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D. PROJECT ABSTRACT SUMMARY Title: New Mexico Level Two Health Insurance Exchange Establishment Grant CFDA #: 93.525 FON #: IE-HBE-12-001 Applicant: New Mexico Health Insurance Exchange (NMHIX) Address: 6301 Indian School Rd. NE Suite 100 Albuquerque, NM 87110 Congressional Districts Served: NM 1, 2, 3 Contact: Amy Dowd, Chief Executive Officer Phone: (505) 314-5300 Fax: (505) 998-3814 Email: adowd@nmhix.com Website: www.BeWellNM.com Category of Funding: Level Two Project Dates for Project Completion: January 1, 2015 – December 31, 2017 Goals for Level Two Establishment Grant Application: New Mexico is applying for a Level Two Health Insurance Exchange Establishment Grant solely to:

Enhance functionality of technology systems after the initial launch to improve the customer shopping experience, including broker notifications and alerts, ability for consumer to select QHP which offers best coverage for consumer’s prescriptions, and a centralized provider directory technology capability.

Cover the additional cost of the recent CMS design changes for enhanced integration with HSD/Medicaid. Please note that this is not rework.

Cover the costs to be incurred as a result of pushing the go-live date of the individual exchange to 10/1/2015.

New Mexico is a hybrid Exchange through 2015 with the SHOP operated by the NMHIX and individual exchange operated by the Federally-facilitated Exchange. NMHIX is in the process of developing its own individual platform to be complete for open enrollment beginning October 1, 2015. NMHIX is working with HSD to develop a CMS-compliant eligibility verification process. This requested funding will allow continued implementation of the NMHIX for the period January 1, 2015 through December 31, 2017. Ongoing maintenance and operations of the SHOP, starting in 2015, and ongoing maintenance and operations of the Individual Exchange, starting in 2016, will not be covered by this grant. Additionally, this grant is requested solely

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for the costs required for IT functionality noted above and will not be used for rework. A total of $97.9 million in funding is requested for this Level Two grant.

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NEW MEXICO HEALTH INSURANCE EXCHANGE LEVEL TWO GRANT TABLE OF CONTENTS

A. STANDARD FORMS (electronic) B. REQUIRED LETTERS OF SUPPORT......................................................................................... 1

LETTER FROM GOVERNOR MARTINEZ…………………………………………………………….……… 1 LETTER FROM NEW MEXICO DIVISION OF INSURANCE…………………………………………. 3 LETTER FROM HUMAN SERVICES DEPARTMENT/ MEDICAID AGENCY………….…….….. 4

C. APPLICANT’s APPLICATION COVER LETTER…………………………………………………………..………… 6 D. PROJECT ABSTRACT SUMMARY…………………………………………………………….……………………… 7 TABLE OF CONTENTS………………………………………………………………………………………………………… 9 ACRONYMS………………………………………………………………………………………………………………..…….. 11 E. PROJECT NARRATIVE………………………………………………………………………………………………………12

a. DISCUSSION OF EXISTING EXCHANGE PLANNING AND PROGRESS…………………….……13 1. Background Research…………………………………….……………………………………........13 2. Legal Authority and Governance…………………………………………….………………..…13 3. Stakeholder Consultation…………..……………………………………..………………………..15 4. Long-term Operational Costs…………………………………………………………….………..16 5. Program Integration…………………………………………………………..……………………….16 6. Business Operations of the Exchange………………………………………………………….17 7. IT Gap Analysis and Exchange IT Systems…………………...………………………………17 8. Reuse, Sharing, and Collaboration……………………………….……………………………..17 9. Organizational Structure…………………………………………….……………………………. 19 10. Program Integrity………………………………………………….…….…..………………………. 24 11. Affordable Care Act Requirements ….…………………….…………………………………. 24 12. SHOP……………………………………………………………………………………………………..….. 24

b. PROPOSAL TO MEET PROGRAM REQUIREMENTS…………………….…………………………… 26 1. Current Exchange Pathway………………………………………………………………………. 26 2. State’s Strategy to Complete the Exchange Activities ……………………………… 26 3. State’s Strategy to Address Early Benchmarks in Section I.4……………………… 45 4. Proposed Solution for IT System ………………………..…………………………………….. 45 5. IT Seven Standards and Conditions……………………………..……………………………. 51 6. Organizational Structure……………………………………………..……………………………. 51 7. Coordination with the Federal Government on Exchange Activities………….. 51 8. Strategies for Reuse, Sharing, Collaboration for NMHIX Activities with the

Federal Exchange and Other States…………………………………………………………….51

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9. Strategies to Ensure Financial Integrity Mechanisms to Prevent Fraud, Waste, and Abuse and Provide Oversight of Cooperative Agreement Funds and the Exchange………………………………………………………….……………..……………………….. 51

10. Challenges That May Affect Progress in Work Plan…………………………………… 52 11. SHOP………………………………………………………………………………..………………………. 52

F. WORKPLAN………………………………………………………………………………………..………………………… 53 G. BUDGET AND BUDGET NARRATIVE……………………………………………………………………………… 56 H. ADDITIONAL LETTERS OF AGREEMENT AND/OR DESCRIPTION(S) OF PROPOSED/EXISTING PROJECT ………………………………………………………….…………………………………………………………………60 I. DESCRIPTION OF KEY PERSONNEL AND ORG CHART……………………..…………………………………61 J. COST ALLOCATION METHODOLOGY…………………………………………………………………………………62 K. DOCUMENTATION SUPPORTING ELIGIBILITY OF APPLICANT (LEVEL TWO EXCHANGE ESTABLISHMENT ONLY) ………………………………………………..…………….………………………………………81

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ACRONYMS ACA or PPACA Patient Protection and Affordable Care Act AHBE American Health Benefits Exchange APTC Advance Premium Tax Credits CSR Cost Sharing Reductions FPL Federal Poverty Limit GSA Governmental Services Agreement HSD New Mexico Human Services Department IAD New Mexico Indian Affairs Department IHCIA Indian Health Care Improvement Act ISD Income Support Division ISD2R Integrated System Delivery Replacement Project MAD New Mexico Medical Assistance Division MMIS Medicaid Management Information System MAGI Modified Adjusted Gross Income NAIC National Association of Insurance Commissioners NMHIA New Mexico Health Insurance Alliance NMHIX New Mexico Health Insurance Exchange NMMIP New Mexico Medical Insurance Pool OHCR New Mexico Office of Health Care Reform OSI Office of the Superintendent of Insurance PSC Professional Services Contract QHP Qualified Health Plan RFP Request for Proposals SCI State Coverage Insurance SDLC Software Development Life Cycle SERFF System for Electronic Rate and Form Filing SHOP Small Business Health Options Plan SOA Service Oriented Architecture

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E. PROJECT NARRATIVE

INTRODUCTION

The Affordable Care Act (ACA) allows states to develop Health Insurance Exchanges to help individuals and small businesses purchase health insurance. The New Mexico Health Insurance Exchange (NMHIX) has been designed to be high quality, cost-efficient, self-sustaining, and tailored to meet the diverse needs of New Mexicans. New Mexico faces many challenges in developing and implementing NMHIX, including health workforce shortages, language and cultural barriers, significant poverty, poor educational attainment, rural and remote areas, and a majority of its small businesses do not offer health insurance to employees. Of New Mexico’s population of two million, Medicaid covers approximately 530,000 individuals, Medicare covers 300,000 and 430,000 are uninsured. Of the uninsured, an estimated 175,000 may become eligible for Medicaid and up to 211,433 for NMHIX between 2014 and 2020. An estimated 171,557 uninsured individuals will enroll in 2014; approximately 89,000 through Medicaid expansion, and 82,557 in the NMHIX. The New Mexico Legislature passed the “New Mexico Health Insurance Exchange Act,” during the 2013 Regular Session, and Governor Susana Martinez signed the Act on March 28, 2013. New Mexico applied for and, on November 29, 2011, received a Level One Health Insurance Exchange Establishment Notice of Award of $34.3 million to develop the NMHIX. An additional grant of $18.6 million was awarded to New Mexico in July 2013. These initial grants were awarded to the New Mexico Human Services Department (HSD) and have now been transferred to the NMHIX as required by statute through a Change of Grantee of Record process. The NMHIX was also awarded a third Level One grant totaling $69.4 million on 1/22/2014. NMHIX is requesting a No Cost Extension to increase the duration of this grant to 12/31/2015. This grant was awarded on 1/22/2014 with an end date of 12/31/2014. New Mexico is a hybrid Exchange through 2015 with the SHOP operated by the NMHIX and utilization of the federal platform for individual enrollments. NMHIX is in the process of developing its own individual platform to be complete for open enrollment beginning October 1, 2015. NMHIX is working with HSD to develop a CMS-compliant eligibility verification process. Through this proposal, New Mexico seeks $97.9 million for continued implementation of the NMHIX for the period January 2015 – December 2017. Ongoing maintenance and operations of the SHOP, starting in 2015, and ongoing maintenance and operations of the Individual Exchange, starting in 2016, will not be covered by this grant. Additionally, this grant is

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requested solely for the costs required for IT functionality and integration with HSD, will not be used for rework. a. Discussion of Existing Exchange Planning and Exchange Establishment Progress 1. Key Findings of Background Research New Mexico conducted in-depth planning and research activities during the initial Level One grant planning period. Enrollment projections indicate the following projected take-up for the NMHIX for both the individual and SHOP markets:

2. Legal Authority and Governance Governance and Exchange Structure--The NMHIX was created by the New Mexico Legislature in 2013 as a quasi-governmental nonprofit entity to “Provide qualified individuals and qualified employees with increased access to health insurance in the state and shall be governed by a board of directors constituted pursuant to the provisions of the New Mexico Health Insurance Exchange Act (the “Act”). The legal authority for establishment of the Exchange is provided in the Act, which was submitted as part of the second Level 1 grant application and is on file at CCIIO. The NMHIX is governed by a 13-member board of directors that was appointed in April 2013; the members have outstanding qualifications and will comply with state and federal conflict of interest requirements. Composition of the Governing Body and Selection Process-- By statute, the NMHIX Board has 13 voting directors:

The Superintendent of Insurance or his designee.

Six directors appointed by the Governor (including the secretary of HSD, a health insurance issuer, and a consumer advocate).

Six directors appointed by the Legislature (with three appointed by the president pro tempore of the senate including one health care provider, and three appointed by the

Individual 38,333 60,564 76,416 121,654 127,737 134,124 140,830

SHOP 600 650 700 750 800 850 900

Total Members 38,933 61,214 77,116 122,404 128,537 134,974 141,730

Member Months 460,000 681,248 859,562 1,084,548 1,368,423 1,436,844 1,508,686

10/2014-

3/2015

10/2015-

3/2016

10/2016-

3/2017

10/2017-

3/2018

10/2018-

3/2019

10/2019-

3/2020

10/2020-

3/2021

* 2014 restated down based on actual results through September 2014

Membership Count Projected at End of Open Enrollment

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speaker of the house of representatives including one health insurance issuer. One of the directors appointed by the president pro tempore and one of the directors appointed by the speaker shall be from a list of at least two candidates provided by the minority leader of the senate and the minority leader of the House of Representatives.

