NFP Health’s turnkey solution allows smaller, traditional Medicaid plans to seamlessly enter the ACA commercial marketplace. Our comprehensive model features a robust online shopping portal, as well as a full administrative platform including: shopping, sales, underwriting & enrollment, premium billing, operations, and reporting. In a recent engagement with Network Health, a 220,000-member health plan that serves Massachusetts residents with low and moderate incomes, NFP Health recently implemented its hosted Medicaid solution. The solution included a private shopping portal, underwriting & enrollment, billing & collections, XML transfer for real-time rate quotes, EDI 820/834, and a standard and customized reporting package. Network Health began offering its first commercial health plan in 2013, after a quick six-month implementation, making them well-positioned for 2014 and beyond.

1. NFP Health Case Study:
How One Medicaid
Plan Prepared for
the ACA Commercial
Marketplace

2. NFP Health designs, implements and
operates the administrative infrastructure
needed by Medicaid plans to enter the
commercial market.
About NFP Health
NFP Health’s turnkey solution allows traditional Medicaid plans to seamlessly enter
the ACA Commercial Marketplace. Our comprehensive model features a robust online
shopping portal, as well as a full administrative platform including: enrollment &
underwriting, premium billing, call center and EDI.
Come see us at Booth 316 or contact us at www.nfphealth.com,
(888) 703-3332 or info@nfphealth.com
HOW ONE MEDICAID
P L A N P R E PA R E D F O R
THE AC A COMMERCIAL
MARKETPLACE
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3. Executive Summary
Network Health is a Massachusetts health plan that serves more than 222,000 members
with low and moderate incomes. In 2012, Network Health looked at the costs to build
internally the needed capabilities to enter the commercial marketplace or to work with
an experienced exchange provider, such as NFP Health.
Why? The looming impact of health care reform on Network Health’s membership
brought to light that they could not afford to avoid addressing the changes that were
coming in 2014.
While a few health insurance products
have been available in the past,
individuals and small groups now will
As a result, Network Health chose to partner with NFP Health to implement and host a
full suite of services and tools, including modules for shopping, quoting, underwriting
and enrollment, and financial services.
have a broader array of options and will
Based on proven expertise honed as the operator of one of the nation’s premier multicarrier health benefits exchanges for more than forty years in New England, NFP Health
designs, implements and operates the administrative infrastructure needed by Medicaid
plans to enter the commercial market.
their needs, based on cost-sharing and
be able to select a plan that best meets
benefit levels.
Six months after Network Health selected NFP Health, a successful implementation
was completed on time and on budget, and Network Health began offering its first
commercial product, Network Health Choice, in March 2013.
Health Care Reform and the
Historical Market
Health care reform offers new business opportunities for health plans to better serve
the individual and small group markets. These segments historically have been under
served, with government programs focusing on the subsidized market and commercial
health plans focusing on medium and large employer groups. However, due to health
care reform, the landscape is changing.
Beginning in 2014, individuals and their families, as well as small employer groups, will
be able to compare and purchase health insurance on either a federal or state health
exchange, as well as directly from a health plan.
While a few health insurance products have been available in the past, individuals and
small groups now will have a broader array of options and will be able to select a plan
that best meets their needs, based on cost-sharing and benefit levels.
While it certainly is good news that people buying insurance will have more choice, the
changing landscape presents both a challenge and an opportunity for Medicaid plans as
they look for ways to expand their membership, by attracting new members, perhaps
who were previously uninsured, and by retaining members who move from subsidized
plans into the commercial market as their incomes increase.
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ALL RIGHTS RESERVED

