Undecided future of premium billing in health insurance exchange by Sutherland Global Services

Undecided Future of Premium Billing in Health Insurance Exchange June 2013

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Agenda

Process Maps – Before and After HIX Implementation

HIX Implementation Status

Emerging Scenarios – Membership Premium Billing

Federal Premium Collections Guidelines

Challenges for Payer in Premium Collections

Technology Solutions for HIX

www.sutherlandglobal.com June 18, 2013

Agenda

Process Maps – Before and After HIX Implementation

HIX Implementation Status

Emerging Scenarios – Membership Premium Billing

Federal Premium Collections Guidelines

Challenges for Payer in Premium Collections

Technology Solutions for HIX

www.sutherlandglobal.com June 18, 2013

Currently, insurers work directly with individuals, brokers, and small groups (SHOP) and their processes aren’t equipped to integrate with HIX’s

Current Process Map

Individual

Education and Customer Service Eligibility Determination

Broker

Health Plan

Business Service

Technical Infrastructure

Customer Services

Customer Relationship Management Systems

Coverage Rating and Quoting

Product & Benefits

Enrollment and Renewal

Enrollment & Billing

Membership, Billing and other Systems

General Ledger Premium Billing/ Reconciliation

Small Group (SHOP)

Member Management

Data Warehouse

Comments • According to the healthcare reform, states need to have a Health Insurance Exchange (HIX) operational by Oct. 1, 2013 • Currently payers processes are not equipped to integrate with HIX. These processes include customer service, eligibility determination, coverage rating, enrollment, renewal, billing, reconciliation, member management and more • Majority of these processes are supported by proprietary technical infrastructures making integration with HIX difficult Source: News articles

www.sutherlandglobal.com June 18, 2013

Post HIX implementation, payers must integrate with the newly formed HIX Process Map Post HIX implementation

Individual

Small Group (SHOP)

Education and Customer Service

Coverage Rating and Quoting

Eligibility Determination

Enrollment and Renewal

Coverage Rating and Quoting

Premium Billing/ Reconciliation

Product & Benefits

Member Management

Enrollment & Billing

Enrollment and Renewal Premium Billing/ Reconciliation

Health Insurance Exchange (HIX)

Health Plan

Customer Services

Technical Infrastructure Customer Relationship Management Systems Membership, Billing and other Systems General Ledger

Customer Service

Member Management

Individual Consumer

Business Service

Member Management

Data Warehouse

Self Service Capabilities

Subsidy Reconciliation Bill, Pay, Delinquency and Customer Service

Comments • The implications of PPACA for payers are significant. As HIX goes online, payers must integrate with the newly founded HIX in order to enroll subscribers • Post HIX implementation, insurers need to integrate and showcase their products across multiple state exchanges – This integration requires insurers to conform to various PPACA and state specific guidelines, such as health plan certification, reporting, tracking subsidies, enrollments, dis-enrollments, life status change requests, billing and many others Source: News articles

www.sutherlandglobal.com June 18, 2013

Agenda

Process Maps – Before and After HIX Implementation

HIX Implementation Status

Emerging Scenarios – Membership Premium Billing

Federal Premium Collections Guidelines

Challenges for Payer in Premium Collections

Technology Solutions for HIX

www.sutherlandglobal.com June 18, 2013

Status of State Implementation of Health Insurance Exchanges State Establishment of a State-based Exchange

States Defaulting to a Federally-facilitated Exchange

California*

Nevada*

Colorado*

New Mexico^

Alabama

North Dakota

Connecticut*

Oregon*

Alaska

New Jersey

District of Columbia*

Vermont*

Arizona

North Carolina

Hawaii*

Washington*

Florida

Ohio

Idaho*

Kentucky**

Georgia

Oklahoma

Maryland*

New York**

Indiana

Pennsylvania

Massachusetts*

Rhode Island**

Kansas

South Carolina

Minnesota*

Utah^^

Louisiana

South Dakota

Maine

Tennessee

Mississippi

Texas

Missouri

Virginia

Montana

Wisconsin

Nebraska

Wyoming

State Establishment of a State Partnership Exchange Arkansas^ Delaware Illinois^ Iowa^

