Premium Reports
Health Insurance Enrollment Solutions 2017

Health Insurance Enrollment Solutions 2017

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This first-time KLAS report takes an early look at the vendor solutions used for health insurance exchanges and insurance enrollment in the ACA market. Faced with the uncertainty, political instability, and complex regulation that characterize the ACA market today, healthcare payers are searching for vendors who can help them successfully weather the storm. Based on interviews with healthcare payer executives, this KLAS report gives initial but important insight into how well—or poorly—some of the key solution vendors are meeting needs.

INDUSTRY INSIGHTS & CONTEXT

INTRODUCTION TO KLAS

KLAS' mission is to improve healthcare by measuring vendor performance.

Covering over 750 healthcare vendor software solutions and services, our research and reports include client ratings and experiences gathered from the 25,000+ interviews that KLAS conducts with healthcare customers annually.

The data KLAS publishes (1) helps create transparency for healthcare provider and payer organizations as they make purchasing decisions and (2) acts as a catalyst for vendors to improve their products and services.

INTRODUCTION TO HEALTH INSURANCE ENROLLMENT SOLUTIONS

Key Industry Challenge

The process of understanding and selecting health insurance is widely regarded as confusing and cumbersome for both consumers and businesses, and it is further exacerbated by complex and ever-changing healthcare regulations.

Market Drivers

Regulation
The Affordable Care Act (ACA) has changed the requirements for health insurance; notably, (1) coverage must be made available regardless of preexisting conditions, and (2) individuals who don’t carry health insurance must pay a financial penalty.

Employers
Instead of offering health insurance plans directly, employers may direct employees to choose an insurance plan from the Federally Facilitated Marketplace (FFM).

Consumers
Demand from consumers is growing for better health plan coverage options and for a simple, user-friendly enrollment experience.

Health Insurance Exchanges

Health insurance exchanges (HIXs) are state- and/or federally-facilitated marketplaces where individuals and businesses can shop for health insurance. Individual states can run their own exchange or participate in a federally run marketplace. Most individuals and businesses can use an exchange to shop for health insurance plans, though only certain people qualify for subsidies or cost assistance.

THIS KLAS REPORT

Health insurance enrollment solutions—which KLAS defines as commercially available vendor software designed to electronically automate and help simplify the process of shopping for and selecting health insurance—are often used for health insurance exchanges. Specifically focused on the healthcare payer market, this KLAS report is a first-time look at payer-reported needs, satisfaction, and experiences regarding payers’ health insurance enrollment solutions.




1. ACA/Exchange Market Creates Icy Roads in Overall Low-Performing Market

The Affordable Care Act (ACA) and the relatively new exchange market are driving urgency among health plans and other organizations for strong health insurance enrollment solutions. However, due to complex use cases and regulations, such solutions currently score well below the average of all healthcare software products rated by KLAS. Regardless of vendor, health plans report some common performance challenges: (1) enrollment systems tend to be complex for health plans and to lack usability and certain functions needed by health plans; (2) regulatory changes from the government must be incorporated into updates and product enhancements; and (3) enrollment vendors generally aren’t seen as being much further ahead than their health plan clients or as providing proactive guidance to help clients understand where the market is going.

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2. Connecture Seen as Market Anchor, but Not without Misses

Used by some of the largest health plans, Connecture is recognized as the largest vendor dedicated to health insurance enrollment and is viewed by most clients as an overall solid choice. Clients feel Connecture stays closely tied to ongoing regulatory changes and delivers a strong product, especially for Medicare and Medicare Advantage enrollment. However, the same Connecture products and services that are viewed as strengths by some clients are identified as weaknesses by others. The areas in which client experience is most often polarized are the quality of implementations and upgrades, support and executive relationships, and customers’ ability to customize the solution.

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3. Early Data Indicates Softheon’s Vision Overshadowed by Currently Missing Fundamentals

Performance data on Softheon came from a random, but limited, sample of healthcare payer clients and could vary significantly as additional client ratings are gathered. This small sample describes Softheon as a viable and capable option, though some—particularly smaller organizations—often find the vendor to be unresponsive and ineffective when product support is needed. While Softheon’s system was designed to be a simple solution specifically for the complex issues of the ACA market and has the capability to handle payments and premium billing, clients feel the vendor is trying to move too fast and thus fails in several cases to provide some fundamentals, including usability for health plan users, error-free data and billing, and the guidance clients need to be successful with the highly technical product.

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4. Small Vendor Online Insight Seen as Compelling for CO-OPs, Small Payers

As a smaller vendor in health insurance enrollment, Online Insight fills a niche in meeting the needs of smaller health plans and consumer operated and oriented plans (CO-OPs). Online Insight’s current client base does not include any larger health plans. KLAS interviewed all current Online Insight customers, and most feel the vendor has a customer-centric, partnering culture and fosters nimble, proactive relationships. Several customers report integration as a pain point, however. Training is also reported as a weakness, possibly due to Online Insight suffering from the staff and investment constraints typical of smaller firms.

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5. Some Health Plans Use Core Claims Vendors Cognizant (TriZetto), HealthPlan Services, and MedHOK for Enrollment

While most health plans use a dedicated, best-of-breed vendor for their eCommerce and health insurance enrollment needs, some payers use functionality or a module from their core claims vendor instead, especially for Medicaid lines of business, for which the member-enrollment process tends to be more streamlined. In this report, KLAS validated use of core claims vendors Cognizant (TriZetto), HealthPlan Services, and MedHOK for enrollment functionality. Health plans not using these core claims vendors or the best-of-breed vendors discussed above often consider Benefitfocus and, less frequently, hCentive.

Key Industry Challenge

The process of understanding and selecting health insurance is widely regarded as confusing and cumbersome for both consumers and businesses, and it is further exacerbated by complex and ever-changing healthcare regulations.

Market Drivers

Regulation
The Affordable Care Act (ACA) has changed the requirements for health insurance; notably, (1) coverage must be made available regardless of preexisting conditions, and (2) individuals who don’t carry health insurance must pay a financial penalty.

Employers
Instead of offering health insurance plans directly, employers may direct employees to choose an insurance plan from the Federally Facilitated Marketplace (FFM).

Consumers
Demand from consumers is growing for better health plan coverage options and for a simple, user-friendly enrollment experience.

Health Insurance Exchanges

Health insurance exchanges (HIXs) are state- and/or federally-facilitated marketplaces where individuals and businesses can shop for health insurance. Individual states can run their own exchange or participate in a federally run marketplace. Most individuals and businesses can use an exchange to shop for health insurance plans, though only certain people qualify for subsidies or cost assistance.

Key Topics

  1. ACA/Exchange Market Creates Icy Roads in Overall Low-Performing Market
  2. Connecture Seen as Market Anchor, but Not without Misses
  3. Early Data Indicates Softheon’s Vision Overshadowed by Currently Missing Fundamentals
  4. Small Vendor Online insight Seen as Compelling for CO-OPs, Small Payers
  5. Some Health Plans Use Core Claims Vendors Cognizant (TriZetto), HealthPlan Services, and MedHOK for Enrollment
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This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2019 KLAS Research, LLC. All Rights Reserved. NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.