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Colorado Health Benefits Exchange
IT and Implementation Committee Strategic IT Decisions
December 21, 2011
Overview
• On-going Activities
• SHOP Business Development and Operations
• Option for Ownership of Call Center/Customer Support Assets
• Plan Shopping and Enrollment Interoperability
• Additional Information from RFI Process
• Evaluation Committee
• Next Steps
2
3
On-going Activities
4
On-going Activities
• 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
5
SHOP Business Development and Operations
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SHOP Business Development and Operations
• Three risks associated with the SHOP:
• Market risk
• Performance risk
• Schedule risk
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SHOP Business Development and Operations
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)
8
SHOP Business Development and Operations
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
9
SHOP Business Development and Operations
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
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SHOP Business Development and Operations
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)
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SHOP Business Development and Operations
Solution Set Individual Solution Component Required Bundling
Individual Exchange1.A Individual Exchange Application, Maintenance and Support1.B Individual Exchange Application Hosting and Support
1.A, 1.B and 1.C must be bid together
Individual Exchange Development and Services
1.C Individual Exchange Services, Training & Outreach
SHOP Exchange2.A SHOP Exchange Application, Maintenance and Support2.B SHOP Exchange Application Hosting and Support
2.A and 2.B must be bid together
SHOP Exchange Development and Services
2.C SHOP Exchange Development, Administrative Services, Training and Outreach
If a bidder responds to 2A./2. B then the bidder must also respond to 2.C2.C may be bid independent of all other solution components
Proposed table for RFP showing bundling/unbundling of solution components
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Option for Ownership of Call Center/Customer Support Assets
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Option for Ownership of Call Center/Customer Support Assets
• 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
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Enrollment “Interoperability”
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CBMS/PEAK &Medicaid/CHIP Eligibility & EnrollmentBusinessProcesses
COHBEEligibility & EnrollmentSystemsand BusinessProcesses
InteroperabilityBetween COHBE& State Medicaid/CHIP Systemsand Business Processes
• Single/shared MAGI eligibility process for Private Insurance and Medicaid/CHIP
• Single sign-on• Comprehensive MPI (Exchange and Medicaid/CHIP population)• Data only entered once• Request only information needed for determining eligibility for
healthcare• Maximize “no touch” eligibility adjudications • Interface from PEAK to MAGI process to support “no wrong door”
requirement for medical eligibility• Provide links to non-medical eligibility processes and pre-populate with
data previously collected during medical eligibility processes
Plan Shopping and Enrollment Interoperability
Minimum level of interoperability as discussed at last meeting
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Plan Shopping and Enrollment Interoperability
• 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
17
Small Business Owners& Employees
IndividualHouseholds &Small BusinessEmployees
IndividualHouseholds(seeking public assistance,i.e. Medical, Food
or Cash Assistance)
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
Select Plan & Enter Enrollment Information
Eligible for Employer Plan &
Amount of Coverage
Interface Enrollment
Information to MCO Systems
Minimal Interoperability
HouseholdMember(s) Eligible for
Medical or HS Programs
Boundary between COHBE and State Systems
Boundary between COHBE and State Systems
Plan Shopping and Enrollment Interoperability
Eligibility Interoperability
Shopping and Enrollment Interoperability
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Plan Shopping and Enrollment Interoperability
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
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Plan Shopping and Enrollment Interoperability
• 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)
20
Call Center Interoperability – TBD
“Optimal” Level of “Interoperability” with State Medicaid/CHIP Systems and Business Processes
21
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 critieria
22
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.
23
Additional Information from RFI Process
24
Company Respondents
End-to-EndSolution
Exchanges OperatingModel
Current Clients
Partners MAGI Rules engine
ACS/Choice/Benefitfocus Yes Individual &
SHOPSaaS only
FL, NJ, CT, VA Insurance companies, employers, education
systems
Choice Admin Benefitfocus
Implements with an
independent rules engine
custom – proprietary
Connecture/MAXIMUS
Yes Individual &SHOP
license & SaaS
CA, TX, CO, IA, NY MAXIMUS (prime) designing for MN
prototype
open source
Getinsured.com Yes Individual &SHOP
license & SaaS
MS Accenture No Drools Flow (jBPM5)
CGI Yes Individual & SHOP
license & Saas
Federal Exchange, New England states, UT, CMS, CCIIO;
hCentive, Exeter, Policy Studies
(PSI)
Yes COTS – HIE360
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 TPA, premium
aggregation
pmpm 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
25
Evaluation Committee
26
Evaluation Committee
Proposed Committee members:
1. Patty Fontneau COHBE - ED2. Shawn Raintree COHBE - Staff3. Myong KimCOHBE - Staff4. Nathan Wilkes COHBE - Board5. TBD Technology Company Executive6. TBD OIT7. TBD HCPF8. TBD DOI
Support Staff:
• Gary Schneider COHBE – GMS • Chuck FishCOHBE – GMS • Larry Redd COHBE – GMS • Craig TobinEventus• Kevin Appleton Eventus
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Next Steps
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Next StepsRFP
Work with Eventus:• Sample contract terms and conditions• Call center/customer support scope, SLAs, etc.• Pricing worksheets
Work with HCPF:• Interoperability (interfaces, security)
Complete Appendices• Appendices (business processes, requirements, volume metrics, BI)
Reflect decisions from today in RFP
Plan to complete first draft 12/28 and make available for 1st review cycle
Wrap-up vendor demos & RFI
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Background Material
COHBE Implementation and Start-up Timeline
30
Note: 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 Testing
Design/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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32
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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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 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
Solution Cost Estimate – Cost Drivers 2 of 3
Solution Cost Estimate – Cost Drivers 3 of 3
34
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
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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