hCentive webinsure state

WebInsure StateOverview of hCentive’s State Exchange Solution

Cent ivehTechnology Solutions to Simplify Healthcare


Table of Contents

Introduction

Eligibility & Enrollment

Rules Engine

Eligibility Screening

Quotes & Subsidy

Evidence Management

Enrollment & Renewals

Life Status Change Management

Benefits Management

SHOP Exchange

Employer Portal

Employee Portal

Customer Billing

Health Plan Payments

Broker Payments

Employer Billing

Accounting Integration

Broker Portal

Carrier Portal

Navigator Portal

Security

Rule Engine Support

Browser Compatibility

System Performance & Fail-over

Integration

Hosting & Deployment

Billing & Payments

Exchange Portals

Customer Support

Analytics & Reports

Summary

Technology Overview

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Introduction

We help states launch and operate an Exchange that:

To comply with the requirements of the Patient Protection and A�ordable 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.

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.

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The WebInsure State helps those states seeking to:


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

Design and build an end-to-end Insurance Exchange

Incorporate Exchange modules into an existing infrastructure or design plan

WebInsureState

Billing & Paym

ents

Exchange Portals

SH

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Bene�ts

Management

Rules

Engine

Eligibility

ScreeningEvidence

Management

Life Status Change

Management


Billing&

Payment

Reports

Acco

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EmployerBilli

ng

Broker

PaymentsCustomer

Billing

Broker

Portal

Carrier Portal HealthPlan

Payments

Navigator

Portal

Empl

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Port

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Cust

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Supp

ort

Analytics

&Reports

Quotes &

Subsidy

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Using WebInsure Eligibility & Enrollment Portal, Individuals & Families can:

Using WebInsure Eligibility & Enrollment Portal, Small Employers can:

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

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

Determine their eligibility to purchase health insurance in the ExchangeDetermine their eligibility for federal tax creditsSet up employee enrollmentsManage employee eligibilityDecide cost sharing between employee and employerConfigure related products (dental, vision, life, etc.) a business may want to offer its employeesManage renewals & terminationsManage employee information and benefitsMake changes to enrollments if requiredTrack enrollments by employeesBrand employee enrollment portal with employer logo, company name, contact details, etc.Manage bills & payments 5


Enroll themselves and their family members in plans for which they are eligibleTrack their enrollment status onlineAdd/Remove family members upon life changing events such as marriage, child birth, death, adoption, etc.Make changes to their enrollments during annual enrollment periodsManage terminations and renewalsPay via credit card, bank transfer, PayPal, check, Health Reimbursement Accounts (HRAs) or Health Savings Accounts (HSAs)

Allows maintaining standardized rate sheets with effective datesAllows maintaining rules for eligibility determination for state programs, exchange plans and subsidiesAllows maintaining rules for verification of information provided for eligibility and enrollmentAllows premium calculation and verifications of individual/household information and eligibility determination based on rules

Eligibility determination to Medicaid, CHIP, Basic Health Plan, Exchange plans and Federal subsidies (Premium and Cost sharing)Seamless integration with enrollment processInternal and External verification of eligibility informationMAGI calculation and interface with IRS for income information based on taxes filedReal time eligibility determination

Consistent customer experienceTransmission of eligibility information to/from State agencies through HIPAA 270Eligibility determination for exemption from individual mandateNavigator/Broker access to eligibility determination moduleProcess appeals to eligibility decisionsEligibility determination for other public programs like food support, cash assistance, child care assistance and child support with minimal configuration/customization

Using WebInsure Eligibility & Enrollment Portal, Employees can:

Rules Engine

Rules engine offers the following features:

Eligibility Screening

Eligibility Screening allows the following:

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.

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 con�gurability at bene�t level. Individual is taken through an intuitive and structured eligibility determination process.

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Individuals & Employers can:


Eligibility determination to Medicaid, CHIP, Basic Health Plan, Exchange plans and Federal subsidies (Premium and Cost sharing)Seamless integration with enrollment processInternal and External verification of eligibility informationMAGI calculation and interface with IRS for income information based on taxes filedReal time eligibility determination

Consistent customer experienceTransmission of eligibility information to/from State agencies through HIPAA 270Eligibility determination for exemption from individual mandateNavigator/Broker access to eligibility determination moduleProcess appeals to eligibility decisionsEligibility determination for other public programs like food support, cash assistance, child care assistance and child support with minimal configuration/customization

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

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

Quotes & Subsidy

Connecting Individuals with the Plan that Best Meets Their Needs

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) �nd and purchase the insurance plan that best meets their coverage and �nancial needs taking into account any federal premium subsidies that they are eligible for.

