Transcript connectforhealthco.com

IT and Implementation Committee
Strategic IT Decisions
December 7, 2011
1
•
Action items from 11/30 meeting
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RFI and “Pulse” of Marketspace
•
Acquisition Process
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Financial Model
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Cornerstone elements of RFP
Analysis and Scoring of Proposals
Outline of RFP
Evaluation Committee
Legal resources
Costs Comparison: Asset Acquisition vs. SAAS (ROM and Directional) Engineer’s
Estimate as Major Component of COHBE Operating Expense
Impact on COHBE Sustainability Model
Revenue Source to Fund Operational Expenses
“Optimal” Level of “Interoperability” with State Medicaid/CHIP Systems and
Business Processes
•
•
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Storyboard
Areas of Potential Interoperability and Input (IT, Call Center, Plans)
Cost Allocation of Interoperability
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Agenda and Affirmations for 12/12 Board Meeting
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Review of Gameplan Leading to Start of Formal Acquisition Process
2
3
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Action Item: Review State of MO RFI and companion material and determine applicability
to COHBE strategy and Acquisition
•
Gary sent email on 11/30 summarizing RFI process and differences between MO and
CO’
•
Gary spoke to Dwight Fine (MO Insurance Department) to understand context of their
effort and potential synergy; in addition to information provided on 11/30 estimated
project cost is $125M for fully integrated eligibility and exchange solution; State
portion being funded by foundation(s) not SGF
•
Action Item: Provide Committee members with list of vendors receiving COHBE RFI
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Copy of vendors engaged to-date and on the radar on Slide #7
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Action Item: Review selection criteria from MO
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Good content; can leverage; will be developing requirements and leveraging RFPs
from WA and MD
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Action Item: Identify need for legal resources
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Legal resource requirements and timeframes identified on Slide #14
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Action Item: Stay informed on work NAIC is doing to assist carriers to load plans into
Exchanges using a standard format
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Will monitor NAIC activities through Julie Fritz and report back periodically; do not
currently see any impact on RFP; carries should embrace this standardization
4
5
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Few states in the Exchange Acquisition process at this stage; many
waiting for legislative approval process or determining strategy
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Vendors anxious to present solutions, get a foothold and begin
implementation for leading states
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End-to-end solutions seen to-date range from small gaps to significant
gaps which will require design, development and implementation by
vendor(s) (i.e. risk)
•
Many vendors will “team” to provide the three core areas of systems and
services needed by COHBE
•
Still in process of getting additional data points to verify price point ranges
and pricing options; cost data presented today is preliminary and nonbinding on vendors
•
Actual cost data will be provided in early-May when proposals are
received
6
Vendors receiving/responding to COHBE RFI
Company Name
Contact
Meetings
RFI
comments
Choice Administrators
www.choiceadmin.com
Joe De La Cruz 714.718.9369
[email protected]
web meeting – 12/12
sent 11/30
Ceridian
www.comdata.com
Matt Spencer 801.903.7290
[email protected]
web meeting – 11/28
sent 11/29
CGI
www.cgi.com
Holli Ploog 703.267.8626
[email protected]
12/2 11a phone call
b/w 12/14 & 12/21
sent 12/1
[email protected]
703.267.5043
lobbyist – Jim Carpenter
Connecture
www.connecture.com
Dana Leopold 404.964.4098
[email protected]
Web meeting – 11/10
CHI –12/6
sent 12/1
partnering w/Maximus
Getinsured.com
www.getinsured.com
Sephy Hambaz 650.618.4609
[email protected]
CHI –12/13
sent 12/1
Chini Krishan 650.618.4609
[email protected]
eHealth
www.eHealthinsurance.co
m
Sam Gibbs 202.290.3911
[email protected]
408.887.1488 (m)
TBD
sent 12/5
Partnered on other projects with
Deloitte and/or Curam (sp)
BenefitMall
www.benefitmall.com
Benjamin Waters 720.837.6726
[email protected]
web meeting – 12/8
sent 11/30
partnering w/ACS
7
8
Key Cost Drivers for SAAS model:
• Enrollment
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•
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Combination of Wakely/Gruber #’s;
“moderate” Wakely #’s in ’14 & ’15
Gruber: ultimately 540K – 960K in exchange; used 750K (midpoint)
• SaaS PMPM (per member per month) rate
• Rate depends on:
1) Vendor
2) Breadth of functionality and services, i.e. “thick” vs. “thin”
exchange
Exchange Enrollment
(000's)
800
600
400
200
'13
'14
'15
'16
'17
'18
9
Slide 17
SaaS model yields annual costs of $20M – $60M at 750K enrollment.
