Facing the most sweeping health care reform since Medicare and an aggressive federal timeline for implementing changes, in 2012 the State of California was required to act quickly to introduce Covered California — a paradigm-changing insurance concept with a uniquely complex set of moving parts.
Among the challenges facing Covered California: finding experienced industry
executives to lead the charge. With the entire nation required to go live on the same day, individual states and the federal government were vying for resources from a limited pool of unique talents to set up their exchanges.
To build a health benefits exchange ready to accept enrollment by Oct. 1, 2013, despite the political stops and starts.
The Tori Group Expertise
Covered California chose The Tori Group, LLC for its team of health benefits exchange veterans with unrivaled expertise in the following:
• Senior leadership in insurance exchanges
• Deep knowledge of the California health care market
• Risk management as well as building and maintaining exchange portfolios
• Understanding of distribution and channel marketing/sales
• Project management, training and certification, and customer service operations
Leesa Tori, President and CEO of The Tori Group, served as Interim Director of Plan Management prior to, and during, the successful launch of the exchange.
Senior members of The Tori Group served on the executive team during unprecedented rate negotiations with carriers and the implementation of the Go Live process.
The Tori Group’s work included analyzing and advising Covered California on tough policy issues, including President Obama’s announcement of extended grandfathering of non-Affordable Care Act compliant plans.
Throughout the process, The Tori Group served as consumer-focused advisors to senior leaders of Covered California as they considered compass-setting policy decisions.
Performed the role of Interim Plan Management Director beginning in July 2013, managed the health insurance exchange portfolio, and implemented the Go-Live process for Oct. 1, 2013 — meeting strict federal timelines. Certified and contracted 11 health plans for participation. Designed, directed, and implemented the Qualified Health Plan (QHP) Certification / Recertification Program for the health plans and a multitude of dental carriers, which included participating on the executive team for rate negotiations. Restarted the Pediatric Dental program using the Tori Group’s “3 P” framework: setting policy compass first, building products, and then compiling portfolios. Developed and launched the Plan-Based Enrollment program which increased resources available for assisting California consumers during the transition. Managed stakeholder relations to help ensure collaboration of efforts.
Small Business Health Options Program (SHOP)
Developed the Small Business Health Options Program (SHOP) health insurance marketplace. Performed the role of SHOP Director until the position was filled in August 2014.. Designed, developed and negotiated products for a robust and well-priced portfolio. Authored adopted SHOP regulations, and established enrollment and eligibility rules and guidelines for SHOP. Assessed and coordinated significant changes and upgrades to SHOP administration software. Initiated project to establish agent contracting inclusion of Medi-Cal for payment — requiring over 12,000 agent contracts. Directed and oversaw the development of the renewal strategy and implementation for 2015.
Covered California Sales and Marketing
Developed a program for lead management and distribution — resulting in 12,800 closed leads and approximately 20,000 enrollments. Authored Agent Regulations as well as Agent of Record process and guidelines and served as point position for Agent interface and policy setting. (Agents represent 40% of all Exchange Sales Channel Enrollment). Provided in-person oversight of the SHOP enrollment process by the third party administrator, and made regular site visits, often with Covered California management. Monitored and managed communication issues between agents and Covered California service center. Provided Covered California leadership with agent expectations and needs relevant to 2015 individual Exchange renewals.
Company-Wide Knowledge Management System
Co-designed and staffed a Go-Live Support Center to answer and archive consumer questions, thousands of which had never been anticipated nor asked until after Go-Live. The support team channeled questions and answers to appropriate parties in addition to leveraging existing technology to develop an information management and distribution process.
Covered California University
Developed the organizational process that supported training and information distribution. Filled interim roles of: CCU Director, Learning Management System Manager and Coordinator, and Knowledge Center Analyst. Developed the Knowledge Center, Learning Management System Program, and Training Center.
Established the central governance model for Covered California Interactive Voice Response (IVR) application. Conducted assessment of Customer Relationship Management (CRM) application including overview of Knowledge Base to improve proper usage of solutions. Lead transitioning of all technical and operational support of the IVR and CRM applications to Covered California IT. Analyzed service center staffing requirements and volumes to procure sufficient resources to meet target service level agreements for an enhanced consumer experience. Provided senior leadership and operational assessment of service center with recommendations to improve efficiencies in key areas.
Measures of Success
By the end of open enrollment, nearly 1.2 million Californians enrolled in private health insurance under Covered California — many for the first time in their lives. This was nearly double the prediction of the state, policy, and health plan stakeholders.
Going into the second year of the exchange, the average weighted premium increase for all participating health plans was just 4.2 percent. This is one of the smallest weighted average increases in recent years — and is far below increases reported by other state-based agencies. The Tori Group was recognized by Covered California for its efforts in achieving this through its successful negotiations with
Qualified Health Plans.
California reduced the number of uninsured in the state by one-half -- from 22 to 11 percent — according to a recent Commonwealth Fund report.