A critical best practice for building an exchange that can operate as expected on day one was learning to say "no," according to the experience of the executives leading the Connecticut and District of Columbia health insurance marketplaces.
They needed to be able to prioritize what was essential to launch and test it thoroughly.
"I had to say no, no, no in many venues, many times. It wasn't that I disagreed with the policies, it's just the timing. We had to focus on the core functions," said Mila Kofman, executive director, DC Health Benefit Exchange Authority, at a recent conference sponsored by America's Health Insurance Plans (AHIP).
The DC Health Link exchange locked in its business requirements by late spring, with final testing in September. Among the delayed functions and services that will come in future releases will be offering provider networks in its portal to make it easier for consumers to find physicians and hospitals.
Both DC and Connecticut respectfully declined to incorporate certain changes from federal agencies as 2013 progressed because it would not leave them enough time to design and test properly.
For example, the IRS issued regulations in the spring that it could not show enrollees their prior year income. The DC system was built assuming that applicants could obtain their income once past a certain point in the process. As a result, Kofman had to develop financial resources and take time to fix the system "so we wouldn't blatantly be in violation of the IRS regulations."
Similarly, when the Health and Human Services Department consolidated some apps in March, Kevin Counihan, CEO of Access Health CT, told HHS "with all due respect" that Connecticut would implement the changes in a future release.
The exchange scaled back its desired functionality by 30 percent in order to assure system stability, with a lot of business requirements pushed into 2014.
"You have to move backwards with this, and at some point you have to make decisions about what you can do and can't do," he said.
As of mid-December, the spread among the metal plans in Access Health CT was 27 percent opting for the Gold plan; 49 percent, Silver; 19 percent, Bronze; and the balance into the catastrophic. The carriers are Anthem Blue Cross Blue Shield, ConnectiCare, and HealthyCT.
"The Silver enrollment is pretty much where we thought it would be, but we were predicting more like 15-18 percent for the Gold and 27-30 into Bronze. That's not what happened," Counihan said.
The Connecticut exchange found a method to effectively handle its 834 enrollment data transactions with insurers by posting them on a server rather than sending them to the carriers, which access the server and draw the eligibility data out. The team brainstormed with Aetna and other plans on the schematic for 834 transmissions, designing it together so it would be the least disruptive to the insurers as possible.
Counihan has organized the exchange like a small start-up business and is looking to make it more self-reliant, add customer-sensitive services and contingencies, the most recent being remote identity proofing.
The DC exchange serves a small jurisdiction, with 43,000 uninsured and 21,000 in the individual market. It offers metal plans on the individual market from Aetna, CareFirst Blue Cross Blue Shield, and Kaiser Permanente, and on the small group side, also UnitedHealthcare.
From early-bird data, out of the first 600 paid in the individual market, most have surprisingly selected the Platinum plan, with the second highest the Gold plan. The largest group by age in the early birds was 27-34-year-olds; then 55-64; and 35-44.
"The final numbers will look different, but it's helpful for evaluating our outreach strategies and the information they are receiving," Kofman said. "This has to be a long-term vision."