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easySBC+ EMSaaS Solution Summary

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THE CAST

The Centers for Medicare and Medicaid (CMS)

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The Cast

Summary of Benefits and Coverages (SBC)

M&M

SBC

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The Cast Healthcare Plan Organization Business Team

Product Manager1

Operations Manager (Ops)2

Document Owner3 Administrator

(Admin)4

Database Manager (db)5

The Cast Elixir Technologies Solutions & ServicesTeam

Elixir Professional Services (PS)

1Elixir Solutions Architects (SA)2

Elixir WorkFLOW and Business Process Consultants (BPC)

3 Elixir Tech Support (TS)4

Elixir Account Managers (AM)

5

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THE DOCUMENT

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The Document The Summary of Benefits and Coverages (SBC) is as ubiquitous as it is important; it is integral for consumers, agents and brokers. It is also the guiding document for online access to compare plans and benefits through exchanges and member protals to individuals in the marketplace and online through health exchanges. The Affordable Care Act requires health insurers and plans to provide “clear, consistent, and comparable information about their health plans and benefits.” Today, 180 mill ion Americans get this information from SBC documents.

Summary of Benefits Coverage template.

Elixir HeathcareWelcome to

The Document The SBC template is the result of a concerted effort to facilitate access to fair and objective plan and benefit information for all health plan consumers. The SBC is both consumer advocate and helping hand; and it enables online shopping on health exchanges. The variable fields in the SBC table are engineered to verify and adapt plan data and benefit information for online presentment to facilitate direct shopping for the individual consumer. We once relied heavily on agents and brokers for such guidance; today, the SBC walks us through the healthcare plan marketplace, acting on our behalf, as both an advocate and personal shopper. Noncompliant SBCs can incur $1,000 penalties, per violation. CMS audits are performed regularly to ensure SBC compliance, among other things. According to one source, “more than 70% of audits in 2013 resulted in fines or other corrective action.” Most CMS audits are triggered by participant and member complaints, along with the errors and inconsistencies found in SBC documents.

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The SBC is more than a compliance regulation. Though healthcare plan marketing departments cannot change the language and formatting on the SBC, it still has immense practical value as a marketing tool. The SBC enables fair plan comparison and facilitates consumer choices based on real plan and benefit value. Since consumer choices are the force that stimulates competition in the marketplace (demand), the SBC will effectively advocate for better quality plans.

It also lets individuals compare several versions of a clearly defined benefit type across plans, which will give actuarial focus to create better plans, for specific demographic groups and their medical needs. The SBC will continually shape the way consumers understand health plans. In fact, according to economic theory, the SBC should exert increasing force on the health plan marketplace; it holds the power, via consumer choice and actuarial R & D, to drive strategic benefit and plan development. and Tango

The Document

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THE CHALLENGE

24/7

The SBC is a notoriously challenging document. Maintaining compliance and meeting CMS deadlines and template updates is a daunting task, especially when plan data resides in several locations, and content is stored in employee desktops, and various other devices.

employees looking forsiloed plan data and content

The ChallengeSubject Matter Expert (SME)approval and review cycles are integral for SBC assembly compliant. The SMEs involved may work in separate departments, and sometimes multiple lines of business are involved. Cross-departmental SBC workflows (when combined with tedious, manual processes, and IT queues) translate into extended timelines and missed deadlines. Manual processes are not conducive to speedy SME cycles, which is why the SBC has become known as a time-con-suming and draining document.

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Product Managers, Marketing Managers, and Product Owners increasingly spend more of their time and effort performing menial tasks, in an effort to ensure that compliance and associated deadlines are met. Time and effort get wasted on these tedious, repetitive tasks, while important SME review and approval cycles get lost in the cracks.

The ChallengeRepairing broken business processes takes too much time and effort to be a viable and immediate solution for the administrative challenges faced by today’s healthcare plan organizations. Many lines of business do not have the resources to formulate a sound strategy, let alone implement one. Managing and planning operational change is far from simple, especially when human (and other) resources are tapped out. Many healthcare plan organizations struggle

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to meet growing regulatory demands; and most of the time, employees and management must focus on member services, enrollments, and customer acquisition and retention, on top of mounting daily work loads.

The SBC is more than a compliance regulation. Though healthcare plan marketing departments cannot change the language and formatting on the SBC, it still has immense practical value as a marketing tool. The SBC enables fair plan comparison and facilitates consumer choices based on real plan and benefit value. Since consumer choices are the force that stimulates competition in the marketplace (demand), the SBC will effectively advocate for better quality plans.

