The client, a leading New England health insurer, is a local carrier with a national reputation for quality and care management. The client offers a variety of commercial products in addition to Medicare and Medicaid products, and covers almost one million members across two states.
The client knew that 2013 would bring unprecedented change as the industry prepared to comply with the Affordable Care Act (ACA). The broad IT requirements were known: issuers had to build interfaces to quote and sell plans via state exchanges, synchronize enrollment and eligibility information with the exchanges, and receive and reconcile premium and subsidy payments from the exchanges and from CMS. However, the federal and state regulations had not been finalized, and it was not known when several major questions would be resolved. Regardless, issuers were required to enroll via the exchanges on October 1, 2013, and plans would need to be active as of January 1, 2014.
Even with these ambiguous requirements, the client realized that the IT work necessary to comply with the ACA would represent one of the largest, most complex projects it had ever undertaken.
The client engaged Ninestone to manage all aspects of the software development lifecycle, from business requirements analysis to final implementation. Ninestone was selected because of our long-standing relationship with the client, our ability to lead projects using their rigorous project management approach as well as our experience with a number of the software applications that were part of the implementation.
Ninestone broke down multiple related workstreams and prioritized and planned the implementation over an extended timeframe. The workstreams included developing a rating framework for the state exchange, and implementing 834 (enrollment) transaction with state exchange, and ACA-specific 820 (payment) transaction with state and CMS. Another ACA-related workstream was the development of a data extract with claims, pharmacy, and enrollment information to comply with the federal risk adjustment and reinsurance program, and the configuration of an on-site “edge server” to share data with CMS.
The Ninestone project manager worked directly with representatives from relevant state and federal agencies to understand and communicate requirements to the client teams and also to negotiate and coordinate testing and implementation timeframes between multiple entities.
There were a number of technologies involved in this complex implementation: Health Plan Administration, Reporting, Portal, Application Configuration, Claims, EDI, and Billing and Eligibility.
The client met its October 1, 2013 objectives of quoting and shopping on the state exchange, and met the regulatory deadline of being ready to process claims by January 1, 2014. State officials recognized the relationship that the client team and the state exchange team forged as a true partnership that leveraged our clients industry expertise to inform and guide the development of state standards and processes.