Coordination with HSD—the statute requires the Medical Assistance Division of HSD to cooperate with the NMHIX to share information and facilitate transitions in enrollment between the Exchange and Medicaid. Coordination with OSI –The Act charges the Superintendent of Insurance with promulgating rules necessary to implement and carry out the NMHIX, including rules to establish the criteria for certification of Qualified Health Plans (“QHPs”) offered on the exchange. NM OSI has the regulatory responsibility for licensing Qualified Health Plan (QHP) issuers and reviewing and approving QHP policies. On April 15, 2013, DOI released its submission guidelines for qualified health plans (QHPs). The Act expressly prohibits the NMHIX from duplicating, impairing, enhancing, supplanting, infringing upon or replacing the powers, duties, or authority of the superintendent, including the superintendent’s authority to review and approve premium rates pursuant to the provisions of the NM Insurance Code. Carriers are required to offer Silver and Gold levels of coverage, and must offer at least one statewide plan at each metal level for which the carrier submits a plan. Carriers can offer plans in either the individual Marketplace or SHOP, and will not be required to offer the same plan in both Marketplaces. Final guidelines were promulgated in August 2013. Five companies have been certified as QHPs for individual plans, four companies for SHOP, and two companies for dental coverage. During 2014, one of those carriers certified for both individual and SHOP left the market, and a new company entered the individual market. Thus, going into 2015 Open Enrollment, New Mexico has three plans certified as QHPs for SHOP, and five carriers certified as QHPs for the individual exchange. Coordination with Native Americans—Coordination with Native Americans—the Act requires designation of a Native American liaison to assist the Board in developing and ensuring implementation of communication and collaboration between the NMHIX and Native Americans in the state. Currently the Native American Coordinator serves as the Native American Liaison and is expected to be officially designated as Native American Liaison at the November Board of Directors meeting. The Native American liaison will serve as the contact person between the NMHIX and the New Mexico Native American Nations, Tribes, and Pueblos and will ensure that training is provided to the staff of the NMHIX to ensure cultural competency, understanding of Indian health laws, and other Native American issues. The Act also allows permissive language for the establishment of a Native American Service Center to ensure that the NMHIX is accessible to all Native Americans, complies with the provisions of the Indian Health Care Improvement Act and Indian-specific provisions of the ACA, and facilitates meaningful, ongoing consultation with Native Americans.

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NMHIX has officially convened a Native American Advisory Committee that has officially developed and implemented a Guiding Principles and Protocols. This document includes provisions for proper communication with Native American leadership and communities as well Guidelines for proper Collaboration efforts. The Native American Advisory Committee convened every month for the first half of 2014 and every other month thereafter. NMHIX and its partners have also established a Native American Enrollment Counselor Network statewide. Currently there are sub-agreements with every federally recognized Native American tribe in New Mexico providing for on-site Enrollment, outreach and education on each reservation. Other Governance Strategies To ensure that the NMHIX has an accountable and transparent governance structure, is staffed with competent leadership, and is in compliance with requirements of the statute, the NMHIX Board of Directors:

a) Conducts monthly public meetings, adhering to NM Open Public Meetings law. b) Implemented Conflict of Interest Policies (for both board members and NMHIX staff). c) Maintains, posts, and updates an Exchange website with meeting agendas, minutes,

and other materials related to Exchange activity and operations. d) Develop a Plan of Operations shortly after the Exchange was established and updated

it at the board first anniversary meeting. e) Maintains communication with NM Medicaid/HSD and NM OSI.

3. Stakeholder Consultation Prior to the creation of the NMHIX, the Human Services Department held public stakeholder meetings beginning in December 2010 and continuing through December 2012. HSD created the NMHIX Exchange Advisory Task (ATF), composed of 14 members, and NMHIX Advisory Work Groups, composed of 12-18 members. The Task Force and Work Groups represented a variety of perspectives, including consumers, tribal representatives, large and small employers, self-employed, health care providers, hospitals, insurance carriers, brokers, government leaders and agencies, underserved populations, and other community representatives. These members acted in an advisory role to inform and provide recommendations in the following areas:

Essential Health Benefits

Outreach, Education, Adoption, and Enrollment

Employer Participation

Exchange Market Regulation

Native Americans

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Program Integration

Financial Sustainability

Legislative Public attendance was encouraged at every meeting, dial-in phone numbers were provided, and press releases were submitted to newspapers of general circulation and posted on the HSD website to encourage participation. An email box was created to allow public comments and acknowledge requests for information through email. The NMHIX statute requires establishment of the following advisory groups:

a) Stakeholders, including health insurance issuers, health care consumers, health care providers, health care practitioners, brokers, qualified employer representatives and advocates for low-income or underserved residents;

b) Advisory committee made up of members insured through the NMHIA and the NMMIP to make recommendations to the board regarding the transition of each organization’s insured members into the Exchange; and

c) Advisory committee made up of Native Americans, some of whom live on reservations and some of whom do not live on a reservation, to guide the implementation of Native American-specific provisions of PPACA and federal Indian Health Care Improvement Act.

d) Public input is solicited at every NMHIX board meeting and additional listening sessions are being held.

4. Long Term Operational Costs The Act provides that the Board may “generate funding, including charging assessments or fees, to support its operations in accordance with provisions of the NMHIX solely for the reasonable administrative costs of the exchange. NMHIX Board of Directors has established a Finance Committee which is responsible for financial sustainability, budget development and review of monthly financials. NMHIX recently completed a Financial Sustainability Plan proposal after having 6 Finance Committee meetings, solicitation of public comment, and a Public Finance Committee Meeting. NMHIX expects to attain financial self-sustainability in January 1, 2016 for the Individual Exchange and January 1, 2015 for the SHOP operations. The recommended revenue source that has been approved by the Finance Committee and will be presented to the Board of Directors on November 21, 2014 is a broad assessment of all health insurance carriers in the state. Prior to approval at the December 2014 Board Meeting, the financial sustainability plan will be posted for 30 days for public comment. 5. Program Integration Program Integration --The NMHIX will continue to work with all stakeholders to address any issues that could have an impact on the development and implementation of the NMHIX. The

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NMHIX relies on the HSD ASPEN Medicaid eligibility verification engine and, with HSD, is in the development phase of the IT system development life cycle. Memoranda of Understanding— the Act requires HSD and MAD to cooperate with the NMHIX. A second MOU was also developed with HSD in May 2014 for purposes of providing a mechanism for moving federal funds received by NMHIX to HSD for costs associated with design, development, and implementation of an information technology (IT) system that facilitates eligibility, advance premium tax credit, and cost sharing reduction determinations through the ASPEN Medicaid System. A MOU was also developed with New Mexico Office of Superintendent of Insurance (NM OSI) for purposes of providing a mechanism to support regulatory and quasi-regulatory activities carried out by NM OSI in support of the NMHIX and New Mexico’s implementation of the Affordable Care Act with funds received by NMHIX. ACA’s Blue Print activities related to Plan Management were delegated to NM OSI by the New Mexico statute. 6. Business Operations of the Exchange Business Operations of the Exchange were described at length in the 3rd Level One Establishment Grant Request which was awarded on 1/22/2014 (HBEIE 140193). 7. IT Gap Analysis and Exchange IT Systems The NMHIX utilizes GetInsured’s Commercial Off-The-Shelf (COTS) product for Marketplace functions and ASPEN for Medicaid functions. New Mexico has conducted detailed gap analysis of both the systems against what is required to implement full State Based Marketplace. Based on the identified gaps design and development work has begun to close those system gaps. Establishment Reviews by CCIIO/OIS The following establishment reviews have been conducted by CCIIO to date:

An establishment review was conducted in October 2012. New Mexico received conditional approval for its State Based Exchange in January 2013.

SHOP Design and Operational Readiness Reviews on September 26, 2013

Project Baseline (Planning) Review of the Individual Marketplace on February 11, 2014

Detailed Design Review of the Individual Marketplace on April 10 – 11, 2014

Final Design Review of the Individual Marketplace on June 10 – 11, 2014. 8. Reuse, Sharing, and Collaboration New Mexico will inform and assist other states through various means, including HHS Learning Collaborative and User Groups. Beyond reuse and sharing of IT, New Mexico is committed to

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leverage existing infrastructure and re-purpose business functions and processes to maximize resources and is working with other states to determine how aspects of their systems can be replicated in New Mexico. This is demonstrated through the partnership with the State of Idaho in sharing in the cost of certain functionality described within this request.

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9. Organizational Structure, as of 11/12/2014

Organizational Chart

New Mexico Health Insurance ExchangeBoard of Directors

Advisory Committees

Chief Executive Officer

Amy Dowd

Executive AssistantLisa Garcia

Admin. AssistantTracy Gwash

Broker Relations ManagerIn Recruitment

Chief Financial OfficerAnita Schwing

Director of Communications and MarketingLinda Wedeen

Native American Coord.Scott Atole

Sr. AccountantGenelyn McFarlane

Accountant Kimberly Llamas

Reconciliation Specialist TBD

Native American LiaisonTBD

Shop SupportTeresa McLane

Shop SupportIn Recruitment

Customer Service Center Director

Michael Dineen

Customer Support staff/walk in center

TBD

Information Technology Director Raj Shethia

Technical AnalystKaren Galbreath

Business/Technical Analyst In Recruitment

Compliance Officer Yolanda Miles

Human Resources Manager

Michelle Brooks

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Key Personnel Amy Dowd – Chief Executive Officer, NMHIX, August 2014. Amy Dowd started her career in healthcare working for a regional BlueCross BlueShield health plan in operations where she held leadership positions in membership and billing, enterprise program management office, and vendor relations. She was also a national practice health care consultant at Ernst & Young LLP, advising several of the largest national health insurance carriers on Affordable Care Act strategy, implementation, and compliance. Amy has over 20 years of experience leading large-scale technology and operational improvement projects across the private, public, and non-profit sectors. Amy has a Bachelor of Science degree, and holds Project Management Professional certification.

Amy started working on the Idaho Health Insurance Exchange, now known as Your Health Idaho, in 2010 leading efforts to define options for implementing an exchange in Idaho. Since May of 2013, she has served as Executive Director of Your Health Idaho, which achieved the second highest exchange enrollment per capita in the nation within four months of launch. Amy recently joined the New Mexico Health Insurance Exchange (NMHIX) as the newly appointed Chief Executive Officer (CEO). She is currently working with the NMHIX Board, staff and key stakeholders to continue NMHIX on a path to success.

Anita Schwing—Chief Financial Officer, NMHIX, September 2013. Ms. Schwing brings over 20 years of financial management experience, including ten years in New Mexico managed care. She previously worked four years as Chief Financial Officer at Coventry Health Care’s Medicaid Managed Care Organization, in St. Louis, MO. Prior to that, she was Chief Financial Officer at Molina Healthcare of New Mexico (four years), Controller at Cimarron Health Plan (4 years), and Director of Finance at Lovelace Health Plan (two years). She also worked seven years for CIGNA Corporation, in Philadelphia, PA. Ms. Schwing has served on the Board of the New Mexico Medical Insurance Pool, as well as the Board of the New Mexico Health Insurance Alliance. She is a Certified Public Accountant, and has a Master of Business Administration degree from Temple University, Philadelphia, PA.

