IT and Implementation Committee
Strategic IT Decisions
December 21, 2011
1
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On-going Activities
•
SHOP Business Development and Operations
•
Option for Ownership of Call Center/Customer Support
Assets
•
Plan Shopping and Enrollment Interoperability
•
Additional Information from RFI Process
•
Evaluation Committee
•
Next Steps
2
3
•
Additional IT Resources
•
Eventus – call center/customer support and legal support
•
Provided Patty with options for increasing COHBE capacity
•
Progress on RFP
•
Working on first draft; expect to complete by 12/28 and begin first
review cycle
•
Additional dimensions of scope
•
Eventus providing input into RFP (customer support and legal)
•
Continue Interacting with the Vendor Community; this week:
•
Infosys
•
CGI
•
eHealth
•
Continue Working with HCPF
•
Use cases for interoperability eligibility processes
•
Defining interfaces and other interoperability requirements
4
5
•
Three risks associated with the SHOP:
•
Market risk
•
Performance risk
•
Schedule risk
6
Market Risk:
•
Existing, competitive well-established market interests
•
New competitors emerging now, before exchanges are formed
•
Market inertia: protect current business (insurers, brokers, TPA’s)
•
Adverse selection: trend toward self-insurance (among small firms)
7
Performance Risk:
•
Skepticism of state running an exchange
•
Challenges of trying to compete in a public governance model
•
Very small incentive to participate (tax credits) for a short time (2 years)
•
No active purchaser model
•
The only successful SHOP exchange models have been privately
owned
•
Employee choice and defined contribution operations are complex:
premium payments, admin, customer service, marketing, Section 125
admin, etc.
•
Voluntary insurer participation
8
Schedule Risk:
•
IT procurement is within reach for SHOP within our timeframes
•
However, there is insufficient time to develop a team that can execute
operations
9
Options:
a) Adjust expectations for SHOP
b) Find a partner to develop and operate it; pay for
performance
Would the state require SHOP participation in order to participate
in individual exchange? (insurer participation issue)
•
Impact on RFP…
• Unbundle SHOP (application, hosting and services, i.e.
development and operations) to provide flexibility for
COHBE to select “best of breed” vendor to develop and
operate the SHOP
• Mitigate identified risks (market, performance, schedule)
10
Proposed table for RFP showing bundling/unbundling
of solution components
Solution Set
Individual Exchange
Individual Exchange
Development and Services
SHOP Exchange
SHOP Exchange Development
and Services
Individual Solution Component
1.A Individual Exchange
Application, Maintenance and
Support
1.B Individual Exchange
Application Hosting and Support
1.C Individual Exchange
Services, Training & Outreach
2.A
SHOP Exchange
Application, Maintenance and
Support
2.B SHOP Exchange Application
Hosting and Support
2.C SHOP Exchange
Development, Administrative
Services, Training and Outreach
Required Bundling
1.A, 1.B and 1.C must be bid
together
2.A and 2.B must be bid
together
If a bidder responds to 2A./2. B
then the bidder must also
respond to 2.C
2.C may be bid independent of
all other solution components
11
12
•
Eventus (Craig Tobin) recommends that COHBE
consider acquiring/retaining ownership of call center
assets such as:
•
•
•
•
•
IVR
Help desk software
Knowledge base
Training tools
Pros/cons
+ Strategic assets
+ COHBE will have more leverage in negotiating extensions since switching costs will be less
+ Use federal funds to acquire assets to improve sustainability
- Knowledge base and training content is IP that will be “owned” by COHBE
- Unsure how much this will actually decrease operating costs
- Unsure how vendors will react, i.e. most likely have processes, SOPs, training materials,
etc., used in their current call center/customer support
- Call center technology changing rapid; why own rapidly depreciating assets
- Ownership of assets may limit enhancements
- Vendors less able to improve efficiencies
13
14
Minimum level of
interoperability as
discussed at last meeting
•
•
•
•
•
•
•
•
CBMS/PEAK &
Medicaid/CHIP
Eligibility &
Enrollment
Business
Processes
Interoperability
Between COHBE
& State Medicaid/
CHIP Systems
and Business
Processes
COHBE
Eligibility &
Enrollment
Systems
and Business
Processes
Single/shared MAGI eligibility process for Private Insurance and
Medicaid/CHIP
Single sign-on
Comprehensive MPI (Exchange and Medicaid/CHIP population)
Data only entered once
Request only information needed for determining eligibility for
healthcare
Maximize “no touch” eligibility adjudications
Interface from PEAK to MAGI process to support “no wrong door”
requirement for medical eligibility
Provide links to non-medical eligibility processes and pre-populate with
data previously collected during medical eligibility processes
15
•
Plan shopping and enrollment interoperability is the ability for
consumers to shop in the Exchange for and enroll in plans for which
they are eligible
•
Carriers offering plans that bridge private and public healthcare
coverage to enable household to be covered by one carrier/similar
provider network, etc.
