Health Benefit Exchange (HBE) – Call Center Functionality & Services

Health Benefit Exchange (HBE) – Call Center Functionality & Services

For Health Exchanges, Call Center will be the heart of delivering better service. The primary goals of the HBE Call Center will be to assist individuals and small employers in obtaining health insurance coverage and be able to respond to the following:

  • The types of Qualified Health Plans (QHPs) offered in the HBE
  • Categories of assistance available, including APTCs and cost-sharing reductions as well as assistance available through various Medicaid/CHIP programs
  • Plan selection and enrollment for SHOP employers and employees
  • The application process for enrollment in health coverage available through the HBE or other programs including Medicaid/CHIP
  • The premiums, benefits, cost sharing and quality ratings associated with the QHPs offered

Call Center functionality for Health Exchanges

  • The role of the Health Exchange (HBE) Call Center is to facilitate the process of acquiring health insurance for individual, family or group, whether it is subsidized, unsubsidized, Medicare / Medicaid supported or via a small business route.
  • The Call Center will receive inquiries and answer questions about health insurance eligibility, application and enrollment, including the availability of tax-credits and cost sharing reductions
  • The Call Center will serve customers with a simple streamlined approach to ensure ease of use and customer satisfaction
  • The Call Center will provide a toll-free phone number to respond to inquiries regarding coverage offered through the HBE
  • The Call Center will be able to facilitate the application and enrollment process to include assistance in web-based and paper-based applications processing
  • The Call Center will help consumers navigate through the Medicaid Expansion program (based on Modified Adjusted Gross Income parameters – MAGI), Advanced Premium Tax Credit (APTC), Small Business Health Options Program (SHOP) and the non-subsidized uninsured seeking services related to Qualified Health Plans (QHPs)
  • The Call Center will also triage calls concerning eligibility for other health benefit programs available to Washington State consumers, and for more complex questions, route accordingly
  • The HBE Call Center will be the first point of contact for many customers with questions about applying for and enrolling in health insurance through the Exchange
  • The Call Center will facilitate services based upon consumer requests which will come from email phone, fax, USPS, and online

Typical Health Exchange Call Center Users Group

  • Individual Customers
  1. Advanced Premium Tax Credit (APTC) Recipients
  2. CHIP
  3. Medicaid
  4. Unsubsidized
  • SHOP Customers
  1. Employers
  2. Employees
  3. Brokers
  • Qualified Health Plans (Insurance Companies)
  • System Integrators / Gateway Companies
  • Health Exchange Employees
  • Regulators / Administrators

Call Types in the Health Exchange Call Center

  • Appeals
  • APTC / SHOP Eligibility questions
  • Billing Questions
  • Case updates
  • Complaints
  • Enrollment assistance
  • Health Plan questions
  • Premium Questions
  • System Access

Major responsibilities of an Exchange Call Center 

  • Accept payments through various means (credit card, money order, etc.)
  • Assist individuals with applying for health coverage
  • Assist/educate clients on appeal, complaint, and certificate of exemption processes
  • Educate clients on premium payment requirements for those required to contribute to health insurance premiums
  • Fulfill client requests for mailed or electronically delivered correspondence/documentation
  • Provide assistance navigating the web portal, assist with APTC eligibility, compare QHPs
  • Provide information about QHP offerings
  • Provide language translation services whether through call center representatives or through a language line service
  • Record all telephone and web-video encounters
  • Refer to state agencies, QHPs, Navigators, or agents/brokers as needed
  • Research and resolve client issues and account discrepancies
  • Respond to inquiries related to eligibility status, enrollment status, and change in circumstances
  • Track all client encounters in a vendor-provided Customer Relationship Management (CRM) solution
  • Utilize an Interactive Voice Response (IVR) system to facilitate automatic selection of the core call center services

A summary of SBE Call Center Services 

  • Eligibility – Providing assistance with applications and collecting the necessary eligibility data, and coordinating the verification of that data
  • Enrollment – Responding to requests to enroll in a health plan and calls to confirm enrollment start date, enrolling and renewing participants in Qualified Health Plans (QHP), and producing enrollment reports
  • SHOP Eligibility and Enrollment Requirements – Enrolling employers and employees, assisting with employee selection of health plans from the employer’s selected tier, and renewing enrollment
  • Financial Management – Receiving calls from clients questioning their invoices, premium amounts, or checking on payment receipts; answering questions around premium processing for Individuals and employers; questions about APTC or Cost Sharing Reductions, fees, and payment transfers to insurance issuers; and taking premium payments over the phone
  • Qualified Health Plans (QHPs) – Answering questions about available health plan offerings and questions about covered services
  • Case Updates – Addressing calls to report income changes, address changes, and qualifying events
  • Customer Inquiry – Facilitating the solution to a variety of consumer questions, ranging from navigating the web portal, addressing system problems, or forwarding clients to the appropriate destination for additional assistance
  • Language Support – Not only the Call Center is expected to service in English and Spanish but will also have to adhere to CMS ruling on the language support

For Health Exchange Call Center Services, call Manish Jaiswal @ 646.644.3049


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425 Washington Blvd., Jersey City,
New Jersey 07302, USA

Phone: +1 201.258.4704 / 201.258.4704
Fax: +1 201.604.3480