Raj Shethia – Director of Information Technology, NMHIX, November 2013. Mr. Shethia came to the NMHIX after working at Lovelace Health Plan for seven years in various IT roles, including over two years as the Technical Lead, Chief Architect and Subject Matter Expert on the Health Insurance Exchange/Marketplace implementation for the health plan’s integration with the Federal and New Mexico Health Insurance Marketplace. He also served as Lovelace’s representative on NMHIX’s Information Technology and Integrated Services RFP evaluation team, providing the opportune introduction to full participation as an employee. Mr. Shethia has a Master of Science in Software Engineering from the University of Houston, and a Bachelor of Engineering in Computer Science from the University of Mumbai. In addition, he holds a Master’s Certificate in Project Management from the University of New Mexico as well as a Certificate in Supervisor Academy from Central New Mexico Community College.

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Linda Wedeen – Director, Communications and Outreach, NMHIX, October 2014. Ms. Wedeen has been in the Strategic Marketing and Communications for more than 30 years. Her areas of expertise include: Executive Communications, Strategic Planning, Brand Awareness and Development, Community Connections Lobbying, and Program and Vendor Management. Ms. Wedeen recently joined the New Mexico Health Exchange as Director, Communications and Outreach to lead a strategic team of vendors and staff to ensure success during the November 2015 Open Enrollment period and into the future. Previously Ms. Wedeen worked with a number of corporations and private entities including the New Mexico Cancer Center Foundation, Hewlett Packard, First Community Bank, and AT&T. Ms. Wedeen has also owned her own consulting firm focusing on Strategic Planning and Evaluation. Additionally, Linda has an extensive community network through her association with many local, state and national organizations. Yolanda Miles – Compliance Officer, NMHIX, June 2014. Ms. Miles brings 25 years of experience in the health insurance industry. She held the positions of Director of Enrollment & Eligibility and Director of Project Management prior to joining NMHIX. Ms. Miles is exceptionally knowledgeable about all operational, IT, and compliance aspects of Commercial, Medicare Advantage, and Medicaid lines of business. She has worked with governmental and regulatory agencies for several years to ensure program compliancy based on product and line of business. Ms. Miles is certified as a Project Management Master and was awarded the Circle of Excellence award in her previous positions. She attended University of New Mexico and New Mexico State University.

Michael Dineen – Customer Service Director, NMHIX, October 2013. Mr. Dineen will oversee call center and customer support operations as well as SHOP operations. He has more than 15 years of call center experience, specializing in technology and healthcare. Prior to joining NMHIX, Dineen worked with America Online, T-Mobile and Lovelace Health Plan. He has a strong focus on the customer experience and customer service. Michelle Brooks–Human Resources Manager, NMHIX, January 2014. Ms. Brooks brings over ten years of Human Resources Management experience to the NMHIX. She is experienced in recruitment, policy and procedure development and compliance, compensation and benefits, team building, supervision and leadership, employee relations, and workers comp. Ms. Brooks has a Bachelor of Science in Business Management with a concentration in Human Resources from the University of Phoenix. She is an active member of the Human Resource Management Association (HRMA) and the Society of Human Resources Management (SHRM). Scott Atole—Native American Coordinator, NMHIX, September 2013. Mr. Atole is an enrolled member of the Jicarilla Apache Nation, is responsible for facilitating communication and collaborative efforts with Native American communities and leadership in New Mexico to address health care coverage and health insurance issues. Mr. Atole has earned a Bachelor’s of Science in Education & Community Health at the University of New Mexico and is currently completing a Masters of Public Administration/Health Policy and Administration. Mr. Atole has twenty years of

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experience in working at multiple levels with diverse populations to identify and engage a variety of health education and prevention initiatives, research, curriculum development and health program administration. Professional experience includes UNM-MPH & MPA Research, Albuquerque Area Indian Health Board Program Manager, Health Educator/Prevention Specialist and IHS Community Health Program(s). In addition to previous appointments to the American Cancer Society’s Advisory Group, the New Mexico State Tobacco Advisory Committee, and the NM Statewide Strategic Planning Committee and Native American Workgroup. Mr. Atole also serves as the Jicarilla Apache delegate to the New Mexico Department of Health’s American Indian Health Advisory Committee. Karen Galbreath--Technical Analyst, NMHIX, February 2014. Mrs. Galbreath is primarily focused on providing ongoing analysis, maintenance, and technical and functional support for application systems throughout the organization. She brings over 15 years of experience in the healthcare industry, including 2 years at Lovelace Health plan, and 6 years at UNM Health Science Center. She has a Master’s Degree in Information Systems. Genelyn McFarlane--Senior Accountant, NMHIX, September 2014. Ms. McFarlane has over 14 years of experience in Finance, Accounting and Retail Management. Prior to joining NMHIX, she was the Accounting Supervisor for Pueblo De Cochiti. Managing over 30 Federal and State Grants, Ms. McFarlane has an extensive knowledge in budgeting, analysis, auditing, payroll, accounting, federal and state grants. In addition, she was the Finance Manager for Foothill Community Health Center in San Jose, CA. She has experience in private, public and non-profit organizations. Ms. McFarlane earned her Bachelor degree in Accounting from San Jose State University. Kimberly Llamas—Accountant, NMHIX, December 2013. Ms. Llamas brings over 15 years of experience in accounting, including 9 years with Delta Dental of New Mexico. Since coming to NMHIX, she has participated in the development of reconciliation processes for the premiums billed on the SHOP marketplace. In this role, she will work with the carriers in the 820/834 reconciliation processes for both SHOP and Individual Marketplaces. She is also responsible for accounts payable, vendor contract tracking and encumbrance reconciliation, and fixed assets. Ms. Llamas has a Bachelor’s Degree in Business Accounting from the University of Phoenix. Lisa Garcia – Executive Assistant, NMHIX, August 2013. Ms. Garcia has served in this position since August 1, 2013. Prior employment was at the New Mexico Institute of Mining and Technology as the Executive Assistant to the Vice President for Research and Economic Development where she was responsible for the management of the Division and the research entities within the Division for over 16 years. Prior to that she was the Office Manager for the Center on Aging within the Population Research Institute at Pennsylvania State University for four years. She brings extensive knowledge of planning, management and customer service to her position at the Exchange. Ms. Garcia earned an Associate of Science from New Mexico Institute of Mining and Technology in 2007.

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Tracy Gwash--Administrative Assistant, NMHIX, January 2014. Since coming the NMHIX, Ms. Gwash has received her Healthcare Guide Certification and Presumptive Eligibility Determiner Certificate. Prior to coming to the Exchange, Mrs. Gwash was Office Manager/Assistant to the Director at New Mexico Press for over 13 years. She brings extensive knowledge of planning, management and customer service to her current position. Mrs. Gwash earned her Medical Receptionist Certificate from Franklin Medical College. Mrs. Gwash also earned a Medical billing and Coding Degree from the University of New Mexico.

Key Board Members: James R. Damron, M.D., FACR, NMHIX Board Chair - Dr. Damron is an attending radiologist at UNM, Health Science Center, School of Medicine and teaches in the specialty of Clinical Mammography, overseeing radiology residents and providing lectures to medical students on state and federal health policy issues. Prior to UNM, he was President of Santa Fe Radiology, P.C., providing diagnostic radiology imaging services in Santa Fe for 30 years before he retired. Dr. Damron received his Medical Degree from Indiana University School of Medicine, his radiology training at the University of Kentucky Medical Center and completed a Nuclear Medicine Fellowship at the University of New Mexico. He is Board Certified by the American Board of Radiology and the American Board of Nuclear Medicine. He is a Fellow in the American College of Radiology. Dr. Damron has been associated with numerous state and national professional organizations and boards and is the author of several peer-reviewed articles. He has received several national awards, such as the Capitol Dome award and the Physician’s Award for Outstanding Service from ACS, the 2006 Physician of the Year award from the National Republican Congressional Committee and the NRCC 2007 Congressional Order of Merit. He also serves on the NM Coalition for Literacy Board, the St. Vincent Hospital Foundation Board and has served on other numerous community boards, state committees and task forces. Dr. Damron was the Republican Nominee for Governor in 2006 and a candidate for Lt. Governor in 2010. Jason Sandel, NMHIX Vice-Chair- is a native of Farmington, New Mexico and was elected to the Farmington City Council in March of 2006. Jason Sandel is the Executive Vice-President of Aztec Well Servicing and its subsidiaries in Aztec, New Mexico. He is the 3rd generation of the Sandel family to dedicate himself to the company and the community. Jason attended the University of New Mexico where he received a B.A. in Political Science and served as a Senior Leadership Analyst for the New Mexico State Senate. Along with his appointment to the Board of the New Mexico Health Insurance Exchange, Jason serves as the Vice-Chairman of the New Mexico Medical Insurance Pool, immediate past President of the Four Corners Safety Council, member of the New Mexico Oil and Gas Executive Committee, former member of the Statewide Economic Development Commission, and was honored with the Paul Harris award by the San Juan Rotary Club.

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John G. Franchini, Superintendent of Insurance—Mr. Franchini is a native New Mexican and graduate of Creighton University, with 35 years of experience in the insurance industry. He joined Consolidated Agency, his father’s independent insurance agency, purchased it ten years later and expanded it to four locations employing 82 people and servicing nearly 15,000 customers. He served on the New Mexico Workers’ Compensation Assigned Risk Pool Board of Governors, the Patient Compensation Administration Board of Directors, and was elected president of the Independent Insurance Agents of New Mexico. In 1998, Poe & Brown, a national insurance broker, purchased the business. He was named vice president. His responsibilities included new business production, development of specialized insurance programs, and agency acquisitions. He joined New Mexico Mutual in 2002 and later named Vice President of Government and Industry Affairs. He is a member of the Leadership New Mexico Class of 2007, former board member of the Rocky Mountain Insurance Information Association, and past president of the NM Insurance Association. 10. Program Integrity The NMHIX hired a Compliance Office in June 2014 to focus on program, system, and financial controls within the operating system and business processes of the Exchange. Additionally, the NMHIX was subject to its first A-133 and financial statement audit in September 2014, with a favorable audit opinion. Financial and internal controls have been developed to ensure that the NMHIX can account for grant funds in accordance with CMS expectations. The NMHIX will continue adhere to HHS financial monitoring activities for the Level Two Establishment Grant. NMHIX successfully completed a business assessment by CMS in July 2013. 11. Affordable Care Act Requirements Health Insurance Market Reforms--The Department of Health and Human Services (HHS) determined that New Mexico had an effective rate review program as of August, 2011. 12. SHOP Summary of State’s Small Group Market--New Mexico’s current small group market has approximately 60,500 covered lives with $277 million in earned premiums. Market shares are as follows: Carrier Members (2011) Market Share Earned Premium (2011) Market Share Blue Cross Blue Shield of NM 19,566 32.4% $100,722,000 36.4% Lovelace Health Plan 16,355 27.1% $ 68,451,360 24.7% Presbyterian Health Plan 17,821 29.5% $ 74,432,580 26.9% United Health Care 6,693 11.1% $ 33,202,618 12.0% Total 60,435 100% $276,858,558 100%

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Research/Reports on Small Group Market Issues/SHOP Operations and Stakeholder Consultation on SHOP--An Employer Participation work group held extensive meetings to work on various SHOP issues and provide recommendations. Issues reviewed included participation requirements, definition of “small business”, adverse selection issues, defined contribution, premium aggregation, and plan selection. The NMHIX utilized the information from the stakeholders in designing the NMHIX SHOP program with the following features:

Minimum 50 percent participation requirement (except for a “golden enrollment period” in November and December 2013 when there will be no participation requirement).

