White Paper: HIX Consumer Experience
Published Date: 08/19/12
I.
This white paper explores the topic of the consumer experience within the Health Insurance Exchange
(HIX) context. The “consumer experience,” or the sum of a consumer’s interactions with a supplier of goods or services over the duration of the relationship or during a specific transaction with that supplier, has emerged as the one of the most important aspects of achieving success for companies across all industries. We expect the same will hold true for the HIX.
The success of the HIX will be driven by the quality of the consumer experience that it provides.
Therefore, the question arises: What steps should states take during HIX establishment to ensure a high-quality, positive consumer experience? This paper focuses its
analysis on the consumer experience in using the HIX through the web portal and examines how other market
entry points can support the online user experience.
To answer this question, we begin by examining online interfaces provided by successful companies from three unique industries—travel, tax preparation, and e-commerce—that have successfully adapted to the online marketplace and can provide valuable insights for HIX developers. We describe the current consumer experience environment for leaders in these industries, and then examine how they relate to the current health insurance landscape. We then outline the Affordable Care Act’s (ACA) vision of consumer experience and the key features of a positive consumer experience in the HIX. Next, we identify the key challenges that states and developers face in creating a HIX that delivers a high quality consumer experience, and make recommendations to help states address these challenges.
We close with a call to action urging that the end user be kept in mind from initiation to completion of the
HIX development process. We remind readers that the “end user” does not fit a single profile—it encompasses anyone who comes into contact with the web portal: the diverse populations applying for services, and the many intermediaries who assist applicants throughout the process. Thus, the HIX portal needs to be attractive, intuitive, and informative. The brokers, Navigators, and other assisters should be well-integrated into the HIX system. Finally, the design process does not end when the technological design and interface are complete. The roll-out must plan for and incorporate education for end users and intermediaries, including budgeting time and expense to allow for the educational learning curve for firsttime users. To illustrate how the Workgroup envisioned the totality of the consumer’s experience with an
HIX, we have included a graphic in Appendix 4 titled, “Lifecycle for an Individual.” It serves as a reminder of how many “touch points” any one person may have when interacting with an HIX. A welldesigned HIX can make a tangible impact on each individual user’s life—multiply this by the millions of consumers served by an HIX to get a sense of how powerful a positive HIX consumer experience could be.

White Paper: HIX Consumer Experience
Published Date: 08/19/12
II.
1) What makes a positive consumer experience in the digital marketplace?
Establishing a nationwide structure of online HIX systems represents a giant leap forward for an industry that has traditionally lagged behind other sectors in embracing e-commerce. Because other sectors have already developed strong consumer-oriented service delivery models over the
Internet, developers of health insurance exchanges would be wise to learn from the best practices of other industry leaders. We identified four key components to the successful user experience: integration, simplification, an intuitive user interface and top-notch customer service .
Expedia® and TurboTax® excel at the first two components in their respective industries.
Amazon’s user interface is arguably “best in class” across the e-commerce marketplace, and serves as an exemplar for top-shelf consumer service in the way that it supports its user experience with a responsive Contact Center.
Integration – Expedia®
Expedia® has successfully consolidated hotel, airfare, rental vehicles, and virtually everything else related to taking a trip in a single location.
Expedia® brings together competitors from across the lodging, air travel, and rental industries in a simple interface that walks consumers
through each stage of a trip. The site allows consumers to make a single purchase that secures their airfare, their rental car, and their hotel- a possibility that, prior to the growth of the Internet, could only be realized with the help of a travel agent. Enabling this sort of all-encompassing purchase empowers consumers, allowing them to personally choose what they would like at each stage of their trip.
Seamlessly consolidating many services, such as access to Medicaid, Federal tax credits, and private insurance, as well as comprehensive information about the coverage options offered by competing health insurance providers, in a single location is a laudable goal for HIXs and would create a true one-stop shop for Americans’ health insurance needs. Similarly, enabling consumers to quickly and easily obtain services across sectors that have traditionally been disconnected empowers the consumer to tailor their choices to better fit their individual needs.
Simplification – TurboTax®
TurboTax® has successfully developed a user-friendly interface that allows even novice computer users to complete and submit the highly complex process of filing their state and federal taxes online. Users can transfer W-2s and 1099s into an electronic format that automatically plugs their information into their 1040; then the interface conducts the basic calculations required to complete their taxes with minimal user input. This level of automation would help streamline the health insurance application process across the board. However, the true strength of the TurboTax® interface is that it takes the technical and intimidating task of

