Colorado Health Benefits Exchange

1

Colorado Health Benefits Exchange

IT and Implementation Committee Strategic IT Decisions

December 14, 2011

Overview

• 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

Discussion points from 12/12 Board meeting

4

Discussion points from 12/12 Board Meeting

• 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

5

“Optimal” Level of “Interoperability” with State Medicaid/CHIP Systems and Business Processes

6

What is the “optimal” level of “interoperability” and coordination with the State’s Medicaid/CHIP systems, business processes and existing customer support services?

CBMS/PEAK &Medicaid/CHIP Eligibility & EnrollmentBusinessProcesses

COHBEEligibility & EnrollmentSystemsand BusinessProcesses

InteroperabilityBetween COHBE& State Medicaid/CHIP Systemsand 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


7

Small Business Owners& Employees(% and # expected)

IndividualHouseholds &Small BusinessEmployees(% and # expected)

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

(% and # expected)

Pre-screening

SHOPExchange

PEAK

IndividualExchange

Account Mgmt & MPI

EligibilityDetermination

Plan Selection &Enrollment

MAGI(including interfacing w/ federal data hub)

Set-up Employee Roster

Create Account

MMISCBMS

Should Pre-Screening Step be

Included?

Enrollment inCarrier Systems

Create Account

Review Subsidy/Out-of-Pocket Costs

Select Plan & Enter Enrollment Information

Interface Enrollment

Information to Carriers’ Systems

Review Out-of-Pocket Costs


Eligible for Employer Plan &

Amount of Coverage


Information to MCO Systems

Moderate Interoperability – MAGI & MMIS Interface

Does CBMS Need Enrollment Data?

Enroll Eligible HouseholdMembers into Family

Medical Program into MMIS

HouseholdMember(s) Eligible for Other

Medical or HS ProgramsState Systems

COHBE Systems

8

What is the “optimal” level of “interoperability” and coordination with the State’s Medicaid/CHIP systems, business processes and existing customer support services?

Gather business requirements

Gather technicalrequirements

Define interoperability “musts”” for 2013

including ACA

Prioritize all interoperability

requirements, i.e. musts, strong wants, nice wants (and who)

Develop 3 options with increasing levels of

interoperability, complexity, risk, costs, etc.

Define design alternatives (functions and feature sets

for each option)

Evaluate feasibility of design alternatives

Test use cases for impact on consumer considering design principles, guiding principles and best practices

Compare feasible alternatives against criteria;

make recommendation

Draft/Negotiate Deloitte SOW

Requirements Musts Strong Wants Nice Wantsa Xb Xc Xd Xe Xf Xg Xh Xi Xj Xk Xl X

Prioritization of RequirementsRequirements Option 1 Option 2 Option 3

a X X Xc X X Xj X X Xb X Xe X Xg X Xk X Xd X Xf Xh Xi Xl X

Tiered Sets of Requirements

“Musts”

Strong “Wants”

Nice “Wants”

Draft & Submit IAPD

Small Business Owners& Employees(% and # expected)

IndividualHouseholds &Small BusinessEmployees(% and # expected)

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

(% and # expected)

Pre-screening

SHOPExchange

PEAK

IndividualExchange

Account Mgmt & MPI

EligibilityDetermination

Plan Selection &Enrollment

MAGI(including interfacing w/ federal data hub)

Set-up Employee Roster

Create Account

MMISCBMS

Should Pre -Screening Step be

Included?

Enrollment inCarrier Systems

Create Account

Review Subsidy/Out-of-Pocket Costs



Information to Carriers’ Systems

Enroll Eligible HouseholdMembers into Family Medical

Program Into MMISWho pays for this interface ?

Review Out-of-Pocket Costs


Eligible for Employer Plan &

Amount of Coverage


Information to MCO Systems

Moderate Interoperability – MAGI & MMIS Interface

Does CBMS Need Enrollment Data?