•
Prevalence of “mixed” household populations being researched, e.g.
1.
2.
Single parent eligible for subsidized private coverage and children eligible for
CHIP.
One parent receives subsidized coverage from SHOP employer, spouse eligible
for subsidized private coverage and children eligible for CHIP
16
Minimal Interoperability
Pre-screening
Small Business
Owners
& Employees
SHOP
Exchange
Account Mgmt
& MPI
Eligibility
Determination
Set-up Employee
Roster
Create Account
Eligible for
Employer Plan &
Amount of
Coverage
Plan Selection &
Enrollment
Review Out-ofPocket Costs
Select Plan & Enter
Enrollment
Information
Interface
Enrollment
Information to
Carriers’ Systems
Eligibility Interoperability
Individual
Households &
Small Business
Employees
Individual
Exchange
Boundary between COHBE and
State Systems
Should PreScreening Step be
Included?
MAGI
Create Account
(including interfacing
w/ federal data hub)
Household
Member(s) Eligible for
Medical or HS Programs
Review Subsidy/Outof-Pocket Costs
Select Plan & Enter
Enrollment
Information
Shopping and Enrollment
Interoperability
Boundary between COHBE and
State Systems
Individual
Households
(seeking public
assistance,
i.e. Medical, Food
PEAK
Enrollment in
Carrier Systems
CBMS
MMIS
Interface
Enrollment
Information to
MCO Systems
or Cash Assistance)
17
Coverage of the
Spelmer household
requires three
different plans
In the example on the
right all members of
the household enroll
via the Exchange
Spelmer’s only see
plans for which they
are eligible to see,
i.e. only Medicaid
“eligibles” see
Medicaid
plans/MCOs
18
19
•
Four types of calls anticipated:
1.
2.
3.
4.
•
Exchange call center – eligibility, site, information, assistance, billing, etc.
State Medicaid call center (MAXIMUS) – eligibility, claims, etc.
Carrier call center – policy questions, claims, etc.
Division of Insurance – complaints
Should #1 and #2 be combined? (shared /consistent support processes, infrastructure,
capacity management flexibility, consumer experience, need for specialization or
separation)
20
Analysis of Interoperability Alternatives – feasibility of alternatives versus critieria
Alternative
Cost
Description/ Implementatio
5-Year
Approach
n Costs
Operational
(federal &
Costs (federal
SGF)
& SGF)
Consumer
Experience
Impact of
Change on
Workforce
Reliability/
Maintainability/
Scalability
State of System
after
Investment
(MITA/Tech
Arch/Platform)
Impact on
COHBE
Operations
and Systems
State’s
Strategic
Direction and
Latitude
Stakeholder
Acceptance
Minimum 2013
Interoperability
Moderate 2013
Interoperability
Maximum 2013
Interoperability
2015
Interoperability
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Consumer Experience
- Make enrolling in coverage for the individual/household as fast and as simple as possible
- Balance administrative simplicity, efficiency and effectiveness
- Enable continuity of care
- Provide user-friendly access to all eligible CO citizens and small CO businesses that desire access
- Leverage and integrate with State systems and business processes as appropriate
Reliability/Simplicity in Getting Consumer Enrolled
- Make enrolling in coverage for the individual/household as fast and as simple as possible
- Leverage and integrate with the State system(s) and business processes
Reliability/Backend Complexity of Having All Solution Components Fully Functioning
- Leverage and integrate with the other systems w/o reducing reliability
Privacy and Security
- Leverage and integrate security, i.e. account management and MPI
- Minimize proliferation and transmission of PII
Cost
- Minimize costs to the COHBE, consumers, employers and carriers
Risk to COHBE Project Deadlines
- Minimize Risks of: 1) not meeting federal milestones, 2) delivering baseline scope and 3) completing the project within the
baseline budget
Strategic Direction and Latitude
- Maximize flexibility to change its direction; enable the state to go in a different direction in the future without COHBE or State
incurring a large potential cost impact or disruption to end users; this could include a different Exchange solution provider (recompete) or a different Exchange solution direction such as building or buying the HIX software and integrating with State system
in future
Stakeholder Acceptability
- Recognize limitations of interoperability given political realities, funding constraints, etc.
