Success Story
How a U.S. Health Plan Accelerated ACA & Medicaid Growth Usings Facet
The Challenge: Using Technology to Scale and Serve More Members
Health plans looking to grow typically have three paths: increase membership, expand into new regions, and participate in government programs like Medicaid and Medicare. Achieving any of these goals requires strong technological infrastructure—particularly around benefit configuration, claims processing, and data management—all of which must be certified for use in new markets.
However, technology alone isn’t enough. You also need experts who can navigate complex systems and pivot quickly across operational functions. It’s rare to find individuals, let alone a full team, who can adapt rapidly and build out new product lines with precision.
That’s where Paradigm IT came in.
The client approached us during their migration from a legacy claims system to TriZetto’s Facets platform, seeking support for a previously delayed ACA (Affordable Care Act) expansion. Their goal was to enter multiple new states with newly designed product lines—and launch Medicaid coverage in a completely new region from the ground up.
At the time, their internal team lacked Facets experience. There were no structured testing or documentation protocols, and their project tracking system was misconfigured—leaving executive leadership without clear insight into project progress.
The Solution: Leveraging Facets to Launch New ACA & Medicaid Lines
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Requirements → Design → Build → Test → Deploy
Paradigm IT’s Role: Strategic Partner, Mentor & Engineering Lead
We acted as an integrated extension of the client’s team—owning the Facets implementation roadmap and guiding the process from start to finish.
For the Medicaid rollout, we tackled a major challenge: analyzing and grouping 160 age-based fee schedules (which Facets does not support natively). These had to be logically matched with taxonomy codes and converted into 500 distinct qualifier groups that Facets could use to generate accurate claim agreements.
For the ACA expansion, Paradigm IT provided hands-on mentorship across all levels of the organization—from front-line call center reps to senior executives. Since documentation was either missing or outdated, we also introduced a structured documentation process and set up detailed storyboards to support testing and future enhancements.
The Outcome: Seamless Expansion and Market Success
The client was able to launch new product lines and expand into additional states faster than originally projected. As a result, they evolved from a third-party administrator (TPA) into a fully certified Qualified Health Plan (QHP) on the health insurance exchange.
With deep Facets expertise and a commitment to delivering turnkey solutions, Paradigm IT helped this client achieve fast, scalable growth—positioning them for long-term success in both ACA and Medicaid markets.