RFR Exhibit A - Current State of Operations~2.docx

RFR EXHIBIT A – CURRENT STATE OF OPERATIONS

Current State of Operations

This information is provided to outline the current state of the Health Connector.

For additional context, please see RFR Exhibit G – Calendar of Business Events and RFR Exhibit I – Current Process Flows For current volumes, please see RFR Exhibit B – Reference Materials.

Scope

The primary scope of the Current Vendor is to review communication materials delivered to both non-Members and current Members. All materials are vetted through a structured process that includes translation, plain language, literacy, accessibility, and design. This work supports the contact center, back office, Escalations, and Document Processing and Verification teams by ensuring clear and consistent communication.

Overview

The Health Connector’s mission is to provide Massachusetts residents with access to quality and affordable health insurance, dental insurance, and information that allows residents to make informed decisions about their health and dental insurance. To accomplish this mission and fulfill key requirements of the ACA, the Health Connector has developed an online application and shopping experience for Members and new Applicants. Through MAhealthconnector.org, individuals and families can apply and shop for health and dental insurance plans and may receive financial assistance in connection with their purchase and/or use of such plans. The coverage available through the online application includes MassHealth (Massachusetts’ Medicaid and CHIP), Health Connector subsidized/unsubsidized health and dental plans for purchase from multiple Carriers. In addition to Advanced Premium Tax Credits (“APTC”), Massachusetts residents enrolled in the ConnectorCare program receive state premium and cost-sharing reduction subsidies to maintain Member premium and copay contributions at pre-ACA levels. As of March 2026, the Health Connector enrolls 343,102 Members in its health plans, of which 141,236 Members are also enrolled in a dental plan. More information and details about Health Connector membership can be obtained from the Health Connector Summary Report available at https://www.mahealthconnector.org/about/data-and-reporting/health-connector-monthly-enrollment-dashboard.

The Health Connector currently works with three (3) vendors and EOHHS to provide services to our Applicants and Members.

(1) Eligibility and enrollment system development, operation, and maintenance is provided by OptumInsight, Inc. (“Optum”), a health services and IT business, which operates the Commonwealth’s Health Insurance Exchange/Integrated Eligibility System or “HIX/IES”).

(2) Enrollment, premium billing, and payment processing functionality is provided by Softheon, Inc. (“Softheon”). Softheon is also responsible for the production and fulfillment of all enrollment and billing notices and eligibility-related notices originating from the HIX/IES. Softheon is integrated with the contact center vendor and provides all Carrier outbound and inbound EDI files exchange services and associated technology.

(3) Customer service and back office services are provided by Automated Health Systems (AHS). Customer service includes an inbound call center, escalations team, document processing, and associated technology. Back office services include case creation for completion of Member interactions with the HIX/IES, Softheon, carriers, billing, payment processing cases, and enrollment issues.

Ombuds and Appeals cases are handled by Health Connector staff directly, but there is significant reliance on AHS staff to support these areas.

Eligibility Determination and Plan Shopping

The Health Connector, in conjunction with MassHealth, has implemented an integrated eligibility and enrollment system (the HIX/IES) to facilitate online application and plan shopping. This system is based on an OptumInsight, Inc. (“Optum”) exchange product that was configured and customized for Massachusetts to handle state-specific integrated eligibility and rules. Ongoing maintenance and operations for the eligibility and enrollment system are currently supported by Optum, which also maintains an identity management system. The identity management system controls Applicants’ access to self-service their application, eligibility, and enrollment. Applicants needing assistance with accessing their account are required to obtain help from the contact center vendor for resolution beyond that available via self-service.

The eligibility and enrollment system enables Customers to self-serve and go online to obtain a determination of their eligibility for health insurance coverage and any associated subsidies, and to shop for health and dental plans by reviewing their features and premium costs. If the Customer wishes to enroll in a health and dental plan, the online system assists with this process. Customers who wish to either initiate enrollment or complete an online enrollment with assistance may opt to do so by contacting AHS, via call, or seeking assistance from Assisters available throughout the state for this purpose. In order to provide Customers with the most relevant information to enable them to make the best decision when selecting the health or dental plan, the HIX/IES is integrated with third-party software to enable provider and formulary search tools as part of the shopping experience.

During the application process, the Customer’s eligibility information in the eligibility system is presented in real time to the Federal Data Services Hub (FDSH) for identity and eligibility verification. Once the application is submitted, the HIX/IES determines eligibility and initiates any necessary documentation verification requests. This allows Customers to receive an immediate eligibility determination, or details on any required documentation for eligibility verification finalization, if applicable. Once their eligibility is determined, the HIX/IES triggers an eligibility notice and any associated requests for verification documents and enables the Customer to select a health and/or dental plan.

If an Applicant is asked to send in information to prove their eligibility, they have 90 days to submit it. While the eligibility verifications are pending, Applicants are able to enroll in a health and/or dental plan via the HIX/IES system. If Applicants fail to send in requested documentation their eligibility, subsequently, their enrollment may change when their determination is re-run by the system.

