NFP Health Case Study:

How One Medicaid

Plan Prepared for

the ACA Commercial

Marketplace

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About NFP HealthNFP Health’s turnkey solution allows traditional Medicaid plans to seamlessly enter

the ACA Commercial Marketplace. Our comprehensive model features a robust online

shopping portal, as well as a full administrative platform including: enrollment &

underwriting, premium billing, call center and EDI.

Come see us at Booth 316 or contact us at www.nfphealth.com, (888) 703-3332 or info@nfphealth.com

NFP Health designs, implements and

operates the administrative infrastructure

needed by Medicaid plans to enter the

commercial market.

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Executive SummaryNetwork Health is a Massachusetts health plan that serves more than 222,000 members with low and moderate incomes. In 2012, Network Health looked at the costs to build internally the needed capabilities to enter the commercial marketplace or to work with an experienced exchange provider, such as NFP Health.

Why? The looming impact of health care reform on Network Health’s membership brought to light that they could not afford to avoid addressing the changes that were coming in 2014.

As a result, Network Health chose to partner with NFP Health to implement and host a full suite of services and tools, including modules for shopping, quoting, underwriting and enrollment, and financial services.

Based on proven expertise honed as the operator of one of the nation’s premier multi-carrier health benefits exchanges for more than forty years in New England, NFP Health designs, implements and operates the administrative infrastructure needed by Medicaid plans to enter the commercial market.

Six months after Network Health selected NFP Health, a successful implementation was completed on time and on budget, and Network Health began offering its first commercial product, Network Health Choice, in March 2013.

Health Care Reform and the Historical MarketHealth care reform offers new business opportunities for health plans to better serve the individual and small group markets. These segments historically have been under served, with government programs focusing on the subsidized market and commercial health plans focusing on medium and large employer groups. However, due to health care reform, the landscape is changing.

Beginning in 2014, individuals and their families, as well as small employer groups, will be able to compare and purchase health insurance on either a federal or state health exchange, as well as directly from a health plan.

While a few health insurance products have been available in the past, individuals and small groups now will have a broader array of options and will be able to select a plan that best meets their needs, based on cost-sharing and benefit levels.

While it certainly is good news that people buying insurance will have more choice, the changing landscape presents both a challenge and an opportunity for Medicaid plans as they look for ways to expand their membership, by attracting new members, perhaps who were previously uninsured, and by retaining members who move from subsidized plans into the commercial market as their incomes increase.

While a few health insurance products

have been available in the past,

individuals and small groups now will

have a broader array of options and will

be able to select a plan that best meets

their needs, based on cost-sharing and

benefit levels.

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The Medicaid to Commercial OpportunityMassachusetts, long recognized as the model for national health care reform, is unique

in that it has operated a full service pubic exchange since 2006, which, in 2007, began

offering an unsubsidized (i.e., commercial) product, Commonwealth Choice, for the

individual and small group market.

Similarly, under health care reform, individuals and small groups nationwide will be able

to purchase commercial insurance from a Qualified Health Plan (QHP) either through a

public exchange (state or federal) or directly from a health plan.

Medicaid carriers, in particular, have much to gain by offering commercial products in

this marketplace.

Not only does offering commercial products provide an opportunity for growth by

attracting new members, but it is also essential to maintaining current members, and

providing continuity of coverage, as individuals and their families move above 400% of

the Federal Poverty Level (FPL).

A goal for Medicaid carriers such as Network Health, heading into 2014 and beyond, is to

retain their members as they move from subsidized to commercial health insurance.

Offering a commercial product provides a relatively easy way for Medicaid plans

to maximize their membership and revenue potential, despite the changes in the

marketplace that could easily threaten Medicaid plans if they are not prepared for the

changes of health care reform.

While most health plans have the necessary networks, clinical programs and claims

payment processes in place to operate in the commercial market, unfortunately, many

Medicaid carriers do not have the required expertise and infrastructure—people,

processes, technology – to be a commercial health plan.

NFP Health partners with Medicaid plans to implement an economical, turnkey solution

to allow the health plan to enter the commercial market on time and on budget, with

proven expertise and infrastructure that both removes the risk of building the required

capabilities from scratch, and leverages the benefits of forty years of experience in

building and operating both private and public exchanges.

A goal for Medicaid carriers such as

Network Health, heading into 2014 and

beyond, is to retain their members as

they move from subsidized to commercial

health insurance.

Medicaid

(subsidized)

< 133% FPL

Qualified Health Plans

(subsidy eligible)

133%-400% FPL

Commercial Health Plans

(no subsidy)

> 400% FPL

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Network HealthNetwork Health, a nonprofit, comprehensive health plan that serves more than 220,000

Massachusetts residents with low and moderate incomes, is a Medicaid Managed Care

Organization (MMCO) contracted by Massachusetts to provide health care coverage

for the state’s Medicaid population (those eligible for MassHealth and Commonwealth

Care), as well for the state’s Medical Security Program (MSP) Direct Coverage plan.

