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Health Insurance Exchange


									                                                                      Health Insurance Exchange

       An important part of the new health reform legislation found in the Patient Protection and
       Affordable Care Act (PPACA) is the requirement for states to develop what many now refer to as
       a “health insurance exchange”—a state-based health benefits exchange (HBE) and small business
       health options (SHOP) system. According to PPACA, the health insurance exchange must be
       administered by a government agency or a non-profit organization and support both HBE and
       SHOP together or as two separate exchanges.

       The scope is aggressive.
       A health insurance exchange is not a simple system, and the PPACA establishes many
       requirements for it by law. The key elements of a health insurance exchange include:

         • a single, integrated eligibility portal,
         • a single, standardized enrollment portal,
         • online and paper-based services, most notably a carrier menu,
         • a premium aggregator, and
         • a premium collection and remittance system.

       The exchange must support eligibility determination for all healthcare plans, standardize
       enrollment across all health plans, provide insurance counselor assistance, and support portability
       of coverage.

       The exchange must also operate a toll-free consumer hotline for information; inform consumers of
       eligibility requirements for public insurance plans; develop a single form for applying for state
       healthcare subsidy programs that can be filed online, in person, by mail, or by phone; contract
       with the state’s Medicaid program to determine eligibility for tax credits; certify mandated
       exemptions; use a standard format for presenting all coverage options; and establish a mandated
       navigator program for education and outreach.

       In short, a health insurance exchange truly is a one-stop-shop for health coverage functions.
       The timeline is aggressive.

       The PPACA legislation and the Department of Health and Human Services (HHS) have established
       an aggressive schedule for establishing health insurance exchanges—aggressive in part, because
       it comes at a time of implementing 5010 requirements, migrating to ICD-10, establishing statewide
       health information exchange (HIE), and supporting providers in achieving meaningful use of
       electronic health records.

         Mar 2010 to Jan 2015   HHS awards grants to establish health insurance exchanges
         Jan 2013               HHS must receive each state’s plan for establishing a health insurance exchange
         Jan 2014               The exchange must become operational
         Jan 2015               The exchange must be self-sustaining
         Jan 2017               Large group plans may participate in the exchange

       The federal government is making funds available for planning for health insurance exchange now.

(480) 481-5965 | 7926 Jones Branch Drive, Suite 330 | McLean, VA 22102 | |
                                                                   Health Insurance Exchange

       Shared services can help.

       Fortunately, the requirements for a health insurance exchange overlap with requirements for other
       systems that Medicaid and state leadership are already addressing, such as statewide HIE and
       Medicaid Management Information Systems (MMIS). For example, a health insurance exchange
       has a need for eligibility and enrollment services, presumptive eligibility determination services,
       provider verification services, pre-existing condition and diagnosis verification services, payer
       access to clinical information, program integrity, a master client/patient index, provider
       enumeration, payer enumeration, and a myriad of various system interfaces. Many of these
       components are needed by HIEs and MMIS as well.

       Cognosante’s vision of shared services allows you to build these services once—using funding for
       statewide HIE, for health insurance exchange and/or for MMIS—for use across many systems.
       Shared services not only simplify the state’s overall health information technology structure, they
       ensure consistent information across all systems and programs, and help extend already
       overextended federal dollars.

                                                                           Also see our demo on a Shared
       Health Insurance Exchange Demonstration                             Service Approach toIntegrated
                                                                               Eligibility and Enrollment.
       We are already working on Health Insurance Exchange.

       This demonstration illustrates many of the capabilities required to establish a health insurance
       exchange. It establishes a simple-to-use portal that accesses shared services for functions such as
       eligibility determination and enrollment. The approach allows states to immediately address the
       coming Medicaid bubble of increased participants while also supporting the health insurance
       exchange requirements required by PPACA.

       The focus of our demonstration is on providing a member portal and the tools needed to manage
       the eligibility and enrollment process from an administrator’s point of view. When integrated with
       shared eligibility and enrollment services, the exchange can use services that comply with the
       Medicaid Information Technology Architecture (MITA) framework to automatically verify applicant
       data during the process of determining program eligibility and enrolling a participant.

       This demo is a partnership among Cognosante, Connextions, and eServices

       Managing the Future with Confidence
       Cognosante is a woman-owned small business that develops, manages and executes large,
       complex healthcare information programs and infrastructures. FOX, a Cognosante company, is
       a recognized leader in Medicaid business processes and management information systems.
       Cognosante’s broad-based expertise includes healthcare policies, standards, interoperability,
       clinical practice, informatics, population health, public health surveillance, and Medicaid.

       For more information, please contact Mark Shishida at (480) 423-8184 or email

(480) 481-5965 | 7926 Jones Branch Drive, Suite 330 | McLean, VA 22102 | |

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