State-Based Marketplace

Softheon Marketplace provides an end-to-end, cloud-based solution, enabling members to enroll in affordable healthcare. This State-Based Marketplace ecosystem is a comprehensive, MITA-aligned, SaaS platform designed with ease-of use in mind. From shopping and plan comparison, to enrollment, payments, and data analytics, Softheon Marketplace, a Commercial-Off-the-Shelf (COTS) exchange platform, allows states to define how their marketplace functions. States also have the option of implementing individual modules of our Softheon Marketplace. We listen to our customers and follow changing state and federal guidance and regulations so we can provide the right modular solutions at the right time.  

Softheon Marketplace

Softheon Marketplace is a comprehensive, end-to-end solution, providing states a COTS State Based Marketplace. The Softheon Marketplace is comprised of a Member Portal, where members experience guided shopping and plan comparison displaying available subsidies, enroll in plans, pay premiums, and review and make changes to their plan(s). Our Financial Management component handles premium payment processing through multiple methods and bill noticing. Enrollments generate EDI files that are securely transferred to Health Plans.

Softheon Marketplace is comprised of the modular components detailed below. Softheon is prepared to establish an end-to-end State Based Marketplace or replace one or more components of an existing marketplace.

Benefits:

  • End-to-end state-based exchange solution
  • MITA-Aligned and modular design
  • Built-in Business Intelligence tool

Decision Support

Intuitive guided shopping is now a reality with Softheon’s Decision Support tool. Answering a few questions yields a tailored result of the plan that best suits the members’ needs, at the right price. The portal uses state-of-the-art algorithms for greater accuracy of provider and pharmacy networks and advanced reporting.

The Decision Support module provides a personal shopping experience and can calculate eligible subsidies that are applied to pricing while shopping. Provide a great shopping experience to your members with our Decision Support tool.

Benefits:

  • The ability to support a wide variety of health and ancillary products
  • In-depth plan comparison functionality
  • Comprehensive account management capabilities
  • Seamless enrollment processes
  • Configurable interface/accessibility for employees and employers
  • Modular component - can be implemented as standalone product

EDI

Softheon’s EDI platform was designed to eliminate the risks and issues with importing bad data. Softheon’s HIPAA-compliant EDI platform normalizes all incoming transactions so that accurate and complete data is processed, resulting in more members receiving the coverage they need on time.

Gateway allows your employees to see enrollment information in a usable format while converting that data securely to and from health plans using the standard EDI files.

Benefits:

  • Requires that all files passed through, meet the necessary structural checks before proceeding downstream
  • Generate and process:
  • Enrollment and Eligibility Data (EDI 834)
  • Financial Remittance Data (EDI 820)
  • Medical and Pharmacy Claim Files (EDI 837)
  • Acknowledgement Files (999s / TA1s)
  • Eligibility Benefit Inquiry and Response Files (EDI 270 / EDI 271)
  • Financial and Medical data files for ETL (Extract, Transform, and Load)
  • Modular component - can be implemented as standalone product

Reconciliation

Every year, CMS creates new guidelines and complexities for health plans during Open Enrollment. Softheon’s Cost-Sharing Reduction and Reconciliation (CSR) solution was developed to aid health plans in projecting cost-sharing exposures, validating payments, and reconciling year-end results.

Supports Baseline RCNI, Baseline RCNO, Pre-audit and additional processes that will ensure a high level of accuracy.

Benefits:

  • Identify and address any enrollment or payment discrepancies
  • Reduce discrepancies and associated expenses
  • Modular component - can be implemented as standalone product

SBM Enhanced Direct Enrollment

Since the implementation of the Affordable Care Act (ACA), states are increasingly creating their own State-Based Marketplaces (SBMs) instead of relying on the Federally Facilitated Marketplace (FFM). For Brokers and Insurance Carriers, it has become clear that the need for eligibility determination without redirecting the user to HealthCare.gov is paramount to enrolling members in quality, affordable insurance plans. Enhanced Direct Enrollment (EDE) bypasses the need to go to Healthcare.gov, and instead allows members to enroll and manage plans all in one system, while reducing costs.

Softheon can provide a custom API suite to facilitate the Enhanced Direct Enrollment process for your state.

