals, disenrollment and terminations Notifications to individuals, employers, employees, carriers and state agencies and federal agencies (in case of tax credit) on changes in enrollment status 8 Enrollment into health benefit plans limited to initial and open enrollment periods


hC ent ive

Technology Solutions to Simplify Healthcare

Life Status Change Management Life status change management allows State residents to file for changes in their family or life status when they occur even when enrollment is not open. User has to fill a simple life status change form and our solution re-determines their new eligibility in real time and notifies carrier or state agency about the life status change. Any change is enrollment status is communicated to the individual for further action.

Life status change management allows the following: Seamless integration with eligibility & enrollment module and user profile for eligibility redetermination Structured and intuitive life status change process Print and fill life status change forms for offline filing

Benefits Management WebInsure State Benefits Management allows managing multiple benefits in additional to medical and health like dental, vision, life insurance, parking, 401k etc. Small employers can offer these additional benefits to their employees and employees can enroll themselves and their family members into these additional benefits. Benefits Manager allows enrollment and administration of these

SHOP Exchange SHOP Exchange help states launch and operate an exchange that: Helps small businesses find affordable health plans that meet the needs of their employees in accordance with the Small Business Health Options Program (SHOP) Offers a simple, easy-to-understand experience designed for individuals who possess little or no knowledge of health insurance Operates cost-effectively and eliminates administrative complexity Meets all federal and state regulations and timetables States have the option to operate separate exchanges for consumers and small businesses, or to offer a single combined exchange. 9


hCent ive

Technology Solutions to Simplify Healthcare

Employer Portal Employer portal helps small businesses determine their eligibility for exchange and find the insurance plan that best meets the coverage and financial needs of the business and its employees. It provides a unique, user-friendly online experience that has been specifically designed for small business owners.

Small Business owners (or authorized personnel) can: Determine eligibility to Exchange Define fixed or percentage based contribution Configure related products (dental, vision, life, etc.) that a business may want to offer its employees Determine eligibility to federal tax credits Find available health plans Screen plans that cover all employee zip codes Review and understand health plans, options and costs to employer and employee Sort & filter based on various parameters, e.g. Deductible, Co-pay, Co-insurance, Out-of-pocket maximum, Premium, etc. View Plan details, download, compare, and e-mail to other employees whose input may be important in the plan selection process Define enrollment period Offer plan(s) to employees Manage employee information and benefits Make changes to enrollments if required Track enrollments by employees Brand employee enrollment portal with employer logo, company name, contact details, etc. Connect instantly to a customer help line or licensed insurance brokers for assistance

Employee Portal Employee portal allows small business’ qualified employees to enroll themselves and their family members in various plans made available to them by their employer, track their enrollments and make changes to their enrollment during open and special enrollment periods. 10


hCent ive

Technology Solutions to Simplify Healthcare

Using Employee portal, employees can: Enroll themselves and family members Review plan details; compare plans if more than one plan choice is offered by the business Use recommendation engine to decide which plan to enroll in if more than one plan choice is offered by business Decline/waiver employer coverage View employer and employee portions of the premium Select amount of funds they want to contribute to HSA (Health Savings Account) Select amount of funds they want to contribute to FSA (Flexible Savings Account) Track their enrollment status online Add/Remove family members upon life changing events such as marriage, child birth, death, adoption, etc. Make changes to their enrollments during annual enrollment periods Manage terminations and renewals

Billing & Payments The WebInsure State allows the insured individual/employee, small business, federal agency or carrier to receive invoices and make payments simply and easily. Our solution supports multiple payment modes like credit card, account debit, paycheck deduction, payment through checks and direct billing and reconciliation of payments from all parties.

WebInsure State allows the following: Allows individual to pay via credit card, bank transfer, or payroll deduction Collects payment contribution from employers Collects subsidy portion from state and federal programs Collects payments from Health Reimbursement Accounts (HRAs) and Health Savings Accounts (HSAs) Submits final payment to insurer upon approval Provide remittance information to insurers Billing to individuals/households, employer, employees, Federal agencies, Navigators/brokers and carriers Aggregation of payment from different entities Notifications in the event of non-payment by any party when it is due Notifications to federal agency about any changes in enrollment that impact subsidy payments

11


hCent ive

Technology Solutions to Simplify Healthcare

Exchange payments solution has the following sub modules.

Customer Billing WebInsure State supports timely generation of bills to customer when premium becomes due. Bills are sent using customer’s preferred mode of communication and can also be accessed via customer’s online account.

Customer Billing covers the following: Seamless Integration with enrollment module for billing amount Bill access through user account Tracking of previous bills and dues Bill generation based on user preference - paper billing, email etc. Reconciliation with customer payments

Health Plan Payments WebInsure State supports collection and aggregation of payment from customers and making payments to carriers.

