IT and Implementation Committee
Strategic IT Decisions
December 14, 2011
1
•
Discussion points from 12/12 Board meeting
•
“Optimal” Level of “Interoperability” with State
Medicaid/CHIP Systems and Business Processes
• Storyboard
• Areas of Potential Interoperability and Input (IT,
Call Center, Plans)
• Cost Allocation of Interoperability
•
Additional Information from RFI process
•
Path Forward
2
3
•
•
Input into RFP
•
Risk management
•
Ask vendors how they would reduce implementation risk
•
Ask vendors how they would reduce operational risk (2+ options; pros/cons of
each; one biased towards pmpm and one pmpm neutral
•
How will they align with the COHBE on a sustainable basis
•
Heavy weighting on call center / customer service experience
•
Provide COHBE latitude to create partnerships with “best of breed” companies by
unbundling (recommend one technology solution for SHOP and individual exchanges)
Evaluation Team
•
•
•
6 – 8 members is ideal
HCPF will participate
Concerns re adequacy of IT resources
•
Developing options
4
5
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
Extent of “interoperability” (i.e. amount of overlap) between
COHBE system and business processes and CBMS/PEAK
and associated State eligibility and enrollment business
processes increase s complexity and schedule risk but improves
some consumer populations’ experience
6
Moderate Interoperability – MAGI & MMIS Interface
COHBE Systems
Small Business
Owners
& Employees
Pre-screening
SHOP
Exchange
Account Mgmt
& MPI
Eligibility
Determination
Set-up Employee
Roster
Create Account
Eligible for
Employer Plan &
Amount of
Coverage
(% and # expected)
Individual
Households &
Small Business
Employees
Plan Selection &
Enrollment
Enrollment in
Carrier Systems
Review Out-ofPocket Costs
Select Plan & Enter
Enrollment
Information
Interface
Enrollment
Information to
Carriers’ Systems
Individual
Exchange
Should PreScreening Step be
Included?
MAGI
Create Account
(including interfacing
w/ federal data hub)
Review Subsidy/Outof-Pocket Costs
Select Plan & Enter
Enrollment
Information
(% and # expected)
Enroll Eligible Household
Members into Family
Medical Program into MMIS
State Systems
Household
Member(s) Eligible for Other
Medical or HS Programs
Individual
Households
(seeking public
assistance,
i.e. Medical, Food
or Cash Assistance)
(% and # expected)
PEAK
CBMS
MMIS
Interface
Enrollment
Information to
MCO Systems
Does CBMS Need
Enrollment Data?
7
Approach to Determining Optimal
Interoperability Strategy
Moderate Interoperability – MAGI & MMIS Interface
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
(% and # expected)
Individual
Households &
Small Business
Employees
Plan Selection &
Enrollment
Enrollment in
Carrier Systems
Review Out-ofPocket Costs
Select Plan & Enter
Enrollment
Information
Interface
Enrollment
Information to
Carriers’ Systems
Individual
Exchange
Should PreScreening Step be
Included?
MAGI
Create Account
(including interfacing
w/ federal data hub)
Review Subsidy/Outof-Pocket Costs
Select Plan & Enter
Enrollment
Information
(% and # expected)
Enroll Eligible Household
Members into Family Medical
Program Into MMIS
Who pays for this interface?
Individual
Households
Gather technical
requirements
Prioritize all
interoperability
requirements, i.e.
musts, strong wants,
nice wants (and who)
Define interoperability
“musts”” for 2013
including ACA
Gather business
requirements
Prioritization of Requirements
Requirements
Musts
a
b
c
d
e
f
g
h
i
j
k
l
X
Strong Wants
X
X
X
X
X
X
X
X
X
X
Evaluate feasibility of design alternatives
Test use cases for impact on consumer
considering design principles, guiding
principles and best practices
(% and # expected)
Develop 3 options with
increasing levels of
interoperability,
complexity, risk, costs, etc.
PEAK
CBMS
MMIS
Interface
Enrollment
Information to
MCO Systems
Does CBMS Need
Enrollment Data?