The ChallengeHealthcare plan databases often inhibit administrative efficiency and progress. Many of these databases have not kept up with the increasingly rigorous demands associated with generating Medicare and CMS compliance documents. There is no way around the imperative to clean, reformat, and standardize healthcare plan data and databases. Today, good document solutions must help healthcare plans jump the data hurdle, before they can make real progress toward streamlining infrastructure and business processes. The ultimate goals of administrative simplification are well-oiled and unified workflows that stretch across organizations, from data input to document generation.

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The ChallengeHealth care payers that offer Medicare, Medicaid, and hybrid, government-sponsored plans must comply with inflexible formatting, document models, and tight deadlines, per rules and regulations both established and enforced by the Centers for Medicare and Medicaid Services (CMS). Failure to remain in full compliance places these payers at risk. CMS non-compliance translates to heavy financial penalties, legal action; and plans in violation are, can be barred from the marketplace. CMS regulations have pushed plan payers to either fully outsource document generation, resort to tedious manual tactics, or to implement new technology for generating compliant documents; but the tools, alone, cannot solve their problems.

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THE SOLUTION

The Elixir EasySBC+ Managed Solution as a Service (EMSaaS) is a cooperative solution designed to empower health care plan business teams.

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Elixir has no interest in holding hostages or imposing our own priorities and deadlines on clients. The easySBC+ is intended to give you full control over your plan data, human resources, and deadlines. Elixir focuses on managing the CMS template, including all changes and updates to formatting, content, and model language. The cooperation between your team and Elixir Solutions and Services makes the SBC easy. Elixir also handles all the processes involved in assem-bling and generating compliant SBC documents, so you can say goodbye to tedious manual processes and errata.

The Elixir SBC+Team has been producing SBC documents for some of our nation’s largest, and most respected, healthcare plan organizations from day one of the implementation of theACA & CMS regulations and associated compliance documents implementation. We are well versed in building compliance documents.

Your engagement with Elixir’s SBC+ brings measurable value to your team and your organization. The first step is a consultation with Elixir’s experienced solutions team. This is where we build a cooperative strategy to extract and format your plan data, so it is ready to drop into our SBC+Mas-terTemplate.

easySBC+ is a solution. Our offering is akin to a subscription business partnership. Elixir provides give you the CMS model SBC document template, and ensures easy and on-demand generation of all your CMS-com-pliant SBCs.

Your contribution is access to the requisite plan data, and collaboration with our team to extract and correlate relevant data, per the CMS template guidelines, for affected plan offerings. Before our technology gets to work generating SBCs, Elixir professional service experts work alongside your business teams, to build a solid strategy to extract, clean, and format all relevant plan data.

THE SOLUTION

This is all Elixir needs to generate your SBCs.

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You will have access to your own SBCs, anytime, through your browser. Your SBC+ subscription includes updates and changes to current plans, plus the ability to generate SBCs for any new plan. You have control of your products.

THE SOLUTION

Elixir SBC+ is One Source of Truth for plan data and CMS compliance.

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THE SOLUTION

The Elixir Solutions & Services team works alongside business teams to objectively analyze, quantify, and ultimately improve existing business processes. Our technology is not a stand-alone solution; in our decades of experience, we have learned that in order to improve work experience and efficiency, we have to comprehend current processes and logic to effectively design a customized, end-to-end solution, and automate manual processes. The first step is to get familiar with existing workflows, including database[s]/input, relevant business processes, documents/output, and workflow victories and challenges.

ConsultationTHE SOLUTION

ELiXir’s SBC+Solution gives you quality, compliance, and control to manage your own products, end-to-end. The easySBC+ features Tango+ powered audit trails and change management, so review and approval cycles are unified and compliant with CMS regulations.

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Compliance

Audittrails

Approvalcycles

End-to-EndWorkflow

THE SOLUTION

Your annual subscription includes storage on Tango+EDS; this means your approved SBCs are ready for electronic presentment, and easily integrate with member portals & health exchanges, so agents, brokers, and individuals can access the SBC for any plan, online and on-demand.

Elixir and SBC+ integrates easily with your choice of benefit input and ratings & quotes systems, for the increasingly diverse needs of plan offerings in the evolving health plan marketplace.

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Easy Integration

SBCPortals

on-damand

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THE SOLUTION

Elixir Solutions Architects and Professional Services teams have been working alongside business and IT teams in North American healthcare plan organizations for years. We are experienced doing the work your team actually does. Generating compliant Medicare and Affordable Care Act (ACA) compliance documents is our job. Elixir Solutions experts collaborate with our clients’ teams, to recognize and help solve all of the challenges associated with health plan document workflows.

Once the data is uploaded, our team maps and resolves your plan data into the current CMS template, to generate your accurate, errata-free SBCs. Tango

errata-free

ACA

DataMapping

PS

THE SOLUTION

Want to experience the power of Tango+?Click here to see more and get in touch.

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