The enactment of the Patient Protection and Affordable Care Act (ACA) and the subsequent upholding of the majority of the law by the United States Supreme Court will continue to result in significant changes to the way Americans access health insurance. A key feature of the ACA, and one that may have the biggest impact on state budgets and personnel, is the requirement to have a Health Insurance Exchange (HIX) available and functioning by government-defined deadlines. The Consumer Assistance function of the exchange provides the primary means by which applicants and consumers receive information about the HIX and their options, as well as make health plan enrollment choices.

2. Consumer Assistance and Health Insurance Exchanges
Analysis of Options Available to States
October 2012
Contents
INTRODUCTION ............................................................................................................................................ 1
HIX CONSUMER ASSISTANCE ..................................................................................................................... 2
CONSUMER ASSISTANCE/CALL CENTER OPTIONS ................................................................................... 3
1. FFE AND SPE MODELS: USE FFE CONSUMER ASSISTANCE ....................................................................... 3
2. SBE AND SPE MODELS: ADD EXCHANGE CALLS TO EXISTING STATE CALL CENTER ................................... 3
3. SBE AND SPE MODELS: USE VENDOR WITH CALL CENTER AND FFE EXPERIENCE TO HANDLE HIX CALLS3
QUESTIONS TO CONSIDER ........................................................................................................................... 4
ABOUT COGNOSANTE .................................................................................................................................. 4
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3. Consumer Assistance and Health Insurance Exchanges
Analysis of Options Available to States
October 2012
INTRODUCTION
The enactment of the Patient Protection and Affordable Care Act (ACA) and the subsequent upholding of
the majority of the law by the United States Supreme Court will continue to result in significant changes
to the way Americans access health insurance. A key feature of the ACA, and one that may have the
biggest impact on state budgets and personnel, is the requirement to have a Health Insurance Exchange
(HIX) available and functioning by government-defined deadlines.
There are six functions of the HIX that are mandated by ACA:
Eligibility/Enrollment. Establishing a seamless process for determining eligibility for qualified
health plans (QHPs) and all insurance affordability programs; handling eligibility appeals; and
processing redeterminations of eligibility. Enrolling consumers into QHPs and connecting Medicaid
and Children’s Health Insurance Program (CHIP) eligible consumers with the appropriate state
agency to effectuate enrollment (or at the state option, directly effectuating the enrollment into
Medicaid/CHIP plans); transmitting enrollment information to plans; and transmitting to the federal
government information necessary to initiate advanced premium tax credits (APTCs) and cost-sharing
reductions (CSRs).
Plan Management. Determining plan standards beyond federal minimums; certification, selection
and oversight of plans; collection, review and analysis of plan rates, benefits and quality information;
issuer outreach, training and oversight and the exchange of issuer and plan data with the state
department of insurance and with the Centers for Medicare and Medicaid Services (CMS).
Consumer Assistance. Providing assistance, education and outreach to consumers; Navigator
management; call center operations; website management; and general support of the Exchange’s
eligibility and enrollment functionality.
Financial Management. Developing a sustainable business model; collecting user fees; handling
transfer payments related to tax credits and CSRs; assuring financial integrity; and applying risk
adjustment, reinsurance and risk corridor programs.
Oversight. Ensuring accurate an accounting of all activities, receipts, and expenditures, including
required reporting to HHS, participating in audits and cooperating with HHS investigations as needed.
Quality. Evaluate quality improvement strategies and oversee implementation of enrollee satisfaction
surveys, assessment and ratings of health care quality and outcomes, information disclosures, and
data reporting.
Due to the amount of time required to design and implement most of these functions, almost all states
must decide how they intend to meet HIX requirements. There are three options for how states can choose
to meet the ACA exchange requirements
State-Based Exchange (SBE). State implements and operates all areas of the HIX.
Federally Facilitated Exchange (FFE). Federally implemented and operated exchange available for
use by those states that will not or choose to not have an SBE functional by the deadline:
HHS provides, hosts and operates all system components and business functions included in the
FFE scope, including SHOP, Plan Management, and Consumer Assistance
State is responsible for implementing some functionality that is not included in the FFE scope
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4. Consumer Assistance and Health Insurance Exchanges
Analysis of Options Available to States
October 2012
State Partnership Exchange (SPE): State elects to implement and operate some functions of the
exchange, and rely on the Federal Exchange for the remainder:
HHS provides, hosts and operates most system components and business functions included in the
FFE scope
State is responsible for implementing the functions not included in FFE scope
State can choose to operate plan management, consumer assistance or both functions
HIX CONSUMER ASSISTANCE
The Consumer Assistance function of the exchange provides the primary means by which applicants and
consumers receive information about the HIX and their options, as well as make health plan enrollment
choices.