Define scope for Exchange System(s) and Services

(RFP/RFQQ)

Define scope for modifications to PEAK &

CBMS

Begin Formal Exchange Acquisition

Process

Approach to Determining Optimal Interoperability Strategy

“Optimal” Level of “Interoperability” with State Medicaid/CHIP Systems and Business ProcessesInteroperability System and Business Process Alternatives• Minimum level of systems interoperability (from design principles,

guiding principles and best practices):• 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

• Moderate level of systems interoperability:• Interfaces

• TBD

• Maximum level of systems interoperability:• TBD

9


Tiered Sets of Requirements

10

Interoperability Feasibility Criterion Minimum Moderate MaximumCommon "no touch" MAGI eligibility X X X

No "wrong door" X X XShared MPI and Account Management X X XNo data entered more than 1x; re-use data X X XDo not ask for data not relevant to medical eligibility X X X

Meet all minimum ACA reqs X X X

Shared call center XSame carriers for some private and public plans XInterface PEAK to Exchange for MAGI Eligibility X XLink and data population Exchange MPI to PEAK X XInterface Exchange to CBMS for other medical and human services X XTBD X XTBD X

Interoperability LevelImpact on Exchange RFP

Example Only


Analysis of Alternatives – use cases and preliminary estimate of populations

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ComboSubsidized Private

Unsubsidized Private

Medicaid CHIP

Employee-Only SHOP

Spouse SHOP

All-Family SHOP

TANF Food Stanps

People 1000s

1 X 300Currently buying private insurance

2 X X 382Unemployed uninsured with children plus 1/2 public insured

3 X X 100One fourth of expected small firm participants

4 X X X 100One fourth of expected small firm participants

5 X 100One fourth of expected small firm participants

6 X 300

Currently unemployed w/private insurance plus 1/2 public insured

7 X X 100One fourth of expected small firm participants

Pre

limin

ary


Use Cases and interoperability considerations

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System Entry Point

Use Case Construct

Household Composition

Use CasesPopulation

Account Mgmt/MPI/M

AGI

PEAK Interface MMIS Interface CB MS Interface Carrier Plans (MCOs)

Call Center Rules Engine Other

COHBE Individual Household

Eligible for subsidy

TBD expected to be >200K

Y N/A N/A N/A N/A Y

Not eligible for subsidy

TBD Y N/A N/A N/A N/A Y

SHOPSingle person TBD Y N/A N/A N/A N/A YChildless couple TBD Y N/A N/A N/A N/A YFamily including children

TBD Y N/A N/A N/A N/A Y

Program Eligibility

PEAK/CBMSFamily Medical Eligible for

Family MedicalTBD expected to be > 300K

Y Y Y N Y Y Y

CHIP Eligible for CHIP TBD Y Y Y N Y Y YLong Term Care Eligible for LTC TBD Y Y N Y Y not in COHBE Y YDisability Eligible for

DisabilityTBD Y Y N Y Y not in COHBE Y Y

TNAF Eligible for TNAF What is intersecting population?

Y N N N N/A Y Future

SNAP Eligible for SNAP What is intersecting population?

Y N N N N/A Y Future

CHIPEligible

Eligible forSubsidizedPrivateCoverage

What is this population? CHIPEligible

Eligible forSHOPCoverage

What is this population?

Carrier Systems

Individual and Household w/ Income

Less than 133% PL

Individual and Household w/ Income between

133% and 200% PL


between 133% – 400% PL

User Enters:- Resident of KS- Zip Code- Age- Family or Individual- Income- SHOP ID- Excemptions

Yes

Preliminary Eligibility Determination for Medicaid/SCHIP(show potentially eligible programs)

May be Eligible for Medicaid/SCHIP

(Including Expansion)

Preliminary Eligibility Determination for Subsidized

Private Coverage(show estimated and non -verified subsidy amount)

Business Objective for Each Process

SHOP Employee completes on -line application to capture any additional required information(pre-populate to max extent possible )

May receive assistance from:· Navigator/Broker/Agent· Case worker· Community-based worker· Volunteer(?)

