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Show Coverage: Exchanges face operational challenges

Publish date: JUN 15, 2011

Health insurance exchanges don’t have to be in place until 2014, but states are quickly gearing up for their launch. Dhan Shapurji, director, Deloitte Consulting, along with two of his colleagues, neatly packaged the challenges facing exchanges into nine operational components:

  • Marketing;
  • Products and services;
  • Comparison shopping;
  • Enrollment;
  • Eligibility and subsidy determination;
  • Customer service;
  • Premium reconciliation;
  • Collaboration between stakeholders; and
  • Role of the navigator/advisor.

“Each component has features that potentially affect current legacy operations or may require developing new capabilities and services to help address the needs of businesses on the exchange,” Shapurji said. For example, some plans are contemplating developing a limited network to present a low-cost option for the exchange.

Shapurji explored four major issues associated with the operational factors–channel disruption, financing and reconciliation, eligibility dynamics and the customer experience, the latter two affected by the growing number of persons who will enter the insurance pool.

“We know that health exchanges will be transformational, ” Shapurji said. “We anticipate seeing variability in models among states, which will need to offer different levels of benefits in order to create a competitive environment and keep premiums down. There are still many questions left on the table, from information interoperability to premiums and the delivery of services. ”

Shapurji foresees that state exchanges will look to HHS for guidance on how household income will be calculated and monitored for subsidy eligibility; who will undertake premium collection, reconciliation and determine disenrollment if the premium is not paid; and what mechanisms will be established to smoothly transfer customers between products and services.

He noted that plans also have to prepare themselves by determining which markets they are going to compete in and what type of competition they will face. Once they determine the scope of their markets, they can analyze the types of services and capabilities required to compete.

Rate review under the Patient Protection and Affordable Care Act will take effect September 1, and many states still have a great deal of groundwork to do. States will have the primary responsibility for reviewing rate increases, while the Department of Health and Human Services will serve in a backup role.

Heads up, health plans. If you want to compete in a health insurance exchange, the time to prepare is now, said Sarah Rodehorst, director, government health programs for Atlanta-based Connecture, a Web-based administration solutions company. She co-presented a session on Wednesday on building an infrastructure to meet exchange requirements.

MANAGED HEALTHCARE EXECUTIVE brings you three days of onsite coverage from Institute 2011 in San Francisco, including today's "Preparing for Exchanges" educational conference. Creating strategies to address the emerging exchange models remains a monumental challenge for managed care, and according to experts, the states are taking a variety of approaches.


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