IT and Implementation Committee Strategic IT Decisions December 21, 2011

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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

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• • • • • •

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

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• Three risks associated with the SHOP: • Market risk • Performance risk • Schedule risk

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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 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

Required Bundling

1.A, 1.B and 1.C must be bid together

SHOP Exchange SHOP Exchange Development and Services 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 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

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• • 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

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• • • • • • • • CBMS/PEAK & Medicaid/CHIP Eligibility & Enrollment Business Processes Minimum level of interoperability as discussed at last meeting 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 Interoperability Between COHBE & State Medicaid/ CHIP Systems and Business Processes COHBE Eligibility & Enrollment Systems and Business 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.

Single parent eligible for subsidized private coverage and children eligible for CHIP.

2.

One parent receives subsidized coverage from SHOP employer, spouse eligible for subsidized private coverage and children eligible for CHIP 16

Small Business Owners & Employees

SHOP Exchange

Individual Households & Small Business Employees

Individual Exchange

Boundary between COHBE and State Systems

Individual Households (seeking public assistance, i.e. Medical, Food or Cash Assistance)

PEAK

Minimal Interoperability Pre-screening Account Mgmt & MPI Eligibility Determination Plan Selection & Enrollment Enrollment in Carrier Systems

Eligibility Interoperability

Should Pre Screening Step be Included?

Set-up Employee Roster Create Account Create Account Eligible for Employer Plan & Amount of Coverage Review Out-of Pocket Costs Select Plan & Enter Enrollment Information Interface Enrollment Information to Carriers’ Systems

MAGI

(including interfacing w/ federal data hub) Review Subsidy/Out of-Pocket Costs Select Plan & Enter Enrollment Information Household Member(s) Eligible for Medical or HS Programs

Shopping and Enrollment Interoperability

Boundary between COHBE and State Systems

CBMS MMIS

Interface Enrollment Information to MCO Systems 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

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• • 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 Description/ Approach Cost Implementatio n Costs (federal & SGF) 5-Year Operational Costs (federal & 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 (re compete) 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.

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Company Respondents ACS/Choice/ Benefitfocus Connecture/ MAXIMUS Getinsured.com

CGI Vendors w/ partial solution BenefitMall

No

Ceridian eHealth End-to-End Solution

Yes Yes Yes Yes

Exchanges

Individual & SHOP Individual & SHOP Individual & SHOP Individual & SHOP

Operating Model

SaaS only license & SaaS license & SaaS license & Saas

Current Clients

FL, NJ, CT, VA Insurance companies, employers, education systems CA, TX, CO, IA, NY MS Federal Exchange, New England states, UT, CMS, CCIIO;

Partners

Choice Admin Benefitfocus MAXIMUS (prime) Accenture hCentive, Exeter, Policy Studies (PSI)

MAGI

Implements with an independent rules engine designing for MN prototype No Yes

Rules engine

custom proprietary open source – Drools Flow (jBPM5) COTS – HIE360 No No SHOP SaaS pmpm TPA, premium aggregation Individual pmpm SaaS only CO – Anthem BCBS MD – CareFirst BCBS CO broker – Jim Sugden 130,000+ using payroll & benefit mgmt services Mass HealthConnector Florida w/Ceridian MD – Dell, Oracle, Cognascante Solution works with a number of structures Deloitte (MN, WA) Support –Ceridian No No No No custom No 24

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Proposed Committee members:

• • • • • 1.

2.

3.

4.

5.

6.

7.

8.

Patty Fontneau COHBE - ED Shawn Raintree COHBE - Staff Myong Kim COHBE - Staff Nathan Wilkes TBD TBD COHBE - Board Technology Company Executive OIT TBD TBD HCPF DOI

Support Staff:

Gary Schneider COHBE – GMS Chuck Fish COHBE – GMS Larry Redd COHBE – GMS Craig Tobin Kevin Appleton Eventus Eventus 26

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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 1 st review cycle

Wrap-up vendor demos & RFI

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High-Level Timeline – COHBE Policy & Business Decisions and IT 2011 2012

11/11 01/12 03/12 05/12 07/12 09/12 11/12

Supreme Court Ruling on Mandate

Policy & Business Decisions and Activities

Policy & Business Decisions Impacting IT Evolving Policy and Business Decisions based on CCIIO/CMS/Board/Executive Director/Legislative Oversight/etc.

Start-up and Operational Decisions 01/13 03/13

COHBE Certification by HHS

2013

05/13 Operational Activities 07/13 Start-up Activities

IT/Systems

HIX - SHOP

Analysis/Confirmation of Current Approach & Prel RFP

Establish PMO

Procure IT Systems & Services for HIX Design/Build/Test HIX Systems for SHOP HIX SHOP Integration Testing

Pilot Phase 04/13 – 10/13

HIX Deployment

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

Pilot Phase 06/13 – 10/13

HIX Deployment

Note: Accompanying timeline for required enhancements to PEAK & CBMS not shown

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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 and Business Lines 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) the Individual Exchange

Market Competition

Encourage competition in the market whether it is inside or outside the Exchange.

Continuity of Care Integration with Medicaid Federal Deadlines

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). 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.

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.

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Exchange Capability and/or Service Category Eligibility, Plan Shopping and Enrollment (System) Exchange Capability and/or Service Strawman Priority for 2013 (depends on “who” is asked)

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

High

X X X X

Moderate Low

X

Broker-Related Features & Tools (System)

Directory of available brokers and qualifications Ability for broker to access SHOP employer data Ability to develop comparative quotes and to sort information to 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 X X X X X

Impact on Implementation and Operational Costs Impact on Implementati on Cost Impact on Operation al Costs

High High High Moderate Moderate Moderate Moderate High Moderate Low Moderate Moderate Moderate Moderate Low Low Low Low Moderate Moderate Low Moderate 32

Exchange Capability and/or Service Category Exchange Capability and/or Service Customer Service

Call center support for on-line eligibility and enrollment (individual households, SHOP employees) Call center support for SHOP employers and brokers 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

Financial Management

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)

(depends on “who” is asked) High

X X X X X X X X X X X X X

Strawman Priority for 2013 Moderate

X

Low Impact on Implementation and Operational Costs Impact on Implementation Cost

Moderate

Impact on Operational Costs

High Moderate Low Low Moderate Moderate Moderate Moderate Moderate High Moderate Low High High High High High High High High High Moderate Moderate Moderate High High High 33

Exchange Capability and/or Service Category Exchange Capability and/or Service 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 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) Electronic content management to store and access electronic documents (notices, receipts, invoices, forms, etc.)

Outreach Services

Promotion of COHBE to public, Navigators, brokers, etc.

Promotion of wellness programs, enrollment, monitoring, etc.

Web and classroom training for brokers, navigators, Counties Content/resources for consumers, agents, brokers, providers, carriers

Strawman Priority for 2013 (depends on “who” is asked) High

X

Moderate Low Impact on Implementation and Operational Costs Impact on Implementat ion Cost Impact on Operation al Costs

High High X X X X X X X X Moderate Moderate Low High Moderate Low Moderate Moderate Low Low Low Moderate Moderate Low 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