Likely Eligible for Medicaid/SCHIP

Individual Creates AccountIn COHBE

Likely Eligible for Subsidized Private

Coverage

Not Eligible for Subsidized Private

Coverage

SHOP Employee Presented Plans Based on Eligibility and Search CriteriaDisplay 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

Based on application information

business rules make determination re eligibility for

Medicaid/CHIP or OtherLikely Medical Benefit

Individual Presented Private Coverage Eligibility and Search CriteriaDisplay Benefit , Out-of-Pocket Cost, etc.Present Medicaid/CHIP plans if available (and provide search capabilities ) based on:

· Location· Network· Costs/Co-pay· Benefits· Specialties· Other

COHBE and HCPF End-to-End Solution – Preliminary High Level Business Process and Systems Model

Initial Screening Account Management Eligibility Determination

Plan Management

Insurance Exchange Marketplace

Eligibility

Approval Fulfillment OperationsPremium

Collection/Aggregation

Determine if individual wants to see if he /she qualifies for financial assistance, i.e. Medicaid/CHIP or subsidized private coverageCollect 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 hubIndividual enters required information , creates password, answers challenge questions, etc.

RenewalPlanSelectionBusiness Processes

Core ExchangeFunctions

Enrollment

Interface to HHS Data Hub SSA, IRS, HHS,

DHS

Individual Selects Plan/

Coverage Type

Show total cost and cost breakdown and terms and conditionsCollect any additional informationObtain user acceptance & e-signatureProcess financial transaction (if applicable)

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.)

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.)

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

Send Subsidy Transactionsto US Treasury and Carriers

Approve AssignmentsAssign Individual/Family Members to

Pools

SHOP Employee

Selects Plan/Coverage Type

Show total benefit package andterms and conditionsCollect any additional informationObtain user acceptance & e-signature

Enroll Individual/Family Members in MMIS

Provide medical card /proof of insurance when needed

Approve and process allowable claims on behalf of enrollee

US Treasury Systems/Subsidy Payments to Carriers

and Tax Credits for SHOP Employers

Call Center and Customer Assistance Track Enrollment and Changes to Enrollment

Effective as of 2014Main 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 .

Guaranteed-issue health insurance coverage – which ensures that individuals are not denied coverage or forced to pay higher premiums because of pre -existing 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 .

Rqmt # Requirement Requirement Description

CUE

CUE1 Web Portal Implement a web portal where consumers and businesses can view coverage opt ions, with benefits and costs presented in a standardized format.

CUE2 Hotline Operate a toll-free hotline for consumer assistance.

CUE3 Calculator 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;

CUE4 Medicaid/CHIP Eligibil ity Screening

Be able to screen eligibil ity for, and enroll people in, Medicaid, the Children’s Health Insurance Program (CHIP), and other public programs.

CUE5 Standardized Enrollment Use a standardized enrollment form for coverage.CUE6 Enrollment Periods Provide for an initial enrollment period as well as annual and special enrollment periods.

CUE7 Navigators Establish “navigators”—individuals or entit ies 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 ExemptionsHave the capability to identify , and inform the U.S. Treasury , about consumers who are exempt from the law’s individual responsibility requirements.

PC

PC1 Essential Benefits Coverage for a federally determined essential benefit s package (as well as any other benefits the state requires) in a plan that has the required out -of-pocket caps;

PC2 Plan Offerings

The offering of only specified tiers of coverage: bronze, silver, gold, and plat inum. 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).

PC3 Number of Network Providers Availability of an adequate number of providers in the plan’s network , including providers that serve predominantly low -income, medically underserved individuals (where applicable).

PC4 Marketing Standards Marketing standards.PC5 Quality and Accreditat ion Specified quality, quality improvement, and accreditation standards.