SaaS pmpm scenarios
annual costs
($ M per year)
$80
$ 6.50*
$60
$ 5.00
$40
$ 3.50
$20
$ 2.00
'13
Enrollment
550K
'14
'15
650K
720K
'16
750K
'17
'18
760K
770K
* Rates remains flat over the years for these scenarios.
SaaS – Software-as-a-Service
PMPM – per member per month
10
• Key Cost Drivers for acquisition model:
• Software license acquisition
• Monthly operating costs depends on:
• annual maintenance and support (% of license)
• application support and hosting (fixed cost/mo)
• administrative service (per member per month) rate
• Administrative services linked to enrollment and likely to
be 10-50x system costs
11
Slide 18
$5M
Acquisition model estimates by component.
Implementation – $2M
($ 000's) per year
$800
software – $3M
$30M
$25M
$600
$20M
$400
$15M
$10M
$200
$5M
'12
Enrollment (December)
'13
'14
'15
'16
'17
'18
550K
650K
720K
750K
760K
770K
maintenance/support
hosting
operations ~$3.00 pmpm
12
Key Cost Drivers of SaaS and acquisition model are administrative
and customer services:
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Eligibility
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Plan Management/Shopping
•
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MAGI eligibility
SHOP Exchange
Interfaces and services for carriers to load approved plans into COHBE
Search criteria, multi-dimensional
Track plan mandate costs
Reimbursement system for exchange enrollees for additional mandated costs
Broker tools for quotes/comparisons
Financial Management
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•
•
•
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Full A/R disbursement, collections, online presentation & billing customer service
automated billing aggregation for employers, individuals, families, insurance companies, & agents
Online payment service Integration for individuals and employers to include ACH, credit card,
Account management, view, search, adjust
Electronic and paper invoices
Automated notification to manage delinquent, late payments
Support for web advertising
Collect and maintain data to calculate billings determined necessary to compensate
Integrate with general ledger/accounting systems
Cafeteria plan integration for payments
Billing help desk support
13
Key Cost Drivers of SaaS and acquisition model are administrative
and customer services:
• Customer Service
•
•
•
•
•
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Multilingual online system for specified languages
Multilingual help desk/enrollment support for specified languages
Promotion of health management and wellness initiatives
Flexible spending account, health reimbursement account and health saving account support
Sponsorship/assistance for state exchange outreach programs
Simultaneous online access for agent/navigator and consumer from different sites
Wellness Programs enrollment, monitoring and portability
• Communications
•
•
•
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Classroom and/or online training programs for agents and navigators
Resource library for consumers, agents, brokers, employers and providers
Associated document management to store and access electronic and paper communication
Complete forms library for all plans
14
Acquisition model results in $14M – $18M annual
savings based on the assumptions below.
$50
$5 pmpm
($ M per year)
SaaS
$40
$17M—$18M/yr;
$ 1.88 pmpm
$30
$20
Acquisition
$10
'12
Enrollment (December)
'13
550K
'14
650K
'15
'16
720K
750K
'17
760K
'18
770K
15
Cumulative cost savings based on estimate assumptions.
$250
$200
($ M)
$87M
$150
$50M
SaaS
$100
$50
Acquisition
'12
Enrollment (December)
'13
'14
550K
650K
'15
'16
'17
720K
750K
760K
'18
770K
16
Assuming 1.8 members/policy (Wakely), $5—$9 per policy per
month required to fund ongoing exchange operations.
$5.43
$8.82
per policy per month
$10
$8
Acquisition
SaaS
$6
$4
$2
Enrollment
'13
'14
'15
'16
'17
'18
550K
650K
720K
750K
760K
770K
17
18
Timeline for COHBE Solution Selection Process
Iterative w/ CCIIO for Review and Comments
12/01
01/23
12/15
Begin formal
Acquisition
Process
Define Acquisition
Strategy and
Gather Requirements
Draft RFP
Review RFP
(Board)
RFP
Approved
for
Release?