Define design alternatives
(functions and feature sets
for each option)
Tiered Sets of Requirements
Nice Wants
X
(seeking public
assistance,
i.e. Medical, Food
or Cash Assistance)
Requirements
a
c
j
b
e
g
k
d
f
h
i
l
“Musts”
Option 1
Option 2
Option 3
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Strong
“Wants”
Nice
“Wants”
Define scope for Exchange
System(s) and Services
(RFP/RFQQ)
Begin Formal
Exchange Acquisition
Process
Compare feasible alternatives
against criteria;
Draft & Submit IAPD
make recommendation
Define scope for
modifications to PEAK &
CBMS
Draft/Negotiate
Deloitte SOW
8
Interoperability System and Business Process Alternatives
•
Minimum level of systems interoperability (from design principles,
guiding principles and best practices):
•
•
•
•
•
•
•
•
•
Moderate level of systems interoperability:
•
•
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
Interfaces
•
TBD
Maximum level of systems interoperability:
•
TBD
9
Tiered Sets of Requirements
Interoperability Level
Interoperability Feasibility
Criterion
Impact on Exchange RFP
Minimum
Moderate
Maximum
X
X
X
No "wrong door"
Shared MPI and Account
Management
No data entered more than 1x;
re-use data
Do not ask for data not relevant
to medical eligibility
X
X
X
X
X
X
X
X
X
X
X
X
Meet all minimum ACA reqs
X
X
X
Common "no touch" MAGI
eligibility
Shared call center
Same carriers for some private
and public plans
Interface PEAK to Exchange for
MAGI Eligibility
Link and data population
Exchange MPI to PEAK
Interface Exchange to CBMS for
other medical and human
services
TBD
TBD
X
X
X
X
X
X
X
X
X
X
X
10
Analysis of Alternatives – use cases and preliminary estimate of populations
Subsidized Unsubsidized Medicaid EmployeeCombo Private
Private
CHIP
Only SHOP
X
X
X
Unemployed uninsured with
382 children plus 1/2 public insured
X
7
One fourth of expected small firm
100 participants
X
One fourth of expected small firm
100 participants
X
X
One fourth of expected small firm
100 participants
Currently unemployed w/private
300 insurance plus 1/2 public insured
X
One fourth of expected small firm
100 participants
X
5
6
Preliminary
X
3
4
Currently buying private
300 insurance
X
1
2
Spouse All-Family TANF Food People
SHOP SHOP
Stanps
1000s
X
11
Use Cases and interoperability considerations
System Entry
Point
COHBE
Use Case
Construct
Individual
Household
Household
Composition
Use Cases
Eligible for
subsidy
Population
TBD expected
to be
>200K
TBD
Not eligible for
subsidy
SHOP
PEAK/CBMS
Single person
TBD
Childless couple TBD
Family including TBD
children
Program
Eligibility
Family Medical Eligible for
Family Medical
CHIP
Eligible for CHIP
Long Term Care Eligible for LTC
Disability
Eligible for
Disability
TNAF
Eligible for TNAF
SNAP
TBD expected
to be > 300K
TBD
TBD
TBD
What is
intersecting
population?
Eligible for SNAP What is
intersecting
population?
Eligible for
Subsidized
Private
Coverage
Account
PEAK Interface MMIS Interface CB MS Interface Carrier Plans
Mgmt/MPI/M
(MCOs)
AGI
Y
N/A
N/A
N/A
N/A
Y
Y
N/A
N/A
N/A
N/A
Y
Y
Y
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
Y
Y
Y
Y not in COHBE
Y not in COHBE
Y
Y
Y
Y
Y
Y
Y
N
N
N
N/A
Y
Future
Y
N
N
N
N/A
Y
Future
What is this population?
CHIP
Eligible
Call Center
Eligible for
SHOP
Coverage
What is this population?
Rules Engine
Other
CHIP
Eligible
12
•
Storyboard shows moderate level option of interoperability
COHBE and HCPF End-to-End Solution – Preliminary High Level Business Process and Systems Model
Core Exchange
Functions
Eligibility
Initial Screening
Business Processes
Business Objective
for Each Process
Determine if individual wants to see if he/she qualifies for financial
assistance, i.e. Medicaid/CHIP or subsidized private coverage
Collect minimal personal data and make preliminary determine if individual
qualifies for financial assistance, i.e. Medicaid/CHIP or subsidized private
coverage. No confidential information requested.