White Paper: HIX Consumer Experience
Published Date: 08/19/12 filing taxes and turns it into a step-by-step process that is accessible to users with wide-ranging computer, math, and accounting skill levels.
Similar to filing taxes, navigating the health insurance market is an inherently complex process.
It represents a major purchase for most consumers, and requires that individuals to make choices that will have a direct impact on their health and wellbeing. One of the most important goals of the HIX must be to foster a more informed consumer, who can make rational choices in the health insurance marketplace. Simplifying the technical process behind purchasing health insurance allows users to better choose a plan based on their individual needs. Ultimately, the ability to purchase an appropriate plan will help consumers become rational actors in the insurance market, thereby helping the insurance market function more efficiently.
User Interface, Consumer Service –
Amazon.com®
Amazon® has managed to consolidate the music video, kitchen, and second-hand store into a single online location with a renowned user-friendly interface. Clicking on a product not only reveals its price, but whether a used version of the item is available for a discounted price, how many items are in stock, and user reviews of the product. The
shopping cart clearly shows what consumers plan to purchase, the quantity, and the price.
Amazon® consumer service works to quickly and effectively address any problems during the transaction. Amazon® even works to streamline product returns although it lacks a physical location where individuals can return unwanted goods. Consumers can leave feedback for products and sellers that allow other consumers to learn from their experiences, creating an online community of Amazon® users.
Interface and consumer service are key attributes to the success of the HIX. The user interface for the HIX must be robust enough to capture the nuances of a complex subject, while also being simple enough for users who are inexperienced with computers and the Internet to use the interface effectively. In cases where individuals need assistance to navigate the HIX, reliable customer service must be provided. The HIX seeks to provide customer service through many points of entry, as discussed below. The real test of customer service, however, is in how effectively service representatives resolve consumer issues, not how many different ways a consumer can contact the representatives – an important lesson for HIX developers.
Expedia®, TurboTax® and Amazon® have all achieved what HIXs hope to: consolidate traditionally isolated, technically challenging, and yet widely used services into a user-friendly online interface. That being said, the complexity of the health insurance product should not be underestimated. Health insurance products are different from consumer goods. They include such complicated factors as network inclusions, deductibles, co-pays, and benefit exclusions. In addition, states do not have the luxury of building an e-commerce store from the ground up. An

White Paper: HIX Consumer Experience
Published Date: 08/19/12 integrated, online HIX must fit into and account for the current health insurance landscape, which is described below.
2) Where We Are Today: The Consumer Experience in Obtaining Individual and Small
Business Health Insurance
In the current health insurance market, user experience varies widely depending on the point of entry through which the consumer accesses the market. The experience of an individual obtaining
insurance through public programs, such as
Medicaid, Children’s Health Insurance Program
(CHIP), or Medicare, differs greatly from that of someone who is shopping for insurance in the private market either individually, through an employer, or through an insurance agent or broker. This section examines the current environment with regard to consumer experience and systems integration in each of the market access points noted above.
Public Insurance Programs
The experience of Medicaid and CHIP beneficiaries varies widely across the states based on several factors, including accessibility, decision processing times, and the availability of coverage information.
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Accessibility
While some states have transitioned to electronic application processes for their public insurance programs, many still rely on paper applications and in-person meetings at local social service agency offices. In these cases, individuals must visit their local offices, which can be a challenge for those applicants who live in rural areas, have mobility issues, or lack a reliable means of transportation. Applicants typically must bring documentation showing their financial situation and the makeup of their household. In states where electronic applications are accepted, these traditional difficulties are being replaced with new challenges: access to, and familiarity with, the Internet.
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Processing times and availability of information
Once an individual applies for benefits, the wait time for a decision varies from case to case. It is uncommon for applicants to receive a same-day decision, especially in states that do not have an electronic application system. The amount of information readily accessible to Medicaid beneficiaries also varies from state to state. Some states, like West Virginia, offer detailed coverage guides online, while others do not. Still other states rely on networks of individuals and organizations, such as Rhode Island’s Family Resource Counselors, who are trained to provide information and assistance to Medicaid applicants and beneficiaries.
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Medicare and Medicaid: Comparing and Contrasting consumer experiences
Consumer experiences in these public health insurance programs vary. Medicare brings strong online resources and well-defined eligibility and decision horizons for applicants. On the other

