With its beautiful foliage and cooler temperatures, fall is a time of reflection on the achievements of the current year and preparation for the upcoming year. Reflecting on 2012, it has been a year of significant change and uncertainty in the healthcare industry. As we look forward to 2013, we can expect more change as healthcare reform provisions gain more momentum.

The mandated implementation date for Health Insurance Exchanges (HIX) is approaching fast, and with it comes changes to the Managed Care Organization (MCO) operating model as we shift to a consumer retail shopping environment. To date, 18 states plus the District of Columbia have decided on an exchange model. Three states are still in the planning stages, with nine others showing little activity.* Many states delayed or slowed their planning efforts due to the pending Supreme Court decision. Now that the decision has been released, states are challenged with making up for lost time in a relatively short period of time. Unfortunately, those delays, along with ongoing political debates about healthcare reform and the November elections, have the potential to derail MCO reform initiatives. Regardless of the political climate or status of exchange planning in your state(s), there are things you can do now in order to prepare for HIX.


Open enrollment for HIX will begin in October 2013 and, in order to be ready for the stipulated January 2014 launch, plans must be operationally ready by October 2013. Preparation for HIX can be categorized into three areas: Certification, Implementation, and Operational Readiness. The necessary changes are pervasive and interdependent, and they require close coordination in order for an MCO to be successful.

As with any new model that is introduced in the marketplace, the exchange model requirements will continue to evolve over the next few years. Therefore, it is important that MCOs avoid over-investing in or building a model that is unable to evolve with the changes.

Nolan’s point of view is that organizations can protect their investment and reduce risks by conducting a three-dimensional evaluation of HIX requirements: 1) Consider the probability that various HIX requirements will remain in place, change, or be eliminated; 2) Assess your organization’s current capabilities and determine to what degree you can meet those requirements; 3) Identify the impact requirements, capability gaps, or weaknesses have on your organization’s critical path for HIX. This approach, combined with a maturity assessment of your processes, will provide a clear picture of where your organization stands with HIX, the areas that require additional investment, and the key initiatives for your HIX road map. 

The one thing we know for certain about HIX is that it will continue to change and evolve over 2013 and 2014. Planning and building for that change will position your organization for success as we continue to navigate our way through healthcare reform.
*http://healthreform.kff.org/tags/exchanges.aspx. August 2012, Establishing Health Insurance Exchanges: An Overview of State Efforts.