*Legislation Enacted

Michigan

^Legislation Pending

New Hampshire

**Establishing an State-based Exchange via Executive Authority

West Virginia

^^Authority Has Not Yet Been Established

Comments • As of December 17, 2012, seventeen states and the District of Columbia have declared their intention to establish a State-based Exchange (SBE), and an additional seven states are pursuing a State Partnership Exchange. • All twenty-five State-based and Partnership Exchanges have been conditionally approved by HHS. • Twenty-six states have declined the opportunity to operate an SBE or State Partnership Exchange, and instead will default to a Federally-facilitated Exchange (FFE)

Source: Center on Budget and Policies Priorities - USA

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Agenda

Process Maps – Before and After HIX Implementation

HIX Implementation Status

Emerging Scenarios – Membership Premium Billing

Federal Premium Collections Guidelines

Challenges for Payer in Premium Collections

Technology Solutions for HIX

www.sutherlandglobal.com June 18, 2013

Scenario (1/4): The exchange manages collection and aggregation

• The exchange manages collection and aggregation - The HIX collects individual premium payments from the subset of members who choose to remit payments to the exchange, aggregates the collected payments and forwards them to issuers. The payer’s role is largely limited to reconciliation with the exchange • Individual premium payments from the subset of members who choose to remit payments to the exchange, aggregate the collected payments, and forward them to Qualified Health Plan (QHP) issuers – The exchange will thus absorb, and must offset, the cost of premium payment administration for this subset of exchange members

PROS

CONS

• Reduces the cost to QHP issuers of premium payment administration; this may be a benefit to issuers in the Exchange although the cost to the Exchange which is ultimately charged to the health Plans would likely provide a net increase in costs • One aggregated bill and a standardized payment frequency regardless of number of plan issuers • Provides the subset of Exchange members who opt to remit payments to the Exchange with a single point of contact for eligibility, enrollment, and premium payment status and problem resolution • Allows the Exchange to offset its administrative costs for the subset of members who opt to remit payments to the Exchange by subtracting them from the premiums collected rather than by invoicing QHP issuers • Reconciliation and reporting is streamlined between the Exchange and Issuers

• Requires the Exchange to implement two sets of processes for tracking and reconciling premium payments, one for payments remitted directly to the Exchange, and a second for those remitted to QHP issuers • Requires building a State payment processing infrastructure from the ground up in fewer than 18 months, including building this functionality into the Exchange IT system, establishing relationships with the State Controller and Treasurer, and hiring and training State staff • Because the number of members who will opt to remit payments to the Exchange is unknown, processing volume is unknown; scaling the staff to support this function will be difficult • Requires the Exchange to assume the cost of processing dishonored payments while building a financially sustainable operation by January 2015 • May require a State clearing account for dishonored payment instruments and funding to cover ongoing losses • Likely to increase the total cost of health coverage as Health Plans costs for premium processing is likely less than the costs that would be incurred for a lower volume of payments processed by the Exchange.

CUSTOMER IMPACT • The family would view plans and make a plan selection with the Exchange • The initial premium payment would be made to the Exchange at the time of plan selection • The family would receive a single bill from the Exchange on a recurring basis for all insurance plans elected Source : Board Recommendation Brief - California Health Benefit Exchange Individual Premium Payment Management

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Scenario (2/4): The billing vendor manages collection and aggregation

• The billing vendor manages collection and aggregation - An exchange contracts the management of individual premium payment processing and aggregation for a subset of members who opt to remit payments to the HIX. Again, a payer’s billing role is generally limited to reconciliation with the exchange. • The Exchange would elect to contract out the management of individual premium payment processing and aggregation for the subset of members who opt to remit payments to the Exchange

PROS • Offers the same advantages as Alternative • Provides greater flexibility in establishing the infrastructure and operations required to process premium payments for this subset of Exchange members

CONS • Possesses the same disadvantages as Alternative 1, except for the requirements associated with standing up a State operation • Requires a comprehensive and transparent procurement process, including development of a Request for Proposal, competitive bid evaluation, and potential bidder protests; estimated time to complete – six months • Requires the selected vendor to stand up a complete payment processing infrastructure in less than one year, including the implementation of an IT system and hiring and training staff • Outsourced vendors likely are a higher cost, given that the Exchange would be processing lower volumes than existing plan payment processing operations