SHOP employers and brokers must create an account to proceed with SHOP coverage administration
and account management.
Individual must create account in order to enter personal data which will be stored and verified by
interfacing with federal data hub
Individual enters required information, creates password, answers challenge questions, etc.
COHBE and PEAK
Entry Points
(Portals)
COHBE & State Systems
Broker Accesses CHOBE
Broker Tools and Authorized
SHOP Employer Information
Brokers
SHOP Employers
Brokers and
SHOP Employees
SHOP Employer
Broker or
SHOP Employee
Small Employers
and Employees
Manage SHOP Employee Roster and Benefits is accessed only in the
COHBE. It is for establishing and administering benefits for SHOP
employees. It defines who is eligible for what Metal of coverage. This
process is not applicable to SHOP employees, individuals or households.
Insurance Exchange Marketplace is a presentation
of plans for which the user is eligible. Tools to
search, sort and compare plans along a variety of
dimensions such as price, deductable, location/
availability of network and out of network
providers
Eligibility Determination #2 is the determination if and to what extent an individual meets the criteria for a given category or categories of
medical coverage. This will be performed by applying business logic to a set of data the required data will be different depending on the
type of coverage, it may include but is not limited to: age, smoking, disability status, income, assets [resources], medical expenses, etc.)
COHBE Only
Plan
Selection
Plan Selection is the action of
selecting a plan in the
Marketplace
COHBE & State Systems
Plan
Management
Financial Management
Tax Credits and Advance Aggregation of
Approve and Load QHP
Payment of Premiums
Premiums
Enrollment
Enrollment is the assignment of eligible individuals to health care plans that are available to that eligibility
category. Plans may be restricted to eligible beneficiaries based on geography, funding stream, or other
criteria. (Enrollment generally includes options to choose a plan, but may also have a time-driven default
assignment based on a fairly sophisticated algorithm that could include geography and funding streams,
but also could include patients previous care providers, an agreement for the exchange to allocate default
assignments according to some percentage across plans, or other criteria to be determined, etc.)
Aggregate information and transactions
Aggregate information and
transactions
Plan Management is the processes to get State-approved
QHP from carrier systems into the Exchange
Carrier Operations and Backoffice Functions
Approval
Guaranteed-issue health insurance coverage – which ensures that individuals
are not denied coverage or forced to pay higher premiums because of preexisting conditions or poor health status may, require the gradual elimination of
medical underwriting due to the restrictions outlined in the bills on rating
practices and the requirement that all individuals have access to coverage
regardless of their health conditions.
Fulfillment
Yes
SHOP Employer and/or
Broker Administer
Benefits and Account
SHOP Employer Authorizes
Broker to Access Employee
Information
Carrier Systems
SHOP Employee Presented Plans Based on
Eligibility and Search Criteria
Display Benefit, Out-of-Pocket Cost, etc.
Present Medicaid/CHIP plans if available
(and provide search capabilities) e.g.:
· Location
· Network
· Costs/Co-pay
· Benefits
· Specialties
· Other
CUE3
SHOP Employee completes on-line
application to capture any
additional required information
(pre-populate to max extent
possible)
SHOP
Employee
Selects Plan/
Coverage Type
Show total cost and cost breakdown and
terms and conditions
Collect any additional information
Obtain user acceptance & e-signature
Process financial transaction (if applicable)
Enroll Individual/Family Members in
Carrier Plans
Assign Individual/Family Members to
Pools
Approve Assignments
Send Medical
Cards
Administer/Pay
Claims
High-Level Requirements
May receive assistance from:
· Navigator/Broker/Agent
· Case worker
· Community-based worker
· Volunteer(?)
SHOP Employee Creates an
Account or Logs In
Employees
Rules Engine
Cascading Eligibility
CUE
Based on application
information
business rules make
determination re eligibility for
Medicaid/CHIP or Other
Likely Medical Benefit
Account Management
Master Data Management
Paper
Application
May be Eligible for
Medicaid/SCHIP
(Including Expansion)
SHOP
Individual and Household
w/ Income
between
133% and 200% PL
Federal
Data Hub
Likely Eligible for
Medicaid/SCHIP
Show SHOP Employee
Eligibility for any
Additional Medical
Benefits (Public or Private)
CHIP Eligible
Children?
