As the ACA's second open enrollment period closes, many health plans are likely to find themselves in the midst of a lot of data analysis and submission work, to ensure a good consumer experience and fair deals from the 3Rs.
While the consumer experience of browsing, selecting and enrolling in subsidized plans remains the public face of the Affordable Care Act's exchanges, a key part of the new individual market's long-term success is usability for insurers.
As Andy Slavitt, principal deputy administrator at the Centers for Medicare & Medicaid Services, said recently, the agency and its contractors are working hard on improving the backend administrative system connecting the federally-run exchanges with insurers.
"We continue to build out the element of the site that lets us continually automate processes," including paying issuers, said Slavitt, a former executive vice president at UnitedHealth Group's Optum technology subsidiary.
Getting insurer-HIX data exchange right -- not to mention automating the processes -- is crucial to ensuring consistent experiences and for accuracy in the risk adjustment, risk corridor and risk adjustment programs.
According to Emily Washington, director of operations for data and analytics company Infogix, a number of the backend exchange problems that plagued insurers last year are still not fully resolved.
"While the overall process to send and receive information from the exchanges has stabilized and they have much more transparency into the open issues compared to last year, there still are plenty of data issues as it comes out of the exchange," said Washington.
Among the persisting problems are duplicate enrollees, multiple enrollees being assigned to the same identifier and missing data elements. Insurers are the owners of the data once they get it, as far as the feds are concerned, so accuracy and any needed corrections or reconciliation is their responsibility.
Still, Washington said health plans the company is working with "don't have a lot of confidence in the data they receive from the exchanges, so they have to dedicate resources that allow them to identify and research those potential discrepancies."
If insurers aren't able to get accurate data or improve it, the downstream impacts on the member side can include late ID card welcome packets,, incorrect premium credits, an inability to track payments, past-due notices and, in the worst case, policy terminations for non-payment.
Even if the basic information is accurate enough for new members have a smooth onboarding, incorrect or insufficient data can lead to trouble for insurers when it comes to getting paid -- or having to pay -- in the 3Rs.
Massachusetts is an extreme case of what can go wrong with flawed data and calculations.
Many health plans there are worried that they will have to make oversized risk-sharing payments based on data of questionable integrity and applicability. Massachusetts has its own risk adjustment formula, using membership information from an all-payer claims database and the Massachusetts Connector exchange, and some of the issues stem from its unique pre-ACA market. But exchange data integrity is an ongoing challenge everywhere and one being watch closely in the 3Rs.
Large insurers seem to be mitigating these challenges while also girding for a scaleback of the 3Rs, as the risk corridors and reinsurance are phased out in 2016.
Humana, which is selling in 15 ACA exchanges, is expecting to at least break even on the new membership this year. The insurer is also looking to new customers as potential future and long-term members.
"We continue to be pleased with the mix of our membership both the across the medal tiers and by age distribution," said Humana CEO Bruce Broussard in a recent conference call. "We also believe that the 55 to 64 age ranges are an opportunity to develop a relationship with these members before they age into Medicare Advantage."