Source : Board Recommendation Brief - California Health Benefit Exchange Individual Premium Payment Management

www.sutherlandglobal.com June 18, 2013

Scenario (3/4): Direct payment approach

• Direct payment approach - The exchange would leverage the payers’ existing payment processing infrastructure and direct HIX members to remit premium payments directly to a payer. The HIX will provide consumer assistance for unresolved billing questions and other issues. Payer premium billing would be modified to clearly identify both the HIX and health plan on the bill, as well as the federal tax credit that reduces the premium obligation to the consumer.

PROS

CONS

• Billing and Collections operations are external to Exchange • Fully meets the ACA’s requirement that members be allowed to remit payment directly to QHP issuers • Distributes premium payment processing to Exchange QHP issuers, which already have the requisite payment processing infrastructure and administrative overhead accounting procedures in place • Accords with Treasury policy related to the distribution and reconciliation of APTC and CSR. • Eliminates the complexity associated with accommodating two premium payment remittance processes • Lowest cost solution

• Requires Exchange members to remit payments to an entity other than the Exchange; the role of the Exchange in members’ access to health coverage would be focused primarily on eligibility and enrollment processes, outreach and marketing, service center and support/referral services • Requires the Exchange to invoice QHP issuers for administrative costs • Reconciliation between the Exchange and Issuers is complex • Consumers can not complete enrollment process in one-step – Exchange would require a notification from Issuer regarding delivery of initial payment from consumer – Consumer would be directed to carrier website to complete transaction

CUSTOMER IMPACT • • • •

The family would view plans and make a plan selection with the Exchange The initial premium payment would be made to the Exchange at the time of plan selection The family would be re-directed to three carrier websites for future premium billing information The family would receive multiple bills, from multiple carriers, at varying frequencies for on-going billing

Source : Board Recommendation Brief - California Health Benefit Exchange Individual Premium Payment Management

www.sutherlandglobal.com June 18, 2013

Scenario (4/4): Exchange Collects Initial Payment, On-Going Payments are Collected by the Issuer

Exchange Collects Initial Payment, On-Going Payments are Collected by the Issuer

PROS

CONS

• Allows for completion of initial enrollment within the Exchange

• Consumer experience is altered after initial payment

• Billing and Collections operations are partially external to Exchange

• Handling consumer “life changes” would be difficult • Reconciliation between the Exchange and Issuers is complex • Multiple bills and billing frequencies would exist for on-going payments • Need to build entire billing and payment system to full capability for the initial bill

CUSTOMER IMPACT • The family would view plans and make a plan selection with the Exchange • The initial premium payment would be made to the Exchange at the time of plan selection • The family would be re-directed to carrier websites for future premium billing information • The family would receive multiple bills, from multiple carriers, at varying frequencies for on-going billing Source : Board Recommendation Brief - California Health Benefit Exchange Individual Premium Payment Management

www.sutherlandglobal.com June 18, 2013

Agenda

Process Maps – Before and After HIX Implementation

HIX Implementation Status

Emerging Scenarios – Membership Premium Billing

Federal Premium Collections Guidelines

Challenges for Payer in Premium Collections

Technology Solutions for HIX

www.sutherlandglobal.com June 18, 2013

Federal Premium Collections Guidelines Premium Collection in SHOP • SHOP Exchanges are required to provide premium collection services – including issuing monthly bills to employers that break down employer and employee contributions, collecting total premiums due and transmitting them to the QHPs, and maintaining enrollee records • In addition, SHOP Exchanges are encouraged to create standard operating procedures for premium payment and remittance

Premium Collection in the Individual Exchange • Exchanges have the option but are not required to provide premium collection functionality for consumers who enroll in QHPs through individual Exchanges • If an Exchange chooses to provide individual premium collection services, federal guidance encourages multiple payment options • The final rule also requires that Exchanges allow consumers to pay premiums directly to their QHPs if they choose. Exchanges may create a default payment mechanism, such that individuals are automatically provided with collection services unless they opt out, and may also require selection of the collection option at initial enrollment