PC6 TransparencyTransparency 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 part icipate).

OR

OR1 Stakeholder Participation

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.

OR2 TransparencyExchanges must publish specified financial information for public inspection and must undergo annual audits by the Secretary of Health and Human Services.

OR3 Financial StabilityExchange 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.

Actual Source

1 Implementing Health Insurance Exchanges, A Guide to State Ac tiv it ies and Choices, Familes USA Oc tober 2010

Legen d

CUE Consumer Usability and Enrollment

Exchanges must be able to enroll individuals and small businesses (with up to 100 workers) into coverage in a user-friendly way.

An exchange must be able to certify that plans sold in the exchange meet a number of standards outlined in the Affordable Care Act.

Additionally, Exchanes must meet these additonal requirements.

High-Level Requirements

Paper Application

Rules EngineCascading Eligibility


Carrier Operations and Backoffice Functions

Aggregate information and transactions

Enroll Individual /Family Members in Carrier Plans

COHBE Only COHBE or State MMIS

Call-in

CUE1

CUE3

CUE3

CUE4

CUE6

CUE7

CUE8

CUE9

CUE2

CUE2

Individual

Plan Selection is the action of selecting a plan in the Marketplace

SHOP

Plan Management is the processes to get State -approved QHP from carrier systems into the Exchange

Account ManagementMaster Data Management

Send MedicalCards

Send MedicalCards

KEES Integration with Federal Exchange

Version 2.0 September 25, 2011

Gary Schneider

Individuals/Households


greater than 400% PL

Enrollment Financial Management

Tax Credits and Advance Payment of Premiums

Aggregation of Premiums

Plan Management

Approve and Load QHP

Aggregate information and transactions

PC2

Federal Data Hub

Boundary between COHBE and PEAK/CBMS

SHOP Employers Brokers and

SHOP Employees

SHOP Employee Eligible (Defined Contribution) for Employee Only or Employee Household

PC2

SHOP

Small Employersand Employees

SHOP EmployerBroker or

SHOP Employee Employers

Employees

SHOP Employer Creates anAccount or Logs In

Brokers

Broker Creates anAccount or Logs In

Broker Accesses CHOBE Broker Tools and Authorized SHOP Employer Information

SHOP Employer AuthorizesBroker to Access Employee

Information

Manage SHOP Employee Roster & Benefits and

Admin ToolsManage 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.

Broker Accesses CHOBE Broker Tools and Authorized SHOP Employer Information

COHBE & State SystemsCOHBE & State Systems

SHOP Employee Creates anAccount or Logs In

SHOP Employer and/or Broker Administer

Benefits and Account

Does Employee have

Household Family Members Who are

Not Covered?

COHBE and PEAK Entry Points

(Portals)

Yes

Does EmployeeWant to Check

Eligibility for CHIP or Subsidized Private

Coverage?

No

Yes

Individual completes on -line application

May receive assistance from:· Navigator· County case worker· COHBE customer service· Community-based worker· Volunteer

Show SHOP Employee Eligibility for any Additional Medical Benefits (Public or Private)

Show Individual/Household Eligibility for any Medical Benefits (Public or Private)

Based on application information

business rules make determination re eligibility for

Medicaid/CHIP or OtherLikely Medical Benefit


Yes

Does SHOP Employee /Individual

Want to Enroll Childrenin CHIP?

CHIP EligibleChildren?