Minimum employer contribution of 50 percent.

Employers select a “metal” level and a reference plan as a cost parameter and then employees may select plans from within that metal level.

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b. PROPOSAL TO MEET PROGRAM REQUIREMENTS 1. Current Exchange Pathway On December 14, 2012 New Mexico submitted its Blueprint application to HHS to operate a State-Based Exchange and the Blueprint was conditionally approved on December 31, 2012 and additional conditional approval was received in July 2013. The State of New Mexico has elected to operate a hybrid health insurance marketplace where initially the State will operate its own SHOP marketplace and utilize the Federally Facilitated Marketplace (FFM) for the Individual marketplace. Starting October 1, 2013 NMHIX has begun the process of developing a state-based individual marketplace with the aim to Go-Live for 2016 Open Enrollment. Once New Mexico is live with core marketplace functionality in 2015 New Mexico will continue to add capabilities to support our goal to increase enrollment and enhance self-sustainability. 2. State’s Strategy to Complete the Exchange Activities The chart below shows the status of the NMHIX activities as a State-Based Exchange:

EXCHANGE ACTIVITIES STATUS

Legal Authority and Governance

New Mexico has enabling legislation creating the NMHIX to operate the Exchange and SHOP – SB221. To ensure the NMHIX has an accountable and transparent governance structure, is staffed with competent leadership and is in compliance with applicable conflict of interest provisions, the NMHIX Board of Directors conducts monthly public meetings, adheres to open public meeting laws, developed a Plan of Operations, and implemented a Conflict of Interest Policy, Procurement Policy, and Communication Policy.

Consumer and Stakeholder Engagement and Support

Advisory groups will be continued through the NMHIX throughout the development and implementation of the NMHIX to ensure stakeholder engagement and support. A comprehensive outreach and education plan has been developed that ensures culturally and linguistically appropriate materials and ensures access to information and enrollment for individuals with disabilities. A website has been developed in English and Spanish. A Health Care Guide program with associated training requirements and broker roles has been developed.

Eligibility and Enrollment NMHIX has implemented its SHOP eligibility and enrollment system. NMHIX is coordinating with HSD on eligibility and enrollment which will be documented through regular meetings between the NMHIX and HSD staff. NMHIX plans to have the capacity to accept and process applications for the individual market by October 1, 2015. NMHIX is working with HSD to develop appropriate exchange interfaces. GetInsured is developing a system for NMHIX enrollment with capacity for notices, verifications, privacy and security protections, storing and processing documents, determine eligibility for enrollment in QHPs, to

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process QHP selections and terminations, and comply with required reporting to HHS. See more in the section below – as this grant request focuses on this blueprint core area.

Plan Management NM’s enabling legislation delegated to the Office of the Superintendent of Insurance (OSI) the authority to certify and oversee QHPs and is coordinating with the NMHIX. The NMHIX has a plan management system to support the collection of QHP issuer and plan data and facilitate the certification and renewal process and integrate with other Exchange business areas.

Risk Adjustment and Reinsurance

New Mexico plans to use the federal service for risk adjustment and reinsurance.

SHOP The NMHIX SHOP system allows for the enrollment and billing of employer groups and employees, online invoice payment capability as well as premium aggregation and remittance to insurance carriers. It also has required electronic reporting functionality.

Organization and Human Resources

The NMHIX has hired core staff and continues to hire additional staff for performance of NMHIX activities.

Finance and Accounting The NMHIX is developing a long-term operational cost, budget and management plan through its Finance Committee. A Financial Sustainability Plan Proposal is scheduled to be presented at the November 21, 2014 Board of Directors Meeting for approval and adoption. NMHIX is exploring functionality and options in the technology solution that will ensure financial sustainability beyond 2015-2016, by enhancing consumer facing functionality.

Technology The NMHIX has contracted with Get Insured to ensure adequate technology infrastructure and bandwidth, and to achieve essential functionality for all NMHIX activities.

Privacy and Security The NMHIX’s IT solution ensures required privacy and security within the technology solutions.

Oversight, Monitoring, and Reporting

The NMHIX is complying with all oversight, monitoring, and reporting requirements.

Contracting, Outsourcing, and Agreements

NMHIX has contracted with Get Insured and PCG for ongoing development of the Exchange; Xerox for the Call Center and SES for IV&V functions.

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Consumer and Stakeholder Engagement The NMHIX is implementing a process for a formal Advisory Committee to obtain consumer and stakeholder input and engagement as required by statute. Each of the NMHIX outreach and enrollment partners are being asked to provide a representative to serve on the initial Advisory Committee for one year. The Advisory Committee meets quarterly to provide input and feedback to the NMHIX with the first meeting held December 2013. The meetings have been held in various locations around the state to allow broad geographic input during public comment portions of the meetings. The Committee is being structured to allow representation from various stakeholders including consumers, business groups, providers, brokers, QHPs, enrollment partners, and others. The NMHIX will continue to enhance the stakeholder engagement process as the NMHIX is implemented. Outreach, Education, and Enrollment Program The comprehensive outreach and education program that began in 2013 will continue to be implemented throughout the state in 2014 for 2015 open enrollment. An assessment of the effectiveness of the initial outreach and education activities will be conducted after the first 90 days of open enrollment to refine and expand outreach, education, and marketing activities as necessary. Ongoing activities will include the following components:

Outreach and education with ACI, New Mexico Association of Counties, Albuquerque Hispano Chamber of Commerce, New Mexico Green Chamber of Commerce, UNM and NMSU and the higher education system, and additional contracts for hard-to-reach populations.

Additional outreach will be conducted based on a comprehensive assessment of initial strategies. In January 2014, NMHIX will review all strategies and results and make modifications and expansion of activities as necessary to increase enrollment. It is anticipated that significant recalibration of messaging and additional media and strategies will be necessary due to the federal technology delays.

Implementation of a series of focus groups in spring 2014 to assess reasons why people may have not signed up for coverage and exploration of alternative strategies to generate enrollment.

Continued implementation of significant “in-reach” for existing patients of clinics and hospitals, as well as outreach. Over 60,000 postcards will be mailed in early November to reach as many patients as possible. Additional postcard strategies are being developed for use at events with signature authorizations by consumers to allow a Health Care Guide to call them back to provide information and help them sign up for coverage.

Development of additional strategies with diverse partners, such as Rotary, Kiwanis, schools, trade associations (restaurants, retail, credit unions, banks, realtors, utilities, homebuilders, etc.)

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Ongoing marketing and media activities in partnership with BVK and local marketing partners, including TV, radio, print, billboards, and social media. In January 2014, NMHIX reviewed all marketing and media strategies and results and made modifications to increase enrollment. The campaign was refreshed to run again in late summer 2014 for the second open enrollment period. Weekly press releases and public relations.

Enrollment activities will continue through contracts with NMPCA, NAPPR, and other enrollment entities. The enrollment network and capacity will be assessed on an ongoing basis and additional enrollment sites added as necessary. Performance goals with enrollment metrics will be established for each county in the state and monitored and additional resources will be targeted to counties not meeting enrollment goals. Group training sessions will also be implemented to accommodate enrollment demand in the shortened timeframe due to the federal technology issues.

Targeted Native American assistance programs will also continue to be implemented to serve New Mexico’s Native American population in partnership with NAPPR and the Navajo Nation.

To support the second open enrollment period, NAPPR opened a Walk-In Center in Albuquerque on a pilot basis, which may be taken state-wide if found to be effective, to provide specialized technical assistance and support to New Mexico’s Native population. This Walk-In Center will also serve the non-Native population as well, with enrollment guides from NMPCA

NMHIX will use a variety of methods to assess enrollment and outreach strategies, including consumer surveys that will be completed after each interaction with a Health Care Guide, reviews of decreased number of uncompensated care patients at clinics, hospitals, and with County Indigent Funds, social media feedback, media metrics, and feedback solicited by all outreach partners. NMHIX will monitor enrollments bi-weekly through reports from NMPCA, NAPPR, and UNMHSC and with monthly reports from CCIIO. Eligibility and Enrollment— NMHIX is building an ACA compliant marketplace IT system that supports an online single-streamlined application process to provide consumers with access to Insurance Affordability Programs and an online tool to shop and enroll in commercial insurance. The Customer Service Center shall also support a mail room function in the event that a consumer prefers to complete a paper application. The mail room will mail the applications to individuals as well as employees who request a paper application to enroll in a small employer and/or individual benefit plan. The mail room will also receive completed paper applications. The New User Open Enrollment exhibit below shows high level design flow of our planned integrated eligibility and verification system.

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New Mexico is developing an Integrated Eligibly and Verification System based on principles laid out in Guidance for Exchange and Medicaid Information Technology (IT) Systems version 2.0. New Mexico has developed a single streamlined application (based on CMS SSAp guidelines) and a Single Rules Engine that can be used by consumers who apply for either QHP on the individual marketplace and for insurance affordability programs. Upon entry into New Mexico’s integrated shared portal, enrollees will be asked if they wish to complete an insurance affordability assessment (anonymous shopping). If an enrollee decides they do not want to pursue financial application path, he or she will be asked to provide information on a shorter version of single streamlined application and guided thru process to

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enrollee in QHP. New Mexico will send a web services query a Shared Data Services HUB for verification of enrollee’s information as required in 45 CFR part 155. For enrollees who wish to pursue financial application path, NMHIX will seamlessly transition to insurance affordability single streamlined application that will collect the required data from enrollees and family members. New Mexico will send a web services query a Shared Data Services HUB for verification of enrollee’s information as required in 45 CFR part 155. The system has capacity to assist consumers with disabilities or with limited English proficiency that comply with all applicable federal policies and laws, through the following features:

User friendly, plain English, web portal with mouse-over help feature 508-compliant web portal for the visually impaired Text Telephone (TTY) services for the hearing impaired Third-party language translation services for individuals with limited English proficiency Applications and supporting materials, notices, and correspondence in multiple

languages upon request. New Mexico will develop a system that is able to generate and send correspondence in electronic formats, print correspondence onto standardized paper, and provide services for sending notices, which includes folding, postage, and delivering correspondence. Additionally New Mexico IT System will be able to accept and process updates, and responses to redeterminations from applicants and enrollees (see figure below that shows high level design flow).

