Cognosante Marketplace and Eligibility

Meeting Your Challenges

Budgets and staffs are shrinking — but needs are not. Cognosante helps you cost effectively meet marketplace and eligibility challenges while optimizing business processes for all health insurance programs. We combine a broad national perspective with industry-leading business process, technical and systems design expertise to plan, implement, and support your unique Marketplace vision for your state.

From replacing legacy eligibility and enrollment systems to improving business processes and optimizing business rules, our transformational Integrated Eligibility and Enrollment (IE&E) solution provides a superhighway for eligibility determination, enrollment, and renewal to meet today's growing enrollment rolls while ensuring compliance with ACA, the Seven Conditions and Standards, and other mandates.

Cognosante's solution consists of carefully selected and proven commercial off-the-shelf (COTS) products. For most eligibility projects, our solution provides at least 80% functionality out of the box. We believe a COTS eligibility solution provides a quicker implementation time, better value, lower cost of investment, and flexibility to adapt to program changes with low implementation risk. Moreover, Cognosante's eligibility solution is designed with future operations, maintenance costs, and risks in mind.

Our Solutions and Services

We provide services across the five domains that are critical to successful Health Insurance Marketplace initiatives, including eligibility and enrollment, plan management, Small Business Health Insurance Options Program, financial management, consumer assistance, and reporting. Our services include:

  • Marketplace Implementation, Interoperability, and Systems Integration 
  • Assessment and Planning
  • Consumer Assistance Ongoing Operations
  • Assistance to States with FFM Off-Ramp – SBM Planning and Integration
  • System/Business Requirements and Gap Analysis 
  • Business Process and Business Rules Analysis and Modeling
  • Eligibility Engine Business Rules
  • Functional Architecture/Technical Architecture and Design
  • Shared Business Services
  • Federal Compliance – Gate Review Process and Artifacts
  • Technical Architecture – CMS Seven Conditions and Standards and MITA

The Cognosante Difference

Cognosante’s deep understanding of and experience in the following allows us to offer unmatched expertise for Marketplace and/or eligibility solutions:

  • Federally Facilitated Marketplace: Our work with CMS on the FFM allows us to offer our Marketplace customers lessons learned, future-proofing, off-ramping, and integration with related capabilities such as eligibility and enrollment.
  • Medicaid and Integrated Eligibility Systems: With over 25 years of experience working with Medicaid and integrated eligibility systems, we have a successful record of implementations and unmatched knowledge of state and federal eligibility rules.
  • Compliance Confidence: With extensive experience performing MITA state self-assessments, meeting CMS Seven Conditions and Standards, achieving qualification for Enhanced Federal Funding guidelines, and other mandates, we deliver compliance and peace of mind.
  • Total Interoperability: Our interfaces use HIPAA, the Health IT Policy Committee, the National Information Exchange Model, CAQH, and NIST standards to ensure complete interoperability.
  • A Future-Ready Enrollment Solution: We deliver a seamless, one-stop-shop solution for eligibility determination, enrollment, and renewal that can easily be extended to your Health Information Exchange or Electronic Health Record system.

Cognosante Health Data Standards

Cognosante is the industry leader in navigating health data standards for improved interoperability.

Cognosante Health Information Exchange (HIE)

Cognosante delivers unsurpassed knowledge and expertise to build your HIE, link to the Federal Exchange, and plan for/meet Meaningful Use Stage 2+ criteria.

Cognosante Fraud Waste and Abuse

Cognosante delivers industry-leading solutions targeting fraud, waste, and abuse. Backed by 25 years of health IT experience linking all levels of government, Cognosante’s knowledge and expertise is unsurpassed in ensuring the integrity of Medicaid and other health and social services programs.