In 2012, Network Health decided to enter the commercial market by offering Network

Health Choice – unsubsidized health insurance for individuals and small groups. Offering

a commercial plan would allow Network Health to extend its mission “to improve the

health and wellness of the diverse communities [it] serves,” to prepare themselves

to be a Qualified Health Plan (QHP) under the Affordable Care Act, and to grow its

membership and revenue.

While Network Health had operated historically as a solely subsidized health insurance

provider, the business decision to enter the commercial market included evaluating

whether they should build or outsource key functionality required, such as sales,

enrollment, and billing, services typically provided by the state for subsidized plans.

After weighing the options, it became clear that it would be more economical and

efficient to leverage the capabilities of an external partner. Network Health was looking

for a partner that had a HIPAA compliant, fully integrated, turnkey platform, and was

willing to be flexible in customizing the solution for Network Health’s particular needs.

Based on these needs, as well as on cost and reputation, Network Health selected NFP

Health as their partner to launch into the commercial marketplace. Though Network

Health decided initially not to focus on the broker channel, the option to leverage

NFP Health’s strong broker program with over 2,500 affiliated brokers was appealing

should they decide to redirect sales, as Network Health had little to no experience in the

business market segment.

“NFP Health was able to provide all the functionality that we needed, from a private

shopping portal with real time rate quotes, to enrollment and billing functionality, to

customized reports. We are pleased that we made the strategic decision to leverage

their capabilities for both implementation and ongoing operations, rather than build

the required functionality ourselves”, Deborah Gordon, Chief Sales & Marketing Officer at

Network Health.

After weighing the options, it became

clear that it would be more economical

and efficient to leverage the capabilities

of an external partner.

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NFP Health’s Modular, Medicaid to Commercial Solution NFP Health has operated one of the nation’s premier multi-carrier health benefits

marketplaces in New England, covering several hundred thousand members with its

products and services over the past 40 years.

NFP Health’s leadership has extensive experience working with individual health plans,

as well as multi-carrier state operated exchanges, government benefits programs, and

newly created co-ops. They have developed the technology, processes and relationships

needed to successfully implement a highly modular, cost-effective, turnkey solution.

By partnering with NFP Health to take care of the administrative processes and required

integration capabilities, health plans can focus on serving their members with access to

affordable, high quality health care.

NFP Health’s leadership has extensive

experience working with individual health

plans, as well as multi-carrier state

operated exchanges, government benefits

programs, and newly created co-ops.

• Robust reporting suite

• Customized plan-specific reports: recurring and ad-hoc

Reporting

Customer Service

Premium Billing &

Collection

Enrollment

Sales

• NFP Health call center

• Warm transfer from health plan’s member service department

• Dedicated line for health plan

• Monthly member premium billing and collection, with E-Pay option

• Reminders, termination letters

• Monthly financial reports to health plan via 820 EDI

• Multi-carrier exchange and private, health plan-branded web portal

• Product and real-time rate display based on prospective member data

• Online application, link to health plan’s provider search tool

• Live web chat

• Eligibility verification per health plan’s underwriting guidelines

• Application processing and first month’s premium collection

• Renewals

• Member data to health plan via 834 EDI

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Deborah Gordon, Chief Sales & Marketing

Officer at Network Health, states:

NFP Health was an invaluable

partner as we moved from being a

subsidized insurance plan only to offering

our first commercial product. Everyone at

NFP Health was knowledgeable, flexible

and a pleasure to work with, and we

launched Network Health Choice on time

and within budget. I highly recommend

NFP Health!

Implementation of the Network Health Marketplace The implementation of the Network Health Marketplace, including planning,

development, and end-to-end testing, was a six-month, collaborative process between

NFP Health and Network Health.

NFP Health’s project management staff provided a detailed work plan that incorporated

key dates and milestones in Network Health’s overall project timeline. Weekly calls and

in-person meetings, as necessary, ensured that issues were discussed and resolved in a

timely manner.

A Network Health-branded shopping portal was created using NFP Health’s technology

and Network Health-specific branding, content, rules and data, to ensure an optimal

shopping experience for prospective members.

Network Health was also offered on the multi-carrier marketplace operated by HSA

Insurance (www.hsainsurance.com), a subsidiary of NFP Health.

Network Health’s Results With an aggressive target of six months from signing to implementation, Network

Health successfully entered the commercial market on time and on budget, with a

Network Health-branded, single carrier shopping and enrollment portal unique to the

marketplace.

Network Health’s shopping portal can be seen live at: http://network-health.nfphealth.com.

Network Health is now well positioned to retain its members who transition out of

subsidized programs, as well as to grow by attracting new members, in 2013 and beyond.

www.nfphealth.com

135 Wood RoadBraintree, MA 02184

(888) 703-3332info@nfphealth.com ©2013 NFP Health Services AdministratorsAll rights reserved

NFP Health’s turnkey solution allows traditional Medicaid plans to seamlessly enter the ACA Commercial Marketplace. Our comprehensive model features a robust online shopping portal, as well as a full administrative platform including: enrollment & underwriting, premium billing, call center and EDI.