National Plan Case Study

Summary of Impact

This National Plan, a FORTUNE 500 company, provides managed healthcare services under the Medicaid and Medicare programs and through their state insurance Marketplace (Exchange). The plan services over 5 million members through its locally operated health plans.

Challenge

Supporting the Marketplace member rewards programs through paper and mail services was a poor member experience, operationally inefficient, and costly. This plan sought a technology partner that would provide an automated process for members to track their incentives and redemptions from their Member Portal. The solution needed to be scalable across 15+ states while meeting each state’s regulations and allowing customization based on plan specific initiatives.

Solution

Expanding on an existing relationship with PDHI for its NCQA-certified health assessment and self-management tools, the plan was able to easily implement PDHI’s incentive management capabilities to support its program.

Marketplace members access the reward program through single sign-on from their member portal. The incentivized activities are customized to align with plan goals to promote member engagement, close gaps in care, improve HEDIS scores, and comply with state regulations. Incentive earning activities are further personalized for each member based on data delivered from claims. Qualifying reward activities include attending an annual physical and completing a health assessment. Depending on the state, the program also incentivizes HEDIS-related measures, including colorectal screenings, quarterly HbA1c tests for members with diabetes, and quarterly blood pressure checks for members with hypertension.

Members can easily redeem points for select gift cards, streamlining the redemption process.

PDHI’s platform flexibility allows the plan to comply with state-specific reward limitations, including:

• Reward type and value specified for each state and line of business.
• Cards not redeemable for cash.

Real-time reports are used by program administrators to analyze results, target program communication, identify members for earlier interventions with care management, and provide feedback to State regulators and HEDIS adjudicators.

Results

Marketplace incentive program engagement rates doubled in the second year, demonstrating the effectiveness of the PDHI platform in engaging members.

Partnering with PDHI reduced the monthly cost per member, improving the cost effectiveness of the program.

After a successful initial pilot in California, the program incentive was doubled and expanded to 15 additional states while meeting individual state regulations.

• Increased engagement with a seamless member experience
• Met state regulations for Rewards & Incentives programs
• Cut administrative costs by improving program efficiency
• Improved outcomes for HEDIS measures