Hotline
Calculator
Medicaid/CHIP Eligibility
Screening
Standardized Enrollment
CUE5
Does SHOP
Employee /Individual
Want to Enroll
Children
in CHIP?
Yes
CUE6
Enrollment Periods
CUE7
Navigators
PC2
CUE4
Based on application
information
business rules make
determination re eligibility for
Medicaid/CHIP or Other
Likely Medical Benefit
CUE1
Individuals/
Households
SHOP/
Financial
Assistance
Yes or No
Yes
User Enters:
- Resident of KS
- Zip Code
- Age
- Family or Individual
- Income
- SHOP ID
- Excemptions
CUE8
Individual Creates Account
In COHBE
350K
Call-in
Show Individual/Household
Eligibility for any Medical
Benefits (Public or Private)
CUE9
No
Individual and Household
w/ Income
between 133% – 400% PL
Rules Engine
Cascading Eligibility
Consumer Information
Inform consumers of plan quality and enrollee satisfaction ratings.
Exemptions
Have the capability to identify, and inform the U.S. Treasury, about consumers who are exempt from the law’s individual
responsibility requirements.
Preliminary Eligibility
Determination for Subsidized
Private Coverage
(show estimated and nonverified subsidy amount)
Likely Eligible for
Subsidized Private
Coverage
Individual
Selects Plan/
Coverage Type
Show total benefit package and
terms and conditions
Collect any additional information
Obtain user acceptance & esignature
Coverage for a federally determined essential benefits package (as well as any other benefits the state requires) in a plan that has
the required out-of-pocket caps;
The offering of only specified tiers of coverage: bronze, silver, gold, and platinum. A bronze plan covers 60 percent of medical
costs for covered services (excluding premiums) for an average enrollee population; silver covers 70 percent; gold covers 80
percent; and platinum covers 90 percent.2 Any insurer participating in the exchange must offer at least one plan at the silver level
and one plan at the gold level. Insurers may also offer “catastrophic” plans for people under 30 and people who are exempt from
the individual responsibility requirements (see Section 1302 of the Affordable Care Act).
Essential Benefits
PC2
Plan Offerings
PC3
Number of Network Providers
PC4
Marketing Standards
Availability of an adequate number of providers in the plan’s network, including providers that serve predominantly low-income,
medically underserved individuals (where applicable).
Marketing standards.
PC5
Quality and Accreditation
Specified quality, quality improvement, and accreditation standards.
PC6
Transparency
Transparency standards, such as disclosure of information on claims denials, plan finances, cost-sharing information, and
enrollee rights in plain language.
PC7
Preimum Increases
Prior justification of any premium increases (which will be made public, and which exchanges are asked to consider when
determining whether to allow an insurer to participate).
OR
Additionally, Exchanes must meet these additonal requirements.
OR1
Stakeholder Participation
OR2
Transparency
Exchanges must publish specified financial information for public inspection and must undergo annual audits by the Secretary of
Health and Human Services.
Financial Stability
Exchange administration must be self-financing by January 1, 2015 (through premiums or other sources). Until 2015, federal
grants will be avaialable to help states implement exchanges.
Enroll in selected plan
Send Subsidy Transactions
to US Treasury and Carriers
OR3
Consumer and public input: Exchanges must consult with stakeholders, including educated health care consumers, enrollment
experts, small business representatives and self-employed individuals, and advocates with experience enrolling hard-to-reach
populations.
Actual Source
Secure Interface from Exchange
MAGI Eligibility Process to CBMS
CUE
Consumer Usability and Enrollment
US Treasury Systems/
Subsidy Payments to Carriers
and Tax Credits for SHOP
Employers
Not Eligible for
Subsidized Private
Coverage
Individual and Household
w/ Income
greater than 400% PL
An exchange must be able to certify that plans sold in the exchange meet a number of standards outlined in the Affordable Care Act.