350KSHOP/Financial

AssistanceYes or No

Eligible for SHOP

Individual

May be Eligible for Subsidized Private

Healthcare Coverage

No

PEAKMMIS

CBMSCounty case worker entersapplication and interviews client

Individual and Household seeking public assistance for

Medical and/or SNAP and/or TNAF and/or other

Federal and State programs

Visit County Office

Mail ApplicationInto HCPF

Processing Center

MAXIMUS employee enters application and notifies client

Secure Interface to Exchange/MAGI Eligibility Process from PEAK

CBMS determine eligibility for non-MAGI population and other

human services programs

Secure Interface from ExchangeMAGI Eligibility Process to CBMS

Exchange Only

Administer/Pay Claims

PrivateCoverage

Boundary between COHBE and PEAK/CBMSBoundary between COHBE and PEAK/CBMS

CUE4

Call Center and Customer Assistance Track Enrollment and Changes to Enrollment

Enroll in selected plan

Yes


• Storyboard shows moderate level option of interoperability

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“Optimal” Level of “Interoperability” with State Medicaid/CHIP Systems and Business ProcessesInteroperability System and Business Process Alternatives

• Shared call center with HCPF• Four types of calls anticipated:

1. Exchange call center – eligibility, site, information, assistance, billing, etc.2. State Medicaid call center (MAXIMUS) – eligibility, claims, etc.3. Carrier call center – policy questions, claims, etc.4. 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. 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

14


15

Alternative Description/Approach

CostConsumer 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

Implementation Costs

(federal & SGF)

5-Year Operational

Costs (federal & SGF)

Minimum 2013 Interoperability

Moderate 2013 Interoperability

Maximum 2013 Interoperability

2015 Interoperability

Analysis of Interoperability Alternatives – feasibility of alternatives versus critierai

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Interoperability Decision CriteriaConsumer 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 appropriateReliability/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 processesReliability/Backend Complexity of Having All Solution Components Fully Functioning- Leverage and integrate with the other systems w/o reducing reliabilityPrivacy and Security- Leverage and integrate security, i.e. account management and MPI- Minimize proliferation and transmission of PIICost- 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 budgetStrategic 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 futureStakeholder Acceptability- Recognize limitations of interoperability given political realities, funding constraints, etc.

17

Additional Information from RFI Process

State RFP’s – Vendor Input

• 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

All state-run procurements.

COHBE RFI summary

19

Company Respondents

End-to-End

Solution

Exchanges OperatingModel

Current Clients

Partners MAGI Rules engine

ACS/Choice/Benefitfocus Yes Individual &

SHOPSaaS only

FL, NJ, CT, VA Insurance companies, employers, education

systems

Implements with an

independent rules engine

custom – proprietary

Connecture/MAXIMUS

Yes Individual &SHOP

license & SaaS

CA, TX, CO, IA, NY MAXIMUS (prime)

designing for MN

prototype

open source

Getinsured.com Yes Individual &SHOP

license & SaaS

MS Accenture No Drools Flow

(jBPM5)

CGI Yes Individual & SHOP

Individual & SHOP

license & Saas

Federal Exchange, New England states, UT, CMS, CCIIO;

hCentive, Exeter, Policy Studies (PSI)

Yes COTS – HIE360

Vendors w/ partial solution

BenefitMall No SHOP

SaaSpmpm

CO – Anthem BCBS MD – CareFirst BCBS

CO broker – Jim Sugden

MD – Dell, Oracle,

Cognascante

No No

Ceridian No Individual SaaS only(?)

130,000+ using payroll & benefit mgmt services

Solution works with a number of

structures

No custom

eHealth No Individual SaaS only Mass HealthConnector Florida w/Ceridian

Deloitte (MN & WA)Support – Ceridian

No No

COHBE RFI Summary

• 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

Background Material

RFP Workplan

22

RFP Section Key Points/Direction Lead Assist Other Reviewers Materials Draft Complete

1. Purpose of RFP, Vision, Concept of OperationsWhat/Why/How from 30K ftBenefits and what we're trying to accomplishNeed to contain costs for sustainability

Gary Chuck, Larry Myong, Shawn, Patty Business ConceptSB 200

15-Dec

2. COHBE Background Information on entity and mission Gary Shawn Myong, Shawn Business ConceptSB 200 15-Dec

3. General and Administrative Procurement Information and Timeline

Structured defined procurement processTimeline set for procurementShow timeline for project (SHOP and Individual)

Gary Chuck, Larry HCPF Procurement Officer

Briefings

16-Dec

4. Scope of Implementation and On-going Services

Define scope for core areasDefine populationsSystem implementationSystem support and maintainanceSystem hosting and operationsOptional application licensing

Gary Chuck, Larry Shawn, Patty KS RFP/BAFOPopulation estimates from CHI, Gruber, etc.