4. The Medicaid to
Commercial Opportunity
A goal for Medicaid carriers such as
Network Health, heading into 2014 and
beyond, is to retain their members as
they move from subsidized to commercial
health insurance.
Massachusetts, long recognized as the model for national health care reform, is unique
in that it has operated a full service pubic exchange since 2006, which, in 2007, began
offering an unsubsidized (i.e., commercial) product, Commonwealth Choice, for the
individual and small group market.
Similarly, under health care reform, individuals and small groups nationwide will be able
to purchase commercial insurance from a Qualified Health Plan (QHP) either through a
public exchange (state or federal) or directly from a health plan.
Medicaid carriers, in particular, have much to gain by offering commercial products in
this marketplace.
Not only does offering commercial products provide an opportunity for growth by
attracting new members, but it is also essential to maintaining current members, and
providing continuity of coverage, as individuals and their families move above 400% of
the Federal Poverty Level (FPL).
A goal for Medicaid carriers such as Network Health, heading into 2014 and beyond, is to
retain their members as they move from subsidized to commercial health insurance.
Medicaid
Qualified Health Plans
Commercial Health Plans
(subsidized)
(subsidy eligible)
(no subsidy)
< 133% FPL
133%-400% FPL
> 400% FPL
Offering a commercial product provides a relatively easy way for Medicaid plans
to maximize their membership and revenue potential, despite the changes in the
marketplace that could easily threaten Medicaid plans if they are not prepared for the
changes of health care reform.
While most health plans have the necessary networks, clinical programs and claims
payment processes in place to operate in the commercial market, unfortunately, many
Medicaid carriers do not have the required expertise and infrastructure—people,
processes, technology – to be a commercial health plan.
HOW ONE MEDICAID
P L A N P R E PA R E D F O R
THE AC A COMMERCIAL
MARKETPLACE
NFP Health partners with Medicaid plans to implement an economical, turnkey solution
to allow the health plan to enter the commercial market on time and on budget, with
proven expertise and infrastructure that both removes the risk of building the required
capabilities from scratch, and leverages the benefits of forty years of experience in
building and operating both private and public exchanges.
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5. Network Health
Network Health, a nonprofit, comprehensive health plan that serves more than 220,000
Massachusetts residents with low and moderate incomes, is a Medicaid Managed Care
Organization (MMCO) contracted by Massachusetts to provide health care coverage
for the state’s Medicaid population (those eligible for MassHealth and Commonwealth
Care), as well for the state’s Medical Security Program (MSP) Direct Coverage plan.
In 2012, Network Health decided to enter the commercial market by offering Network
Health Choice – unsubsidized health insurance for individuals and small groups. Offering
a commercial plan would allow Network Health to extend its mission “to improve the
health and wellness of the diverse communities [it] serves,” to prepare themselves
to be a Qualified Health Plan (QHP) under the Affordable Care Act, and to grow its
membership and revenue.
After weighing the options, it became
clear that it would be more economical
and efficient to leverage the capabilities
of an external partner.
While Network Health had operated historically as a solely subsidized health insurance
provider, the business decision to enter the commercial market included evaluating
whether they should build or outsource key functionality required, such as sales,
enrollment, and billing, services typically provided by the state for subsidized plans.
After weighing the options, it became clear that it would be more economical and
efficient to leverage the capabilities of an external partner. Network Health was looking
for a partner that had a HIPAA compliant, fully integrated, turnkey platform, and was
willing to be flexible in customizing the solution for Network Health’s particular needs.
Based on these needs, as well as on cost and reputation, Network Health selected NFP
Health as their partner to launch into the commercial marketplace. Though Network
Health decided initially not to focus on the broker channel, the option to leverage
NFP Health’s strong broker program with over 2,500 affiliated brokers was appealing
should they decide to redirect sales, as Network Health had little to no experience in the
business market segment.
“NFP Health was able to provide all the functionality that we needed, from a private
shopping portal with real time rate quotes, to enrollment and billing functionality, to
customized reports. We are pleased that we made the strategic decision to leverage
their capabilities for both implementation and ongoing operations, rather than build
the required functionality ourselves”, Deborah Gordon, Chief Sales & Marketing Officer at
Network Health.
©2013 N F P H E A LT H S E R V I C E S A D M I N I S T R ATO R S
ALL RIGHTS RESERVED
5

