Retail Orientation
and Consumerism

The Affordable Care Act (ACA) and Medicaid/Medicare expansion are driving payers to shift to retail oriented business processes. This shift is creating the need for a new backend to connect and streamline the member process.

Newly Insured Members 2013-20201

Non-Government Individuals 11.5M-50M2

Individuals who enrolled through the federally facilitated marketplaces (FFM) in 20153

Nearly 11.7 million Americans signed up or were re-enrolled through the marketplace as of February 22, 2015. We are finally moving the needle on reducing the number of uninsured.

Sylvia Mathews Burwell, Health and Human Services Secretary
Source: Huffington Post

Process enrollments from different sources across multiple insurance

Coordinate revenue from multiple sources for an individual

Track the lifecycle/360 degrees of the member

Deploy billing competencies that are transparent and support migration of consumer across lines of business

Facilitate convenient validation and timely adjustments by exchange agencies and issuers

Provide transactional visibility into enrollment file updates

Validate enrollment and payment transaction data

Implement dashboards, control totals and key performance indicator capabilities to monitor performance

Key Implementation Capabilities

Enrollment Lifecycle

Avoid point-to-point Integrations with the FFM and state Marketplace environments.

Health plans are focused on the end-to-end consumer experience, from shopping to payment, enrollment and fulfillment.

Learn how Edifecs Enrollment Management can help.

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Standardize enrollment intake formats and workflow.

Learn how Edifecs Enrollment Management can help.

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Hold binder payments and reconcile premiums and subsides from all sources for each individual.

Learn how Edifecs Enrollment Management can help.

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Establish the member account and codify benefits in the core membership system.

Learn how Edifecs Enrollment Management can help.

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Generate and present a customer invoice for monthly premium.

Future capabilities of Edifecs Consumer Enrollment.

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Understand patterns in customer preferences, disenrollment and buying habits to refine member retention strategies.

Learn how Edifecs HIX Integration can help.

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Project trends in product profitability, contribution margin, loss ratio and health risk. 

Learn how Edifecs HIX Integration can help

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Retail Orientation and Consumerism Maturity Model

Are you preparing for ACA Open Enrollment while still expanding into new lines of business? In order to do it right requires a consolidated maturity model that focused on scalability across their segmented audiences and markets.

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  • CS

    Case Study

    One State's Story, Seizing HIX Promise, Evading Pitfalls

    A small northeastern state already leads the nation. Among the first in the U.S. to establish guaranteed issue and charging forward with its own HIX.

    View Case Study

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    Case Study

    New Approach to Open Enrollment: Health Net Video Case Study

    The Health Net team a the completion of their project, had consolidated five claim systems, reduced input times and potential for errors while adding advanced automation capabilities.  And Health Net has markedly improved their customer experience

    View Case Study

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1. Newly Insured Members 2013-2020 Source: CMS


2. Non-Government Individual 11.5M-50M. -Vernon K. Smith, PhD 
Source: MHPA


3. Individuals who enrolled through the federally facilitated marketplaces (FFM) in 2015 Source: HHS