PC1
Legend
May receive assistance from:
· Navigator
· County case worker
· COHBE customer service
· Community-based worker
· Volunteer
CUE2
Provide for an initial enrollment period as well as annual and special enrollment periods.
Establish “navigators”—individuals or entities that help consumers and employers learn about, and enroll in, coverage options.
CUE8
1 Implementing Health Insurance Exchanges, A Guide to State Activities and Choices, Familes USA October 2010
Individual completes on-line
application
May be Eligible for
Subsidized Private
Healthcare Coverage
Private
Coverage
Individual Presented Private Coverage
Eligibility and Search Criteria
Display Benefit, Out-of-Pocket Cost, etc.
Present Medicaid/CHIP plans if available
(and provide search capabilities) based on:
· Location
· Network
· Costs/Co-pay
CUE3
· Benefits
· Specialties
· Other
CUE6
PC2
Make an online calculator available so that people can see the actual costs of their coverage after accounting for the premium tax
credits they may receive;
Be able to screen eligibility for, and enroll people in, Medicaid, the Children’s Health Insurance Program (CHIP), and other public
programs.
Use a standardized enrollment form for coverage.
CUE9
Yes
Interface to HHS Data
Hub SSA, IRS, HHS,
DHS
Requirement Description
Implement a web portal where consumers and businesses can view coverage options, with benefits and costs presented in a
standardized format.
Operate a toll-free hotline for consumer assistance.
Web Portal
CUE2
CUE3
CUE4
CUE4
Requirement
Exchanges must be able to enroll individuals and small businesses (with up to 100 workers) into coverage in a user-friendly way.
CUE1
PC
Preliminary Eligibility
Determination for
Medicaid/SCHIP
(show potentially
eligible programs)
Renewal
Plan Management
Does Employee
Want to Check
Eligibility for CHIP or
Subsidized Private
Coverage?
Yes
SHOP Employee Eligible
(Defined Contribution)
for Employee Only or
Employee Household
SHOP Employer Creates an
Account or Logs In
Employers
Does
Employee have
Household Family
Members Who are
Not Covered?
Broker Accesses CHOBE
Broker Tools and Authorized
SHOP Employer Information
Individual
CUE7
Premium
Collection/
Aggregation
Approve and process allowable claims on behalf of enrollee
Exchange Only
COHBE or State MMIS
Operations
Provide medical card/proof of insurance when needed
Rqmt #
Individual
Individual and Household
w/ Income
Less than 133% PL
Insurance Exchange
Marketplace
Eligibility Determination
No
Broker Creates an
Account or Logs In
SHOP
Enrollment
Manage SHOP Employee
Roster & Benefits and
Admin Tools
Account Management
Rules Engine
Cascading Eligibility
Eligible for SHOP
CUE2
Effective as of 2014
Call Center and Customer Assistance
Main article: Patient Protection and Affordable Care Act#Effective by January 1, 2014
· State health insurance exchanges for small businesses and individuals open.
· Individuals with income up to 133% of the federal poverty level qualify for Medicaid coverage.
· Healthcare tax credits become available to help people with incomes up to 400 percent of poverty
purchase coverage on the exchange.
· Premium cap for maximum "out-of-pocket" pay will be established for people with incomes up to 400
percent of FPL.[10][62] Section 1401 of PPACA explains that the subsidy will be provided as an
advancable, refundable tax credit[63] and gives a formula for its calculation.[64] Refundable tax credit is a
way to provide government benefit to people even with no tax liability[65] (example: Child Tax Credit).
According to White House and Congressional Budget Office figures, the maximum share of income that
enrollees would have to pay for the "silver" healthcare plan would vary depending on their income relative
to the federal poverty level, as follows:[11][66] for families with income 133–150% of FPL will be 4-4.7% of
income, for families with income of 150–200% of FPL will be 4.7-6.5% of income, for families with income
200–250% of FPL will be 6.5-8.4% of income, for families with income 250-300% of FPL will be 8.4-10.2%
of income, for families with income from 300 to 400% of FPL will be 10.2% of income. In 2016,the federal
poverty level is projected to equal about $11,800 for a single person and about $24,000 for family of
four.[66] See Subsidy Calculator for specific dollar amount.[67]
· Most people required to obtain health insurance coverage or pay a tax if they don't.