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Call Center—The New Mexico initial Call Center (currently primarily a referring call center) will be expanded to accommodate all Call Center activities once the Individual Marketplace is implemented in October 2015. It will be capable of assisting New Mexicans with questions related to open enrollment, eligibility, plan selection, complaints, and all NMHIX activities. NMHIX will issue a RFP for a comprehensive call center for its State Based Exchange for both individual and SHOP full functionality. Plan Management The Superintendent of Insurance has authority over all health insurance plans sold in New Mexico. OSI is responsible for plan management functions, including QHP certification, of the NMHIX solution. OSI and the NMHIX have developed a standard QHP contract whereby issuers certify that they will comply with all applicable state and federal laws, regulations, and guidelines. In the event of an adverse event or adverse finding from a periodic assessment that may affect a QHP’s certification status, OSI coordinates support to resolve the issue. OSI will notify NMHIX to remove the QHP from sale upon finding cause to decertify a QHP. OSI is responsible for the management of the consumer complaint process for QHPs, including complaints referred from the call center, and will coordinate among internal units as needed to resolve consumer complaints or identify potential compliance issues. SERFF will be used to record all QHP administrative data. The QHP service area must cover a minimum geographical area that is at least an entire county or group of counties, unless the NMHIX determines that serving a smaller geographic area is necessary, nondiscriminatory, and in the best interest of the qualified individuals and employers. The QHP service area must be established without regard to racial, ethnic, language, health-status related factors, or other factors that exclude specific high utilizing, high cost, or medically-underserved populations. OSI ensures that the QHP has made its provider directory available for online publication (or has provided the source of online publication) and has indicated providers who are no longer accepting new patients according to PPACA § 156.230(b). Rating areas are a consideration in the QHP review process. A third party actuary assists the state in defining rating areas for QHPs. OSI ensures QHP compliance with market reform rules in accordance with all applicable regulations and guidance. New Mexico currently has a small number of carriers and a total of 56 plans offered on the NMHIX. OSI provides all QHP certification for the NMHIX. New Mexico has a new CO-OP plan, New Mexico Health Connections, which is offering plans on the NMHIX. DOI will provide recommendations to CMS on whether the CO-OP plan meets NMHIX standards for a QHP to assist CMS in its decision to deem CO-OP as certified to participate according to 42 CFR 156.520 (e). OSI is responsible for oversight of the licensure, solvency, and market conduct of issuers who submit QHPs to be offered on the NMHIX. Market conduct exams will be conducted every 3 years and compliance issues will be addressed. QHPs may be decertified or withdrawn in the course of ongoing or periodic monitoring or as the result of an adverse event reported to OSI. If there is a voluntary company/issuer withdrawal from the state, the company must give the state 180 days’ notice. For QHP individual plan withdrawal, OSI sends notification to the

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consumers. For SHOP plan withdrawal, OSI will coordinate with the NMHIX to send notifications to the employers. Risk Adjustment and Reinsurance New Mexico is utilizing the federal system for risk adjustment and reinsurance. SHOP NMHIX has implemented the SHOP program and will continue to refine operations. The SHOP is fully compliant with regulatory requirements of 45 CFE Sec. 155, Subpart H. The NMHIX SHOP is performing premium aggregation. IRS reporting capabilities are in progress and are expected to be functional in time for 2014 reporting. Organization and Human Resources NMHIX has hired key staff, including a Chief Executive Officer, Chief Financial Officer, IT Director, Compliance Officer, Native American Coordinator, Customer Service Director, Director of Marketing and Outreach as well as support staff. Finance and Accounting NMHIX hired a CFO in September 2013. The NMHIX purchased a fund accounting system to provide the necessary control and reporting capabilities required for the grant. The NMHIX has been through two budget seasons, an A-133 and financial statement audit, and has received approval from the NMHIX Finance Committee to take their Financial Sustainability Plan Proposal to the Board of Directors for approval. Financial policies and procedures have been developed to provide the financial control structure desired for grant management and reporting. Technology

The State of New Mexico has elected to operate a hybrid health insurance marketplace where initially the State will operate its own SHOP marketplace and utilize the Federally Facilitated Marketplace (FFM) for the Individual marketplace. Starting October 1, 2013 NMHIX has begun the process of developing a state-based individual marketplace with the aim to Go-Live for 2016 Open Enrollment. Once New Mexico is live with core marketplace functionality in 2015 New Mexico will continue to add capabilities to support our goal to increase enrollment and enhance self-sustainability. General theme for types of enhancement work that will be undertaken in 2016 and 2017 are:

• Catalyze enrollment through active and increasing participation of brokers • Broaden distribution opportunities maximally through a range of enrollment options

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• Enhance ease of use by users, particularly for New Mexico specific user communities NMHIX has retained the services of GetInsured (GI) to implement both the SHOP marketplace and the Individual marketplace. NMHIX produced a set of functional requirements for the SHOP and Individual marketplace systems that were incorporated into the Request for Proposals (RFP) to which GI responded. NMHIX has retained the services of Public Consulting Group (PCG) to assist with various aspects of implementing the SHOP and Individual marketplaces, including a Project Management Office (PMO). In addition NMHIX has contracted with Software Engineering Services (SES) as an Independent Verification and Validation to oversee the design, development, and implementation of the marketplace functions. Among the functions of the PMO and IV&V are to work with GI to ensure that:

o Standard industry Systems Development Life Cycle (SDLC) protocols are followed, including iterative and incremental development methodologies.

o Requirement specifications, analysis, design, code, and testing are developed and carried out in accordance with CMS/CCIIO requirements and generally accepted professional practice.

o The design takes advantage of a Web Services Architecture and Service Oriented Architecture approach for design and development.

o The services description/definition, services interfaces, policies and business rules are published as required and the solution provides role-based access to underlying data.

o The solution adheres to standards published by the Office of the National Coordinator (ONC) and the National Institute of Standards and Technology (NIST).

o The GI system is interoperable and integrated with State Medicaid/ Children’s Health Insurance Program (CHIP) programs and is able to interface with HHS and other data sources in order to verify and acquire data as needed.

o The GI system achieves any required interoperability with other health and human services programs for purposes of coordinating eligibility determinations, referrals, verification or other functions.

Systems Design New Mexico’s IT Solution will be created to insure more New Mexicans while fostering competitiveness, encouraging efficiency, and creating sound individual and small employer private health insurance choices. Qualified individuals and small employers will be able to shop, compare, and choose a Qualified Health Plan (QHP) as well as apply for other insurance affordability programs. The IT System will:

1. Create an integrated Health Insurance Exchange that provides the following functionalities:

a. Integrated Individual Eligibility & Enrollment b. SHOP Eligibility & Enrollment

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c. Determination of Eligibility for Individual Federal Subsidy of Insurance Premium, Advanced Premium Tax Credit (APTC), Cost Sharing Reduction (CSR) as well integrate with HSD system for other Insurance affordability programs

d. Carrier and Plan Certification and Recertification e. Monitor Carrier and Plan Certification Compliance f. Display Carrier Ratings by Price and Quality (Star Rating) g. Maintain Operational Data h. Process Change in Plan Enrollment Availability i. Premium Processing/Payment Aggregation j. Issuer Payment Transfers k. Web Portals architecture for Call Center CSRs, Navigators, Tribal Assistance,

Marketing/Outreach Personnel, Agents and Brokers l. Receive, Process and Retain Client Correspondence m. Management of Exchange Operations n. Identity and account management o. Federal, State and Management Reporting p. Interface with Shared Data Hub

2. Meet as prudently as possible the critical deadlines associated with Health Care Reform

requirements set forth in the PPACA and New Mexico related regulations. 3. Provide integrated screening, choice, coordination, eligibility and enrollment; aligning

systems to support health plan selection; and aggregating payments. 4. Implement a modern technology that meets New Mexico’s business needs, is flexible

to changing requirements, and is easily maintainable. The high level major factors that have influenced the technical design of the proposed system are:

ACA Section 1561 standards

MITA 3.0 framework and guidelines

Security, privacy and operational standards required by HIPAA, HITECH, NIST, FIPS and IRS standards

Providing a first class customer experience.

Maintaining cross-program integration so that consumers continue to enjoy a breadth of on-line support

Being able to offer on-line, real-time eligibility determination and enrollment capabilities

Providing seamless integration of systems to provide efficient and effective service delivery

Relevant Standards The relevant standards that will be followed by NMHIX and its supporting solutions are:

• ACA Section 1561 standards for enrollment • ACA Section 1104 operating rules for each HIPAA transaction

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• National Information Exchange Model (NIEM) common language • MITA 3.0 standards for reusable components and modularity • Service Oriented Architecture (SOA) standards • HIPAA (5010 compliant) • HITECH • NIST • FIPS • Federal security standards for cloud computing environments

(http://www.gsa.gov/portal/category/102371) • NIST standards for Disaster recovery and Continuance of Operations Program (COOP)

(http://csrc.nist.gov/publications/nistpubs/800-34-rev1/sp800-34-rev1_errata-Nov11-2010.pdf)

• ADA Section 508 and W3C standards for disability support • Limited English Proficiency (LEP) standards

Design Goals for New Mexico Solution: Design principles for New Mexico solution are in line with Guidance for Exchange and Medicaid Information Technology (IT) Systems version 2.0. The following are the design goals and its supporting solutions:

• System design that is consistent with section 1561 guidelines • System design to achieve first class consumer experience • System and interface design to achieve real-time and seamless integration with Federal

and State systems (web services) • Design that will allow maximum reusability for other states • System design to achieve real-time and seamless integration with relevant state portals • System design that is consistent with HIPAA (5010), NIST, HITECH, FIPS and IRS

guidelines and standards • System design that accommodates the accessibility guidelines by ADA section 508 and

W3C • Application of MITA 3.0 standards as appropriate • System design that accommodates the Limited English Proficiency (LEP) guidelines • Agile Development based methodology • Active and ongoing participation of the stakeholders and Subject Matter Experts

(SMEs) throughout the design and development phases • Working prototype based development approach (AGILE Development) • Clear integration and maintenance expectations expressed in RFP for vendors to

understand and comply with • Service Oriented Architecture (SOA) that is consistent with MITA • Services managed on an Enterprise Service Bus (ESB) • Rules engine that follow the 1561 Standards and is a loosely coupled service that can

support re-use • System architecture based on open standards

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• Reusable services and system components • Flexible architecture that can easily incorporate change and new features • Highly available and highly scalable architecture • Robust disaster recovery

High Level Architecture NMHIX solution is based on a service-oriented architecture (SOA) that defines common business and technical services that are loosely coupled and can be modified relatively easily to accommodate changing business and regulatory needs. This architecture is consistent with CMS guidelines that define the key business processes, functional groupings and underlying services. The GetInsured exchange architecture is developed as a modular system consisting of open source components and libraries wherever appropriate. Business rules and process workflows are built as separate components that support and enable the core engine of the exchange to be extended and configured with ease. GetInsured’s SOA-based architecture is scalable and provides a degree of customization without the need to make costly and complex changes.

GetInsured exchange architecture is consistent with the CMS Technical Reference Architecture (TRA), the Medicaid Information Technology Architecture (MITA) and the Exchange Reference Architecture. Business process and technical services are exposed using standard, defined interfaces. These services interoperate based on a formal definition that is independent of the underlying platform and programming language. The interface definition hides the implementation of the language-specific service. Key to these services is their loosely coupled nature i.e., the service interface is independent of the implementation.