RFI and Other
Information
Gathering
•
•
•
•
•
•
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Develop Vendor
List
A
03/19
Approx 10 days
Conduct System
Demos and Orals
w/ Finalists
Release RFP
Approx 30 days
Vendors
Prepare & Submit
Proposals
Approx 5 days
Approx 5 days
Approx 5 days
Finalists Develop
BAFOs
Evaluate
BAFOs
Approx 15 days
Evaluate
Proposals
(Technical & Cost)
Select Preferred
Vendor(s)
Down Select to
2-4 Finalists &
Notify Vendors
04/15
Negotiate w/
Preferred
Vendor(s)
A
Conduct
Reference Checks
for 2-4 Vendors
Evaluate:
Software solution
Hosting
Services
Costs
Skills/qualifications of vendor
Skills/qualifications of proposed team
Implementation approach and methodology
04/02
Develop BAFO Guidance
(for each vendor) &
Transmit to Finalists
03/09
02/27
Award
05/07
Draft Statement
0f Work
Project Kick-off
19
Key Elements of Acquisition Strategy:
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Three core areas (system, hosting/IT ops, administrative services) w/
system acquisition as an option
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Teaming OK but single point of accountability, i.e. “prime” contractor
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Fixed-price by scope element
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Strict adherence to SLAs w/ material penalties for non-performance
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At least one team member in healthcare exchange business for five
years
Need direction from Committee:
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Asset acquisition as an option for COHBE (is this a “must” for bidders,
i.e. if they will not agree to license solution will proposal be rejected?)
•
Three-year operating agreement with five (5) one-year options?
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Call center operations (and jobs) shall be located in CO?
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Other TBD
20
Analysis and Scoring of Proposals
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Solution Fit/Coverage and Gaps – single vendor or teaming arrangement must
provide required system and services that constitutes entire solution
•
Experience and Wherewithal of Vendor in Exchange Space and Knowledge of
Healthcare Reform
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Company Qualifications and Resources (Corporate and Proposed Project Team)
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Cost (implementation, 3-Year, Option Years)
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Strategic Fit
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Partnership Fit
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References
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Exceptions to Proposed Contract Ts & Cs
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Other Factors TBD
Beyond meeting minimum requirements, weighting matters; will propose
approach to weighting later, i.e. during evaluation team orientation (mid-Feb)
21
Outline of RFP:
1.
2.
3.
4.
5.
Purpose of RFP, Vision, Concept of Operations
COHBE Background
General and Administrative Procurement Information and Timeline
Scope of Implementation and On-going Services
Proposal Response – System, Implementation Services, On-going
Operations and Administrative Services:
•
•
6.
7.
Solution Proposal (business, technical)
Cost Proposal (cost model will be provided ; line items broken down between
implementation and on-going costs to insure ability to accurately compare costs)
Proposed Contract Terms and Conditions
Appendices:
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Appendix A – Business Process Models
Appendix B – Business Requirements (functional, technical)
Appendix C – Interoperability with State Medicaid Systems and Business Processes
Appendix D – Reporting and Business Intelligence
Appendix E – Technical Architecture
Appendix F – Operations, SLAs, and Continuity of Operations
Appendix G – Interfaces
Appendix H – Conversions
Appendix I – Deliverables
Appendix J – Turnover
22
Evaluation Committee
•
Seeking volunteers to participate in COHBE vendor selection; crucial
decision which can only be made once (for several years); leverage
experience and perspective of diverse group will lead to better decision
•
Duties and time commitment:
•
Review and rank proposals using evaluation sheets provided; note areas
of concern, be available to discuss evaluation and proposal rankings (need
to be able to review all qualified proposals)
•
Depending on number of quality proposals received likely 40 hours during
first two weeks of March
•
Demonstrations/orals likely 20 hours in late March
•
BAFO review and recommendation 16 hours in early April
23
Legal services needed to support acquisition
process and timeframes services will be required
•
Develop initial contract for acquisition of Exchange system and
services to include in RFP – 01/03 – 01/13
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Review and advise re vendors’ responses/exceptions to
proposed contract – 03/03 – 03/09
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Advise on how to ensure information provided during
demos/orals/discovery sessions and BAFO becomes binding –
03/19 – 03/24
•
Participate in contract negotiations 04/06 – 04/15
•
200 – 300 hours estimated for legal services to support
acquisition process
24
25
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
26
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?
