Amy Santenello: Health Benefit Exchange

Date: 05.15.2013 | Zach Urbina">Zach Urbina

Amy Santenello, Vice President Strategy and Product Marketing, Curam Software

transcribed from a video recorded on June 19, 2012

(click to watch video- free registration required)

Amy Santenello begins by talking about Curam’s role in software for health benefit exchanges.  She shares about how states are or are not preparing for the 2014 ACA timeline, planning, organizing, and preparing for health benefit exchanges.  She relates the implementation activities of states and the upcoming Supreme Court ruling on ACA as  “the perfect storm.”

Santenello communicates the urgency of enrolling Americans in health exchanges ahead of the 2014 deadline and says that no matter what SCOTUS rules regarding ACA that “the genie is out of the bottle.”

There are current opportunities for states to received federal funding to begin building HIEs and Medicaid infrastructure, reports Santenello.  Assuming that ACA is upheld, Santenello reports that states have two options.

Option One:

  • Take no action ahead of the 2014 deadline and defer to the federal government.
  • Ironically, reports Santenello, states that most opposed healthcare reform will end up with the federal government running their exchanges.

Santenello relates the resistance of some states as taking the side of politics over progress.

The intent of HCR according to Santenello is to “provide consumers with No Wrong Door.  To make it easier to apply for government services.”

Option Two:

  • States begin to work with the federal government to build a partnership.
  • States handle exchanges on their own.
  • States choose to defer entirely to the federal government.

The five core functions of an exchanges, as identified by CMS include:

  • Consumer assistance
  • Plan management
  • Eligibility
  • Enrollment
  • Financial management

(click to watch video- free registration required)

Santenello then presents several what-if scenarios.

If states, state-federal partnerships, or federal government run health information exchanges, who will handle:

  • Case management
  • Mixed household (i.e. different benefit packages)
  • Churning between programs (i.e. changing jobs)
  • Multiple state programs
  • Duplicate records
  • Fraud (i.e. inappropriate payments)

If states use the federal exchange program, who handles:

  • Eligibility for Medicaid
  • QHP Enrollment
  • Financials
  • Notifications and communications
  • Appeals

A subset of state responsibilities includes plan management functions, collecting data from issuers, consumer assistance functions, according to Santenello.  She also reports on the need for “serious” service-level agreements to be in place for state exchanges and federal government to work together.  “How do you support a system that you don’t build or manage?” asks Santenello.

Federal partnerships lead to risk and complexity, according to Santenello.  She reports that Curam is using Medicaid software and is currently building HCR software.  She also highlights that state assistance programs are not ready to be handled by the federal government.

In another what-if scenario, Santenello posits: “How will verification of income work?”  She notes that many states have systems with more up to date income info than the IRS and reflects on the difficulty of passing documentation from the state level to a federal government level.

Also stressed are the needs on individuals who phone call centers.  Santenello also sheds light on the need to update Medicaid systems and again highlights the current availability of funds from the federal government to update those systems.  Santenello draws particular attention to the state of Maryland as an early innovator of state exchanges.

Before concluding her prepared remarks, Santenello compares the current state of change in healthcare to a tornado.  She then opens the floor up to questions.

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