White Paper: HIX Consumer Experience
Published Date: 08/19/12 hand, Medicaid is administered differently between states, which results in varying degrees of web integration and information availability, as well as inconsistent application processes.
Medicare does not suffer from the same inconsistencies across state lines that Medicaid does because a national application processes and coverage standards exist. Further, except in special circumstances, individuals have a firm timeline for applying for coverage during the Medicare open season, which begins three months prior to their 65 th
birthday, and they have a predetermined date that their coverage will begin, their 65 th
birthday.
The Medicare program also benefits from its extensive coordination with the Social Security retirement program. Individuals who elect early retirement automatically become enrolled in basic Medicaid when they become eligible, and often individuals can apply for both Social
Security and Medicare at the same time. Medicare also employs a robust web interface that allows beneficiaries to access their accounts online, obtain information about coverage and benefit plans, and find local providers.
Private Insurance
Consumers who shop for insurance either on the individual market or through a health plan provided by their employers experience the health insurance marketplace in an entirely different way than individuals applying for public insurance programs.
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Individual market
Individuals who choose to shop for health insurance on their own face the daunting task of locating available plans, comparing the coverage provided by competing private insurers, and affording policy premiums that have skyrocketed in recent years. If individuals attempt to compare private plans on their own, they must cross-reference multiple websites and information sources that often portray information in different ways. Consumers who are able to navigate and interpret the various data formats on company websites benefit from being able to choose from any insurance provider that operates in their area. To avoid the cumbersome process of shopping for insurance on their own, some consumers hire health insurance brokers to help them choose the right plan for their needs and their budget. Others may choose online aggregators to build their profile and requirements, and then compare several suppliers that may meet their needs.
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Employer-sponsored market
Individuals who shop for insurance through the employer-sponsored insurance market often rely on another source of information about the plans available to them—their Human
Resources (HR) staff. Individuals who obtain insurance through an employer with an HR staff have the advantage of an unbiased source of information about the options available to them.
Often companies provide plan summaries and coverage details for the plans they offer to help their employees understand their coverage options.
Consumers in the two private insurance market entry points can experience the same issues of inconsistency as those who participate in public insurance programs. For example, the amount