27
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
28
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
Provide links to non-medical eligibility processes and pre-populate with data
previously collected during medical eligibility processes
Interfaces
•
To MMIS for automatic enrollment for Family medical and CHIP
•
To CBMS for eligibility determinations for all other medical programs
Maximum level of systems interoperability:
•
•
Shared rules engine
Single entry point (portal)
29
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
Interface from Exchane to
MMIS for no touch for Family
Medical and CHIP enrollment
Shared rules engine *
* has other implications
X
X
X
X
X
X
X
X
X
X
X
30
Use Cases, expected populations 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
31
•
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
Account Management
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
Brokers
SHOP Employers
Brokers and
SHOP Employees
SHOP Employer
Broker or
SHOP Employee
Small Employers
and Employees
Eligibility Determination
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
Broker Accesses CHOBE
Broker Tools and Authorized
SHOP Employer Information
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
Operations
Yes
Carrier Systems
Coverage?
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 Eligible
(Defined Contribution)
for Employee Only or
Employee Household
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
Rqmt #
Rules Engine
Cascading Eligibility
May receive assistance from:
· Navigator/Broker/Agent
· Case worker
· Community-based worker
· Volunteer(?)
CUE
CUE4
Show SHOP Employee
Eligibility for any
Additional Medical
Benefits (Public or Private)
CHIP Eligible
Children?
Does SHOP
Employee /Individual
Want to Enroll
Children
in CHIP?
Yes
Hotline
Calculator
Medicaid/CHIP Eligibility
Screening
Standardized Enrollment
CUE5
Yes
Automatically Enroll
Eligible Children In
CHIP
Less than 133% PL
Paper
Application
Federal
Data Hub
Likely Eligible for
Medicaid/SCHIP
Rules Engine
Cascading Eligibility
Interface to HHS Data
Hub SSA, IRS, HHS,
DHS
Individual and Household
w/ Income
between
133% and 200% PL
180K
CHIP
CUE4
Individuals/
Households
350K
between 133% – 400% PL
SHOP
PC2
Based on application
information
business rules make
determination re eligibility for
Medicaid/CHIP or Other
Likely Medical Benefit
CUE1
Individuals/
Households
Individual and Household
w/ Income
May be Eligible for
Medicaid/SCHIP
(Including Expansion)
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
CUE9
No
May receive assistance from:
· Navigator
· County case worker
· COHBE customer service
· Community-based worker
· Volunteer
Healthcare Coverage
Preliminary Eligibility
Determination for Subsidized
Private Coverage
Likely Eligible for
Subsidized 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
Individual
Selects Plan/
Coverage Type
Send Subsidy Transactions
to US Treasury and Carriers
Show total benefit package and
terms and conditions
Collect any additional information
Obtain user acceptance & esignature
Likely Eligible for Other
Medical or Human Services
Programs
Individual completes on-line
application
May be Eligible for
Subsidized Private
(show estimated and nonverified subsidy amount)
Private
Coverage
Medicaid
Call-in
CUE2
Show Individual/Household
Eligibility for any Medical
Benefits (Public or Private)
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
Based on application
information
business rules make
determination re eligibility for
Medicaid/CHIP or Other
Likely Medical Benefit
Account Management
Master Data Management
Requirement Description
Requirement
Exchanges must be able to enroll individuals and small businesses (with up to 100 workers) into coverage in a user-friendly way.
CUE1
CUE6
Enrollment Periods
CUE7
Navigators
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.
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
Consumer Information
Inform consumers of plan quality and enrollee satisfaction ratings.
CUE9
Exemptions
Have the capability to identify, and inform the U.S. Treasury, about consumers who are exempt from the law’s individual
responsibility requirements.
PC
Preliminary Eligibility
Determination for
Medicaid/SCHIP
(show potentially
eligible programs)
Renewal
Approve and process allowable claims on behalf of enrollee
Plan Management
Does Employee
Want to Check
Eligibility for CHIP or
Subsidized Private
Yes
Benefits and Account
SHOP Employee Creates an
Account or Logs In
Employees
CUE7
Premium
Collection/
Aggregation
Provide medical card/proof of insurance when needed
Exchange Only
COHBE or State MMIS
SHOP Employer and/or
Broker Administer
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
SHOP Employer Authorizes
Broker to Access Employee
Information
Individual
Individual
Individual and Household
w/ Income
Insurance Exchange
Marketplace
No
Broker Creates an
Account or Logs In
SHOP
Enrollment
Manage SHOP Employee
Roster & Benefits and
Admin Tools
An exchange must be able to certify that plans sold in the exchange meet a number of standards outlined in the Affordable Care Act.