• The final rule confirms that Exchanges are not obligated to pursue unpaid premiums for issuers • Grace periods for non-payment of QHP premiums will largely be managed by the issuer when the Exchange does not adopt collection responsibilities. However, Exchanges do have information sharing responsibilities, particularly at the point of enrollment termination due to non-payment of premiums

Source : Manatt Health Solutions resource database

www.sutherlandglobal.com June 18, 2013

Agenda

Process Maps – Before and After HIX Implementation

HIX Implementation Status

Emerging Scenarios – Membership Premium Billing

Federal Premium Collections Guidelines

Challenges for Payer in Premium Collections

Technology Solutions for HIX

www.sutherlandglobal.com June 18, 2013

HIX implementation throws many challenges to be faced by the Payers industry

Accounting Challenges

Tracking Eligibility Criteria

No Standard process across HIXs

• As HIXs come online, payers will have to regularly reconcile customer’s benefits eligibility, their respective subsidy based on the previous year’s tax filing, and the amount to bill the state versus the customer – Moreover, payers will also be required to manage and aggregate premium and subsidy payments, late payments as well as possible new administration fees – To add to the complexity, payers will need to process Federal subsidy payments and reconcile the cost of health services used by enrollees with the premiums received

• Due to HIX, Payer will need to track the eligibility criteria for Medicaid versus commercial insurance based on consumer income levels – Income fluctuations has the potential to cause consumers churn between available plans offered on the public exchange and Medicaid

• Each HIX will run differently, so the insurers participating in more than one HIX will have to develop systems and processes flexible enough to deal with each HIX in which it is participating • While a majority of states are deferring premium billing to payers, a few state exchanges (such as Washington and Nevada) have decided to support premium aggregation – Depending on the exchange, payers will need to configure their billing systems to accept or send an enhanced HIX 820 (HIX payment file) from or to an exchange at a predefined frequency

www.sutherlandglobal.com June 18, 2013

Agenda

Process Maps – Before and After HIX Implementation

HIX Implementation Status

Emerging Scenarios – Membership Premium Billing

Federal Premium Collections Guidelines

Challenges for Payer in Premium Collections

Technology Solutions for HIX

www.sutherlandglobal.com June 18, 2013

Xerox – CHOICE Administrators Exchange Solutions Xerox – CHOICE Administrators Exchange Solutions Overview • In 2012, Xerox formed an alliance with CHOICE Administrators Exchange Solutions in all 50 states to offer a comprehensive, secure, cloud-based Health Insurance Exchange (HIX) solution – CHOICE Administrators Exchange Solutions delivers the framework of the HIX Solution Suite, a software-as-a-service cloud-based platform, which allows participants to make informed enrollment decisions while providing their sponsoring employers the infrastructure to maintain affordable budgets

Exchange Key Components • Individual and Family Quoting • Small Group Quoting • Medicaid/CHIP Integration • Net Cost Comparison • Provider/Rx Search • Broker/Navigator Assisted Shopping

• Individual and Family Plans and Small Group Enrollment Underwriting • Fulfillment • Broker/Navigator Assisted Enrollment

• Individual and Group Policies Small Group Quoting • Life Events • Employment Events • Plan and Coverage Changes • Member Services • Membership System Integration

Enrollment

Policy Management

Shop and Review

Xerox – Nevada State health Insurance Exchange • Nevada has awarded Xerox a contract worth $72 million to provide the technology and services to design and build the state's health insurance exchange (HIX) – Under the agreement, Nevada's Silver State Health Insurance Exchange will use Xerox's cloud-based technology and Web portal to support the HIX website, where individuals and small business employers will compare and buy health insurance plans that meet their needs – Company's technology and services will support premium billing, processing, collection, aggregation and remittance, data analytics and actuarial support, health plan quality review and compliance reporting, and incorporation of tax credits and subsidies in cost calculations

• • • • •

Commissions Carrier Disbursements Adjustments Contribution Management Member and Group Payment Processing • Collections