22
23
Company
Respondents
End-to-End
Solution
Exchanges
Operating
Model
Current
Clients
Partners
MAGI
Rules
engine
Benefitfocus
Yes
Individual &
SHOP
SaaS only
FL, NJ, CT, VA
Insurance companies,
employers, education
systems
Choice Admin
Benefitfocus
Implements
with an
independent
rules engine
custom –
proprietary
Connecture/
MAXIMUS
Yes
Individual &
SHOP
license &
SaaS
CA, TX, CO, IA, NY
MAXIMUS (prime)
designing for
MN
prototype
open
source
Getinsured.com
Yes
Individual &
SHOP
license &
SaaS
MS
Accenture
No
Drools Flow
(jBPM5)
CGI
Yes
Individual &
SHOP
license &
Saas
Federal Exchange, New
England states, UT,
CMS, CCIIO;
hCentive, Exeter,
Policy Studies
(PSI)
Yes
COTS –
HIE360
CO – Anthem BCBS
MD – CareFirst BCBS
CO broker – Jim Sugden
MD – Dell, Oracle,
Cognascante
No
SHOP
SaaS
pmpm
No
No
Ceridian
No
TPA,
premium
aggregation
pmpm
130,000+ using payroll &
benefit mgmt services
Solution works
with a number of
structures
No
custom
eHealth
No
Individual
Deloitte (MN, WA)
Support–Ceridian
No
No
ACS/Choice/
Vendors w/ partial solution
BenefitMall
SaaS only
Mass HealthConnector
Florida w/Ceridian
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25
Proposed Committee members:
1.
2.
3.
4.
5.
6.
7.
8.
Patty Fontneau
Shawn Raintree
Myong Kim
Nathan Wilkes
TBD
TBD
TBD
TBD
COHBE - ED
COHBE - Staff
COHBE - Staff
COHBE - Board
Technology Company Executive
OIT
HCPF
DOI
Support Staff:
•
•
•
•
•
Gary Schneider
Chuck Fish
Larry Redd
Craig Tobin
Kevin Appleton
COHBE – GMS
COHBE – GMS
COHBE – GMS
Eventus
Eventus
26
27
RFP
Work with Eventus:
•
Sample contract terms and conditions
•
Call center/customer support scope, SLAs, etc.
•
Pricing worksheets
Work with HCPF:
•
Interoperability (interfaces, security)
Complete Appendices
•
Appendices (business processes, requirements, volume metrics, BI)
Reflect decisions from today in RFP
Plan to complete first draft 12/28 and make available for 1st review cycle
Wrap-up vendor demos & RFI
28
29
High-Level Timeline – COHBE Policy & Business Decisions and IT
2011
11/11
2012
01/12
03/12
Policy & Business
Decisions and Activities
Policy & Business
Decisions
Impacting IT
05/12
07/12
2013
09/12
11/12
01/13
Supreme Court
Ruling on Mandate
03/13
05/13
07/13
COHBE Certification
by HHS
Evolving Policy and Business Decisions based on CCIIO/CMS/Board/Executive Director/Legislative
Oversight/etc.
Operational Activities
Start-up and Operational Decisions
Start-up Activities
IT/Systems
Pilot Phase
04/13 – 10/13
HIX - SHOP
Analysis/Confirmation of
Current Approach & Prel
RFP
Procure IT Systems &
Services for HIX
Design/Build/Test HIX Systems for SHOP
HIX SHOP
Integration Testing
HIX Deployment
Establish PMO
Pilot Phase
06/13 – 10/13
HIX - Individual
Analysis/Confirmation of
Current Approach & Prel
RFP
Procure IT Systems &
Services for HIX
Design/Build/Test HIX Systems (Eligibility/Enrollment/Plan Mgmt and Associated
Services Interface w/ Federal Data Hub, Other Data Sources, MMIS, PEAK/CBMS)
HIX
Integration Testing
HIX Deployment
Note: Accompanying timeline for required enhancements to PEAK
30
& CBMS not shown
Category
Exchange Functions,
Features and
Business Processes
Guiding Principle
Meet the minimal requirements of federal regulations; enhanced functions, features and integration will
be considered in the future. New business processes to execute Exchange business processes shall
minimize the impact to other State agencies’ business processes or systems.
Exchange Customers Customers of the Exchange are individuals and small business owners and their employees.
There will be a single Exchange. The Exchange will have two business lines: 1) the SHOP Exchange and 2)
and Business Lines
the Individual Exchange
Market Competition Encourage competition in the market whether it is inside or outside the Exchange.
Continuity of Care
Ensuring continuity of care is a personal responsibility; the Exchange will not pro-actively enroll or change
enrollments of consumers (i.e. individuals and small employers and their employees).
Integration with
Medicaid
Minimize integration with Medicaid eligibility in the near-term; consider tight integration (and possible
upgrade of State’s eligibility system) in long-term (i.e. 3-5 years); make investments based on this strategy.
Send consumers to the “right” door first but enable cross (MAGI) eligibility determination.
Federal Deadlines
Work with State Medicaid agency but do not jeopardize meeting federal and state deadlines.
