Health Insurance Marketplaces: Bringing Payers, Providers, and Technology Together in New Ways

Shelley Price, MS, FHIMSS, Director Payer and Life Sciences, HIMSS

Authorized by the Affordable Care Act, and starting in 2014, individuals and employees of small businesses will have access to affordable coverage through a new competitive private health insurance market -- the Health Insurance Marketplace (formerly known as Healthcare Insurance Exchanges). The state-based marketplace will provide individuals and small businesses with a "one-stop shop" to find and compare affordable, quality private health insurance options.

Planning Stage – IT was an early consideration

In 2010, 49 states and the District of Columbia received Exchange Planning grants from CMS totaling more than $54 million.

Six States and a multi-state consortium led by the University of Massachusetts Medical School received over $241 million in Early Innovator grants from CMS to develop model Marketplace information technology (IT) systems. Early Innovator States have committed to ensuring that the technology they develop is reusable and transferable to other States. Using the grants, they will develop the building blocks for Marketplace IT systems, providing models for how the IT systems can be created.

Approval Stage – The Federal Government works through personal data aggregation and exchange

In December 2012, HHS announced the first round of conditional approvals by HHS.  A March 2013 round of conditional approvals brings the number of states to 24.  Gary Cohen, deputy administrator of CMS, and director of the Center for Consumer Information and Insurance Oversight (CCIIO) within CMS announced in December 2012 at AHIP’s Exchange Conference that HHS has begun test their Federal Data Service Hub, which exchanges will access data from the Social Security Administration, the Internal Revenue Service, and the Department of Homeland Security for beneficiary information on income, citizenship, immigration status, as well as minimum coverage offerings.

Ready for open enrollment?

The second open enrollment period begins November 2014.  There are a lot of technology and coordination issues that need to be worked out.  Here are a few:

•    What are the technology needs around making eligibility, enrollment, and billing work across plans?  
•    Individuals will move in and out of different insurance products due to changes in income eligibility (e.g. Dual Eligibility, Individual plans, to State Medicaid).  Will this drive home the need for a unique patient identifier to help track patients as they move from one insurance product to another, which is important to minimizing gaps in care patients change providers as a result in a change in plans.
•    With the employer absent in this model, what do providers need to know about, for example, billing for non-payments, new contracting models, and coverage networks? What types of new IT systems and knowledge will be needed?

HIMSS Marketplace Offerings

HIMSS has launched a new Health Insurance Marketplace “Topic” category in the Resource Library to provide information and resources – such as ACA Requirement: Health Insurance Marketplace (HIM) Overview (Part 1) – so that payers, providers, government, and IT solutions can come together to provide 30+ million Americans with access to more affordable and continuous care.

The HIMSS Patient-Centered Payer Roundtable is starting a learning series on Health Insurance Marketplaces.  Join the Roundtable on the third Thursday of the month to engage on this issue.

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