Exchange environment brings service considerations


Insurance exchanges have an ultimate deadline of January 2014.

Key Points

WHEN THE U.S. Department of Health and Human Services (HHS) issued guidance on July 11 for the health insurance exchanges to be established under the Patient Protection and Affordable Care Act (PPACA), it launched the beginning of an intense process with an ultimate deadline of January 2014.

For health plans that want to participate in the exchanges, the focus is on developing the capabilities necessary to manage new members in a way that meets their needs while also ensuring profitability. After all, membership growth can be a mixed blessing for many health plans. To deal with this growth, plans will need to ensure the scalability of their systems and processes, particularly customer service.

"The biggest change will be the expansion of coverage to new populations who have not heretofore had access to health insurance coverage and by and large do not access the healthcare system except on an emergency basis," says Jordan Battani, principal with Global Institute of Emerging Healthcare Practices Group at consulting firm CSC in San Francisco. "These customers may not know how the system works."

When Massachusetts implemented its healthcare reform law in 2006, plans experienced unforeseen demand for customer service. The focus of the early contacts involved educating consumers about the basics.


Plans that want to participate in the retail-oriented health insurance exchanges will need robust customer service capabilities in addition to the functionality to interact effectively online. At the same time, they must reduce administrative overhead. Plans are looking for ways to increase their business-to-consumer service capabilities, including online and telephonic self-service systems.

"It is important to create an array of different customer service solutions with the goal of moving people from one-on-one interaction to self service modalities with [lower] administrative overhead and costs," says Battani.

How plans deal with and prepare for this will depend on their current level of customer service functionality and capability. Plans that already have automated Web- and telecommunications-enabled solutions might only need to add on specific capabilities or adjust scale to handle higher demand.

Humana Inc. has been upgrading its systems capabilities to enhance customer service for some time.

"We have been moving in a retail-oriented direction for the last couple of years, and that won't fundamentally change because of 2014," says Brian LeClaire, the company's chief service and information officer in Louisville.

For example, the company has established storefronts where individuals can ask questions face to face.

Humana has also enhanced member analytics. For example, if someone in a member's household has a chronic health condition, Humana can provide information on the resources available to help the family. Members might respond to a statement in the mail, a phone call or with online tools.

Finally, Humana sends statements to members showing their healthcare activity, including doctor visits, expenses paid, money-saving opportunities and so on. For example, if a member purchased a brand name drug or used a retail pharmacy, the statement would show how much the member could have saved by choosing the generic or using mail order instead. Likewise, the statement might alert a member to money remaining in a healthcare savings account.

LeClaire likens it to a credit card statement showing monthly activity. He believes that the technology-related investments Humana has made mesh well with the requirements of reform.

"Consumers are becoming more and more empowered, and we need to engage and interact them on that basis," he says. "A lot of these outcomes are likely to be complementary to the changes wrought by healthcare reform and by developments with individual consumers."

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