I was recently invited to participate in the AHIP National Conference on the Individual and Small Group Markets on March 14 - 15, 2019 in Washington, DC. During the panel session my colleagues Daniel J. Miller of the CCIIO & CMS, and Nathanael J. Watters of Centene Corporation, and I fielded questions from industry professionals around the current challenges faced by health plans wanting to improve their on-marketplace experience.
With the ideal of creating of an undivided consumer experience a real possibility through Enhanced Direct Enrollment (EDE), health payers are now faced with a tough decision:
Partner with a vendor or build their own functionality.
Why bother with Enhanced Direct Enrollment?
The Centers for Medicare and Medicaid Services (CMS) manages and operates all Federal Marketplace health plan eligibility processing. In short, a health plan issuer can manage billing, payments, and benefits, but eligibility determination and advanced premium tax credits (APTC) must be managed by CMS specifically through HealthCare.gov.
This two-party process often leads to confused members and presents operational challenges for issuers as applicants are forced to bounce back and forth between a plan’s website that supports Classic Direct Enrollment and HealthCare.gov in a rather complex process.
According to CMS, “The enhanced direct enrollment process streamlines the consumer experience from start to finish when using a third-party website by allowing partners to integrate their websites with back-end data services to provide consumers with the same information and capabilities for managing their coverage that’s available through HealthCare.gov.”
EDE is made possible through a series of CMS-hosted APIs. Using these APIs, member eligibility and plan changes can be processed behind the scenes without the member ever having to leave the health plan’s website, allowing for a cohesive consumer journey from initial enrollment, through mid-year changes, and into renewal.
Sounds amazing! Where do I sign up?
This is where most organizations stand today. They want to implement EDE and now must determine if they should build the functionality themselves or partner with a reputable vendor.
Building EDE functionality is a heavy process that requires great effort and investment:
- Cross-functional team members must be aligned and impacts across the organization understood
- Requirements must be defined as to how EDE will be incorporated into the sales process
- Resource constraints and a limited CMS audit window mean coding and filling security control gaps must be prioritized, and the reality is some functional requirements may not be achievable depending on which phase of EDE was selected
- As a large project, the organization must be ready to approve the investment
- 3rd party auditor(s) must be selected and procured for the security/privacy audit, and for the business audit
But Wait, There’s more!
Here is the kicker: With EDE, the next step is to follow a long and careful process of CMS approval without any confidence on a time frame. Generally, the process takes months, with no guarantees as to when approval will occur.
Additionally, if you hope to implement EDE in calendar year 2019 for PY 2019 and 2020 you must submit your completed audit submission between April 1 and June 30, 2019. CMS has not yet released the next submission window timeframe, but this is likely to be after the PY 2020 Open Enrollment Period (OEP).
If you are not already mid-build, you likely won’t be able to submit your EDE solution for CMS approval until sometime in 2020. Can you afford another OEP without EDE?
Wow! Maybe I need a partner?
If you are like most health plans I know, you may be already suffering from vendor fatigue. Do you have numerous vendors, each only being utilized to solve for separate market segments, or one business problem in the consumer journey? And if you were to look closely, are some of those vendors even offering duplicative services and solutions to another vendor in your partner network?
If this is you, I suspect you are seeking to improve performance levels by reducing the number of partners you employ, not adding to the numbers. Today, with the current CMS approved EDE vendors at a mere two, and both focusing on offering solutions for on-market plans, is your only choice to add yet one more single-solution partner to your disjointed array of point solutions?
What if there was a member acquisition and engagement solution that also had EDE?
For too long, there have been too many holes in health consumer technology solutions. We created the suite of GuideWell Connect offerings to empower our services team and provide our clients a single, truly integrated consumer engagement solution. We have made the EDE commitment, integrating EDE into our web-based shop and apply platform SalesConnect.
GuideWell Connect’s solutions help health plans attract, retain and engage their members with offerings along the entire healthcare consumer journey. The best part? They can be employed for your entire array of plans from: Individual & Family Medical (U65) for on/off Marketplace, Short-term Medical, Dental, Vision, Medicare Advantage, Medicare Part D, and Medicare Supplement
EDE is a big decision. Hearing from multiple conference attendees trying to navigate EDE was enlightening, to say the least. GuideWell Connect has spent years reducing customer paint points with innovative integrated consumer engagement solutions, and by incorporating EDE, we believe we have a better way.
I wish you luck with your buy or build decision, and in solving for your on-market plan challenges. If you need a partner that can truly help you along your path, one that offers data-driven consulting, marketing, sales and engagement solutions to help you navigate the complex world of consumerism, I hope you will reach out to GuideWell Connect. Our mission is to help health plans attract and acquire more members, keep them healthier and keep them longer.
About the Author
Rob Fitzgerald, Senior Director, Product Delivery, is accountable for product management and delivery at GuideWell Connect. He has 17 years of experience in the health insurance industry, particularly in sales, enrollment and consumer data. Prior to his current role, he managed enrollment & billing systems, spent several years in U65 market segment strategy, and led a large issuer’s implementation of the ACA/healthcare.gov. Rob actively participates in strategic and operational workgroups directly with CMS for healthcare.gov.