It provides a unique, user-friendly online experience that has been speci�cally designed to be understandable by individuals who possess little or no health insurance knowledge or experience.

Finding a health insurance plan isn't very hard to do. But �nding the right health insurance plan is. Though there are hundreds of plans available, they are complex and very hard to understand. it is di�cult 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 �lter 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.

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Evidence Management


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

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.


Evidence Management allows the following:


Enrollment & Renewals cover 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

Evidence Management helps state residents and employers upload and maintain evidence for veri�cation 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.

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 con�gurable to some extent at bene�t

program level. Residents can also renew their enrollments for upcoming plan years through a user

friendly and intuitive renewal process.

Selection of health bene�t plansDecision support tools to assist in plan selectionEnrollment in health bene�t plans for which eligibility is establishedTransmission of enrollment information to/from carriers and state agencies through HIPAA 834Enrollment status updates based on veri�cations and actions by carriers and state agenciesProcess renewals, disenrollment and terminationsNoti�cations to individuals, employers, employees, carriers and state agencies and federal agencies (in case of tax credit) on changes in enrollment statusEnrollment into health bene�t plans limited to initial and open enrollment periods

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

Benefits ManagementWebInsure State Bene�ts Management allows managing multiple bene�ts in additional to medical and health like dental, vision, life insurance, parking, 401k etc. Small employers can o�er these additional bene�ts to their employees and employees can enroll themselves and their family members into these additional bene�ts. Bene�ts Manager allows enrollment and administration of these

States have the option to operate separate exchanges for consumers and small businesses, or to o�er

a single combined exchange.

Selection of health bene�t plansDecision support tools to assist in plan selectionEnrollment in health bene�t plans for which eligibility is establishedTransmission of enrollment information to/from carriers and state agencies through HIPAA 834Enrollment status updates based on veri�cations and actions by carriers and state agenciesProcess renewals, disenrollment and terminationsNoti�cations to individuals, employers, employees, carriers and state agencies and federal agencies (in case of tax credit) on changes in enrollment statusEnrollment into health bene�t plans limited to initial and open enrollment periods

Life status change management allows the following:Seamless integration with eligibility & enrollment module and user pro�le for eligibility redetermination

Structured and intuitive life status change process

Print and �ll life status change forms for o�ine �ling

SHOP Exchange help states launch and operate an exchange that:Helps small businesses �nd a�ordable health plans that meet the needs of their employees in accordance with the Small Business Health Options Program (SHOP)

O�ers a simple, easy-to-understand experience designed for individuals who possess little or no knowledge of health insurance

Operates cost-e�ectively and eliminates administrative complexity

Meets all federal and state regulations and timetables

SHOP Exchange

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Employer PortalEmployer portal helps small businesses determine their eligibility for exchange and �nd the

insurance plan that best meets the coverage and �nancial needs of the business and its employees.

It provides a unique, user-friendly online experience that has been speci�cally designed for small

business owners.

Employee PortalEmployee portal allows small business’ quali�ed 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.

Small Business owners (or authorized personnel) can:Determine eligibility to Exchange

De�ne �xed or percentage based contribution

Con�gure related products (dental, vision, life, etc.) that a business may want to o�er 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 & �lter 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

De�ne enrollment period

O�er plan(s) to employees

Manage employee information and bene�ts

Make changes to enrollments if required

Track enrollments by employees

Brand employee enrollment portal with employer logo, company name, contact details, etc.


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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.

Using Employee portal, employees can:Enroll themselves and family members

Review plan details; compare plans if more than one plan choice is o�ered by the business

Use recommendation engine to decide which plan to enroll in if more than one plan choice is o�ered 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

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 �nal 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 di�erent entities

Noti�cations in the event of non-payment by any party when it is due

Noti�cations to federal agency about any changes in enrollment that impact subsidy payments

Billing & Payments

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Customer Billing

Health Plan Payments

Broker Payments

Employer Billing

Exchange payments solution has the following sub modules.

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.

WebInsure State supports collection and aggregation of payment from customers and making pay-ments to carriers.

