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Other than attracting American population with better health insurance coverage at subsidized rates, Obamacare had another central goal – transforming the health insurance mechanism for small employers and their employees. The employer-provided health insurance segment is a primary means of coverage for a large number of the American population, and the state of insurance is not very heartening in this domain. With the Affordable Care Act acting as a catalyst for change, public and private exchanges are seeing a surge in enrollments as employers and employees reconsider their health coverage strategy. Let’s take a look at the outcome of the implementation of law across different systems of employee enrollment.

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What are the common roles & challenges for brokers recruited as Navigators/Assisters?
As a navigator or assister, a broker should be able to:
•    Establish exchange eligibility of the individual, employer, etc.
•    Provide information about different Qualified Health Plans (QHPs)
•    Offer information about premium tax credit eligibility
•    Offer direct enrollment options
•    Execute cost-sharing calculations
•    Identify people or businesses eligible for premium assistance
•    Communicate across linguistic and cultural mix that an exchange caters
•    Offer clarity regarding cost structure of different metal plans—bronze, silver, gold and platinum
•    Advise consumers about primary, secondary insurance coverage options or ancillary health plans to create a comprehensive coverage portfolio
•    Help the state exchange manage its risk pool

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With the onset of healthcare reforms, the individual health insurance market is set for a major expansion. Insurers need to decipher whether they can profitably expand their presence into this segment. Obviously, making the transition is not going to be easy. Insurers have already realized that their overall profitability might be compromised by MLR restrictions with health insurance exchanges likely to be unforgiving on substantial premium hikes. Payers on the exchanges are expected to showcase products with competitive costs. This discussion delves into how payers can continue to drive profits in the face of such rising challenges.

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This is the first part of a discussion about how healthcare leaders should perceive the emerging exchange marketplace and get ready to ensure survival and profitability in this fast-changing domain.

Healthcare reforms can prove intimidating to people who get overwhelmed by its vastness. Yes, health reforms are complex, intertwined with a never-ending series of updates and releases. While healthcare executives can get overwhelmed with compliance issues, they need to address the equally critical aspect of survival in a revisionist market. For developing an effective business strategy in this marketplace, the following should be considered:

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With the goal of making the new healthcare system work for everyone, the PPACA as amended by the Health Care and Education Reconciliation Act created a requirement called Share Responsibility. This is applicable to individuals, insurance companies, medical device companies, medical providers, pharmaceutical companies, employers and the government. On January 30, 2013, the HHS and IRS released a Final Rule and two Proposed Rules related to the individual part of Shared Responsibility.

Shared Responsibility for Individuals
This requirement was put into effect with the perspective of making health insurance feasible for consumers and the payers in the long run. By making a basic type of coverage necessary, health care benefits of individuals and subscriber volumes for insurers are addressed simultaneously. Individuals should maintain a Minimum Essential Coverage (MEC) or be ready to be penalized where the penalties will be levied as Shared Responsibility Payment.

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This is the second part in our discussion about the increasing role of Analytics in the Healthcare industry. Here, we explore how Analytics offer irrefutable benefits to the insurers and try to derive a conclusion. (Please to view the first part of this discussion).

For Payers: Analytics Eases Adaptation to Healthcare Reforms
Payers can benefit from Healthcare Analytics where everything from Electronic Health Records to ICD-10 and Health Information Exchange updates can impact their expenses, profitability and marketing penetration. Typical areas where analytics are immediately useful include categorization of population health indexes, evaluating success of marketing strategies and assessing new provider networks. In addition, analytics invariably yield a more granular form of data which is better suited for disease management programs.

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This is the first of a 2-part discussion that explores the role Healthcare Analytics can play in the era of Health Reforms.  Here, we discuss the contemporary realm of Analytics and the challenges to its usage.

Pharmaceutical companies are perhaps the most seasoned users of Analytics in the healthcare market since detailed analysis is central to their efforts in drug research and clinical trials. Other healthcare entities like payers, provider organizations and government agencies haven’t adopted Analytics as enthusiastically. However, this scenario might change rather soon. With State Exchanges set to redefine the health insurance marketplace, most healthcare organizations have understood that they can either adapt to the reforms or perish. As 2013 progresses, healthcare businesses are realizing that they need to squeeze more out of every dollar spent, limit wastage of resources and eliminate fraudulent practices to achieve profitability-cum-compliance. This translates into many operational and administrative changes. Healthcare Analytics can make this transformation less challenging.

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The Medical Office Building (MOB) marketplace has been largely sluggish since witnessing unprecedented highs during 2006-08. However due to ACA, millions more will gain access to health insurance and thus, graduate to medical care. This will cause increased need for more patient facilities, hospitals, clinics and even community care centers, catalyzing the MOB marketplace. This trend is expected to prevail throughout 2013 and beyond.

Employ-ability Galore: Non-acute Units Can Spell Acute Employment Opportunities
States are predicting the need for more urgent care units, surgery centers and lab facilities. There is a renewed interest in non-acute care facilities that typically cost less to build, maintain and operate as compared to typical, inpatient facilities.

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On December 7, 2012 the U.S. Department of Health and Human Services (HHS) released a proposed rule that advises States to consider broker compensation as a parameter when issuing Quality Health Plan (QHP) certifications to health plans that are keen to market their health products at the Federally Facilitated Exchanges (FFEs) and Federally Facilitated-SHOP Exchanges (FF-SHOPs). The Government believes that the proposed rule would help synchronize and regulate the State’s local Exchange and non-Exchange insurance markets.

The rule proposes that a QHP certification, granted by a FFE and/or a FF–SHOP, should be issued to health plans on the condition that they pay equivalent broker compensation for QHPs sold through the federal exchanges and similar plans offered outside the exchange markets. While this may appear to be another restraining federal mandate, the ruling may really prove to be a blessing in disguise!

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It would be appropriate to say that 2012 was the Year of Health Insurance Exchanges in the U.S, with the State-Federal Partnership Exchanges and Federally Facilitated Exchanges (FFEs) taking center stage in the new healthcare reform developments. The year 2013 also shows signs of continuing in the same vein as last year. As a result, the hCentive team is diving deeper into the Partnership Exchange model to understand what this model entails and the flexibilities States’ will enjoy under this arrangement.

The combined efforts of the States and the U.S. Department of Health and Human Services (HHS) under the partnership model can help in establishing States’ exchanges and can lay the groundwork for a future transition to completely state-based exchanges. As of January 3, 2013, six U.S. States—Arkansas, Delaware, Illinois, Iowa, North Carolina, and West Virginia—have applied for State-Federal Partnership Exchange and 20 states have received approval for their State-based exchange design. The remaining U.S. states have additional leeway only until February 15, 2013 if they chose to apply for a State-Partnership Exchange.

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