Tips for making the leap from Medicaid Managed to healthcare exchanges

For Managed Medicaid plans, the potential rewards of moving into state and federal exchanges are appealing. However, making the leap requires advance preparation, effort, and investment.


In my previous blog post, I explored the three key lessons learned by Medicaid Managed plans as they moved into healthcare exchanges. Today, let’s talk about what you can do to make the transition more successful if you’re in the same position:


Supplement call centers with digital engagement

As Medicaid Managed plans started supporting membership acquired via the public exchanges, they experienced significantly higher call volume and much longer call times. One way to prepare for this influx of questions is by increasing staffing in the customer service department. But increasing it by 10X to handle 10X peak volumes is unrealistic.


A more cost-effective option – and one that has proven successful for our clients – is to offer enhanced member engagement tools that allow members to answer most of their own questions or look up basic information online or from their mobile phones. For example, a simple FAQ section specific to the member’s plan level may provide answers to many questions without the need for a phone call. The member portal or mobile app can also allow members to look up their progress toward deductibles, total out-of-pocket expenditures and other benefit-related information.


A mobile app makes it even more feasible to engage members – especially for younger Millennial-generation members who are accustomed to using their smartphones or tablets for interacting with everyone and everything. Our customers have found implementing a third-party digital engagement solution (rather than attempting to build a portal or mobile app internally) has helped them get to market faster, with a higher quality, less expensive, and more engaging solution in the long term.


Additional call center capacity can be freed by automating responses to provider inquiries. For example, providers checking member eligibility can use technologies such as a provider web portal, interactive voice response system instead of phoning the call center, freeing up staff to handle the more complex member inquiries.


The better consumer experience your plan delivers starting at the point of enrollment and continuing throughout the course of the year, the more likely you are to retain those members when they make the decision whether or not to continue as your customer at re-enrollment time.


Dig in to your data

As they transitioned to public exchanges, many Managed Medicaid plans found it difficult to get data out of their claims systems for members and customer service representatives. They also found it difficult to provide member eligibility and benefits data (such as copay amounts and deductible status) to providers.


The solution here is to engage your claims system vendor to help you identify where the information is being housed and how it can be retrieved to allow members to serve themselves through a portal and/or mobile app. In some cases, it may require a retrofit to re-enable capabilities that were deactivated or repurposed in the past due to a lack of business need. In other cases it may require additional effort to reconfigure the system.


The IT department will then need to do the heavy lifting to ensure these new data elements are made available to members. Making this investment before the new plans are made available on the exchanges will reduce expense and member dissatisfaction down the road.


Invest in education

Plans that made the move from Managed Medicaid to the public exchanges quickly discovered how important member (and staff) education is to success. Plans purchased through the exchanges can be confusing and difficult for members to understand. Payers realized they needed to provide a whole new layer of education about the basics of health insurance, such as definitions of common industry terms written in simple language, to prospects and customers. This education provides two key benefits.


First, it helps these new prospective customers understand what the plan offers. While you may think terms such as “family deductible” are self-explanatory, experience shows they are not. Providing simple descriptive information helps prospective members make better decisions about their plan.


Many of the people who were new to health insurance were nervous about making the wrong selection. Providing materials that are easy to understand helps create a comfort level that simplified the decision.


The second benefit gets back to the consumer experience. When prospective members first come to your website, they may be there to look at pricing. But they are also subconsciously comparing the online experience to those they’ve had on iTunes,, and other retail sites. The more the user experience meets their expectations, the more appealing they will find you.


Having materials on the web portal or mobile app that are clearly written in everyday language (rather than insurance jargon) and architecting the navigation in an intuitive, consumer-centric way goes a long way toward winning the business. Making help available in context – for example, by having an explanation about deductibles in the section where members look up information about their deductibles – further cements the idea that you are the better option. This same approach should carry over into all communications with members – email, regular mail, social media, etc.


Finally, it will likely require additional training for your customer service staff. While they may be excellent at explaining the components of a Managed Medicaid plan to members, they will need to learn how to explain all of the new pieces of marketplace plans in terms that are easy to understand – even by those with no prior experience with insurance.


Making the leap doesn’t have to be difficult. However, there are new skills, capabilities, and technologies required for your organization to prosper in the exchange environment. With the proper planning, and the right people and technology to execute it, you’ll be in a better position to ensure ongoing 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.