White Paper: HIX Consumer Experience
Published Date: 08/19/12 and accessibility of plan and coverage information that is available on private insurers’ websites varies by company, in much the same way that the availability of information about
Medicaid coverage varies by state. Private insurers tend to have robust online services that allow individuals to shop for coverage over the Internet, but these services vary company to company.
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Private Insurance Exchanges
The private market also features insurance exchanges, which bring together information on competing plans and help consumers find affordable insurance options that meet their needs.
These exchanges aid both individual consumers looking for coverage, as well as small businesses shopping for group plans. Insurance broker portals, which operate similar to private exchanges, but target the broker community, also play an important role in the current private insurance market. With the development of the Federally Facilitated Exchange (FFE), it remains to be seen what role these private exchanges will play in the future of the health insurance market in the United States. It is conceivable that they could become obsolete if the
HIX provides a top-notch user experience and a level of detail that is appropriate for both individual consumers and for insurance brokers.
Common factors defining the consumer experience
The current consumer experience environment reveals the fragmented nature of the health insurance market. Individuals who shop for insurance in the private market have a very different experience than individuals applying for public insurance programs. Nonetheless, comparing these two segments of the health insurance market reveals a common set of factors that impact consumer experience. These factors include the availability of eligibility and coverage information, the ease of applying for coverage, the ability to compare coverage options, the key role of intermediaries, and the level of service integration.
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Intermediaries
Whether an individual is shopping for insurance on the private market or applying for coverage in the public market, knowledgeable intermediaries play an important role due to the complexity of the market. In the private market, brokers guide consumers to an appropriate plan that will fit their budget and their healthcare needs. Currently, health insurance companies contribute to a general fund that supports insurance brokers, which ensures that brokers are free to consumers. In the public sphere, county health and human service (HHS) workers, and local or state Agencies on Aging (AoA) provide important assistance to applicants and beneficiaries.
In many states, county HHS workers make the first introduction to Medicaid for the applicant, explaining the eligibility requirements and coverage rules. In some states, such as Maine, local
AoA workers provide one-on-one assistance to new and current Medicare beneficiaries, helping to explain notices and coverage options, while also helping individuals navigate the complex
Medicare appeals process.
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White Paper: HIX Consumer Experience
Published Date: 08/19/12
The experience of the intermediary in the HIX is important not only because the intermediary must act as a guide to the end user, but also because the experience of the end user who utilizes an intermediary will be shaped by that intermediary’s ability to navigate the system.
III.
1) Federal guidance regarding the consumer experience
Health Insurance Exchanges will ultimately be judged by the increase in the number of
Americans with health coverage, and the ease with which these individuals obtain their coverage.
In order for HIXs—state-based or federal—to meet these goals, the consumer’s experience in determining program and plan eligibility, understanding coverage, cost, and subsidy options, and selecting and enrolling in coverage must be simple, clear, seamless, automated, real-time and accessible. Accessibility addresses not just geographic and technical issues, but also accounts for consumers who require live assistance, whether it’s a Navigator, some other community assister, or the HIX Contact Center. Today, many of these processes, in both the public and private markets, are frequently time-consuming, paper-intensive, complicated, cumbersome and fragmented.
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ACA Requires a Consumer-Centered Approach
Section 1311 of the Affordable Care Act (ACA) outlines a consumer-centered approach for the delivery of health coverage and subsidies through HIXs. The ACA specifies the minimum functions of an HIX, including the operation of a toll-free telephone hotline to respond to requests for assistance, maintenance of an Internet website for enrolling in coverage and obtaining standardized comparative information on plans, and the provision of an electronic calculator to determine the cost of coverage after the application of subsidies.
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Additional federal guidance translates the legal requirements of the ACA into a more refined vision of HIX operations, a fundamental principle of which is a modern, seamless consumer experience. The Department of Health and Human Services (HHS) has promulgated rules and IT guidance that require and promote the use of “best in class” technology and
business processes in HIXs to make the consumer’s experience of qualifying for, shopping for, and purchasing health insurance as easy as making a purchase on Amazon.com.
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What does HHS mean by “seamless consumer experience”?
The terms “seamless” and “seamlessness” are peppered throughout federal HIX guidance but are never formally defined. They are often used in conjunction with references to online user experiences with retail transactions. In this context, the federal government suggests that

White Paper: HIX Consumer Experience
Published Date: 08/19/12 seamlessness applies to continuity in the consumer’s experience navigating program eligibility and enrollment, both between programs and systems.
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HHS language about the consumer experience sometimes conflates the experiences of the end user and anyone assisting this user
(called Navigators and assisters, defined and discussed below). “Seamlessness,” therefore, also must apply to the experience of Navigators and other community assisters, as well as the respective consumers they help.
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Coordination between programs: “No wrong door”
All types of coverage should be accessible to a consumer through a single encounter—whether in-person with a county worker or another community assister, or online. Consumers should be able to obtain information about, and request an eligibility determination for, all insurance affordability programs, regardless of their point of entry. Points of entry include the county eligibility office, a HIX web portal, and an HIX Contact Center, accessed by phone. Any of these points of entry may be accessed with the assistance of a Navigator, meaning the
Navigator’s experience dovetails with the user’s and should be accounted for in the quest
for seamlessness. A Navigator is someone who operates under grant funding from the federal
government and is licensed to help individuals and families understand and evaluate the health insurance options available to them through the
HIX. According to the ACA, Navigators may include trade, industry, and professional associations; “consumer-focused” not-for-profit entities; chambers of commerce, unions, Small Business Administration resource partners; or
“other licensed insurance agencies and brokers iv
” A Navigator is a specific example of an assister. In general, an assister is defined to be an individual who works for a community organization, who has been trained to offer some level of consumer assistance to HIX users.
• Integration of channels and systems
CMS envisions integrated systems both “behind the scenes” and at the point of service that will enable a seamless experience from the consumer’s perspective. A consumer should only be asked to enter personal data one time; data is securely transmitted between programs and systems, in real time when possible. Consumers who go through the Medicaid eligibility determination process and are found ineligible should immediately be able to have their eligibility for tax credits and cost-sharing reductions determined without having to re-enter data, change systems, or change offices. The consumer should be able to access system and application support directly from the HIX web portal. The Medicaid-Exchange IT Guidance v2.0 envisions that “all channels will connect with a standardized web-based system to evaluate eligibility.” v
2) What are other features of the federal vision for the consumer experience in an HIX?