Enrollment

Softheon provides a financial management system which is used to maintain enrollment records and execute premium billing for new and active enrollees. After shopping is completed in the HIX/IES, the HIX/IES generates and sends a file every 30 minutes to Softheon for effectuating the Enrollment. Upon receipt, Softheon’s financial management system performs a validation of data integrity in the file, correct data is loaded to the financial management system, and erroneous records are sent back to the HIX/IES for corrections. The financial management system maintains enrollment records that are used for Carrier effectuation, Member billing, and associated reporting.

Enrollment in a health or dental plan is not complete until the enrollee has made an initial (binder) payment for the first month of coverage. Softheon is responsible for billing new and active enrollees, collecting their premium payments, and for file exchange with Massachusetts health and dental plan carriers for effectuation, as well as with the HIX/IES eligibility and enrollment system with the purpose of updating the user interface. Once the enrollee has made a payment, coverage is effectuated, effectuation files are sent to the Carriers and to the HIX/IES, and Carriers then generate Member ID cards. The HIX/IES user interface is updated to reflect that enrollment has been effectuated.

A Customer may cancel their enrollment with the Health Connector at any time. Enrollment cancellations must take place by the end of the current month to be effective for the upcoming month. Exceptions for retroactive activities are available per established rules.

With the exception of enrollment terminations due to non-payment, all enrollment adds, changes, and terminations are initiated from the HIX/IES as a result of a Customer updating their application, a contact center or Assister updating the Customer application on their behalf, or a system batch process.

Premium Billing

The Health Connector performs eligibility determinations for federal and state subsidies, enrolls Customers into health and dental coverage, bills them for monthly premiums, collects payments, and transfers those payments to insurance Carriers.

Initial bills for binder payments are generated the next day after Softheon receives the initial enrollment from the HIX/IES, and they are mailed within three (3) business days from generation.

The Health Connector’s current Members are billed as of their enrollment date for coverage for the following month. Recurring bills are sent to Members within the first ten (10) days of the month for the upcoming month’s enrollment. Bills are sent to enrolled Members, defined as those who have paid their first binder payment and have effectuated coverage.

If a Member’s premium amount changes at any time during the month, an updated bill is generated the next day and mailed to the Member within three (3) business days. This is applicable to both initial and ongoing bills. The reasons for a premium change may include a change in family size or composition, or a reported income change.

All binder and ongoing premium payments are due by the 23rd of each month in order to effectuate a new enrollment and/or to maintain ongoing enrollment in good standing.

Members can make initial and ongoing premium payments online through the Health Connector’s Member portal or guest portal, through the IVR, by mailing in their payments to a designated lockbox, or by making online payments through their bank. Softheon is responsible for the ongoing management of the Health Connector’s Member portal/guest portal and lockbox.

Softheon is responsible for the collection and posting of all Member payments to the financial management system. The Health Connector contracts with Bank of America to provide lockbox services for Members who pay their premiums by check or money order and for Health Connector members who make online premium payments through their bank. Softheon is responsible for posting all premium payments, non-sufficient funds (NSF), and adjustments recorded by the bank to Member accounts in the financial management system.

Premium Billing – Delinquency:

Softheon handles delinquency processing for Members who have not made a payment. Delinquency processing is managed in accordance with strict Member notification standards prescribed by federal rules and regulations and by Health Connector policies. All policies are available on the Health Connector website https://www.mahealthconnector.org/about/policy-center/policies.

Premium Payment Methods:

The Health Connector currently accepts premium payments online by Electronic Funds Transfer (EFT) using a checking or savings account, payments initiated through the Member’s bank or other financial institution, and paper check and money order payments sent by mail to the Health Connector’s lockbox.

Members may elect to set up AutoPay through the Member Portal and can choose to have payments deducted on the 15th and/or the 23rd of each month.

Contact Center and Back Office Support

The Health Connector contracts with AHS to provide contact center and associated back office functions and document processing and verification to its Members. The contact center is open Monday through Friday 8am to 6pm with select Saturdays during Open Enrollment.

Services Provided by AHS:

a) inbound call handling/Customer support

b) text messaging (transactional, reoccurring and ad-hoc campaigns)

c) outbound call handling/Customer outreach

d) robo calls (recurring and ad-hoc campaigns)

e) IVR self-service

f) service recovery

g) incident management

h) case management Inventory (issues requiring manual intervention and/or collaboration with the Health Connector or third parties)

i) customer escalations (directly from Customers or from the Health Connector or third parties)

j) customer satisfaction survey process

k) Member enrollment issue resolution

l) Member premium payment reconciliation and issue resolution

m) Carrier interface, communication and Member premium remediation

n) document processing and verification

o) reporting and analysis

Back office functions provided by AHS include, among others listed above, data entry, including, but not limited to input, processing, and updates to paper applications, call backs related to paper applications, verification of forms and documents, and other data entry or verification work. Other back office functions performed by AHS include but are not limited to trouble-shooting customer accounts, application, eligibility and enrollment issues, retroactive enrollment requests, Member escalations, premium billing related activities, and enrollment reconciliation with Carriers.

