Aside from some low-income exceptions, not having health insurance is illegal in Massachusetts. Given that most state citizens face tax penalties of up to $912 if they don't acquire health insurance, the state aids their insurance selection process through a Web portal. The Legislature passed the insurance mandate in April 2006 with an effective date of July 2007. To give citizens a few months to shop and complete paperwork before the July deadline, however, the state needed to begin aiding the insurance shopping process by May 2007.
The law established the Commonwealth Health Insurance Connector Authority, a clearinghouse for insurance plans and payments from private insurance providers. The agency also runs Commonwealth Care, which fully subsidizes health insurance for citizens below the federal poverty line and partially subsidizes insurance for those who have incomes up to three times the poverty line.
After the seven months it took to establish the Connector Authority, only four months remained to find a vendor, develop and roll out a Web site. The Web site premiered on time with the first of three phases: offering unsubsidized health insurance plans online.
"This was the fastest rollout I have ever seen, and it was for something that was mission-critical," said Dhiraj Goklani, senior account executive for Vignette Corp., the Connector's portal vendor.
For the second phase, the site provided its "voluntary plan," which allows employers that aren't required by law to subsidize their employees' health insurance to enable their employees to partially pay for health insurance with pretax earnings. State employers in Massachusetts with 11 or more employees must contribute to employees' health-care costs. In July 2008, the agency will complete the site's third phase: offering employer health insurance plans. Since going online in May 2007, the state has enrolled more than 340,000 citizens into health insurance plans. That's more than 5 percent of the state's population and more than half of its uninsured population.
The Commonwealth Connector didn't have an implementation strategy for the Web portal when it hired Computer Sciences Corp. (CSC) in December 2006, said Bob Nevins, CIO of the Connector Authority.
"We put a procurement out on the street asking for a company that could help us think through the strategy of what needed to be included in this Web site - what it should look like and what we should copy from other successful Web sites. That same company was charged with helping us implement it - writing the code, the logic and hosting it - while we got it up and running," Nevins said.
Vignette supplied the portal software, but CSC was the overall managing vendor of the project.
The Connector team tapped the Consumers Union, an advocacy and research nonprofit, for input on how consumers rank priorities when selecting health insurance. That research helped determine where on the site the Connector placed various pieces of information. For example, data showed citizens consider monthly premium amounts before anything else.
"That's the first thing we show next to the name of the policy," Nevins explained. "Then they want to know the deductibles. After that, what are the co-payments for doctors, prescriptions and emergency room visits? What's the deal with hospital stay costs and choosing doctors? If they want more details, they can click 'view plan.'"
The site displays each plan in row form with information in the aforementioned order. Providers offer various plans that fall within the Web site's "gold, silver and bronze" price and service categories. Citizens can do side-by-side comparisons of different providers' plans.
"Say you don't have to go to the doctor that much, but you want to have catastrophic coverage," Nevins said.
"You want to be sure you're covered if something bad does happen. You
don't want to pay a lot per month. We wanted [providers] to offer a product in that category. We wanted them to offer a product in a middle tier, which we call 'silver' - a balance between the monthly premium and the co-pay amount. We also wanted them to offer a more comprehensive package that might interest families."
The Connector contracted with six insurance providers, representing roughly 90 percent of the state's health insurance industry, according to the Connector.
"This was the first time consumers could really do this comparison across different health plans," Nevins said. "If you go to Harvard Pilgrim [a provider in the state], they wouldn't tell you what their competitors charge - it doesn't really serve their interest. Because we're an independent state authority, and because our charge is to help people purchase affordable health insurance, we're able to do this."
Citizens get locked into a rate for 12 months once they purchase a plan through the Connector site. However, providers change the promoted rates on a monthly basis. Those operating the back end of the site's operations must stay up-to-date on current prices.
The Connector pays the Small Business Service Bureau (SBSB), a private company, to receive providers' current rate information and run the Connector's insurance plan phone bank. The Connector considers the SBSB its "subconnector." The subconnector submits current rates to the Connector Authority via XML messages.
"It's a big dance going on between us, our subconnector and the carriers to make sure everybody is satisfied that what we're selling is, in fact, what the providers are offering," Nevins said.
The Connector initially paid the CSC $700,000 for the solution over six months. Since then, the agency has paid that amount twice more for two six-month extensions of CSC's help at running the site.
Nevins said the Connector will likely extend its contract for an additional six months from July to December 2008. "Then we're pretty much done with them. We'll operate the thing on our own," Nevins explained, adding he would likely add a few more IT staffers to keep information current on the site.
The Connector agency is fine-tuning the site's features that it didn't have time to perfect during the initial implementation. For example, it's changing the Java code powering the site to a "components-based" model, which would simplify site programming, said Nevins. The components-based approach would enable programmers to fashion "modules" of ready-to-use code they could apply elsewhere on the project.
Heads-Up to Others
States considering health insurance laws similar to Massachusetts' could learn from challenges Nevins faced during his quick rollout. For example, a state should plan to accommodate a larger number of uninsured residents than it initially estimates. The Connector's initial estimate put the number of uninsured at 370,000.
The true number, according to Nevins, was closer to 550,000. Costs rose higher than the Connector planned. The agency expected roughly 136,000 of the uninsured to sign up for Commonwealth Care. Instead, 176,000 people enrolled in the program.
The Connector also had to carefully craft communications when soliciting involvement from insurance providers. Insurance providers didn't want to appear to not support the state's health-care reform effort, said Nevins.
"On the other hand, here we were, having an impact on the market and creating more competition. We had to approach that gingerly," Nevins said.