Health Plan Payments cover the following: Aggregation of customer payments and tax credits from federal agency Applying exchange fee adjustments Payment to carriers Remittance information to carriers

Broker Payments WebInsure State supports collection of broker commission from carriers for all enrollments through brokers.

Broker Payments covers the following: Calculation and Aggregation of broker commission Applying exchange fee adjustments if any Payment to brokers Remittance information to brokers

Employer Billing Webinsure State supports timely generation of bills for employer contribution when it becomes due. Bills are sent using customer’s preferred mode of communication and frequency. 12 They can also be accessed via employer’s online account.


hC e n t i v e

Technology Solutions to Simplify Healthcare

Employer Billing covers the following: Seamless Integration with enrollment module for billing amount Billing access through user account Tracking of previous bills and due bill Bill generation based on user preference - paper billing, email etc. Reconciliation with employer payments Our solution also supports notifications to employers about employees that receive federal subsidies on individual exchange plans, so that employers can make their share of the payments.

Accounting Integration WebInsure State is integrated with a general ledger system that is updated with every financial transaction that occurs on exchange. This general ledger provides data for report generation for various entities.

Billing & Payment Reports WebInsure State allows generation of ad hoc and periodic billing and payment reports. Subsidy, premium, exchange fee, brokerage payments are reconciled and payment data is used to generate reports for the entities involved. These reports are sent to the users through email or in paper form. They can also be accessed via the online account.

Exchange Portals Broker Portal Broker Portal allows certified Agents and Brokers to assist exchange customers. The Portal acts as a complete prospect/client management tool.

Using Broker Portal Agents can: Manage list of prospective customers, both individuals and small employers, including their contact details, status, etc. Search exchange plans on behalf of clients Determine their eligibility to any federal subsidies on exchange plans Send proposals to clients through the System Start application on behalf of clients Check the status of a submitted application General agent & account executives can monitor sub-broker’s sales activities Manage broker commissions from carriers

13


hCent ive

Technology Solutions to Simplify Healthcare

Navigator Portal Navigator portal allows certified Navigators to assist state residents to find the right health insurance program and enroll in it.

Using Navigator Portal Agents can: Determine eligibility to Medicaid, CHIP, Basic Health Plan, Exchange Plans and Federal Subsidies on behalf of individual Manage list of cases they are assisting, both individuals and small employers, including their contact details, status, etc. Search plans for a case Create proposals for cases and print, fax, or email Fill application for a case Check the status of a submitted application Raise and track support tickets for a case Update payment information for a case File life status change for a case

Carrier Portal Carrier Portal allows carriers to upload their plan benefits, rates and other related information and documents to request certification from exchange. It also allows carriers to manage their product on an ongoing basis and track their product sales through exchange.

Using carrier portal, carriers can: Add/Update new rates and products Add product information and brochures Request certification of plans Track status of plan certification request Test health plan benefits and rates prior to production release Manage agents, brokers and agencies Maintain broker commissions Track enrollments to their plans Generate reports Manage carrier portal users

14


hCent ive

Technology Solutions to Simplify Healthcare

Customer Support Exchange users i.e. individuals, small business, brokers, navigators, carriers, at any point should be able to access Exchange customer support staff through various media like chat, phone, online and report any technical or functional issue they are facing during their exchange interactions. Our Customer support solution offers tracking and resolution to these issues in the quickest way possible.

Our Customer Support solution provides for the following: Live chat Ticket creation through multiple media email, call and web form Ticket tracking and management Ticket assignment Managing customer support users Representation on behalf of user to resolve issues Reporting

Analytics & Reports Capturing and understanding key metrics helps monitor performance of the exchange and make important strategic decision regarding exchange operations. WebInsure State provides a range of accurate and timely reports centered around the following metrics: Segmentation of customers by: Age Gender Income demographics Profession (student, working family, small business owner, etc.) Geography Traffic Source Analysis by: Search engine Social media Brokers Traffic Trend Analysis Is the traffic increasing? 15


hCent ive

Technology Solutions to Simplify Healthcare

Conversion Trend Analysis Which Carriers or policies are most popular for a particular consumer segment? Financial Reporting Receivable and payable reports Fund collection reports Reconciliation reports Out-of-box integration with Google Analytics to provide full power of Web analytics

Technology Overview Our solution is based on best design principles, keeping in mind the scalability, extensibility and interoperability of the application. Following are some of the key design principles used in our product: Service Oriented Event Driven Loosely Coupled Able to support assembly and integration Able to leverage existing applications and infrastructure All these key principles allow our solution to provide following short term and long term benefits: Ability to quickly meet customer demands Lower costs associated with the acquisition and maintenance of technology Leverage existing investments in technology Reduce reliance on expensive custom development Provide the ability to build composite applications Create a self-healing infrastructure that reduces management costs Provide a data bridge between incompatible technologies Enhance reliability and extensibility

16


hCent ive

Technology Solutions to Simplify Healthcare

Security We employ rigorous security standards to protect your data. Both you and your users access our system through secure web portals and interfaces. From authentication to role-based authorization and session security, every aspect of protecting customer information is closely managed. All customer data is encrypted during transmission and storage. Our solution is highly secure to protect customer information and meet compliance regulations. We also restrict all external interactions with our data center to a limited number of secure ports. Since these are the only routes by which data moves in and out of the data center, our infrastructure is extremely difficult to infiltrate.

