Are you an insurer worried about integrating to state & federal marketplaces? Are you worried about cost, technology infrastructure, strategy, complexity and deadlines? This white paper addresses these concerns and more. Learn what steps you need to take and what pitfalls to avoid. Let hCentive be your guide through this challenging and changing landscape.

1. hCentiv e
Technology Solutions to Simplify Healthcare
WebInsure Exchange Manager
“Solution to Exchange Integration”
Are you an insurer worried about integrating to state & federal
exchanges? Are you worried about cost, technology
infrastructure, strategy, complexity and deadlines?
This white paper addresses these concerns and more. Learn
what steps you need to take and what pitfalls to avoid. Let
hCentive be your guide through this challenging and
changing landscape.
This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosed—in
whole or in part—for any purpose other than to evaluate hCentive products or services. This document
contains con�dential and proprietary information specific to hCentive, Inc.

2. hCentive
Technology Solutions to Simplify Healthcare
Health Insurance Exchange Integration
Introduction
The Supreme Court ruling on health reform, released June 28, 2012, upheld the two key elements of the
health coverage or pay a penalty; and the massive nationwide Medicaid eligibility expansion, which will
extend health coverage to a broader segment of the U.S. population. The U.S. Census Bureau reports that there
are approximately 50.7 million uninsured Americans, including 8.7 million children. In the near future, it is
According to the healthcare reform, states need to have a Health Insurance Exchange (HIX) operational by
Oct. 1, 2013. To comply and take advantage of the opportunity, insurers need to integrate and showcase their
products across multiple state exchanges. This integration requires insurers to conform to various PPACA and
rollments, life status change requests, billing and many others.
Individual
Business
Services
Education and
Customer Service
Eligibility
Determination
Health
Plan
Technical
Infrastructure
Customer Services
Customer Relationship
Management Systems
Coverage Rating
and Quoting
Broker
Product & Benefits
Enrollment
and Renewal
Enrollment & Billing
Premium Billing/
Reconciliation
Small Group
(SHOP)
Member
Management
Membership, Billing
and other Systems
General Ledger
Member
Management
Data Warehouse
Currently, insurers work directly with individuals, brokers, and small groups (aka Small Business Health
Options Programs or SHOP). Therefore, their processes aren’t equipped to integrate with HIX. These processes
include customer service, eligibility determination, coverage rating, enrollment, renewal, billing,
reconciliation, member management and more. Compounding the problem, the majority of these processes
are supported by proprietary technical infrastructures, which can make integration incredibly difficult.
This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosed—in whole or in part—for any
purpose other than to evaluate hCentive products or services. This document contains con dential and proprietary information specific to
hCentive, Inc.
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3. hCentive
Technology Solutions to Simplify Healthcare
infrastructures, which payers do not know if their systems can support.
systems and
Unfortunately despite PPACA’s aggressive deadlines, many organizations and agencies have had a “wait and
see” attitude and have not taken any meaningful action.
Evolve with the Change or Wither Away?
integrate with the newly founded HIX in order to enroll subscribers. If they choose not to integrate with HIX,
and, most likely, see a decrease in market share.
If they integrate poorly with HIX, they could significantly increase internal costs and offset newly found
revenue.
This new landscape is forcing insurers to transform but they are struggling with what exactly that means. This
Business
Services
Technical
Infrastructure
Customer Services
Customer Relationship
Management Systems
Education and
Customer Service
Eligibility
Determination
Individual
Small Group
(SHOP)
Coverage Rating
and Quoting
Enrollment
and Renewal
Coverage Rating
and Quoting
Premium Billing/
Reconciliation
Product & Benefits
Member
Management
Enrollment & Billing
Customer Service
Member
Management
Enrollment
and Renewal
Premium Billing/
Reconciliation
Health
Insurance
Exchange
(HIX)
Member
Management
Health
Plan
Membership, Billing
and other Systems
General Ledger
Data Warehouse
Subsidy Reconciliation
Self Service Capabilities
Federal Agencies
Bill, Pay, Delinquency and Customer Service
Individual
Consumer
This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosed—in whole or in part—for any
purpose other than to evaluate hCentive products or services. This document contains con dential and proprietary information specific to
hCentive, Inc.
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4. hCent ive
Technology Solutions to Simplify Healthcare
Implementation Readiness
Insurers need to realign their organizational governance to prepare for the reform. A roadmap needs to be
Operational and Technical Readiness
can avoid extensive costs and not unnecessarily tax resources. Integration with multiple HIX requires a new
technical infrastructure. Insurers must be equipped with an automated backend system that seamlessly works
with state HIX for eligibility, enrollment, billing and reconciliation transactions. This is a step that many
organizations had put on hold and are now scrambling to put a plan in place.
Exchange Management and Connectivity Solution
hCentive’s WebInsure Exchange Manager (WEM) can lift the burden of adapting to this new landscape. It acts
as an integration point between HIX, your organization and other related parties to minimize the impact on
existing business services and technical infrastructures.
This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosed—in whole or in part—for any
purpose other than to evaluate hCentive products or services. This document contains confidential and proprietary information specific to
hCentive, Inc.
3