Benefits:

  • Improved Broker and Insurance Carrier participation
  • Existing certified EDE Vendors would be able to “plug in” to your system
  • Modular component - can be implemented as standalone product

HRA Shopping Platform

Health Reimbursement Arrangements (HRAs) have long been argued by thought leaders as the solution to rising healthcare costs, and we are now seeing the potential for them to become a primary component of the American healthcare payer system. Softheon understands the importance of an employer having an avenue to contribute to its employees’ healthcare and can equip states with the ability to facilitate an HRA option. Softheon can provide easy-to-use tools to empower Employers and Employees to make educated healthcare decisions.

Benefits:

  • Modular component - can be implemented as standalone product
  • Employee/Employer Decision Support Tool to aid in data-driven healthcare decisions

Plan Management

Self-service for members has never been easier. Members can review and update their plan, make changes like adding a dependent or terminating a benefit. Members can also pay their bills from the same convenient portal.

Softheon’s Plan Management portal gives the power to the member. Giving the member this level of control greatly reduces the effort needed to resolve common customer requests.

Benefits:

  • Gives power to the member to manage their plans with minimal support
  • Enroll in plans
  • Request new ID Cards
  • Add / Remove dependents
  • Terminate a benefit
  • Modular component - can be implemented as standalone product

Financial Management

Softheon’s premium billing & payment aggregation tool offers an integrated banking solution that provides a customer-friendly billing experience. States can manage financial transactions, premium payments & financial reconciliation. As an accessible PCI DSS 3.1 Electronic Payment platform, Equity serves individuals and brokers with multi-channel options, and offers the back-end processes needed to continually manage and track their payment statuses.

As a designated Payment Facilitator, we can conveniently and quickly process payments without third-party involvement. Softheon’s Financial Management suite supports numerous payment types including credit cards, ACH & e-Check, and lockbox processing, increasing membership retention.

Benefits:

  • Online self-management
  • Electronic bill presentment
  • Multiple payments accepted
  • Credit & debit cards, including: Visa, MasterCard, American Express, and Discover
  • ACH & e-Check: Withdraw payments directly from a customer’s bank account without interchange fees
  • Lockbox processing: Collect and apply paper checks to the appropriate member account with regionally based lockbox processing hubs
  • Third-party payment detection with configurable processing procedures, helping to prevent against authorized sponsors from illegally obtaining higher reimbursement rates
  • Modular component - can be implemented as standalone product

CRM

Softheon’s Customer Relations Management (CRM) platform allows Customer Service Representatives to easily facilitate member requests. Softheon provides numerous automated processes through a user-friendly portal to assist with membership management, such as: adding/removing dependents, changing effective date, terminating benefit, etc. Customer Service Reps can also create Service Requests for the Softheon team, escalating them, for review and assistance.  

Softheon’s CRM solution enables seamless customer support with members when implemented with our other modules, including Financial Management and Plan Management.

Benefits:

  • Functionality can be enabled/disabled per your needs
  • Computer Telephony Integration (CTI) compatible
  • Modular component - can be implemented as standalone product

Business Intelligence

Softheon’s Business Intelligence tool allows states to identify trends within their healthcare ecosystem. Through high level dashboards, states can generate heat maps of their membership, or using detail-oriented reports, states can make more granular decisions or identify anomalies. Softheon BI contains out of the box dashboards and reports and allows for users to generate their own.

Softheon BI features configurable, state-of-the-art tools for non-technical users. Users can analyze data in near-real time reviewing transaction trends, member demographics, geography, financial information, and cost comparisons.

Benefits:

  • Standard reports include, Payment Discrepancy, RCNI – Baseline Reconciliation File, Cost Sharing Reduction Reconciliation, and more
  • Generate and export both custom and standard reports
  • Generate de-identified risk adjustment and reinsurance data sets
  • Extract, Transform, & Load (ETL) from multiple data sources to create HHS-defined claims & enrollment files
  • Comprehensive reporting to track Key Performance Indicators (KPI’s) and Service Level Agreements (SLA’s)
  • Modular component - can be implemented as standalone product

Michael Sasko

Vice President of Government Solutions

Mike Sasko is a specialist in health care IT and Health Insurance Exchanges. Mike leads all strategic government partnerships. He joined Softheon in 2017, after working as a project lead, client lead, and business architect lead for several major State, Federal, and Medicaid healthcare projects. Throughout his career, he has also served various leadership roles within Accenture, Pfizer, and early stage IPO organizations. He can be reached by phone at (631) 662-5101 or email msasko@softheon.com

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