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Web service interoperability protocols provide seamless and automatic connections from one software application to another (Financial Management, Plan Management, Plan Selection, etc.). Web Service Definition Language (WSDL), Universal Description, Discovery and Integration (UDDI) and Simple Object Access Protocol (SOAP) are the fundamental pieces of the SOA infrastructure. WSDL is used to describe the service; UDDI, to register and look up the services; and SOAP, as a transport layer to send messages between service consumer and service provider. SOAP, WSDL, and UDDI protocols define a self-describing way to discover and call a method in a software application—regardless of location or platform. Data is converted into XML request and response documents and moved between software modules using HTTP or message based protocols. Business services are maintained in the exchange by a registry that acts as a directory listing. Applications can look up the services in the registry, get the WSDL for the service that has the description, and invoke the service using SOAP. Universal Description, Definition, and Integration (UDDI) are the standard used for service registry. Business Services are published to a public or private UDDI web services registry. The web services registry is used by exchange software modules to discover and interact with each other. Application Architecture The goal of this project is to produce a user-friendly, web-based system which supports principles of the Medicaid Information Technology Architecture (MITA) and open standards wherever possible. The use of an enterprise architecture shall allow the separate, standalone systems to communicate using exposed, shared services through a common architecture. SOA, coupled with open standards-based-software components, will have a prominent role in the implementation of the enterprise architecture required by the NMHIX. The NMHIX SOA will be used to facilitate functional re-use and data sharing among loosely coupled services and business objects. Services will be loosely coupled to reduce system dependencies and self-contained pieces of business functionality deployed as discrete pieces of code and/or data structures that can be reused. The NMHIX, GetInsured, solution foundation is Service-Oriented Architecture (SOA) with a design pattern that is based on loosely-coupled software components providing application functionality as services to other software components. These software components can be upgraded on a regular basis to avoid obsolescence without affecting the rest of the system. The GetInsured solution uses modern web technologies such as Representational State Transfer (REST), predominate web API design tool, and Web Services. Additionally the software solution is based on the latest software design frameworks. The components and libraries comprising these frameworks are kept current with the latest features.

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Security and Privacy Architecture

Security services will provide the safeguards to protect the Exchange from threats that could lead to the loss of confidentiality of data, the loss of data integrity, the unavailability of data or services and/or any unauthorized use of Exchange resources.

Accounting of Disclosures Report The following diagram depicts how accounting of disclosure reports can be tracked and

provided to an individual.

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Figure 30: Accounting of Disclosures Report

MS Exchange

Exchange Operations

Staff

Broker

Other Users

View / Access

View / Access

View / Access

Accounting of

Disclosures

Report

Reporting

EngineData Store

Protected Health

Information (PHI)

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule requires “covered entities and business associates to account for disclosures of protected health information to carry out treatment, payment, and health care operations if such disclosures are through an electronic health record. Pursuant to both the HITECH Act and its more general authority under HIPAA, the Department proposes to expand the accounting provision to provide individuals with the right to receive an access report indicating who has accessed electronic protected health information in a designated record set.” http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/index.html Whenever NMHIX administrative staff view or access PHI (Personal Health Information), the action is captured by and stored as part of the audit logging functionality. The data is stored and reports are provided when requested by individuals, in accordance with the requirement.

PHI/PII in Transit The following diagram depicts how GetInsured secures all health information (PHI or PPI – Personal Identifiable Information) in transit, rendering it unusable, unreadable, or indecipherable to unauthorized individuals. This is done in accordance with the

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technology and methodology specified by the Secretary of the Federal Department of Health and Human Services in the guidance issued under section 13402(h)(2) of the American Recovery and Reinvestment Act of 2009 (P.L. 111-5), or any update to that guidance.

Figure 31: PHI / PII in Transit

MS Exchange

Data

Transmissions

Web Services

Data Storage

Protected Health

Information (PHI)

Protected Health

Information (PHI)

Encryption Method

Protected Health

Information (PHI)

Data Field

Encryption

SFTP**

SSL Encryption

** Secure File Transfer Protocol

(SFTP) or other secure transmission

method for data transfers.

GetInsured’s solution will provide the ability for web service providers and

service consumers to interact, and will implement security for transport and messaging via web services.

o The Solution will utilize SSL as an encryption method to help ensure data confidentiality prior to data transmission via web services.

Within the solution, PHI will not be transmitted via email.

Physical Security GetInsured’s solution will maintain strict physical access controls to safeguard all

areas where sensitive data could be accessed. This includes, but is not limited to the

following physical safeguards:

All doors to the hosted data center facility will be locked and monitored

via a card-based Access Entry System (AES).

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o Access to sensitive areas within the office space (i.e., the server

room) will be gained using role-based security with the AES.

o The AES will have independent battery backup sufficient to keep

the office secure in the event of power failure until such time as

normal power is resumed or the backup generator cycles on.

All doors and common areas (i.e., break room, conference rooms, the

call-center floor, etc.) will be monitored via IP security cameras.

o The security camera system will record 100% of activity 24x7 and

retain 2 weeks of recordings on disk.

All exterior doors will be connected to an alarm system.

o This alarm system will be remotely managed and will allow for

one-touch emergency calling to the Police, Fire, and Ambulance.

The call center will have a small server room located such that all walls

are interior to the office space and extend through the plenum for fire-

safety reasons.

The server room will contain all security-related management equipment,

and access will be granted solely to IT services and upper management

staff.

Monitoring (including Intrusion Detection) Intrusion detection will monitor access to the Exchange resources maintain logs and issue alerts related to unauthorized access. Unauthorized access also includes the prevention and monitoring for malware and/or malicious software within the confines of Exchange computer systems. This live protection of the Exchange servers shall be centrally managed and provide for at least:

Audit data regarding threats and attacks including false positives; Continual updates to the protection/detection mechanisms and algorithms to

ensure proper detection and response; Procedures and methods to isolate and neutralize an active threat in order to

protect Exchange resources. The Alert Logic Threat Management™ system monitors the GetInsured solution as hosted in the Rackspace Environment. The system is used to detect external and internal threats. When it detects an incident, Alert Logic's ActiveWatch service provides expert guidance from its Security Operations Center (SOC), staffed round the clock by Alert Logic security analysts. Integrated vulnerability scanning helps identify possible points of entry and correct them, and assists with meeting regulatory compliance requirements.

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The figure below visually depicts the Alert Logic’s threat management system.

Figure 25: Alert Logic Threat Management System

The Alert Logic Log Manager™ automatically aggregates, normalizes, and stores log data from GetInsured’s environment. It also features log searches, forensic analysis, and report creation through real-time or scheduled analysis. LogReview, a service enhancement to Log Manager, provides daily event log monitoring and review by a team of Alert Logic security professionals.

Figure 32: Alert Logic Log Manager

The Alert Logic suite provides a rich set of tools for analysis and system log monitoring.

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Contracting, Outsourcing, and Agreements NMHIX has contracted with GetInsured and PCG for ongoing development of the Exchange. In 2014, NMHIX contracted with Software Engineering Systems (SES) for the independent verification and validation (IV&V) efforts. NMHIX has contracted with Xerox for the Call Center and with NMPCA and NAPPR for enrollment functions. Additional local partners and consultants are being utilized for implementation of the outreach and education plan. 3. State’s Strategy to Address Early Benchmarks in Section I.4 Please see the New Mexico Blueprint document for information on early benchmarks.

4. Proposed Solution for Exchange IT Systems The NMHIX SHOP Exchange is fully functional. The individual exchange functions will be implemented in 2015. The NMHIX will have the following functionalities:

a. Individual Eligibility & Enrollment b. Individual Responsibility Exemption c. Small Business Health Options Plan (SHOP) Eligibility & Enrollment d. Verify Eligibility for Individual Federal Subsidy of Insurance Premium e. Data Exchanges/Interfaces f. Carrier and Plan Certification and Recertification g. Monitor Carrier and Plan Certification Compliance h. Establish Issuer and Plan Renewal and Recertification i. Review Rate Increase Justifications j. Display Carrier Ratings by Price and Quality k. Maintain Operational Data l. Process Change in Plan Enrollment Availability m. Advanced Payments in Premium Tax Credit and Cost Sharing Reduction n. Premium Processing/Payment Aggregation o. Data Collection p. Risk Adjustment and reinsurance (to be provided through federal services) q. Issuer Payment Transfers r. Call Center Module s. Navigator Module t. Broker Module u. Client Correspondences v. Management of Exchange Operations w. Federal and Management Reporting x. Interface with Federal Data Hub y. Interface with Medicaid (Aspen) z. Interface with NAIC SERFF

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An intuitive web portal (including mobile device access) through which New Mexico residents can access subsidized and unsubsidized health insurance including: Individual enrollment and plan selection and SHOP portal supporting plan selection and enrollment for small employers and their employees in qualified SHOP health plans.

Back office functions include:

Interface with the integrated eligibility and verification engine Use system components to provide for monthly “window” for American

Indians/Alaska Natives (AI/AN) to enroll in Plans Determine tax credit and subsidy credits for enrollees Use system components to facilitate enrollments into qualified health plans Use system components to certify and manage insurance issuer, health plan and

provider data Provide financial management components (such as: billing, receivables, general and

subsidiary ledgers, premium aggregation, reporting, reconciliation, reduced cost-sharing for AI/AN individuals enrolling in QHP)

Allocate cost for system utilization between NMHIX and Medicaid Have reporting and business analytics capability Provide identity and account management Have document/content management Provide notification services

New Mexico is developing an Integrated Eligibly and Verification System based on principles laid out in Guidance for Exchange and Medicaid Information Technology (IT) Systems version 2.0. New Mexico has developed a single streamlined application (based on CMS SSAp guidelines) and a Single Rules Engine that can be used by consumers who apply for either QHP on the individual marketplace and for insurance affordability programs. Upon entry into New Mexico’s integrated shared portal, enrollees will be asked if they wish to complete an insurance affordability assessment (anonymous shopping). If an enrollee decides they do not want to pursue financial application path, he or she will be asked to provide information on a shorter version of single streamlined application and guided thru process to enrollee in QHP. New Mexico will send a web services query a Shared Data Services HUB for verification of enrollee’s information as required in 45 CFR part 155. For enrollees who wish to pursue financial application path, NMHIX will seamlessly transition to insurance affordability single streamlined application that will collect the required data from enrollees and family members. New Mexico will send a web services query a Shared Data Services HUB for verification of enrollee’s information as required in 45 CFR part 155.