Solution Acquisition
Leverage existing solutions and solution components from other states and federal partners to the
maximum extent possible.
Inter-agency
Partnerships
Work in concert with all State agencies, e.g. HCPF, DHS, OIT and Insurance Department.
Regulatory Authority Maintain the Colorado Insurance Department as the single regulator.
31
Exchange
Capability and/or
Service Category
Exchange Capability and/or Service
Strawman Priority for 2013
(depends on “who” is asked)
High
Eligibility, Plan
Shopping and
Enrollment
(System)
MAGI eligibility for individuals and households (subsidized
coverage and State Medicaid and CHIP) and enrollment
SHOP employee eligibility and enrollment
Eligibility and enrollment of SHOP employees and their household
members in private coverage or State Medicaid and CHIP
Multi-dimensional search criteria (network, provider, disease
specialty, deductable, co-pay, etc.)
Multi-lingual on-line system
Directory of available brokers and qualifications
Broker-Related
Ability for broker to access SHOP employer data
Features & Tools Ability to develop comparative quotes and to sort information to
(System)
support recommendations and decision making
Ability for broker to work remotely and one-on-one with
employer through the system
Plan
Management
Interfaces/admin tools and associated services for carriers to load
plans into COHBE
Admin tools and associated services for regulators to approve
plans in COHBE
Moderate
Low
Impact on
Implementation and
Operational Costs
Impact on
Impact on
Implementati Operation
on Cost
al Costs
X
High
High
Moderate
Moderate
High
Moderate
Moderate
High
Moderate
Moderate
Moderate
Low
Low
Low
Moderate
Moderate
Low
Low
X
Moderate
Low
X
Moderate
Moderate
X
X
X
X
X
X
X
32
Exchange
Capability and/or
Service Category
Customer Service
Financial
Management
Exchange Capability and/or Service
Strawman Priority for 2013
(depends on “who” is asked)
Impact on Implementation and
Operational Costs
Call center support for on-line eligibility and
enrollment (individual households, SHOP employees)
X
Impact on
Implementation
Cost
Moderate
Call center support for SHOP employers and brokers
X
Moderate
High
Support for carriers
Support for regulators
Call center for Navigators
Print/mail for notices
Multi-lingual call center support
Customer support for mail-in applications
Customer support for walk-in applications
X
X
X
X
X
X
X
Low
Low
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Low
High
High
High
High
High
X
High
High
X
High
Moderate
X
High
High
Moderate
High
Moderate
High
High
A/R management (including billings) for premiums
from SHOP employers and consumers; A/P
management for payment to carriers (system and
support) including electronic and paper notifications,
invoices and receipts (systems and services)
Aggregated premium billing for SHOP employers
On-line payment service for individuals and SHOP
employers & employees (ACH, credit card)
Flexible spending accounts, health reimbursement
accounts, health savings accounts (system and
support)
Managing commissions/ payments to brokers and
Navigators (system and services)
Moderate
X
X
Low
Impact on
Operational Costs
High
33
Exchange
Capability and/or
Service Category
Exchange Capability and/or Service
Strawman Priority for 2013
(depends on “who” is asked)
High
Other Exchange
Features
Data repository of all plan/carrier ratings, transactions,
enrollments, disenrollments, trend reporting, performance
indicators/metrics to support COHBE improvements and to provide
useful information to navigators, agents, brokers, carriers,
regulators, consumers
Moderate
Low
Impact on
Implementation and
Operational Costs
Impact on
Impact on
Implementat Operation
ion Cost
al Costs
X
High
High
X
Moderate
Low
X
Moderate
Low
X
Low
Low
Track all consumers/enrollees into and out of plans
Individual homepage and account management (system and
services)
Wellness program functionality (system and services)
On-line advertising capabilities (system and services)
Outreach Services
Electronic content management to store and access electronic
documents (notices, receipts, invoices, forms, etc.)
X
High
Moderate
Promotion of COHBE to public, Navigators, brokers, etc.
X
Moderate
Moderate
Low
Low
Promotion of wellness programs, enrollment, monitoring, etc.
X
Web and classroom training for brokers, navigators, Counties
X
Moderate
Moderate
Content/resources for consumers, agents, brokers, providers,
carriers
X
Moderate
Moderate
34
•
Role is to provide guidance to COHBE executive leadership and
early input into major strategic decisions such as IT investments,
acquisition of services and Acquisition strategy
•
These initial acquisition decision(s) will likely be in the order of tens
of millions of dollars over the first 3 – 5 years
•
Acquisitions will be structured to be competitive, fair and transparent
•
Due to the political sensitivities and visibility surrounding the
COHBE, it is important that there be no real or apparent conflicts of
interest in Acquisitions activities and operational decisions
•
Meet weekly leading up to the start of the formal acquisition process
35