5. hCentive
Technology Solutions to Simplify Healthcare
End-to-End Processing
hCentive’s End-to-End Business Service and Technology Solution provides the operational and technology
components for a health plan to interact with state HIX and federal and state entities, and members/groups.
It includes the following features:
1. Enrollment/Renewal and Payments
a. Collect enrollment information in a variety of formats, such as 834x12, 834 4010 v220, 834
5010 v307, custom XML format, mainframe formats, etc.
b. Collect billing information and calculate premium
2. Customer Service
a.
b. Allow searching of enrollments using HIX, payer member IDs and other
3. Plan Management & Distribution
a.
b. Integrate with HIOS and SERFF as required
c.
4. Reconcile Enrollments and Membership
5. Premium Billing and Reconciliation
a. Provide the ability to generate and distribute invoices, accept online payments, post
payments, manage delinquency and reconcile payments
b. Provide subsidy reconciliation
6. Member Management
a. Collect and process updates, terminations and re-instatements requests
hCentive’s solution will guide your organization to quickly adapt to the changes that are imminent
due to the reform.
This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosed—in whole or in part—for any
purpose other than to evaluate hCentive products or services. This document contains con dential and proprietary information specific to
hCentive, Inc.
4

6. hCentive
Technology Solutions to Simplify Healthcare
Get Organized, Get Started
new Exchange model. This involves a readiness assessment and road map, gap analysis, requirements
steps.
Solution Integration
WEM acts as a middleware, integrating HIX and your organization's backend systems in the most seamless way
possible. This allows you to seamlessly integrate existing business services, including revenue reporting,
enrollment management, reconciliati on, plan management, customer service and more.
While it is necessary for an exchange solution to be able to connect with multiple HIX, it isn’t going to be easy.
Since there aren’t set standards and protocols, it is highly probable that various states’ HIX will not speak same
language. The exchange format and protocol will most likely vary from state to state and organization to
organization. This is why hCentive developed WebInsure Exchange Manager to be input/output (I/O)
agnostic. Due to WEM’s I/O agnostic nature, your organization’s technical infrastructure does not need to
existing infrastructure and various health insurance exchanges.
Features and Functions
Plan Management
many elements that are functions of the state insurance departments. After exchanges are implemented in
2014, states will need to continue to perform these roles to ensure QHPs meet the requirements necessary
for participation.
Carriers will be responsible for uploading and pushing plan information to HIX and maintaining this
information in WEM for data validation.
Other features include:
Ability to generate plan data in appropriate format and upload data to exchanges
Product and Rate Data
Provider Network
Quality Data
Integration with SERFF and HIOS
This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosed—in whole or in part—for any
purpose other than to evaluate hCentive products or services. This document contains con dential and proprietary information specific to
hCentive, Inc.
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7. hCentive
Technology Solutions to Simplify Healthcare
Enrollment Application
The Enrollment Application Management Solution enables the insurer’s existing enrollment processing
system to connect to multiple state HIX without implementing multiple management systems.
Key features include:
Business Rules based routing
Queue and Workload Management
SLA Management
Integration with back end services, such as letter generation, letter tracking, audit capture, etc.
Dashboards and Reporting
Customizable Business Process Management Framework
Reconciliation
Key features include:
Membership Reconciliation
Premium & Subsidy reconciliation
Capability to generate actionable work items and feed business process management systems
from reconciliation results
In Conclusion
hCentive’s WebInsure Exchange Manager is designed to adapt to current and future market changes. It
is expected that the landscape of public and private health insurance exchanges will continue to
evolve in 2014 and beyond. Data models and business processes will continue to change and require
insurers to continually realign their business models to adapt. WEM will help you cope with the rapid
changes brought by the reform; as well as enable you to stay ahead of the market.
existing business services and technical infrastructures. hCentive will leverage your existing IT
investments and resources to help reduce your costs.
Time is the biggest issue. Insurers need to move quickly in order to adapt to the massive changes in the
regulatory environment. hCentive’s WebInsure Exchange Manager enables quick adoption so you can
take advantage of these new opportunities.
This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosed—in whole or in part—for any
purpose other than to evaluate hCentive products or services. This document contains con dential and proprietary information specific to
hCentive, Inc.
6

8. hCentiv e
Technology Solutions to Simplify Healthcare
For Further Reading & Questions:
www.hcentive.com
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Contact Us
hCentive, Inc.
Phone:
800-984-7952
Sales:
sales@hcentive.com
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media@hcentive.com
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Reston, Virginia 20191
-----------------End of White Paper----------------This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosed—in whole or in part—for any
purpose other than to evaluate hCentive products or services. This document contains con dential and proprietary information specific to
hCentive, Inc.
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