White Paper: HIX Consumer Experience
Published Date: 08/19/12
Other key features of the federal vision for the Exchange are consistency and accessibility. These concepts support fairness and equality in the consumer’s HIX experience.
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Consistency and fairness
According to the Centers for Medicare & Medicaid Services (CMS), “States should aim to provide the same customer experience to all individuals seeking coverage, regardless of source or amount of financial assistance for which they may qualify or whether they enter the process through the Exchange, Medicaid, or CHIP. States should aim to replicate this customer experience with other stakeholders and business partners, including plans, employers, and
Navigators” vi
(Medicaid-Exchange IT Guidance 2.0). As described above, regardless of the point of entry or program for which the consumer is applying, all consumers should have a similar experience with HIX consumer assistance.
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Accessibility
Accessibility refers to the requirement to make HIX products and services available to all eligible populations, regardless of their circumstances, including the language they speak, their physical abilities, or their geographic location. For example, the ACA requires all outreach and communications materials and initiatives be “culturally and linguistically appropriate”, meet
Section 504 and 508 accessibility standards, and be made accessible to hard-to-reach and traditionally marginalized populations.
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IV.
Challenge: The need for live assistance may be high, as may be its cost
Even with the best website design, interfaces for real-time verifications, and coordination between agencies and systems, consumers will need live assistance to effectively navigate the HIX’s coverage and subsidy offerings. The subject matter is complicated and the capabilities of HIX users will be as diverse as the population of the United States. Buying health insurance involves more complex decision-making and more inputs than buying a plane ticket or even filing taxes. Major financial decisions, tax implications, complex health needs and family situations all need to be taken into account by HIX users.
States will need to figure out how to optimize the consumer experience in the self-service environment with live support (e.g., by telephone, live online chat sessions, and the ability to click to speak with an
HIX representative) within the budget constraints HIXs will face. Comprehensive live support options such as these can prove costly.
Recommendations: Anticipate live interactions in order to plan for and minimize costs
The need for strong consumer support mechanisms should be kept at the forefront of the HIX development process. The web portal alone is not a panacea. A computer system that users cannot use – due to lack of access or operator errors – is a useless system. To address the challenge of users needing live assistance, HIX developers and their partners in state government can take several steps:

White Paper: HIX Consumer Experience
Published Date: 08/19/12
• Involve consumers early on in the web portal and contact center development, design, and testing process to ensure that outside perspectives help shape system development and keep the consumer experience central to the development process.
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Identify and define the consumer life cycle within the context of the HIX. Integrate “consumer touch points”, such as those illustrated in Appendix 4, from start to renewal, the interaction needed, and examine the best ways to conduct those interactions.
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Don’t reinvent the wheel: States and HIX developers should learn what works now by leveraging the expertise of brokers, county HHS workers, and AoA staff, who are currently responsible for guiding consumers through the complex insurance marketplace.
• Develop and leverage automated outreach capabilities to proactively deliver information, status updates, and notifications about key steps in the process (e.g., using outbound calls with recorded messages, SMS, and email).
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Take a multi-channel approach to deliver HIX services beyond the online portal, using online chat messages, text messages, mobile applications, interactive voice response (IVR) technology, and social media.
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State HIX agencies should plan their budgets pro-actively and account for the high cost of comprehensive in-person consumer assistance, which will likely peak during open-enrollment periods.
Challenge: Seamlessness between Federal and state systems and programs in an FFE
In 2014, many states will opt to participate in a Federally-Facilitated Exchange (FFE). While CMS has not yet released the operational model for the FFE, we do know that the FFE will need to seamlessly integrate with state Medicaid programs and eligibility systems from the consumer’s perspective. For example, an individual who enters the eligibility determination process through a state’s Medicaid door
(such as a county eligibility office) will need to be transitioned “seamlessly” to the FFE if found ineligible for Medicaid.
Recommendations: Upfront collaborations between public and private developers
Meeting this challenge will prove especially difficult. States will need to utilize the expertise of the developers at CMS whenever possible and keep an open line of communication with their federal partners. The Enroll UX2014 project, which brings together federal, state, and private stakeholders in an effort to develop a functional interface, will prove integral to developing a high level of seamlessness between the various independently functioning systems that will make up the HIX.
Assimilating the unique eligibility standards that exist from state to state will require a strong degree of collaboration between CMS and relevant state agencies. In states that opt to use a FFE, user experience will be greatly determined by the interactions—often outside the consumer’s view—between the state and federal systems. Strong collaboration can help to minimize conflicting eligibility determinations, delayed final determinations, and other issues.

