The Affordable Care Act ensures that every person has access to health insurance and that Individual and Family health insurance is available for people and their dependents. Generally, those who do not qualify for Medicare or insurance through an employer (such as Small Group or Large Group plans) will seek out this type of insurance. For Individual and Family, they can purchase their plan on-exchange or off-exchange. On-exchange indicates that the plan can be purchased on a public health exchange. The public exchange shows potential customers health plans from multiple Payors and if the individual qualifies for financial assistance, or subsidies, related to the premium of the plans, they are visible on this health exchange. Individuals can also purchase plans directly from the Payors, sometimes referred to as off-exchange. Here, the customer will often have access to a more comprehensive list of plans and have direct contact with the Payor, although subsidies are not available.
When selling Individual and Family plans, the Payor can offer their products both on-exchange and off-exchange. When offering on-exchange, the Payor can provide a rate quote, but the enrollment is done on the exchange. To show an accurate estimate of the premium, the Payor should display the subsidy for which the Individual is qualified. This can be challenging because a state’s subsidy calculation can be complex and difficult to replicate. Off-exchange plans, sometimes referred to as Direct plans, are more straightforward because there are no subsidies involved. Some Payors choose to show on- and off-exchange plans side by side while others choose to identify those who would qualify for a subsidy early in the process and present only on-exchange (to those who may qualify for a subsidy) or off-exchange (to those who do not qualify for a subsidy).
Rules and pricing can vary between Payors making the choices more complex. For example, some plans may be available to subscribers under a certain age or those who live in a certain jurisdiction. The premium may vary based upon the location of the subscriber or be reliant upon whether the subscriber or his/her dependents use tobacco.
Individual and Family insurance generally must be renewed every year during Open Enrollment if a special enrollment reason is not applicable. Special enrollment reasons,in the form of a qualifying life event (QLE), allow the subscriber to change or purchase new insurance at any time when a scenario, such as the birth of a child, is applied. The Payor needs the renewal process to be as simple as possible to ensure member retention. To achieve this, the Payor will often pre-populate known information about the Subscriber during the renewal process. Additionally, plan offerings may vary from one year to the next and are not directly aligned. For example, plans offered in one year may not be available the following year. The Payor will often align each of the current plans with the closest match for the following year’s plans and present that to the Subscriber during renewal. The goal is to make the process as smooth, efficient, and simple as possible for the Subscriber.
Attentis Consulting has successfully implemented the Salesforce Industries Individual and Family Shop and Enroll solution for several Payors. Many of these implementations were the result of similar challenges, as identified above. Often the differences lie in the exact field labels or the order in which screens are presented rather than in broader variances. We have developed a proven methodology to collect unique requirements for each project while building on the common features that we have seen across multiple projects. This solution takes Brokers, Consumers, and Internal Sales personas into account. Each of these roles resembles the others with slight nuances. Those nuances may be specific to your business but hold similarities across the industry.
Collectively we have provided successful solutions that involved coordination of benefits, selection of primary care providers, collection of documents, and payment information. When working on the coordination of benefits and selection of primary care providers, we have found that some providers wish to connect to other internal systems to retrieve information. For example, when selecting a Primary Care Provider, we can interface with the Provider Network, search for a provider, and retrieve that provider’s information to be able to store the required attributes, such as: Name, Provider Number, and Address. When this information is required for a specific plan, we can also enforce the collection as a required data element while not enforcing this rule for other plan selections. Document uploads can be required for specific plans or under certain circumstances, such as a QLE. If a user qualifies for a special enrollment reason, we can enforce the collection of specific documentation required to support the QLE. Finally, for payment information, we can connect to a client’s third-party payment gateway ensuring that all personal identifiable information (PII) is securely transferred outside of the Shop and Enroll system to mitigate additional system security requirements.
Using our repeatable and proven methodology, we have reusable artifacts that are the starting point for our implementations. We use common components and predefined user stories that can be adjusted to meet the specific requirements for any business. Our solution’s data dictionary can be modified to incorporate an existing Salesforce implementation (including Health Cloud, Sales Cloud, or Service Cloud) and can be used to support a best practices design. This design also ensures that the data required to complete the enrollment has been captured and stored. The Attentis solution for Individual and Family Shop and Enroll is an accelerator that leads to faster delivery with proven success.
The Attentis Individual and Family Shop and Enroll accelerator is built on top of Salesforce and ensures that your sales data resides on one platform. This data, and the Salesforce Individual and Family Shop and Enroll solution, will improve performance, stability, and integrations with other applications. Payors find that the total cost of ongoing technical maintenance decreases as the system meets current and future volume requirements , even during peak times like Open Enrollment. In addition, the shopper experience and satisfaction with the online sales portal are improved for your Individual and Family offerings. The simple, intuitive design allows your customers to trust and utilize the self-service features, getting your plans into their hands faster. This type of implementation is often completed in 4 – 6 months.
Attentis will work with your staff to ensure that implementation knowledge is transferred to enable them to effectively support the solution for subsequent plan years.. When needed, Attentis will be by their side to offer support and guidance for a self-sustainable future. In addition, Attentis offers managed services for a complete outsourcing of your on-going solutions support.
The Attentis Individual and Family Shop and Enroll accelerator and delivery methodology offer a proven, successful implementation approach to meet compliance standards with an affordable and quick path to delivery. Let us show you how we can partner for success.
