SQM Group
State Health Reform Assistance Network

What Should Exchanges Know About Call Centers

Press Release Published in March, 2013 and prepared by Kathie Mazza and Steven McStay, Wakely Consulting Group


A Call Center (sometimes called a Customer Service Center) will play a major role in the overall success of a State-Based Exchange’s mission to connect as many people as possible with affordable—and understandable—health care coverage. As a multi-channel contact center, it will assist far more enrollees than navigators, brokers, and in-person assisters combined. The Call Center is a main face of the Exchange to the outside world, along with the Exchange website and portal and, to succeed, it must have a cohesive strategy for optimizing people, processes, and technology to support Exchange goals and objectives. This brief reviews each of these three components within the context of the Exchange environment and offer tips for strategy development. The brief concludes with an exploration of five Call Center best practices that are relevant to the Exchange environment. And since it is often said that “experience is the best teacher,” several of the best practices are partly drawn from conversations with people who are closest to some of the best-in-class Call Centers in the country, including L.L.Bean, Fidelity Investments, Nordstrom, and Blue Cross Blue Shield of Vermont (BCBSVT).

Core Business Encounters

A core set of customer encounters will need to be supported by the Call Center during the process of enrolling people and maintaining their coverage. To provide context for developing Call Center strategies and for the discussion of best practices which follows, a review of these core encounters includes:

  • Application navigation — assistance with eligibility determinations and navigation through the online (and paper) application process for individuals;
  • Enrollment (and re-enrollment) — enrollee comparison shopping and requests to enroll in a health plan, understanding Advance Premium Tax Credits (APTCs) and Cost-Sharing Reductions; calls to confirm enrollment start date and reinstatement of coverage (for late payment);
  • Health plan issuer questions — inquiries on the status of enrollment or identification cards, general health plan inquiries, and provider network inquiries;
  • Billing questions — questions on invoices, premium amounts, receipt of payment, and refunds;
  • Case updates — these encounters include assistance to enrollees with reported income changes, insurance status changes, address changes, change in dependent information, etc.;
  • Self-service web portal — these encounters include calls to educate/assist with any of the self-service functions of the website (eligibility application, comparison shopping, enrollment, premium payment, change of address, survey, password reset, etc.);
  • SHOP support — assistance with all employer and employee inquiries related to employer set-up, eligibility, tax credits, enrollment, plan selection, billing, etc.;
  • Assister support — includes any questions or other support request from navigators, in-person assisters, agents and brokers;
  • Appeals, grievances, referrals, and notices — includes any complaints or need for escalated assistance, requests for certificate of exemptions, referrals to navigators, in-person assisters, agents and brokers, health plan issuers, and state agencies (including Medicaid), and questions (or appeals) on notices; and,
  • General inquiries — any inquiries that don’t “fit” someplace else and might include general education, health reform questions and inquiries from providers, state legislatures, and media.

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