White Paper: HIX Consumer Experience
Published Date: 08/19/12
Challenge: Designing a simple yet robust user interface that a diverse user base with varying skill levels can use effectively
This is perhaps the paramount challenge to building a seamless consumer experience. The HIX will have a diverse user base, which will range from brokers and Navigators, who are intimately familiar with the health insurance market, to county HHS workers, who specialize in Medicaid but may only know the basics of the private insurance market, to private citizens who will bring varying levels of education, computer skills, and familiarity with the insurance marketplace to the table. Further, with the individual mandate in place, many users of the HIX may be getting health insurance for the first time, and therefore will have no prior experience in the marketplace. With such a wide array of users accessing the system, one user’s seamless experience could be another user’s Rubik’s Cube. Not only must the HIX cater to the needs of all these user classes, but it must also capture the nuances of an inherently complex product line that represents a major financial commitment for the applicant and impacts the applicant’s very health and wellbeing.
Recommendations: Incorporate best practices from e-commerce industry leaders
Although each of the companies examined in Section II offers a set of services very different from health insurance in general, each of their online interfaces contains features that will prove valuable in the development of the HIX. HIX developers should attempt to match the seamlessness with which Expedia® consolidates information from independent industries and competing companies within those industries.
This lesson will prove particularly useful to consolidating public and private insurance options and tax credits in a single interface. If the HIX can present the highly complex set of considerations that goes into selecting the appropriate coverage plan as simply as TurboTax® presents income tax information, even novice users may be able to navigate the exchange effectively. For those users who do experience difficulties, providing a level of customer support on par with Amazon.com® will help get them back on track.

White Paper: HIX Consumer Experience
Published Date: 08/19/12
V.
Ultimately, the success of an HIX will depend in large part on consumers’ ability to navigate it easily, understand their options fully, and make informed choices. Many consumers may rely on approved
Navigators or other in-person or by-phone assisters to help make those decisions. To maximize the success of the HIX, states and the federal government must:
1) Design an HIX website that is attractive, intuitive, and informative to users from various backgrounds. Exchanges must embrace state-of-the-art approaches to information architecture and usability—using leading commercial websites as a benchmark—to provide accurate and relevant information that is easily understood and actionable by consumers.
2) Design a Contact Center capability that supports the online experience by providing an integrated flow of data to ensure that live interaction is optimized for both the consumer and the states operating the Contact Centers. Keep in mind that delivery of Contact Center capabilities likely will consist of a mix of state-operated and outsourced services.
3) Integrate Navigators, brokers and other assisters into the HIX design from inception.
Navigators and other assisters will have a
different set of user requirements than
individuals or small businesses operating alone.
HIX website design and business processes must support Navigators and other assisters in helping consumers make the most appropriate health insurance choices. The call for
“seamlessness” plays out here, where it’s vital that the cohort of people assisting end users, such as the Navigators and brokers, have information and access that is consistent with contact centers and other points of entry.
4) Work aggressively to educate consumers about the HIX before go-live, and prepare to provide additional assistance in the early stages of the HIX. Regardless of how well an HIX website is designed, or how effective the support for Navigators and other assisters is, the HIX can expect a significant learning curve as users become accustomed to shopping for health insurance online.
States should be prepared to provide additional assistance—without onerous waiting times— as needed while consumers grow accustomed to the HIX.
Developing and implementing an HIX at any level is a complex task fraught with risk. Designers of an
HIX must decide on the most appropriate policies, define the business processes that will execute those policies, and establish the organizational and IT infrastructure to support those business processes. To be successful, however, it is critical to keep the perspective of the end user first and foremost in defining and implementing the HIX.