Financial Services

• • • • • •

• • • •

Carrier On boarding Plan Management Product Management Benefits Definition Eligibility Rules Rating Configuration

Program Maintenance

Outreach Coordination Self-Service Portal $330 Bn Call Center Automation Broker/Navigator Management Customer

Customer Relations

Xerox – Florida Health Choices • Florida Health Choices, a corporation established by the state to improve access to health care, has selected Xerox to administer its Insurance Marketplace, a program designed to give small business and eligible individuals more flexibility in finding affordable health insurance and other services – With partner CHOICE Administrators Exchange Solutions, Xerox will provide a cloud-based Web portal and online plan selection tool to give consumers and employers more information when making health insurance selections – Xerox will also provide eligibility determination and enrollment management services for the program, and operate a customer contact center to share information on marketplace offerings – The nine-year contract is valued at $68 million

Source: Company Website; News Articles

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CSC Exchange Connector Solution Components and Services

End-to-End Processing

End-to-End Business Service and Technology Solution which provides the operational and technology components for a health plan to interact with state HIX and Federal and state entities, and members/groups Customer Service • Respond to enrollment, benefits, billing and payment inquiries

Plan Management • Load and maintain products, benefits and rates and route to HIX • Confirm accuracy of submission

Enrollment/Renewal and Reconciliation

Premium Billing and Reconciliation

Member Management

• Collect enrollment information in a variety of formats and facilitate plan enrollment • Collect billing information and calculate premium • Reconcile enrollments

• Provide the ability to generate and distribute a bill, accept online customer payments, post payments, manage delinquency and reconcile payments • Provide Subsidy reconciliation

• Collect and process updates, terminations and re-instatements requests

CSC - Massachusetts Commonwealth Health Insurance Connector • Massachusetts mandated universal coverage for all its residents in April 2006 – A new state board, the Commonwealth Health Insurance Connector Authority, known simply as the Connector, launched initiatives to inform residents of the new requirement and to “connect” everyone in the state who wasn’t already insured to affordable health insurance coverage • The Connector chose CSC as its IT partner for the Web site project, which got underway in December 2006 – CSC designed, developed and launched a first-of-its-kind Web site to help consumers shop for health insurance coverage – The Connector Web site has helped enroll thousands of uninsured residents, increasing the percentage of enrollments completed online from 0 to 80 percent in just the first month of operation Source: Company Website; News Articles

www.sutherlandglobal.com June 18, 2013

CGI Health Insurance Exchange360

Overview

• CGI Health Insurance Exchange360 is a suite of services and technologies for launching HIX exchanges • The platform is aligned with ACA requirements and compliant with Medicaid Information Technology Architecture (MITA) • It enables states to manage eligibility and enrollment, seamlessly exchange data with commercial insurers and government agencies, and respond to regulatory and financial changes

Key Features • Health Insurance Exchange Portal providing plan feature and price comparisons • Eligibility screening and verification • Enrollment and purchasing • Health plan management • Financial management including premium billing/tax credits • Customer service center • Education and outreach • Member management

• • • •

Administration and reporting Infrastructure and hosting services Program management Interfaces through the Federal Data Services Hub to IRS, Homeland Security and Social Security Administration. Interfaces will also include gateways to state systems as needed

Clients • For state governments—CGI is performing implementation work for state-based exchanges in California, Colorado, Hawaii, Massachusetts, Kentucky and Vermont that will be accessible to 58+ million citizens • For the federal government—CGI is developing the Federally Facilitated Marketplace (FFM) to be used by 30+ states not building their own exchanges Source: Company Website and Sutherland Research

www.sutherlandglobal.com June 18, 2013

Softheon Exchange Connector

Overview

• Softheon Exchange Connector is a health insurance exchange solution which serves as an intermediary between Carriers and Insurance Exchanges • Softheon Exchange Connector is available in SaaS platform as well as recently introduced cloud based platform • Softheon's Exchange Connector Cloud is fully integrated BPM/ESB/SOA platform that handles the complexities of state and federal exchange processes and data interfaces

Key Features • • • •

Plan Catalog Management Small Business Health Options Program (SHOP) Eligibility & Enrollment Billing & Financial Management