16-Dec5. Proposal Response – System, Implementation Services, On-going Operations and Administrative Services:

Very prescriptiveResponse format to be structured and consistent


KS RFP/BAFO

16-Dec

5.1 Solution Proposal (business, technical)Vendor description of how solution will function from business and technical perspective

Gary Chuck, Larry Shawn KS RFP/BAFO

19-Dec

5.2 Cost Proposal

Cost templates will be provided ; line items broken down between implementation and on-going costs to insure ability to accurately compare costsOperations for 1,3,5 yearsAttempt to segment between technology and labor (services)For pmpm cost risk use ranges on bid schedulePopulation metrics and pmpm ranges

Chuck Larry, Gary Shawn, Patty Gary to provide starting ptSee KS and MD cost schedules

16-Dec

6. Proposed Contract Terms and Conditions MD's approach to addressing uncertainty in ACA final rules


HCPF Ts&Cs15-Dec

7. Appendices:Appendix A – Business Process Models Larry Chuck, Gary Gary has templates 16-Dec

Appendix B – Requirements (functional, technical)

Functional

Chuck - ExchangeLarry - Medicaid

Gary ShawnJim ReiseburgChris/Antoinette

Gary has starting set

16-Dec

TechnicalGary Sherri Gary has starting set

16-DecAppendix C – Interoperability with State Medicaid Systems and Business Processes

Chris/Antoinette/ Jenny/Deloitte

HCPF work16-Dec

Appendix D – InterfacesBuild small table Larry Gary Chris/Antoinette/

Jenny/DeloitteHCPF workGary will provide format 16-Dec

Appendix E – Conversions

PEAK and CBMS into single account management for single sign-onWhat State systems involved?Need to make sure this is possible

Larry Gary Chris/Antoinette/ Jenny/Deloitte

HCPF workGary will provide formatMay need help from Jeff Mitchell 16-Dec

Appendix F – Reporting and Business Intelligence

Need to get starting set of Exchange metrics ASAPReach out to MA and UT, Brokers, Carriers, Providers, Health Foundations

Chuck Larry,Gary Shawn, Patty Look in CALT

16-Dec

Appendix G – Technical Architecture

Standards Gary Jeff Mitchell Eric/Nathan/Sherri COHBE RFIMD RFPKS RFPKS EI grant app 18-Dec

Appendix H – Operations, SLAs, and Continuity of Operations

Consider graded cost approach Gary Chuck Eric/Nathan/Sherri KS RFP/BAFO19-Dec

Appendix I – Deliverables Balance granularity w/ control Gary Chuck, Larry Shawn, Patty KS RFP/BAFO 13-DecAppendix J – Turnover Ensure data turnover as per Sherri Gary Jeff Mitchell Shawn, Patty KS RFP/BAFO 13-Dec

COHBE RFP Gamplan

COHBE Implementation and Start-up Timeline

23Note: Accompanying timeline for required enhancements to PEAK

& CBMS not shown

Analysis/Confirmation of Current Approach & Prel

RFP

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

Procure IT Systems & Services for HIX

COHBE Certificationby HHS

11/11 01/12 03/12 05/12 07/12 09/12 11/12 01/13 03/13 05/13 07/13

2011 2012

HIXIntegration Testing

Design/Build/Test HIX Systems (Eligibility/Enrollment/Plan Mgmt and Associated Services Interface w/ Federal Data Hub, Other Data Sources, MMIS, PEAK/CBMS)