Integration Our solution is based on component-based design, where each component is interfacess with other components via a defined contract (API). Important attribute of components is that they are substitutable; so that a component can replace another if the successor component meets the requirements of the initial component (expressed via the interfaces). Consequently, components can be replaced with either an updated version or an alternative without breaking the system in which the component operates. This design provides an option to replace existing components with their alternative if needed by providing an adapter implementation. Our architecture includes plug-ability with various custom adapters to provide integration with external system and third party services. Our system currently integrates with external systems via Web-services (REST/SOAP), Messaging systems, Single Sign-on solutions and Administrative and Underwriting systems.

Rule Engine Support Keeping in mind the configurability of the solution and flexibility to support different business rules (without much development) we have employed JBoss Drools into our solution. This provides us the capability to add and deploy new business rules (defining eligibility criteria for various programs and products) to our “Eligibility Engine”. Also for our “Quotes Engine” where there are different rules for calculating rates for various products of carriers, we have used JBoss Drools - Rule Engine to develop our rating engine. Adding a support of new carrier and their products in our Quote-Engine is as simple as configuring a new rule (drools based rule) into our system. This makes our Quote Engine highly manageable for adding/updating rules in the system without any downtime. 17


hCent ive

Technology Solutions to Simplify Healthcare

Hosting & Deployment We support various deployment model with full support and maintenance capabilities for all solutions-

Onsite Hosting: Our solution is built on Java/J2EE based stack, is platform independent and can be hosted on different platform/OS. No development level changes are required for migrating the application to different platform/OS. We can install the system at your data center, using our proven processes. We work with your IT staff to learn about your infrastructure, technology standards and processes, network bandwidth, and security policies and procedures, ensuring a successful installation.

Browser Compatibility Our solution is built using the latest web standards and supports most modern browsers as well as older systems. In particular, Our solutions also support popular mobile devices like iPhone, Android, BlackBerry, Windows mobile and any other phone with a modern browser. Please refer to table below for compatibility of our product on different browsers and operating systems.

Microsoft速 Windows速 Operating System IE7

IE8

IE9

Firefox 3.5+

Chrome10+ Safari 4+

Windows XP Windows Vista Windows7

Apple速 Mac OS速 Operating System - Mac OSX 10.5 Firefox 3.5+

Chrome10+ Safari 4+

Mac OSX 10.5 "Leopard" Mac OSX 10.6 "Snow Leopard" 18


hCent ive

Technology Solutions to Simplify Healthcare

Please note that Web browsers and Operating Systems are continually upgrading, and while we will strive to ensure compatibility with these new updates prior to official releases, we do not support any “Beta� versions.

System Performance & Fail-over Our solution architecture is flexible and scalable to support the high volumes of users. Fault tolerance and redundant servers prevent downtime and ensure reliability. Our solution is based on three-tier architecture and is designed keeping in mind best design principles for scalability. It is possible to scale web-tier or services-tier separately when required. Caching is highly used in the application to avoid any un-necessary hits to database/services. Fail-over of all layers are in place to avoid any issues to end user in case of any server failure. Horizontal scaling: It is possible to add more servers to scale application horizontally. Application is designed keeping this requirement in mind. User requests do not rely on session data and hence application server level clustering is not required. This avoids any performance overhead needed for server clustering. System monitoring scripts handle the launching of any new server. Vertical scaling: Our applications are hosted on cloud platform. Scaling application vertically do not require any application level changes.

Summary WebInsure State supports almost all features required to implement and run a Health Insurance Exchange successfully and within the strict timelines imposed by ACA. These features are customizable by State, and supported by the best technology and design principles.

For Further Reading & Questions: www.hcentive.com

19


hCent ive

Technology Solutions to Simplify Healthcare

Get the hCentive Advantage Corporate Headquarters hCentive, Inc. 12355 Sunrise Valley Drive, Suite 630 Reston, Virginia 20191

Contact Us Phone:

800-984-7952

Sales:

sales@hcentive.com

Support:

media@hcentive.com

Partnerships:

partnerships@hcentive.com

20

hCentive’s State Exchange Solution  

To comply with the requirements of the Patient Protection and A ordable Care Act, states must launch health insurance exchanges that allow e...

Advertisement