• Member Services • Appeals & Grievances

Client • Softheon Exchange Connector Cloud platform will be used to connect Oregon’s Health Consumer Operated and Oriented Plan (CO-OP), a not-forprofit insurance entity to Oregon’s Health Exchange, Cover Oregon • Cover Oregon is a new central marketplace where Oregon individuals and employers will be able to shop for health insurance plans and access financial assistance to help pay for coverage • CareOregon, which provides administrative services to partner health plans such as the CO-OP, contracted with Softheon for this platform • The solution is designed for the regional health plans that need to be operational by September 2013 with their Plan Management, Eligibility & Enrollment, SHOP, Premium Billing and Customer Service solutions

Source: Company Website and Sutherland Research

www.sutherlandglobal.com June 18, 2013

Dell Health Insurance Exchange Solution

Overview

• In 2008, Dell signed contract with Massachusetts Health Connector(Connector), a first insurance exchange in US . The company’s experience in the healthcare and insurance industries enabled it to implement an advanced IT system for Connector • Dell’s HIX solution provides technology solutions for health plans that are creating their own private insurance exchanges • Dell helps to design, price and implement an exchange IT environment, fully compliant with HHS guidance and regulations

Key Features • Systems Design, Implementation and Portal Deployment • Enrollment Processing Services • Billing

• Reimbursement Solutions • Customer Call Centers

Client • In 2006, Massachusetts created Commonwealth of Massachusetts Health Insurance Connector Authority (Connector), a health insurance exchange. The Connector helps individuals and small businesses select and purchase health insurance plans. • In 2008, Connector signed deal with Dell to manage platforms and applications for enrollment, billing, website and customer experience services. • Dell began delivering billing services through its proprietary Xcelys software solution. Through Xcelys, Dell delivers an enhanced billing solution that enables Health Connector to reduce billing and back office costs, while providing added convenience features for enrollees such as the option of paying via electronic funds transfer (EFT) • Dell provides multilingual call center to assist residents in enrollment process and also provides maintenance and development services for the Health Connector’s primary web portal • In 2011 the agreement was extended for another 2 years and is expected to end in mid of 2013 Source: Company Website and Sutherland Research

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Other HIX Solution Provider Healthation • Healthation’s HIX financial management system includes Advance Premium Tax Credits (APTC) and Cost Sharing Reductions (CSR) management, marketplace administrative, fees processing, and Individual and Small Employer Health Options Program (SHOP) enrollment and eligibility processing • In 2013, three state-based health insurance exchanges have selected Healthation to perform various financial management functions, including invoice generation, invoice aggregation, premium collection, premium processing and disbursement. The name of exchanges is not disclosed

Oracle Oracle’s HIX comprehensive functionality includes – Eligibility and Enrollment – Billings, Collections & Premium Reconciliation – Multi-channel Customer Service – Premium Tax Credit Tracking – Broker Management – Payment Processing – Financial & Management Reporting

Ebix • Ebix provides comprehensive, end-to-end solutions for both the private and public health insurance exchange markets • Ebix Health Insurance Exchange solutions includes – Complete accounting and billing platform, Exchange accounting – Premium processing – Individual premium billing – Small employer premium payment transactions

Maximus • Maximus HIX solution includes – Eligibility and Enrollment – Multilingual customer support – Consumer Web portal – Navigator services – Exception and exemption processing – Grievance and appeals assistance – Health plan oversight • In 2013, Maximus signed a new contract with the state of Connecticut to operate the customer contact center operations for Access Health CT, the state’s Health Insurance Exchange. The contract is valued at $15 Mn and started on March 1, 2013, and will end by August 31, 2016

Benaissance

• HBEpoint is the SaaS enterprise class premium billing application optimized for Health Benefit Exchanges and consolidated SHOP premium billing requirements • HBEpoint key features

– APTC and Cost Sharing Reduction Reconciliations – Individual Premium Billing Net of Subsidies – 3rd Party Aggregated Billing – Split Individual / Group Billing – Financial Reporting to State and/or CMS – Creation and Distribution of HIPAA 834 and 820 Files

Source: Company Website and Sutherland Research

www.sutherlandglobal.com June 18, 2013

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