AoA Agencies on Aging
ACA Affordable Care Act
APTC Advance Payments of the Premium Tax Credit
CFR Code of Federal Regulations
CHIP Children’s Health Insurance Program
CMS Centers for Medicare and Medicaid Services
CSR Cost Sharing Reduction
FFE Federally-Facilitated Exchange
HHS Health and Human Services
HIX Health Insurance Exchange
HR Human Resources
IVR Interactive Voice Response
MAGI Modified Adjusted Gross Income
PCP Primary Care Physician
QHP Qualified Health Plan
SHOP Small Business Health Options Plan
SMS Short Message Service
UX User Experience
White Paper: HIX Consumer Experience
Published Date: 08/19/12

White Paper: HIX Consumer Experience
Published Date: 08/19/12
HHS guidance for a seamless HIX consumer experience in both state-based and federally-facilitated HIXs
Through rule-making and guidance, HHS is providing direction to states and creating a foundation upon which an optimal consumer experience can be achieved. To date, HHS has issued the following specific policies, rules and guidance to promote a positive consumer experience:
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Requirement that HIXs use a single, streamlined application for Medicaid, CHIP and the HIX.
(ACA Section 1413) viii
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Expectation that states will utilize a common or shared eligibility system or service across the HIX and Medicaid, and a coordinated set of rules for HIX, Medicaid and CHIP eligibility. (Medicaid-
Exchange IT Guidance v2.0)
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Encouraging states to develop integrated IT systems across the HIX, Medicaid and CHIP to allow leveraging of administration functions and resources across coverage programs. (Medicaid-
Exchange IT Guidance v2.0) ix
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Required use of data matching and secure interfaces with the Federal Data Hub for real-time verification of application data.
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Self-attestation of application information to minimize the need for paper and human intervention in the eligibility determination process. (Exchange and Medicaid Final rules) xi
• Requiring HIXs to transmit consumer account information to Medicaid or CHIP for enrollment if consumer is found eligible for Medicaid or CHIP, and requiring Medicaid and CHIP to pass consumer data to the HIX if potentially eligible for APTC and/or CSR. (ACA and Final Rule).
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Participation in the national UX 2014 project to create a model first-class user-interface for the consumer web portal and a single, streamlined application based on stakeholder involvement and best-in-class design principles and experience.
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CMS’ May 16, 2012, “General Guidance on Federally-facilitated Exchanges,” references a
“positive and seamless consumer experience” throughout, which demonstrates the federal government’s commitment to ensuring a consumer-focused approach to acquisition of coverage.

White Paper: HIX Consumer Experience
Published Date: 08/19/12
HIX approval requirements for states regarding consumer experience
The “Draft Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges” issued by CMS includes the following criteria for states to operate a state-based HIX:
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2.3a The Exchange provides culturally and linguistically appropriate outreach and educational materials to the public, including auxiliary aids and services for people with disabilities, regarding eligibility and enrollment options, program information, benefits, and services available through the
Exchange, the Insurance Affordability Program(s), and the SHOP.
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2.4a The Exchange provides for the operation of a toll-free telephone hotline (call center) which acts as a central line to handle seamless application support, coordinates with other Insurance
Affordability Program(s) and with other State and Federal agencies, and to respond to requests for assistance from the public, including individuals, employers, and employees, at no cost to the caller as specified by 45 CFR 155.205(a).
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2.4b The Exchange provides translation and oral interpretation services and auxiliary aids and services to the public, including individuals, employers, and employees, at no cost to the caller.
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2.5c The Exchange’s Internet Web site provides information in a manner that is accessible to individuals with disabilities and individuals with limited English proficiency, as required in 45 CFR
155.205(b) and (c).
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• 3.1 The Exchange has developed and will use an HHS-approved single, streamlined application for the individual market – or will use the HHS-developed application – to determine eligibility and collect information that is necessary for enrollment in a QHP for the individual market and for insurance affordability programs as specified in 45 CFR 155.405. The Exchange has developed and will use an HHS-approved application for SHOP or will use the HHS-developed application for
SHOP employers and employees as specified in 45 CFR 155.730.
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• 3.2 The Exchange has developed and documented a coordination strategy with other agencies administering Insurance Affordability Programs and the SHOP that enables the Exchange to carry out the eligibility and enrollment activities.
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• 3.3 The Exchange has the capacity to accept and process applications, updates, and responses to redeterminations from applicants and enrollees, including applicants and enrollees who have disabilities or limited English proficiency, through all required channels, including in-person, online, mail, and phone.
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3.4 The Exchange has the capacity to send notices, including notices in alternate formats and multiple languages; conduct periodic data matching; and conduct annual redeterminations and process responses in-person, online, via mail, and over the phone pursuant to 45 CFR 155, subpart
D.
xx
•
3.7 The Exchange has the capacity to determine individual eligibility for enrollment in a QHP through the Exchange and for employee and employer participation in the SHOP. In addition, the
Exchange has the capacity to assess or determine eligibility for Medicaid and CHIP based on
Modified Adjusted Gross Income (MAGI).
xxi
•
3.7d The Exchange has the capacity to accept and process applications that have been transferred from other agencies administering Insurance Affordability Program(s).
xxii

