Lessons learned going from Managed Medicaid to a healthcare exchange

At first glance, creating a health insurance offering for the public exchanges created by the Accountable Care Act (ACA) may seem like a natural move for Medicaid Managed plans. After all, Medicaid Managed plans already have an established provider network they can carry over. They also have a good understanding of beneficiaries who sit below and just above the Federal poverty level. Yet many payers that have already done it are finding it’s more challenging than they originally thought.


Make no mistake – the opportunity is there. But it’s probably going to require your plan to make some significant adjustments to its business operations. Here are some of the lessons learned by Medicaid Managed plans that we have already helped make the leap.


Increased customer service requirements

One of the biggest shocks Medicaid Managed plans receive when they first start supporting membership acquired via the public exchanges is how much more customer service is required.


For example, Healthx has had a client tell us the call volume for marketplace members was 10X greater than for their Medicaid members, and the calls themselves typically lasted 8X to 10X longer.


Why such an increase? One big reason is that plans purchased through the public exchanges are relatively more complex. Suddenly members have questions about deductibles, co-pays and other out-of-pocket expenses. They have questions about how much of a physician visit, emergency department visit or hospital stay is covered by their benefit plan. These are all things the customer service department never had to address when it was focused on Medicaid.


Neither did the new members. Many have never had insurance before, so they’re not even sure of what to ask or how to ask it. The result is a (hopefully) large new group of members asking the same basic questions of an overwhelmed group of customer service representatives.


Then there’s the fact that rather than having a single Medicaid Managed plan, you will be offering different levels of plans, each with their own nuances, on the exchanges.


More data to manage

Many of the same issues come into play when it comes to managing data. Medicaid Managed plans don’t have to deal with data issues such as tracking out-of-pocket maximums for individuals and families. They’re also not used to collecting premiums or out-of-pocket payments from individual members, or making adjustments to allowed amounts based on whether the care was provided by an in-network or out-of-network provider.


Several plans have found it difficult to get that data out of their claims systems so it can be retrieved by customer service representatives or displayed on member portals or mobile apps. It’s not that their claims systems can’t do it; the systems they purchased years ago may have originally had those capabilities. But the data fields are now being used for other things, so job one is learning where that information is stored so it can be exposed and shared with customer service applications and web portals/mobile apps.


These plans are also challenged to respond with accurate answers if a provider asks how much to collect from the member for their co-pay and co-insurance, and whether the member has met their deductible. All of this requires a tremendous amount of data processing expertise.


Low member understanding and confidence

Because plans purchased through the exchanges introduce a higher degree of complexity compared to a Medicaid plan, they can be confusing and difficult for members to understand. This is especially true for those without prior experience purchasing or using commercial health insurance.


Payers realized they needed to provide a whole new layer of education about the basics of health insurance to prospects and customers. In particular, they needed to focus on:


  • Insurance terms – Members had trouble understanding terms like “family deductible.”
  • Plan selection – Many of the people who were new to health insurance were nervous about making the wrong selection.


If you’re planning to make the leap, learn from the experiences of those who have already done so. In my next blog, I’ll outline the planning, people, and technology you’ll need to position your plan for success.

Mike Gordon is the Chief Product and Strategy Officer at Healthx. He has more than 23 years of software and information technology experience, with extensive expertise in product development for healthcare payer organizations.