Customer Support Center Services

The vendor is required to provide customer support center services through multiple communication channels and integrate advanced technology to improve efficiency, reduce response times, and enhance customer experience.
- The ability to meet the needs of the exchange and demonstrate a culture of flexibility, innovation, and adaptability in order to develop and administer customer support center solutions and strategies that align with broader, evolving health insurance and programs.
- Perform core functions as described below for customer support across all communication channels:
1. General inquires
•    For apple health: handle basic inquiries related to state apple health programs, including tax filing status, income limits, and eligibility criteria. 
•    Staff will address navigational and data entry questions supporting customers to navigate the application and selection process. for complex eligibility questions, refer customers to the appropriate state agencies. 
•    Department will manage medicaid post-eligibility review questions and case management. 
•    For qualified health plan (QHP) and qualified dental plan (QDP): assist QHP and 
•    QDP customers with various aspects of the enrollment process, including plan shopping, plan selection, and navigating the payment process to complete enrollment through smart plan finder, a tool on HPF that helps customers find the best health coverage by recommending plans based on their household’s care needs and preferences. 
•    Smart plan finder provides information regarding if doctors are in network, if prescription drugs are covered and total yearly costs.
•    Process general inquiries related to the advance premium tax credit (APTC) and unsubsidized health insurance populations. 
•    This includes providing detailed information on eligibility, application procedures, and enrollment options.
2. Application processing
•    Eligibility determination: CSRs will submit eligibility determination through the exchange’s approved process.
•    Application results notifications: communicate status of application results to customer.
•    Quality assurance: ensure the accuracy and completeness of data entered into the system. regularly review and verify information to maintain high standards of data integrity.
•    Customer support: provide assistance to customers throughout the application process, addressing any questions or concerns they may have. offer guidance on completing applications and understanding eligibility criteria.
•    Outbound customer contact: the vendor may be required to initiate outbound contact with customers in order to: clarify or obtain missing or incomplete application information; provide updates or follow-up regarding application status or required documentation; assist with understanding eligibility results or next steps in the enrollment process.
•    Outbound contact shall be conducted using approved communication channels.
3. Staffing
•    Organizational chart: provide and maintain an organizational chart and narrative description of the team structure, detailing roles, responsibilities, and lines of communication. 
•    This chart will be available upon exchange request.
•    Key staff: the exchange prefers, but does not require, key staff to be state residents. 
•    Key staff must be approved by the exchange as outlined in exhibit d – exchange contract.
•    Customer service representatives (CSRs): CSRs provide engagement with customers via voice, email, text, live chat, and back-office services. 
•    CSRs must be human and 100% dedicated to the exchange account, meaning that they do not perform services for vendor’s other clients while assigned to the exchange account unless approved by the exchange in writing, this includes CSRs during surge and peak season. 
•    The exchange prefers, but does not require, CSRs to be state residents.
•    Back-office team: responsible for processing transactions, handling documentation, and completing non-customer-facing tasks. 
•    The team must have a supervisor for day-to-day management, quality assurance, and performance reporting. 
•    Supervisors manage staffing, training, and performance within their teams and serve as the primary contact for issue resolution and reporting.
•    Escalation team: handles complex or high-priority customer issues requiring advanced resolution or managerial intervention. 
•    They assess and categorize escalated contacts to determine the appropriate action. 
•    Unresolved tickets are elevated to exchange staff for further investigation and resolution.
4. Self-service support
•    Provide self-service support, commonly referred to as level 0, in an automated capability that enables customers to independently access information and resolve issues without the need for direct interaction with a customer service representative (CSR). 
•    This support model is designed to empower customers, reduce call volume, and improve overall efficiency and customer satisfaction
5. Account management
•    Assist customers with resolving technical errors (e.g., password resets, answering security questions, email changes, etc.) using mutually agreed-to exchange processes.
6. Web-based chat
•    Provide live chat functionality that is fully compatible and integrated with HPF.
7. Language interpretation and translation
•    Provide comprehensive language access services in accordance with the language access plan, to ensure effective communication with limited english proficient (LEP) customers. 
•    Language services must be culturally competent, respectful, and privacy-compliant support. 
•    Vendor will collaborate with the exchange to monitor effectiveness and address service gaps. 
•    Provide the following interpretation and translation services:
•    Bilingual staff: vendor must employ qualified staff fluent in english and Spanish to assist LEP customers without interpretation.
•    Interpreter services: for languages not supported by bilingual staff, vendor must provide professional interpretation services, including telephonic and video remote interpreting.
•    AI tools: the exchange may approve a vendor’s use of AI-based translation tools to be used to support internal understanding or assist in low-risk, non-customer-facing scenarios. 
•    Such tools shall not replace human interpreters or bilingual staff in direct customer interactions unless explicitly approved by the exchange and demonstrated to meet accuracy and privacy standards.
8. Complaint processing
•    Document all interactions across communication channels in the customer relationship management (CRM) system, including customer complaints. 
•    complaints are managed using the exchange’s designated ticketing system and escalation support teams. 
•    complaints that cannot be resolved at the csc level are escalated to the exchange for resolution.
9. Imaged documents uploads
•    Access, process, and upload imaged documents to customer dashboards in HPF. 
10. Customer surveys
•    Conduct customer surveys across all communication channels to capture satisfaction levels with customer interaction experience. 
•    Vendor will analyze survey responses, identify trends, and apply insights to drive continuous improvement and share the results with the exchange. 
•    Prior to implementing the surveys, vendor and the exchange shall collaborate on the content, frequency, and format to ensure alignment with strategic goals and customer engagement standards.
- Core functions of customer support center tools
1. Customer relationship management (CRM) solution
•    Provide an integrated, best-in-class customer relationship management (CRM) solution, capable of adding new technical solutions to maintain a modern, customer-centric approach that maximizes savings. 
•    Regular backups and recovery processes must be specified to prevent data loss.
•    Provide, as a component of the csc, workforce management software (WFM) for the CSRs and csc staff. 
•    The WFM software must include detailed features and functionalities such as scheduling, timekeeping, and real-time monitoring. 
•    Integration capabilities with all relevant systems, such as CRM, helpdesk, and other customer service tools, must be included. 
•    Security protocols, including encryption and secure access controls, must be implemented to protect sensitive information. 
•    The WFM shall allow for exchange to access the real-time monitoring, as well as customer service representative (CSR) performance tracking, and full integration with the csc CRM. 
•    The WFM shall be deployed and work with all the communication methodologies deployed or that will be deployed for the csc.
2. Customer communication channels
•    Provide, at minimum, telephony and IVR, live chat, email, secure email, SMS texting, fax, and asl channels. 
3. Generative artificial intelligence (AI)
•    The exchange requires that the vendor's solution does not rely solely on generative AI or include a public-facing AI component that cannot be enabled or disabled through configuration changes or equivalent methods. 
•    The exchange requires all AI capabilities disabled by default and that the solution will continue to meet all the requirements and obligations resulting contract. 
•    Mechanisms to disable AI functions should be straightforward and not require extensive system modification or redeployment.
4. Reporting and analytics
•    The solution shall support comprehensive reporting capabilities, including real-time, ad-hoc, and standard scheduled reports.
5. Data interfaces
•    Support the exchange’s API for csc services, known as express lane. 
•    This serves as a crucial interface between the exchange and the vendor's systems and facilitates key functions.

- Contract Period/Term: 5 years
- Vendor Conference Date: August 27, 2025 to October 6, 2025
- Questions/Inquires Deadline: September 12, 2025