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).
PC1
Essential Benefits
PC2
Plan Offerings
PC3
Number of Network Providers
PC4
Marketing Standards
PC5
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.
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.
OR3
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.
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
1 Implementing Health Insurance Exchanges, A Guide to State Activities and Choices, Familes USA October 2010
Legend
US Treasury Systems/
Subsidy Payments to Carriers
and Tax Credits for SHOP
Employers
Secure Interface from Exchange
MAGI Eligibility Process to CBMS
CUE
Consumer Usability and Enrollment
Yes
Not Eligible for
Subsidized Private
Coverage
Individual and Household
w/ Income
greater than 400% PL
Rules Engine
Cascading Eligibility
Eligible for SHOP
Effective as of 2014
CUE2
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 CHOBE and PEAK/CBMS
Boundary between CHOBE and PEAK/CBMS
Boundary between CHOBE and PEAK/CBMS
Secure Interface to Exchange/
MAGI Eligibility Process from PEAK
Visit County Office
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/or SNAP
and/or TNAF and/or other
Federal and State programs
Enroll Individual/Family Members in
MMIS
Send Medical
Cards
MAXIMUS employee enters
application and notifies client
Mail Application
Into HCPF
Processing Center
Call Center and Customer Assistance
Track Enrollment and Changes to Enrollment
KEES Integration with Federal
Exchange
Version 2.0
September 25, 2011
Gary Schneider
32
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
33
•
Analysis of Alternatives – table showing feasibility against
34
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
35
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
36
& CBMS not shown
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.
37
• Scope and Key Elements of Procurement
• Acquisition Strategy – prime contract (hosting and administrative
services) with option for COHBE to license exchange IT solution
• Recommended level of Interoperability w/ State Medical Systems
and Business Processes
• Acquisition Process and Timeline
• RFP Outline and Proposal Evaluation Criteria
• Evaluation Committee Participation
• Release of RFP Prior to Award of Level 1 Funds
38
Date
11/28 Board
Meeting
Topic of Meeting
Present decision, decision framework, approach
and timeline to Board.
Objective/Decisions/Issues
Can Acquisition of Exchange system(s)
and services proceed prior to award of
the Level 1 grant?
Impact on Next Steps
Sequential process of issuing
RFP/RFQQ after 02/15/12 will likely
reduce implementation time by
approximately 1 month.
Week of 11/28
Present Acquisition process (what/why/when),
timeline, options and highlights from vendor indepth demos and RFI process.
Concur with Acquisition process, options
and timeline.
Plan out remaining activities leading
up to issuance of RFP/RQQ.
Week of 12/05
Present preliminary results of analysis of SAAS
vs. asset acquisition.
Informational.
Ensure that Committee understands
trade-offs.
12/12
Board Meeting
Present results of analysis of SAAS vs. asset
acquisition to Board and associated Acquisition
strategies.
Key asset acquisition decisions.
Strategy and detailed timeline for
systems and services acquisition
needed to proceed.
Week of 12/12
Present outline of RFP/RFQQ, key requirements,
etc., i.e. Acquisition and evaluation guide.
Concur with direction of Acquisition. Will Draft acquisition documents.
Board members serve on acquisition
evaluation team(s)?
Week of 12/19
TBD or catch-up or schedule adjustment.
Week of 01/02
Review draft acquisition documents.
Will likely need turn-around in one week
and approval to present to full Board.
Can draft documents be provided to
federal sponsors for review?
01/09
Board Meeting
Provide final draft of acquisition documents to
full Board.
Will likely need turn-around in one week. Incorporate comments and finalize.
01/23
Board Meeting
Motion to release RFP(s)/RFQQ(s).
Approval of Board to release
RFP(s)/RFQQ(s).
Week of 01/23
Release RFP(s)/RFQQ(s).
Incorporate comments and provide
final draft to full Board.
39
40
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.
41
•
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
42
1. Should the Exchange use a SAAS model or acquire (borrow/build/buy)
the capital IT Exchange assets?
2. What is the “optimal” level of “interoperability” and coordination with the
State’s Medicaid/CHIP systems, business processes and existing
customer support services?
3. With respect to #2, does the State intend to upgrade or replace CBMS so
that near-term investments to modify CBMS and PEAK to meet the
requirements of healthcare reform are rationalized against the State’s
strategic direction?
43