3. hCent ive
Technology Solutions to Simplify Healthcare
Introduction
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.
We help states launch and operate an Exchange that:
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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Technology Solutions to Simplify Healthcare
The WebInsure State helps those states seeking to:
Design and build an end-to-end Insurance Exchange
Incorporate Exchange modules into an existing infrastructure or design plan
The WebInsure State consists of following modules and sub-modules:
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Technology Solutions to Simplify Healthcare
Eligibility & Enrollment
The WebInsure State Eligibility & Enrollment module is a complete Eligibility & Enrollment solution for
individual, families, small employers and employees.
Using WebInsure Eligibility & Enrollment Portal, Individuals & Families can:
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
Using WebInsure Eligibility & Enrollment Portal, Small Employers can:
Determine their eligibility to purchase health insurance in the Exchange
Determine their eligibility for federal tax credits
Set up employee enrollments
Manage employee eligibility
Decide cost sharing between employee and employer
Configure related products (dental, vision, life, etc.) a business may want to offer its employees
Manage renewals & terminations
Manage employee information and benefits
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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Manage bills & payments
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Technology Solutions to Simplify Healthcare
Using WebInsure Eligibility & Enrollment Portal, Employees can:
Enroll themselves and their family members in plans for which they are eligible
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
Pay via credit card, bank transfer, PayPal, check, Health Reimbursement Accounts (HRAs) or Health
Savings Accounts (HSAs)
Rules Engine
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.
Rules engine offers the following features:
Allows maintaining standardized rate sheets with effective dates
Allows maintaining rules for eligibility determination for state programs, exchange plans and subsidies
Allows maintaining rules for verification of information provided for eligibility and enrollment
Allows premium calculation and verifications of individual/household information and eligibility
determination based on rules
Eligibility Screening
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.
Eligibility Screening allows the following:
Eligibility determination to Medicaid, CHIP, Basic Health Plan, Exchange plans and Federal subsidies
(Premium and Cost sharing)
Seamless integration with enrollment process
Internal and External verification of eligibility information
MAGI calculation and interface with IRS for income information based on taxes filed
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Real time eligibility determination
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Technology Solutions to Simplify Healthcare
Consistent customer experience
Transmission of eligibility information to/from State agencies through HIPAA 270
Eligibility determination for exemption from individual mandate
Navigator/Broker access to eligibility determination module
Process appeals to eligibility decisions
Eligibility determination for other public programs like food support, cash assistance, child care assistance
and child support with minimal configuration/customization
Quotes & Subsidy
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.
Connecting Individuals with the Plan that Best Meets Their Needs
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.
Individuals & Employers can:
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
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Compare plans on key benefit and cost parameters
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Technology Solutions to Simplify Healthcare
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
Evidence Management
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.
Evidence Management allows 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
Enrollment & Renewals
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.
Enrollment & Renewals cover the following:
Selection of health bene t plans
Decision support tools to assist in plan selection
Enrollment in health bene t plans for which eligibility is established
Transmission of enrollment information to/from carriers and state agencies through HIPAA 834
Enrollment status updates based on veri cations and actions by carriers and state agencies
Process renewals, disenrollment and terminations
Noti cations to individuals, employers, employees, carriers and state agencies and federal agencies
(in case of tax credit) on changes in enrollment status
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Enrollment into health bene t plans limited to initial and open enrollment periods
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Technology Solutions to Simplify Healthcare
Life Status Change Management
Life 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.
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
Benefits Management
WebInsure 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
SHOP Exchange
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
States have the option to operate separate exchanges for consumers and small businesses, or to o er
a single combined exchange.
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Technology Solutions to Simplify Healthcare
Employer Portal
Employer 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.
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.
Connect instantly to a customer help line or licensed insurance brokers for assistance
Employee Portal
Employee 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.
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Technology Solutions to Simplify Healthcare
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
Billing & Payments
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.
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 11
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Technology Solutions to Simplify Healthcare
Exchange payments solution has the following sub modules.
Customer Billing
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.
Customer Billing covers the following:
Seamless Integration with enrollment module for billing amount
Bill access through user account
Tracking of previous bills and dues
Bill generation based on user preference - paper billing, email etc.
Reconciliation with customer payments
Health Plan Payments
WebInsure State supports collection and aggregation of payment from customers and making pay-
ments to carriers.
Health Plan Payments cover the following:
Aggregation of customer payments and tax credits from federal agency
Applying exchange fee adjustments
Payment to carriers
Remittance information to carriers
Broker Payments
WebInsure State supports collection of broker commission from carriers for all enrollments
through brokers.
Broker Payments covers the following:
Calculation and Aggregation of broker commission
Applying exchange fee adjustments if any
Payment to brokers
Remittance information to brokers
Employer Billing
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.
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They can also be accessed via employer’s online account.
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Technology Solutions to Simplify Healthcare
Employer Billing covers the following:
Seamless Integration with enrollment module for billing amount
Billing access through user account
Tracking of previous bills and due bill
Bill generation based on user preference - paper billing, email etc.
Reconciliation with employer payments
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.
Accounting Integration
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.
Billing & Payment Reports
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.
Exchange Portals
Broker Portal
Broker Portal allows certi ed Agents and Brokers to assist exchange customers. The Portal acts as a
complete prospect/client management tool.
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
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Manage broker commissions from carriers
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Technology Solutions to Simplify Healthcare
Navigator Portal
Navigator portal allows certi ed Navigators to assist state residents to nd the right health insurance
program and enroll in it.
Using Navigator Portal Agents can:
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.
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
Carrier Portal
Carrier 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 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
Manage carrier portal users 14
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Technology Solutions to Simplify Healthcare
Customer Support
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
Analytics & Reports
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:
Segmentation of customers by:
Age
Gender
Income demographics
Profession (student, working family, small business owner, etc.)
Geography
Traffic Source Analysis by:
Search engine
Social media
Brokers
Traffic Trend Analysis
Is the tra c increasing?
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Conversion Trend Analysis
Which Carriers or policies are most popular for a particular consumer segment?
Financial Reporting
Receivable and payable reports
Fund collection reports
Reconciliation reports
Out-of-box integration with Google Analytics to provide full power of Web analytics
Technology Overview
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:
Service Oriented
Event Driven
Loosely Coupled
Able to support assembly and integration
Able to leverage existing applications and infrastructure
All these key principles allow our solution to provide following short term and long term bene ts:
Ability to quickly meet customer demands
Lower costs associated with the acquisition and maintenance of technology
Leverage existing investments in technology
Reduce reliance on expensive custom development
Provide the ability to build composite applications
Create a self-healing infrastructure that reduces management costs
Provide a data bridge between incompatible technologies
Enhance reliability and extensibility
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Technology Solutions to Simplify Healthcare
Security
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
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.
Rule Engine Support
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.
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Technology Solutions to Simplify Healthcare
Hosting & Deployment
We support various deployment model with full support and maintenance capabilities for all solutions-
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.
Browser Compatibility
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.
Microsoft® Windows® Operating System
IE7 IE8 IE9 Firefox 3.5+ Chrome10+ Safari 4+
Windows XP
Windows Vista
Windows7
Apple® Mac OS® Operating System - Mac OSX 10.5
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.
System Performance & Fail-over
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.
Summary
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.
For Further Reading & Questions:
www.hcentive.com
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Get the hCentive Advantage
Corporate Headquarters
hCentive, Inc.
12355 Sunrise Valley Drive, Suite 630
Reston, Virginia 20191
Contact Us
Phone: 800-984-7952
Sales: sales@hcentive.com
Support: media@hcentive.com
Partnerships: partnerships@hcentive.com
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