The business and functional requirements for processing and screening applications, determining eligibility, renewing eligibility, and handling appeals includes the following core processes:

Prepare Initial Individual Application

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Verify Individual Citizenship, Status as a National or Lawful Presence

Determine Individual Exchange

Verify Individual Incarceration Status

Renew Individual Eligibility and

Appeal Individual Eligibility

Verify whether an Individual is a Native American (NA/IA)

Verify Individual Residency in Exchange Service

Verify Eligibility for Other Public Minimum Essential Coverage

Verify Income

Qualify Individual for Enrollment Period

Communicate Eligibility Determination and Coordinate Enrollment

Determine Individual Exemption Eligibility

Renew Individual Exemption Eligibility

Change Reporting

Access to Referral The New Mexico’s Individual Enrollment processes will coordinate seamlessly with its Individual Eligibility processes. For QHP selections, the NMHIX system will be responsible for creating enrollment transactions and providing them directly to insurance issuers or allowing the individual to complete enrollment directly through the insurance issuers’ websites. The IT System will track all health plan enrollments for individuals who have applied for coverage through the Marketplace. It will also be responsible for reporting enrollment, as required by CMS, to the Federal Data Services Hub. The NMHIX Plan Management function consists of the following core elements:

Establish Issuer and Plan Initial Certification and Agreement Monitor Issuer and Plan Certification Establish Issuer and Plan Renewal and Recertification Maintain Operational Data Process Change in Plan Enrollment Review Rate Increase Justifications

NMHIX intends to leverage the SERFF system from the NAIC for the following functions:

Marketing Standards

Accreditation and Quality Notice of Intent Reporting Requirements QHP and state mandate standards Submission at Plan Level Indication of Metal Level Verification of Metal Level Quality measures Benefit Package

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Cost Sharing and Limits Rating Tables Final Determination Issuer and QHP Status Renewal and Certification Decertification of Issuer

Decertification of Plan SHOP Plan Changes Individual Plan Changes

Once New Mexico is live with core marketplace functionality in 2015 New Mexico will continue to add capabilities to support our goal to increase enrollment and enhance self-sustainability. General theme for types of enhancement work that will be undertaken in 2016 and 2017 include:

• Catalyze enrollment through active and increasing participation of brokers; • Broaden distribution opportunities maximally through a range of enrollment options; • Enhance ease of use by users, particularly for New Mexico specific user communities.

New Mexico is looking to implement following enhancements:

Centralized Provider Directory

Prescription Search

Provider Network Stats - Narrow Networks

Provider Maps

Ability to purchase adult dental without QHP

Personalized Plan Scores

Anonymous Shopping for Employers

Automated Reminders

Direct Enrollment Module (EVaaS)

Operational User Alerts -- Part I for Brokers and CSRs (Customer Life-cycle Management)

Operational User Alerts -- Part II for NMHIX administration

Batch Enrollment Engine from SHOP to Individual Exchange

Consumer Assistance Toolset: PDF proposal creators, notifications to designated CC of any change to consumer record, scenario analysis for each family.

Advanced Layered, In-context Help

Native mobile apps for iOs and Android for Employees (iPhone, iPad)

Capability to make differing enrollment choices per family member

Scenario and Prospect Management Workbench for Brokers

PDF Proposal Creator, Rapid employer engagement tool

Brokers and CSRs: Advanced Reporting & Analytics (optional feature with Scenario and Prospect Management Workbench)

Broker Agency Module

Advanced Enrollment Counselor Search

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Enrollment Entity Setup Process Enhancements

Enrollment Counselor certification and learning management integration

Enrollment Counselor self-ticket creation and management

Operational User Alerts -- Part III for Brokers (Customer Life-cycle Management)

Enrollment Counselor recertification or renewal automation

Agent License monitoring and action system

Advanced access to Enrollment Counselor functions to the Enrollment Entity

Agent employer relationship lifecycle - multiple notifications

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Figure: Timeline to implement enhancements to New Mexico’s IT System

NMHIX Timelines

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Centralized Provider Directory Technology Capability

Ability to purchase adult dental without QHP

Addition of GPS Tile-view

Prescription Search

Provider Network Stats - Narrow Networks

Provider Maps

Automated Reminders

Personalized Plan Scores

Anonymous Shopping for Employers Phase 1

Notfication for employer that the agent has declined the broker

designation

CAP Enhancements and Policy Search

Direct Enrollment Module (EVaaS)

Agency Module - Individual

Operational User Alerts -- Part 1 for Brokers and CSRs

Layered, In-context Help

Consumer Assistance Toolset

Scenario & Prospect Management Workbench for Brokers

PDF Proposal Creator, Rapid employer engagemnet tool

Notfication for employer that the agent has declined the broker

designation

Batch Enrollment Engine from SHOP to Individual Exchange

Operational User Alerts -- Part II for NMHIX administration

Ancillary product infrastructure

Native mobile apps for iOs and Android for Employees (iPhone, iPad)

Ancillary Products -- Life, Vision, Critical Illness

Anonymous Shopping for Employers Phase 2: Infrastructure; new

workflows; data transfer

Brokers and CSRs: Advanced Reporting & Analytics

Capability to make differing enrollment choices per family member

Off-Exchange Plans

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5. IT Seven Standards and Conditions Please see the New Mexico Blueprint document for information on Exchange IT systems. 6. Organizational Structure The NMHIX organizational chart is shown on page 16. NMHIX has implemented an MOU with HSD and an MOU with OSI to delineate the roles and responsibilities. 7. Coordination with the Federal Government on Exchange Activities New Mexico will coordinate with the federal government on all its development and implementation activities. 8. Strategies for Reuse, Sharing, Collaboration for NMHIX Activities with the Federal Exchange and Other States As outlined in agreements with HHS, all Exchange systems and system components financed with federal funds are non-proprietary, utilize open architecture standards, and permit re-use by other states and jurisdictions. New Mexico will inform and assist other states through various means, including HHS Learning Collaborative and User Groups. Beyond reuse and sharing of IT, New Mexico is committed to leverage existing infrastructure and re-purpose business functions and processes to maximize resources and is working with other states to determine how aspects of their systems can be replicated in New Mexico. Specifically, Marketplace IT solution is being used by Idaho and Mississippi State Based Marketplace. New Mexico has collaborated with these SBMs and is in process of forming a formal users group. As we look at self-sustainability, New Mexico will continue to collaborate with Idaho and Mississippi SBMs to continue to enhance Marketplace IT solution on a join cost basis via its Marketplace technology vendor GetInsured. 9. Strategies to Ensure Financial Integrity Mechanisms to Prevent Fraud, Waste, and Abuse and Provide Oversight of Cooperative Agreement Funds and the Exchange New Mexico has administrative policies and statutory and regulatory provisions to ensure appropriate financial management of grant funds. Grant funds are administered following comprehensive written procedures and procedures approved by the NMHIX Finance Committee. This includes internal controls and oversight to make sure the system disburses, tracks, and accounts for grant disbursements. New Mexico will ensure NMHIX program operations and management integrity, and that federal cooperative agreement dollars are expended as budgeted in its cooperative agreements and contracts.

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10. Challenges That May Affect Progress in Work Plan New Mexico is monitoring key indicators on a daily basis through its PMO. Weekly project meetings are conducted to review progress towards meeting identified milestones. Issues are Risk are escalated as appropriate to New Mexico Leadership. 11. SHOP Market Challenges—Over 85 percent of New Mexico’s small businesses have fewer than 50 employees and many have never purchased health insurance. Strategic SHOP Plan--NMHIX has successfully implemented its SHOP program. Three major insurers in New Mexico have been certified as SHOP QHPs.

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F. Work Plan NMHIX has retained the services of GetInsured (GI) to implement both the SHOP marketplace and the Individual marketplace. NMHIX produced a set of functional requirements for the SHOP and Individual marketplace systems that were incorporated into the Request for Proposals (RFP) to which GI responded. NMHIX has retained the services of Public Consulting Group (PCG) to assist with various aspects of implementing the SHOP and Individual marketplaces, including a Project Management Office (PMO). In addition NMHIX has contracted with Software Engineering Services (SES) as an Independent Verification and Validation to oversee the design, development, and implementation of the marketplace functions. Among the functions of the PMO and IV&V are to work with GI to ensure that:

o Standard industry Systems Development Life Cycle (SDLC) protocols are followed, including iterative and incremental development methodologies.

o Requirement specifications, analysis, design, code, and testing are developed and carried out in accordance with CMS/CCIIO requirements and generally accepted professional practice.

o The design takes advantage of a Web Services Architecture and Service Oriented Architecture approach for design and development.

o The services description/definition, services interfaces, policies and business rules are published as required and the solution provides role-based access to underlying data.

o The solution adheres to standards published by the Office of the National Coordinator (ONC) and the National Institute of Standards and Technology (NIST).

o The GI system is interoperable and integrated with State Medicaid/ Children’s Health Insurance Program (CHIP) programs and is able to interface with HHS and other data sources in order to verify and acquire data as needed.

o The GI system achieves any required interoperability with other health and human services programs for purposes of coordinating eligibility determinations, referrals, verification or other functions.

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Task Name Start Finish

Phase II Individual and SHOP Enhancements Mon 6/24/13 Fri 1/15/16

On Going PMO Services Mon 6/24/13 Fri 1/15/16

OSI QHP Review dates Sat 3/1/14 Sun 8/31/14

CMS/CCIIO/IRS - Reviews Tue 2/11/14 Wed 8/19/15

Planning Review Meeting Tue 2/11/14 Tue 2/11/14

Design Review Meeting Wed 4/9/14 Thu 4/10/14

Final Design Review Meeting Tue 6/10/14 Wed 6/11/14

Operation Readiness Review Mon 8/3/15 Tue 8/4/15

Internal Readiness Review Mon 8/10/15 Wed 8/12/15

IRS Visit Mon 8/17/15 Wed 8/19/15

Business Area Development Mon 2/3/14 Thu 10/15/15

Identify NMHIX owner for each Functional area Tue 4/1/14 Fri 5/2/14

Review and signoff of JAD documents Thu 3/27/14 Fri 11/14/14

Mail Room Operations Tue 4/1/14 Mon 1/12/15

2.0 Consumer and Stakeholder Engagement and Support Wed 3/12/14 Thu 10/15/15

3.0 Eligibility and Enrollment Tue 2/4/14 Thu 10/1/15

8.0 Finance Tue 4/1/14 Fri 11/28/14

10.0 Privacy & Security Tue 4/1/14 Fri 10/3/14

11.0 Oversight, Monitoring, & Reporting Mon 2/3/14 Mon 4/20/15

12.0 Policies and Procedures Documentation Fri 7/25/14 Wed 1/28/15

Phase II - Technical Mon 12/16/13 Fri 1/1/16

Requirements and Design Validation Tue 1/14/14 Thu 2/19/15

External Dependencies Fri 4/4/14 Wed 8/26/15

Interfaces/Integration Planning Mon 2/17/14 Wed 5/6/15

Infrastructure Mon 1/27/14 Fri 8/14/15

Interfaces - Connectivity Wed 1/29/14 Thu 10/1/15

CP3 Demo for CMS Fri 7/11/14 Fri 7/11/14

OIG Audit Tue 1/28/14 Mon 5/26/14

Release 0 & 1 (Plan Mgt, Agents, Entities/Assisters) and Release 1 (Pre-screener, Anon.Shop. & Acc. Creation) Mon 12/23/13 Wed 11/19/14

NMHIX SHOP Mon 9/1/14 Fri 1/1/16

Release 2 (Public Launch - Open Enrollment) Mon 12/16/13 Mon 11/2/15

2014 Cycle Mon 12/16/13 Thu 2/12/15

Check point 2 (Account Creation, SSA data verification rule engine and HUB interface) Mon 2/3/14 Fri 6/13/14

Check point 3 (Plan Selection, Financial Management, Eligibility) Mon 2/3/14 Fri 7/11/14

Check point 4 (Carrier Interfaces, Individual Portal) Mon 4/7/14 Wed 11/26/14

Check point 5 (Admin Portal, Reporting) Mon 12/16/13 Wed 9/10/14

COTS Deferred Items 2.1 & 2.2 Mon 6/30/14 Fri 1/23/15

INITIAL MEC interface QA (MMIS/Xerox) Thu 5/8/14 Fri 11/7/14

SIT Verification interface formal test (FDSH) - CMS Hub Testing Wed 5/14/14 Tue 7/15/14