2013

Policy & BusinessDecisions and Activities

HIX - IndividualPilot Phase06/13 – 10/13

HIX Deployment

Policy & Business Decisions

Impacting IT

Supreme CourtRuling on Mandate

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

Start-up and Operational Decisions

Start-up Activities

Operational Activities

Analysis/Confirmation of Current Approach & Prel

RFP

IT/Systems

Procure IT Systems & Services for HIX

HIX SHOPIntegration TestingDesign/Build/Test HIX Systems for SHOP

HIX - SHOPPilot Phase04/13 – 10/13

HIX Deployment

Establish PMO

Draft COHBE Guiding Principles for Systems and Implementation

Category Guiding Principle

Exchange Functions, Features and Business Processes

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 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.

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Exchange Capability and/or Service Category

Exchange Capability and/or ServiceStrawman Priority for 2013

(depends on “who” is asked)Impact on

Implementation and Operational Costs

High Moderate LowImpact on

Implementation Cost

Impact on Operation

al Costs

Eligibility, Plan Shopping and Enrollment (System)

MAGI eligibility for individuals and households (subsidized coverage and State Medicaid and CHIP) and enrollment

XHigh Moderate

SHOP employee eligibility and enrollment X High ModerateEligibility and enrollment of SHOP employees and their household members in private coverage or State Medicaid and CHIP X High ModerateMulti-dimensional search criteria (network, provider, disease specialty, deductable, co-pay, etc.)

XModerate Moderate

Multi-lingual on-line system High Moderate

Broker-Related Features & Tools (System)

Directory of available brokers and qualifications X Moderate LowAbility for broker to access SHOP employer data X Low LowAbility to develop comparative quotes and to sort information to support recommendations and decision making X Moderate LowAbility for broker to work remotely and one-on-one with employer through the system

X Moderate Low

Plan Management

Interfaces/admin tools and associated services for carriers to load plans into COHBE

X Moderate Low

Admin tools and associated services for regulators to approve plans in COHBE

X Moderate Moderate

Solution Cost Estimate – Cost Drivers 1 of 3

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(depends on “who” is asked)Impact on Implementation and

Operational Costs


Implementation Cost

Impact on Operational Costs

Customer ServiceCall center support for on-line eligibility and enrollment (individual households, SHOP employees)

X Moderate High

Call center support for SHOP employers and brokers X Moderate High

Support for carriers X Low ModerateSupport for regulators X Low LowCall center for Navigators X Moderate HighPrint/mail for notices X Moderate HighMulti-lingual call center support X Moderate HighCustomer support for mail-in applications X Moderate HighCustomer support for walk-in applications X Moderate High

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)

X High High

Aggregated premium billing for SHOP employers X High Moderate

On-line payment service for individuals and SHOP employers & employees (ACH, credit card)

X High High

Flexible spending accounts, health reimbursement accounts, health savings accounts (system and support)

X Moderate High

Managing commissions/ payments to brokers and Navigators (system and services)

X Moderate High



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(depends on “who” is asked)Impact on

Implementation and Operational Costs


Implementation Cost

Impact on Operation

al Costs

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

X High High

Track all consumers/enrollees into and out of plans

Individual homepage and account management (system and services)

X Moderate Low

Wellness program functionality (system and services) X Moderate Low

On-line advertising capabilities (system and services) X Low Low

Electronic content management to store and access electronic documents (notices, receipts, invoices, forms, etc.) X High Moderate

Outreach ServicesPromotion of COHBE to public, Navigators, brokers, etc. X Moderate Moderate

Promotion of wellness programs, enrollment, monitoring, etc. X Low Low

Web and classroom training for brokers, navigators, Counties X Moderate Moderate

Content/resources for consumers, agents, brokers, providers, carriers

X Moderate Moderate

Role of IT and Implementation Committee

• 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

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Colorado Health Benefits Exchange

Documents

states medicaidchip

enrollment business

medicaidchip populationdata

business processes55what

associated state eligibility

magi process

cohbe latitude

rfi process path