· Health plans no longer can exclude people from coverage due to pre-existing conditions.
· Employers with 50 or more workers who do not offer coverage face a fine of $2,000 for each employee if
any worker receives subsidized insurance on the exchange. The first 30 employees aren't counted for the
fine.
· Health insurance companies begin paying a fee based on their market share.
Track Enrollment and Changes to Enrollment
Boundary between COHBE and PEAK/CBMS
Boundary between COHBE and PEAK/CBMS
Boundary between COHBE and PEAK/CBMS
Secure Interface to Exchange/
MAGI Eligibility Process from PEAK
Visit County Office
PEAK
CBMS
MMIS
County case worker enters
application and interviews client
CBMS determine eligibility for
non-MAGI population and other
human services programs
Individual and Household
seeking public assistance for
Medical and/orMail
SNAP
Application
HCPF
and/or TNAF and/orInto
other
Center
Federal and StateProcessing
programs
Enroll Individual/Family Members in
MMIS
Send Medical
Cards
MAXIMUS employee enters
application and notifies client
Call Center and Customer Assistance
Track Enrollment and Changes to Enrollment
KEES Integration with Federal
Exchange
Version 2.0
September 25, 2011
Gary Schneider
13
Interoperability System and Business Process Alternatives
•
Shared call center with HCPF
•
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)
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
14
Analysis of Interoperability Alternatives – feasibility of alternatives versus critierai
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
15
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.
16
17
All state-run procurements.
•
Maryland – stringent to the point of limiting vendor creativity; all risks put on vendor
•
Minnesota – structured to get the best functional modules; presents significant
integration challenges; Phase 1 complete vendors to built exchange prototypes;
available to other states
•
Washington – design, develop, implement (DDI) model; ignores significant
investment in exchanges currently on market; SaaS only solutions excluded
•
Mississippi – phased approach (e.g. web portal/shop & compare, unsubsidized
exchange, subsidized exchange eligibility determination); open to multiple vendors
across phases; risky with lots of unknowns (federal guidelines, etc)
•
Regular conference call with CCIIO indicates that the following states have or will
have issued RFPs by the time COHBE RFP is issued (MA, MD, MS, WA, NY, OR,
MN)
18
Company
Respondents
End-toEnd
Solution
Exchanges
Operating
Model
Benefitfocus
Yes
Individual &
SHOP
SaaS only
Connecture/
MAXIMUS
Yes
Individual &
SHOP
license &
SaaS
CA, TX, CO, IA, NY
Getinsured.com
Yes
Individual &
SHOP
license &
SaaS
MS
CGI
Yes
Individual
& SHOP
Individual &
SHOP
license &
Saas
ACS/Choice/
Current
Clients
Partners
MAGI
Rules
engine
Implements
with an
independent
rules engine
custom –
proprietary
MAXIMUS
(prime)
designing for
MN
prototype
open
source
Accenture
No
Drools
Flow
(jBPM5)
FL, NJ, CT, VA
Insurance companies,
employers, education
systems
COTS –
HIE360
Federal Exchange,
New England states,
UT, CMS, CCIIO;
hCentive,
Exeter, Policy
Studies (PSI)
Yes
SaaS
pmpm
CO – Anthem BCBS
MD – CareFirst BCBS
CO broker – Jim
Sugden
MD – Dell,
Oracle,
Cognascante
No
No
SaaS
only(?)