Product Assessment Mon 10/20/14 Thu 2/12/15

2015 Cycle Thu 5/8/14 Mon 11/2/15

External Dependency: Additional HSD data needs [place holder] Mon 9/29/14 Fri 3/6/15

External Dependency: CMS Verification Flow Changes (Assessing risk to CMS new changes and possible rework) Mon 2/9/15 Fri 8/14/15

Validate Sprint Schedule Tue 12/30/14 Tue 12/30/14

New Mexico Specific Components Mon 10/6/14 Fri 9/4/15

Develop Test Plan (UAT / SIT) Mon 1/5/15 Mon 2/2/15

Review Content (SSAp Only) Tue 1/13/15 Fri 3/13/15

Develop Training plan Mon 4/6/15 Fri 5/1/15

Develop System Integration testing (SIT) Test Cases Thu 5/8/14 Mon 11/2/15

Performance and Stress Test Mon 8/3/15 Fri 10/2/15

UAT prep - R2, Deferred, CR items Mon 2/2/15 Fri 3/13/15

UAT - R2, Deferred, CR items Sat 12/27/14 Fri 6/12/15

Stakeholder Assessment (GI will maintain a testing server enviornment) Mon 5/11/15 Fri 6/26/15

Training [ R0, R1 and R2 training] Mon 6/1/15 Wed 8/5/15

FFM Renewals & Data Migration [Place Holder] Sun 10/12/14 Fri 9/25/15

2015 Enhancements [Place Holder] Mon 3/9/15 Fri 8/28/15

Deploy Release 2 to pre-production environment [Place Holder] Wed 3/25/15 Wed 4/1/15

Client Review before public launch Mon 8/10/15 Fri 8/14/15

DELIVERABLE: Provide Final Release 0 and 1 Notes to client Mon 8/17/15 Fri 8/21/15

Client approval to deploy R0 & R1 to production Mon 8/24/15 Tue 8/25/15

Deploy Releases 0 and 1 to production Wed 8/26/15 Thu 9/3/15

Release 0 and Release 1 - public launch Fri 9/4/15 Fri 9/4/15

DELIVERABLE: Provide Final Release 2 Notes to client Mon 8/31/15 Mon 8/31/15

Stabilization Period / Launch Mon 9/14/15 Fri 9/25/15

Deploy Release 2 to production environment at the same time as R0 & R1 (Option 1 - based on an October OE) Mon 8/24/15 Thu 9/3/15

NMHIX Requested Production Based Testing Fri 9/4/15 Thu 10/1/15

Plan validation by carriers [MOVE to 2015] Mon 7/6/15 Wed 9/2/15

Release 2 - PUBLIC LAUNCH Fri 10/2/15 Fri 10/2/15

Release 2 Transition to production Mon 10/5/15 Fri 10/16/15

Operational Normalization Mon 10/19/15 Fri 12/11/15

Release XX - to be determined Wed 7/1/15 Fri 1/8/16

Deferred 2.3 - 2015 Renewals [Place holder] Wed 7/1/15 Tue 10/13/15

Deferred 2.3 - CMS / IRS reports (H36 – monthly / H41 – yearly) Mon 11/2/15 Fri 1/8/16

Deferred 2.3 - Test CMS / IRS reports (H36 – monthly / H41 – yearly) Mon 11/2/15 Fri 1/8/16

Project Closure Mon 10/19/15 Fri 1/15/16

NMHIX 2014-2015 Individual Re-Baselined Milestone Plan v1.0

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Timeline to implement enhancements to New Mexico’s IT System

NMHIX Timelines

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Centralized Provider Directory Technology Capability

Ability to purchase adult dental without QHP

Addition of GPS Tile-view

Prescription Search

Provider Network Stats - Narrow Networks

Provider Maps

Automated Reminders

Personalized Plan Scores

Anonymous Shopping for Employers Phase 1

Notfication for employer that the agent has declined the broker

designation

CAP Enhancements and Policy Search

Direct Enrollment Module (EVaaS)

Agency Module - Individual

Operational User Alerts -- Part 1 for Brokers and CSRs

Layered, In-context Help

Consumer Assistance Toolset

Scenario & Prospect Management Workbench for Brokers

PDF Proposal Creator, Rapid employer engagemnet tool

Notfication for employer that the agent has declined the broker

designation

Batch Enrollment Engine from SHOP to Individual Exchange

Operational User Alerts -- Part II for NMHIX administration

Ancillary product infrastructure

Native mobile apps for iOs and Android for Employees (iPhone, iPad)

Ancillary Products -- Life, Vision, Critical Illness

Anonymous Shopping for Employers Phase 2: Infrastructure; new

workflows; data transfer

Brokers and CSRs: Advanced Reporting & Analytics

Capability to make differing enrollment choices per family member

Off-Exchange Plans

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G. BUDGET AND BUDGET NARRATIVE

New Mexico requests $97.9 million in federal funding for a Level Two Establishment grant for the period January 1, 2015 through December 31, 2017. New Mexico received $34.3 million for an initial Level One grant in November 2011. This grant is in the process of being closed. New Mexico also received $18.6 million as an additional (2nd) Level One grant in July 2013. This grant is still open and has a balance of $4.0 million remaining. A No Cost Extension was requested in September 2014, which increased the duration to 10/14/2015. New Mexico received $69.4 million for the 3rd Level One grant, awarded January 22, 2014. A No Cost Extension is being requested to December 31, 2015. Approximately 80% of this grant is encumbered by contracts. Budget detail is provided for each expenditure area as follows:

Salaries and Wages

Total $0 Exchange Establishment Grant: $0

Funding other than Establishment Grant $0 Sources of Funding: Level 1 grant

Funding for Salaries and Wages that are eligible for grant funding is provided by existing grant HBEIE140193, and is discussed in the No Cost Extension for that grant.

a Salaries -$

b Fringe Benefits -$

c Total Personnel Costs -$

d Equipment -$

e Supplies -$

f Travel -$

g Construction -$

h Other -$

i Contractual 97,975,535$

j Total Direct Costs 97,975,535$

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Fringe Benefits

Total $0 Exchange Establishment Grant: $0

Funding other than Establishment Grant: $0 Sources of Funding: Level 1 Grant

Funding for Fringe Benefits that are eligible for grant funding is provided by existing grant HBEIE140193, and is discussed in the No Cost Extension for that grant.

Equipment

Total $0 Exchange Establishment Grant: $0

Funding other than Establishment Grant: $0 Sources of Funding: Level 1 Grant

Funding for Equipment is provided by existing grant HBEIE140193, and is discussed in the No Cost Extension for that grant.

Supplies

Total $0 Exchange Establishment Grant: $0

Funding other than Establishment Grant: $0 Sources of Funding: Level 1 Grant

Funding for Supplies is provided by existing grant HBEIE140193, and is discussed in the No Cost Extension for that grant.

Travel

Total $0 Exchange Establishment Grant: $0

Funding other than Establishment Grant: $0 Sources of Funding: Level 1 Grant

Funding for Travel is provided by existing grant HBEIE140193, and is discussed in the No Cost Extension for that grant.

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Other

Total $0 Exchange Establishment Grant: $0

Funding other than Establishment Grant: $0 Sources of Funding: 0 Level 1 Grant

Funding for other is provided by existing grant HBEIE140193, and is discussed in the No Cost Extension for that grant.

Contractual

Total $97,975,535

Exchange Establishment Grant: $97,975,535 Funding other than Establishment Grant: $0

Contractual services include the following:

1. Get Insured system functionality – These improvements to the core system functionality are intended to enhance the consumer experience to facilitate enrollment growth and ultimately benefit financial sustainability. They include: a) Centralized Provider Directory technology capability to search for and identify provider b) Prescription Search that enables the consumer to enter the names of prescriptions and

then shop for plans based on coverage for that prescription. c) Anonymous Shopping for Employers – this is a new tool that allows employers to enter

minimal data and browse the plans and prices available for their business without creating an account or going through eligibility

System Core Functionality 48,779,480$

Costs for CMS Single Door 32,236,297$

Delay in Implementation of Individual Exchange 2,591,667$

DDI Impact 2,758,380$

Renewal/Data Migration for Individual Exchange 7,500,000$

CMS June 2014 Approved Verification Flow 765,000$

Portion of Change Orders 621,702$

Contingency for additional CMS changes 2,723,010$

Grand Total - Level 2 97,975,535$

Budget Items in Level 2 Grant

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d) Automated Reminder emails for incomplete employer tasks e) CAP Enhancements and Policy Search – the capability to search for enrollments by issuer

enrollment ID, by name of subscriber and other characteristics. f) Direct Enrollment Module that can allow for carriers to easily integrate with NMHIX. This

will encourage greater participation by carriers. g) Operational User Alerts for brokers, customer service reps and NMHIX administration –

System wide alerts for a range of stakeholders for 360 degree service of the customer. h) Batch Enrollment Engine from SHOP to Individual Exchange – this will allow brokers or

employers to quickly model likely eligibility for the Individual Exchange for employee dependents based on Employer offer of coverage to dependent.

i) Provider Network Stats – to allow consumers to visualize the depth of provider networks in their zip codes across plans through simple visualization tools.

j) Provider Maps – Geo maps of provider networks k) Ability to purchase adult dental without QHP l) Personalized Plan Scores

2. CMS Single Door - The cost estimated for development of a single financial application to meet CMS requirement of a fully integrated approach with HSD.

3. Delay in implementation of Individual Exchange – In July 2014 Board meeting, the Board voted to delay the implementation of the Individual Exchange due to concerns about schedule slippage.

4. DDI Impact – Infrastructure and hosting server for the individual exchange delay. 5. Renewal/Data Migration – cost of moving enrollees from the Federal platform to the State

Individual exchange – this is expected to be a manual process. 6. Remaining costs include the CMS Verification Flow, Contingency and Change Orders.

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H. ADDITIONAL LETTERS OF AGREEMENT AND/OR DESCRIPTION(S) OF PROPOSED/EXISTING PROJECT

None to report

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I. DESCRIPTION OF KEY PERSONNEL AND ORG CHART

See Page 19

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J Cost Allocation Methodology Attached below is a draft Cost Allocation Methodology. NMHIX will continue to work closely with HSD to finalize the cost allocation detailed methodology based on the integrated “Single Door” approach.

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K. DOCUMENTATION SUPPORTING ELIGIBILITY OF APPLICANT (LEVEL TWO EXCHANGE ESTABLISHMENT ONLY)

1. New Mexico Senate passed a Bill-221NMHIX that provides necessary legal authority to

NMHIX to establish and operate an Exchange that complies with Federal requirements available at the time of the application. See attached below copy of SB221

2. New Mexico Senate passed a Bill-221NMHIX that established a governance structure for the NMHIX Exchange. See attached below copy of SB221

3. Initial plan discussing long-term operational costs of the Exchange – See below attached draft NMHIX Financial Sustainability Plan

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Senate Bill-221NMHIX

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Financial Sustainability Plan

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