Connecting residents to healthcare access
Offering health insurance through the Federally Facilitated Marketplace can pose challenges:
- High costs — The CMS user fee structure may put a significant and unsustainable fiscal burden on states.
- Limited data access — States often have limited access to essential data, which can hinder effective decision-making and service customization.
- Inflexibility — The marketplace may not meet the needs and preferences of individual states, which can lead to inefficiencies and user dissatisfaction.
- Funding the transition — Securing adequate funding for a state-based exchange can be challenging.
Our state-based exchanges are designed to help states maximize access to healthcare benefits for their residents.
A proven strategy for state-based exchange success
State-specific products
Integrated and tailored solutions
Qualified Health Plans-only: This cost-effective and streamlined solution offers “no wrong door” access for eligibility and enrollment.
Qualified Health Plans with Medicaid real-time determinations: Provides fully integrated eligibility and enrollment for access to Qualified Health Plans, Medicaid and state premium assistance programs. This helps states:
- Simplify the consumer experience.
- Reduce cost per-capita by supporting both Qualified Health Plans and Medicaid.
- Maximize access to care.
Both solutions include intuitive self-service portals for individuals and families, cost-sharing reductions, brokers, issuers and navigators, and operational staff. They also offer easy-to-understand decision support tools for a frictionless experience.
Deep functional knowledge
Trusted partner
We bring deep functional knowledge to each project, supported by our extensive experience in managing state-based exchanges. We currently operate and maintain individual state exchanges in Massachusetts, New Mexico and Vermont.
Beyond our ongoing projects, we have a strong track record of effectively managing state-based exchanges across various states, including Minnesota, Maryland and Hawaii.
As the general contractor for HealthCare.gov, we addressed and resolved critical technical and operational challenges, ensuring a stable and reliable platform for millions of users.
Partnership and support
Demonstrated success
We have demonstrated robust support through our public health emergency unwinding processes. We drive open enrollment renewal rates for our customers, ensuring reliable assistance and continuity of care for users.
States drive operational efficiency with capabilities like advanced data monitoring, automated renewals, trend analysis, enhanced auditing, case management and more.
Reliable technology
Peace of mind
Our reliable technology framework includes error rate reductions and stringent service level agreements (SLAs). These help support high data integrity and operational excellence.
Designed for sustained performance
Transitioning to a state-based exchange offers many benefits.
Lower your cost of ownership
State-based exchanges keep dollars in state and can lead to cost savings when compared to the Federally Facilitated Marketplace user fees.
Leverage better data and analytics
Access to on-demand data and analytics helps you design marketing and outreach programs tailored to your residents.
Enjoy flexible policy implementation
With Optum, states can enact policies to serve the needs of residents, customize the user experience, extend open enrollment dates and more.
Foster better collaboration
Our solution allows you to work closely with insurers and foster a more competitive marketplace.
Improve user experiences and outcomes
Maintain local control of robust, in-person assistance programs, education, communications and customer service for better outcomes.
Reduce risk
Our IT, business operations, program management and consulting resources help control costs, manage obstacles and support your exchange.
State-based exchanges FAQ
The typical sources of funding for state-based exchanges include user fees, which are the most common for Qualified Health Plan-only state-based exchanges. Other state appropriations can be considered as funding sources.
Federal funding options include CMS 90/10 Medicaid funding for exchanges with Medicaid system capabilities and federal discretionary appropriations for program management and program integrity.
The ACA Section 1332 Innovation Waiver from CMS supports new and innovative ways to improve access and lower costs.
Cost factors include:
- Financial management and payment processing: Executed by the exchange or carriers.
- Call center support: Determine the variables in service level and location of support.
- Notices: Identify the sender and delivery method of your notices.
- Qualified Health Plan-only versus Qualified Health Plan with Medicaid: A Qualified Health Plan-only option may reduce exchange costs but might increase Medicaid costs.
Stages and components of the marketplace platform to consider:
- Implementation: Determine your deliverables or milestones.
- Maintenance and operations: Choose fixed or variable pricing.
- Product licensing: Enhancements and compliance updates are regularly required.
- Hosting: Support capacity and environment management.
- Discretionary funding: Identify the cost of enhancements and customizations.
It’s important to set up an oversight body when considering legislative changes for starting up a state-based exchange.
This body should have a structured role and establish policies and procedures for the certification, recertification and decertification of health benefits plans and Qualified Health Plans.
The oversight body also determines the criteria and process for eligibility, enrollment and disenrollment of enrollees and potential enrollees in the exchange.
This process should be coordinated with the human services department to ensure consistent eligibility and enrollment processes and seamless transitions between coverages.
You must also decide if your state-based exchange will be Qualified Health Plans-only, or Qualified Health Plans with Medicaid. You’ll also need to establish reporting requirements and encourage competitive contracts to optimize value.
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