6. NFP Health’s Modular,
Medicaid to Commercial Solution
NFP Health’s leadership has extensive
experience working with individual health
plans, as well as multi-carrier state
operated exchanges, government benefits
programs, and newly created co-ops.
NFP Health has operated one of the nation’s premier multi-carrier health benefits
marketplaces in New England, covering several hundred thousand members with its
products and services over the past 40 years.
NFP Health’s leadership has extensive experience working with individual health plans,
as well as multi-carrier state operated exchanges, government benefits programs, and
newly created co-ops. They have developed the technology, processes and relationships
needed to successfully implement a highly modular, cost-effective, turnkey solution.
By partnering with NFP Health to take care of the administrative processes and required
integration capabilities, health plans can focus on serving their members with access to
affordable, high quality health care.
Sales
Enrollment
Premium
Billing &
Collection
Customer
Service
Reporting
HOW ONE MEDICAID
P L A N P R E PA R E D F O R
THE AC A COMMERCIAL
MARKETPLACE
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• Multi-carrier exchange and private, health plan-branded
web portal
• Product and real-time rate display based on prospective
member data
• Online application, link to health plan’s provider search tool
• Live web chat
• Eligibility verification per health plan’s underwriting
guidelines
• Application processing and first month’s premium collection
• Renewals
• Member data to health plan via 834 EDI
• Monthly member premium billing and collection, with
E-Pay option
• Reminders, termination letters
• Monthly financial reports to health plan via 820 EDI
• NFP Health call center
• Warm transfer from health plan’s member service
department
• Dedicated line for health plan
• Robust reporting suite
• Customized plan-specific reports: recurring and ad-hoc

7. Implementation of the
Network Health Marketplace
The implementation of the Network Health Marketplace, including planning,
development, and end-to-end testing, was a six-month, collaborative process between
NFP Health and Network Health.
NFP Health’s project management staff provided a detailed work plan that incorporated
key dates and milestones in Network Health’s overall project timeline. Weekly calls and
in-person meetings, as necessary, ensured that issues were discussed and resolved in a
timely manner.
Deborah Gordon, Chief Sales & Marketing
Officer at Network Health, states:
NFP Health was an invaluable
partner as we moved from being a
A Network Health-branded shopping portal was created using NFP Health’s technology
and Network Health-specific branding, content, rules and data, to ensure an optimal
shopping experience for prospective members.
subsidized insurance plan only to offering
Network Health was also offered on the multi-carrier marketplace operated by HSA
Insurance (www.hsainsurance.com), a subsidiary of NFP Health.
NFP Health was knowledgeable, flexible
our first commercial product. Everyone at
and a pleasure to work with, and we
Network Health’s Results
launched Network Health Choice on time
With an aggressive target of six months from signing to implementation, Network
Health successfully entered the commercial market on time and on budget, with a
Network Health-branded, single carrier shopping and enrollment portal unique to the
marketplace.
and within budget. I highly recommend
NFP Health!
Network Health’s shopping portal can be seen live at: http://network-health.nfphealth.com.
Network Health is now well positioned to retain its members who transition out of
subsidized programs, as well as to grow by attracting new members, in 2013 and beyond.
7
©2013 N F P H E A LT H S E R V I C E S A D M I N I S T R ATO R S
ALL RIGHTS RESERVED

8. NFP Health’s turnkey solution allows
traditional Medicaid plans to seamlessly
enter the ACA Commercial Marketplace.
Our comprehensive model features a
robust online shopping portal, as well as
a full administrative platform including:
enrollment & underwriting, premium
billing, call center and EDI.
www.nfphealth.com
135 Wood Road
Braintree, MA 02184
(888) 703-3332
info@nfphealth.com
©2013 NFP Health Services Administrators
All rights reserved