The clock is ticking. The Patient Protection and Affordable Care Act's health insurance exchanges are targeted to come online in 2014, which means open enrollment must begin in the fall of 2013. Every state is determining its approach, and everyone in the industry is strategizing on how to tap into a projected market of 25 million enrollees by 2016. The states will take different approaches, but the common denominator is technology. This month we'll look at how technology will be utilized in exchanges and identify other corresponding services that will be necessary to make the exchanges a success.


Exchange requirements

At a high level, designing and implementing an exchange seems relatively straightforward: Provide users with information about the available health plans, determine their eligibility, guide them through the enrollment process and interface with the carrier for service provisioning. The key word in the previous sentence is "users" - in other words, consumers, or even more specifically the uninsured.

The uninsured as a target market cover a broad demographic, including young, "I don't need insurance" people, the suburban and rural poor (many without broadband access), high-risk individuals and the unemployed of all ages. Different users means different requirements and needs and adds significantly to the complexity of an exchange. Dealing with this complexity while overcoming the poor track record of online health insurance sales is a major challenge in achieving a successful exchange.

States do have some flexibility in the model they choose for their exchange. Models will range from open marketplaces where insurers can participate and compete to comprehensive, consumer-oriented end-to-end solutions where states choose insurers based on their own criteria. And everything in between.

In any model, though, the technology of an exchange must provide some level of account management, shopping, eligibility and subsidy calculations, enrollment, carrier services and administration.

Furthermore, to truly meet the needs of the uninsured, the technology of an exchange must be augmented by extensive outreach programs and consumer services. Thus, marketing (outreach) and consumer services need to be integrated into the exchange model as well.

This month we'll cover account management, shopping, eligibility and subsidies, and enrollment. In subsequent months we will look at how carrier services might be integrated into an exchange, administration, marketing and consumer services.


Account management

From the consumer perspective this includes all of the standard functionality we know and expect from any online commercial site - recording and management of personal information, billing information, preferences, passwords, etc. However, an exchange must go deeper into a consumer's background, requiring both personally identifying information (PII) and personal health information (PHI) for not only themselves, but also their family members. Thus security will be of paramount importance for every exchange.



For me, "shopping" is one area where an exchange can add value to the consumer experience. Certainly plan comparison and pricing are givens. But what a great opportunity to not only support the consumer's decision process with appropriate tools and incentives, but also to educate them. And, after their initial purchase, to service their ongoing health care needs. Education can include information about care and disease management, wellness tools, healthy lifestyles, health risk assessments, costs of medical procedures and available carrier services. Imagine providing online centers for cancer, pregnancy, back pain or childhood obesity.

And, as I've written before, people want to know what others like them have experienced. That's one of the great benefits of the Web and something that consumers have come to expect. Using social software capabilities to tap into the experience of other consumers - even those outside of an exchange - is a "must have" for an exchange.

Lastly, states now understand that many consumers will require offline assistance in their purchasing decision and that the benefits expertise of brokers and agents can be utilized to help alleviate this problem. In an exchange, shopping should be expanded to include a "find a broker or agent in your area" service or a connection to a social service organization designated to assist with health insurance purchases.


Eligibility and subsidies

This is one area where an exchange will have to interface with other systems. The need to determine a consumer's eligibility and qualification for a subsidy means consumer information must be current and validated. This includes both the initial determination of eligibility and subsidy and ongoing eligibility maintenance as well. Family incomes change (both up and down), family members get jobs that provide other coverage, and there are a number of life events that can trigger a change in benefits. All of which an exchange must able to manage.

In a broader vision of an exchange, those consumers that aren't eligible through the exchange don't have to be left without assistance. An exchange could at least direct them to other services they may qualify for (e.g., Medicaid, CHIP, COBRA). Exchanges can go further by exchanging information with other programs, thereby giving the consumer a running start and access to programs they may not know about.



Online enrollment for both individual and group health has been around for many years. In an exchange, once consumers enter their account information and selected a plan, they can be easily guided through the enrollment process. Once enrolled, though, there is a good bit of processing that takes place behind the scenes, including transfer of a consumer's benefits elections to the carrier, premium collection and fulfillment (plan documents, insurance cards, etc.). How much of this will fall to the exchange or to the carrier is yet to be determined and may vary based on the exchange model chosen by a given state.

Regardless of the model chosen by a given state, it is clear that an exchange needs to be a dynamic, consumer-oriented online system. The population of the uninsured is itself dynamic, with members moving in and out of the exchange over time. Recognizing the dynamics is important, because an exchange can meet the needs of the uninsured and, ultimately, help manage and reduce health care cost.

Reach Lamb, of Benergy Interworks, at A.D.A.M. Inc., at

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