130,000+ using payroll
& benefit mgmt services
Solution works
with a number of
structures
No
custom
Mass HealthConnector
Florida w/Ceridian
Deloitte (MN &
WA)
Support –
Ceridian
No
No
Vendors w/ partial solution
BenefitMall
No
SHOP
Ceridian
No
Individual
eHealth
No
Individual
SaaS only
19
•
Information on costs will require additional analysis and follow-up with vendors
•
Preliminary estimates for Exchange technology and services range from $30
million to $60 million per year w/ implementation costs amortized over 4 years
20
21
COHBE RFP Gamplan
RFP Section
1. Purpose of RFP, Vision, Concept of Operations
2. COHBE Background
3. General and Administrative Procurement
Information and Timeline
4. Scope of Implementation and On-going Services
5. Proposal Response – System, Implementation
Services, On-going Operations and Administrative
Services:
5.1 Solution Proposal (business, technical)
5.2 Cost Proposal
Key Points/Direction
Assist
Other Reviewers
Materials
What/Why/How from 30K ft
Benefits and what we're trying to accomplish
Need to contain costs for sustainability
Information on entity and mission
Gary
Lead
Chuck, Larry
Myong, Shawn, Patty
Business Concept
SB 200
Gary
Shawn
Myong, Shawn
Structured defined procurement process
Timeline set for procurement
Show timeline for project (SHOP and Individual)
Gary
Chuck, Larry
HCPF Procurement
Officer
Business Concept
SB 200
Briefings
Define scope for core areas
Define populations
System implementation
System support and maintainance
System hosting and operations
Optional application licensing
Very prescriptive
Response format to be structured and consistent
Gary
Chuck, Larry
Shawn, Patty
KS RFP/BAFO
Population estimates
from CHI, Gruber, etc.
Gary
Chuck, Larry
HCPF Procurement
Officer
KS RFP/BAFO
Vendor description of how solution will function
from business and technical perspective
Gary
Chuck, Larry
Shawn
KS RFP/BAFO
Cost templates will be provided ; line items broken
down between implementation and on-going costs
to insure ability to accurately compare costs
Operations for 1,3,5 years
Attempt to segment between technology and labor
(services)
For pmpm cost risk use ranges on bid schedule
Population metrics and pmpm ranges
Chuck
Larry, Gary
Shawn, Patty
Gary to provide
starting pt
See KS and MD cost
schedules
MD's approach to addressing uncertainty in ACA
final rules
Gary
Chuck, Larry
HCPF Procurement
Officer
HCPF Ts&Cs
Larry
Chuck, Gary
Chuck - Exchange
Larry - Medicaid
Gary
Draft Complete
15-Dec
15-Dec
16-Dec
16-Dec
16-Dec
19-Dec
16-Dec
6. Proposed Contract Terms and Conditions
7. Appendices:
Appendix A – Business Process Models
15-Dec
Gary has templates
16-Dec
Appendix B – Requirements (functional, technical)
Functional
Gary
Technical
Appendix C – Interoperability with State Medicaid
Systems and Business Processes
Appendix F – Reporting and Business Intelligence
Gary has starting set
Sherri
Gary has starting set
Chris/Antoinette/
Jenny/Deloitte
HCPF work
HCPF work
Gary will provide
format
HCPF work
Gary will provide
format
May need help from
Jeff Mitchell
Look in CALT
16-Dec
16-Dec
16-Dec
Build small table
Larry
Gary
Chris/Antoinette/
Jenny/Deloitte
PEAK and CBMS into single account management
for single sign-on
What State systems involved?
Need to make sure this is possible
Larry
Gary
Chris/Antoinette/
Jenny/Deloitte
Need to get starting set of Exchange metrics ASAP
Reach out to MA and UT, Brokers, Carriers,
Providers, Health Foundations
Chuck
Larry,Gary
Shawn, Patty
Standards
Gary
Jeff Mitchell
Eric/Nathan/Sherri
Consider graded cost approach
Gary
Chuck
Eric/Nathan/Sherri
COHBE RFI
MD RFP
KS RFP
KS EI grant app
KS RFP/BAFO
Balance granularity w/ control
Ensure data turnover as per Sherri
Gary
Gary
Chuck, Larry
Jeff Mitchell
Shawn, Patty
Shawn, Patty
KS RFP/BAFO
KS RFP/BAFO
Appendix D – Interfaces
Appendix E – Conversions
Shawn
Jim Reiseburg
Chris/Antoinette
16-Dec
16-Dec
16-Dec
Appendix G – Technical Architecture
Appendix H – Operations, SLAs, and Continuity of
Operations
Appendix I – Deliverables
Appendix J – Turnover
18-Dec
19-Dec
13-Dec
13-Dec
22
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
23
& 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.
24
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
25
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
26
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
27
•
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
28