Generally speaking, the consumer assistance requirement of ACA can be interpreted to include:
Operating a consumer support call center
Providing consumers with help through a range of modalities including telephone with interactive
voice recognition (IVR) support, email, online chat, text messaging, social media, walk-ins, mail and
other mechanisms
Establishing and operating a notification management system that allows electronic and paper
notifications to consumers through multiple channels
Allowing consumers to provide feedback to the HIX through multiple mechanisms
For states choosing to participate in the FFE, there may still be an option to implement and operate a
state-specific Consumer Assistance Center, with policies and activities directed towards the goals and
priorities of the state. Many consumers are anticipated to use the consumer assistance function, and it is
imperative that the requirements for each state be defined to accommodate stakeholders. They include:
Individuals shopping for plans
Individuals requesting general or eligibility information
Employers
Employees
Brokers
Navigators
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5. Consumer Assistance and Health Insurance Exchanges
Analysis of Options Available to States
October 2012
CONSUMER ASSISTANCE/CALL CENTER OPTIONS
There are many ways a state can choose to handle the consumer assistance requirement of ACA, all
providing varying levels of control to the states. With the exception of marketing/outreach and navigator
functions, all of the consumer assistance requirements are included in the FFE. States that choose the FFE
option are by default opting to have HHS run and operate those requirements on their behalf. States that
select the SBE or SPE models can choose to insource almost all functions and have them managed by a
state-run call center, or outsource some or all functions to a vendor specializing in this area. States
selecting the SPE model can either use the FFE to provide consumer support services, or can set up their
own state-based consumer support center just like states choosing the SBE model.
Below is a brief review of the options available to states under each of the three HIX models:
1. FFE and SPE Models: Use FFE Consumer Assistance
The FFE does include a consumer assistance function, which is included in the “offering” for any state
selecting the FFE model. Additionally any state selecting the SPE model can choose to have its exchange-
related calls handled by the federal call center. The FFE will include a toll-free hotline staffed by HHS or
an HHS-selected and managed vendor. The state Medicaid and CHIP agencies will need to collaborate
closely with the FFE to establish protocols to help consumers resolve issues that affect both programs,
and to ensure smooth handoffs among entities.
2. SBE and SPE Models: Add Exchange Calls to Existing State Call Center
Many states already operate call centers focused on health care, whether for Medicaid or another
program. These call centers may have the technical capability required to handle HIX-related calls, but
the subject matter and level of systems expertise will be vastly different. Most state Medicaid call centers
use state-specific legacy systems and the callers are mostly Medicaid participants who generally have
some familiarity with the program. HIX calls, on the other hand, will require knowledge of a new
federally-managed system and the skills to work with callers who may have never interacted with any
type of public health program in the past.
3. SBE and SPE Models: Use Vendor with Call Center and FFE Experience to Handle
HIX Calls
Many states currently work with vendors to provide consumer support activities, including Medicaid
hotlines and enrollment brokers. These vendors have the technical capability and policy experience
necessary to handle these types of calls and many may also be able to handle basic exchange
informational calls. However, understanding how the FFE works in relation to other state systems and
programs, and being able to assist new consumers with navigating the new health care program, is a
specialty that requires understanding of state and federal programs and experience working with state
departments of health as well as CMS and CCIIO. At first glance, establishing a new call center to handle
exchange calls may seem less cost-effective than either using the FFE call center or adding exchange calls
to an existing state-run call center. However, having an experienced partner who can facilitate this
process will result in long-term benefits such as reduced time and effort spent by state staff trying to
implement a consumer assistance function.
States that are interested in outsourcing the consumer assistance function still have time to make final
decisions and procure a vendor. For most vendors, it will take 3 – 5 months to establish a HIX-focused
call center, depending on the exact scope of calls and operational requirements. To be ready by October 1,
2013, states should have a vendor selected and working on implementation no later than April 30, 2013 to
ensure sufficient time for implementation, testing, and go-live readiness reviews.
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6. Consumer Assistance and Health Insurance Exchanges
Analysis of Options Available to States
October 2012
QUESTIONS TO CONSIDER
States that have not yet made final determinations regarding their HIX or Consumer Assistance function
of their HIX, should ask themselves these key questions:
States that have not yet selected a model:
How much state control do we want over the consumer assistance operation in our state?
States that want more control and do not want to have the HHS call center handling their calls should
select the SBE or SPE models in order to manage the Consumer Assistance function themselves.
States that have selected the SPE or SBE models:
Do we have the state resources to handle the additional call volume and scope?
Are there ways to combine existing health-related call centers into one operation to reduce costs and
increase efficiencies?
Are there vendors who are better positioned to manage and operate our Consumer Assistance
function?
These options all include a varying degree of risk, state control, cost effectiveness, and efficiency that
must be examined by each state to determine their preferences.
Having a solid, customer-service-focused, efficient Consumer Assistance function is key to ensuring that
all HIX consumers are educated and making the best choices for themselves and their families. During the
beginning stages of the HIX program, consumers will have more questions and concerns, and how those
are handled will set the stage for the future of the program. It is in the best interest of every state to
carefully review the requirements and determine how to best meet them based on their state’s needs and
preferences; making the best choice for the state now will save time and resources, reduce costs and risks,
and improve operational inefficiencies in the future.
ABOUT COGNOSANTE
Cognosante has consulted with many states, such as Utah and District of Columbia, on the
implementation of their HIX programs; we understand the challenges states are facing implementing this
part of the ACA regulation and we are actively working with our clients to find the best possible solutions
to these challenges. Our expertise combines knowledge of ACA, exchanges, and the FFE; understanding
of how health care reform can impact other state programs such as Medicaid and CHIP; and the ability
and capacity to implement and operate both large- and small-scale contact centers. Cognosante currently
supports CMS in developing the FFE, which gives us a unique understanding of the FFE systems and
how they integrate with other state systems
Use or disclosure of data contained on this sheet is subject to the restriction on the title page of this white paper.
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