Escalations Team (Internal Escalations):

The Escalations Team is the tier-two team of agents within the contact center with a goal of improving the Member experience by creating a team of subject matter experts (“SMEs”) to proactively prevent Member escalations and work to resolve the escalations of Member complaints and complicated cases. Escalations agents are required to be trained on all front office and back office procedures in order to provide end to end resolution of Member escalations received internally, from the front office or back office teams, or from the Health Connector.

Assister Community and Assister Line

The Assister Community consists of community-based organizations known as Navigators (Navs) and Certified Application Counselors (CACs) who support Massachusetts residents with their health care eligibility and enrollment needs. The contact center staffs a dedicated Assister line to support the Navigators and Certified Application Counselors who call on behalf of the Members they are assisting.

Document Processing and Verifications

In the process of determining or re-determining eligibility for Enrollment in a health or dental plan, the Health Connector may request that Applicants provide proof of certain information they have provided in their application, when the information on the application is not reasonably compatible with data from electronic sources. This may occur for eligibility criteria such as Massachusetts residency, citizenship and immigration status, and income as well as when Applicants attest to having a Qualifying Life Event (QLE), such as marriage or birth of a child that will allow them to receive a Special Enrollment Period (SEP) to shop for a plan during Closed Enrollment. Additionally, Applicants may fill out a paper application for insurance or send in some documentation requesting changes/updates/actions to be taken on their account.

In all of these cases, Applicants may upload documents to their online account or fax/mail their documents to the document processing center. The Health Connector shares document processing and verification systems and processes with EOHHS.

Contact center staff review documents received from Members and Applicants, determine if these documents meet the necessary threshold of proof, and create or update eligibility information in the HIX/IES eligibility and enrollment system.

Notices and Outbound Mail Fulfillment

Softheon is responsible for providing noticing capabilities. This includes maintaining notice templates for eligibility, enrollment, and billing notices and generating notice PDF files for transmission to the mail house for mailing to Members and Applicants and for making notice PDFs available in the Member portal. Softheon generates eligibility and other program determination related notices by receiving files from the HIX/IES containing data elements necessary for notice generation. The notice functionality is within the Softheon system, which provides triggers for automated generation of enrollment and billing notices. These include enrollment bills for binder payments, monthly bills for ongoing payments, delinquency notices and notices of termination for non-payment. The Health Connector adheres to strict standards for notice formats and mailing timelines prescribed by federal rules and regulations. Notices are available in English, Spanish, Brazilian Portuguese, English large print, Spanish large print, and braille.

The notices are available to view in the Softheon Member portal which, in addition to collecting payments, gives users the ability to view notices online, and sign up for paperless notices delivery. Additional notices and forms are requested via contact center operations/transactions and these requests are sent to Softheon for fulfillment of the documentation to the Member via mail. Softheon subcontracts to a mail house vendor that performs printing, folding, inserting, and mailing services. Softheon’s mail vendor utilizes the National Change of Address (NCOA) database services provided by the U.S. Postal Service to verify Member mailing addresses and mail notices to the most recent address available.

The Health Connector generates approximately 11.3 million notices annually. This includes Enrollment communications, billing statements, contact center notices and forms, and eligibility notices that are sent to Health Connector Members and Applicants. The Health Connector offers Members an ability to opt out of paper notices – Members can select paperless delivery in the Member portal and receive an email notification when a new notice is available to be viewed in the Member portal. Approximately 12% of notices are delivered paperless with the remainder being mailed. The volume of notices is driven by market-wide and Exchange-specific business events, such as Open Enrollment periods and tax filing deadlines; the volume is spread fairly evenly throughout the year with highs prior to and during the annual Open Enrollment period.

Handling of Inbound Mail

Members may be asked to provide the Health Connector with information needed to process their application and finalize their eligibility determination. This may include proof of identity, proof of income, proof of citizenship or immigration status, proof of Massachusetts residency, or a qualifying life event, etc. While the HIX/IES eligibility system allows Members to upload documents online, some Members choose to mail or fax their documents. All inbound documents are mailed to the EDMC staffed and operated by MassHealth that provides intake services on behalf of the Health Connector. Here, mail is prepped, scanned, imaged and indexed, and as a result the mail piece is attached to the Member and placed document into an appropriate work queue. Documents are viewed and processed by AHS Staff in the HIX/IES to finalized eligibility and processing for the Applicant.

Ombuds

Health Connector staff receive and resolve approximately 620+ Ombuds cases (escalations) per year. Ombuds cases are received from Members directly and via external channels, and are most often complex eligibility, enrollment and billing concerns. While Health Connector staff are ultimately responsible for the resolution of these Ombuds cases, they do require and rely on timely assistance of the three vendors on a day-to-day basis.

Appeals

Health Connector staff receive 2,300 Appeals per year on average. Appeals are received from Members and processed directly by Health Connector Appeals staff.