White Paper: HIX Consumer Experience
Published Date: 08/19/12
Image credit: Innovate Forward

White Paper: HIX Consumer Experience
Published Date: 08/19/12
Writers
BerryDunn: Laurel Arnold, Jamie Brennan, Kristan Drzewiecki
First Data: Stuart Venzke
Eservices: Dave Walsh
Reviewers
Innovate Forward Inc.: Mike Stokes
HTMS: Nancy Wise
Trinity Technology Group, Inc.: Christopher Worley, Sean Mahon, Stephen Williamson

White Paper: HIX Consumer Experience
Published Date: 08/19/12
i
Southern Maine Agency on Aging. http://www.smaaa.org/health_insurance_counseling.php
. ii
U.S Government Printing Office. “The Patient Protection and Affordable Care Act.” Public Law 111-148. Section
1311. March 23, 2010. iii
Centers for Medicare and Medicaid Services. “Guidance for Exchange and Medicaid Information Technology (IT)
Systems.” Version 2.0. May, 2011. Page 4. iv
Federal Register. “Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health
Plans; Exchange Standards for Employers.” Volume 77, Number 59. Section 155.210. March 27, 2012. v
Centers for Medicare and Medicaid Services. “Guidance for Exchange and Medicaid Information Technology (IT)
Systems.” Version 2.0. May, 2011. Page 4. vi
Centers for Medicare and Medicaid Services. “Guidance for Exchange and Medicaid Information Technology (IT)
Systems.” Version 2.0. May, 2011. Page 4. vii
Centers for Medicare and Medicaid Services. “Guidance for Exchange and Medicaid Information Technology (IT)
Systems.” Version 2.0. May, 2011. Page 9. viii
U.S Government Printing Office. “The Patient Protection and Affordable Care Act.” Public Law 111-148. Section
1413. March 23, 2010. ix
Centers for Medicare and Medicaid Services. “Guidance for Exchange and Medicaid Information Technology (IT)
Systems.” Version 2.0. May, 2011. Page 6. x
Federal Register. “Medicaid Program; Eligibility Changes under the Affordable Care Act of 2010; Final Rule.”
Volume 77, No. 57. Section 435.952. March 23, 2012. xi
Federal Register. “Medicaid Program; Eligibility Changes under the Affordable Care Act of 2010; Final Rule.”
Volume 77, No. 57. Section 435.945. March 23, 2012. xii
Federal Register. “Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health
Plans; Exchange Standards for Employers; Final Rule and Interim Final Rule” Volume 77, Number 59. Section
155.302. March 27, 2012. xiii
Federal Register. “Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health
Plans; Exchange Standards for Employers; Final Rule and Interim Final Rule” Volume 77, Number 59. Section
155.200. March 27, 2012. xiv
Center for Consumer Information and Insurance Oversight. “Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges.” August 13, 2012. Page 22. xv
Center for Consumer Information and Insurance Oversight. “Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges.” August 13, 2012. Page 22. xvi
Center for Consumer Information and Insurance Oversight. “Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges.” August 13, 2012. Page 22. xvii
Center for Consumer Information and Insurance Oversight. “Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges.” August 13, 2012. Page 23. xviii
Center for Consumer Information and Insurance Oversight. “Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges.” August 13, 2012. Page 26. xix
Center for Consumer Information and Insurance Oversight. “Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges.” August 13, 2012. Page 27. xx
Center for Consumer Information and Insurance Oversight. “Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges.” August 13, 2012. Page 29. xxi
Center for Consumer Information and Insurance Oversight. “Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges.” August 13, 2012. Page 30. xxii
Center for Consumer Information and Insurance Oversight. “Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges.” August 13, 2012. Page 30.