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

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. They can also be accessed via employer’s online account.

Customer Billing covers the following:

Health Plan Payments cover the following:

Seamless Integration with enrollment module for billing amountBill access through user accountTracking of previous bills and duesBill generation based on user preference - paper billing, email etc.Reconciliation with customer payments

Aggregation of customer payments and tax credits from federal agencyApplying exchange fee adjustmentsPayment to carriersRemittance information to carriers

Broker Payments covers the following:Calculation and Aggregation of broker commissionApplying exchange fee adjustments if anyPayment to brokersRemittance information to brokers

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Accounting Integration

Billing & Payment Reports

Our solution also supports noti�cations to employers about employees that receive federal subsidies on individual exchange plans, so that employers can make their share of the payments.

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

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.

Broker PortalBroker Portal allows certi�ed Agents and Brokers to assist exchange customers. The Portal acts as a complete prospect/client management tool.

Employer Billing covers the following:Seamless Integration with enrollment module for billing amountBilling access through user accountTracking of previous bills and due billBill generation based on user preference - paper billing, email etc.Reconciliation with employer payments

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

Exchange Portals

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Navigator PortalNavigator portal allows certi�ed Navigators to assist state residents to �nd the right health insurance program and enroll in it.

Carrier PortalCarrier Portal allows carriers to upload their plan bene�ts, rates and other related information and documents to request certi�cation from exchange. It also allows carriers to manage their product on an ongoing basis and track their product sales through exchange.

Using Navigator Portal Agents can:

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

Using carrier portal, carriers can:

Add/Update new rates and products

Add product information and brochures

Request certi�cation of plans

Track status of plan certi�cation request

Test health plan bene�ts and rates prior to production release

Manage agents, brokers and agencies

Maintain broker commissions

Track enrollments to their plans

Generate reports

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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.


Exchange users i.e. individuals, small business, brokers, navigators, carriers, at any point should be able to access Exchange customer support sta� 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 o�ers 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

Segmentation of customers by: AgeGenderIncome demographicsProfession (student, working family, small business owner, etc.)Geography

Traffic Source Analysis by:

Search engineSocial mediaBrokers

Traffic Trend Analysis Is the tra�c increasing?

Customer Support

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:

Analytics & Reports

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Conversion Trend Analysis Which Carriers or policies are most popular for a particular consumer segment?

Financial Reporting

Out-of-box integration with Google Analytics to provide full power of Web analytics

Receivable and payable reports

Fund collection reports

Reconciliation reports

Service Oriented

Event Driven

Loosely Coupled

Able to support assembly and integration

Able to leverage existing applications and infrastructure

Ability to quickly meet customer demandsLower costs associated with the acquisition and maintenance of technologyLeverage existing investments in technologyReduce reliance on expensive custom developmentProvide the ability to build composite applicationsCreate a self-healing infrastructure that reduces management costsProvide a data bridge between incompatible technologiesEnhance reliability and extensibility

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:

All these key principles allow our solution to provide following short term and long term bene�ts:

Technology Overview

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Security


Our solution is based on component-based design, where each component is interfacess with other components via a de�ned 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.

Keeping in mind the con�gurability of the solution and �exibility to support di�erent 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 (de�ning eligibility criteria for various programs and products) to our “Eligibility Engine”.

Also for our “Quotes Engine” where there are di�erent 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 con�guring 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.

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 di�cult to in�ltrate.

Integration

Rule Engine Support

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

Hosting & Deployment

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 di�erent browsers and operating systems.

Browser Compatibility

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

Microsoft® Windows® Operating System

Apple® Mac OS® Operating System - Mac OSX 10.5

IE7 IE8 IE9 Firefox 3.5+ Chrome10+ Safari 4+

Windows XP

Windows Vista

Windows7

Firefox 3.5+ Chrome10+ Safari 4+

Mac OSX 10.5 "Leopard"

Mac OSX 10.6 "Snow Leopard"

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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 o�cial releases, we do not support any “Beta” versions.

Our solution architecture is �exible 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.

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.

System Performance & Fail-over


Summary

For Further Reading & Questions:www.hcentive.com

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Corporate HeadquartershCentive, Inc.12355 Sunrise Valley Drive, Suite 630Reston, Virginia 20191

Contact UsPhone: 800-984-7952

Sales: [email protected]

Support: [email protected]

Partnerships: [email protected]

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