colorado health benefits exchange

1

Colorado Health Benefits Exchange

IT and Implementation Committee Strategic IT Decisions

December 7, 2011

Overview• Action items from 11/30 meeting

• RFI and “Pulse” of Marketspace

• Acquisition Process• Cornerstone elements of RFP• Analysis and Scoring of Proposals• Outline of RFP• Evaluation Committee• Legal resources

• Financial Model• Costs Comparison: Asset Acquisition vs. SAAS (ROM and Directional) Engineer’s

Estimate as Major Component of COHBE Operating Expense• Impact on COHBE Sustainability Model• Revenue Source to Fund Operational Expenses

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

• Storyboard• Areas of Potential Interoperability and Input (IT, Call Center, Plans)• Cost Allocation of Interoperability

• Agenda and Affirmations for 12/12 Board Meeting

• Review of Gameplan Leading to Start of Formal Acquisition Process

2

3

Action Items from 11/30 Meeting

4

Action Items from 11/30 Meeting• Action Item: Review State of MO RFI and companion material and determine applicability

to COHBE strategy and Acquisition• Gary sent email on 11/30 summarizing RFI process and differences between MO and

CO’• Gary spoke to Dwight Fine (MO Insurance Department) to understand context of their

effort and potential synergy; in addition to information provided on 11/30 estimated project cost is $125M for fully integrated eligibility and exchange solution; State portion being funded by foundation(s) not SGF

• Action Item: Provide Committee members with list of vendors receiving COHBE RFI• Copy of vendors engaged to-date and on the radar on Slide #7

• Action Item: Review selection criteria from MO• Good content; can leverage; will be developing requirements and leveraging RFPs

from WA and MD

• Action Item: Identify need for legal resources• Legal resource requirements and timeframes identified on Slide #14

• Action Item: Stay informed on work NAIC is doing to assist carriers to load plans into Exchanges using a standard format• Will monitor NAIC activities through Julie Fritz and report back periodically; do not

currently see any impact on RFP; carries should embrace this standardization

5

RFI and “Pulse” of the Marketsplace

6

RFI and “Pulse” of Marketspace• Few states in the Exchange Acquisition process at this stage; many

waiting for legislative approval process or determining strategy

• Vendors anxious to present solutions, get a foothold and begin implementation for leading states

• End-to-end solutions seen to-date range from small gaps to significant gaps which will require design, development and implementation by vendor(s) (i.e. risk)

• Many vendors will “team” to provide the three core areas of systems and services needed by COHBE

• Still in process of getting additional data points to verify price point ranges and pricing options; cost data presented today is preliminary and non-binding on vendors

• Actual cost data will be provided in early-May when proposals are received

RFI and “Pulse” of MarketspaceVendors receiving/responding to COHBE RFI

7

Company Name Contact Meetings RFI comments

Choice Administrators www.choiceadmin.com

Joe De La Cruz 714.718.9369 [email protected]

web meeting – 12/12 sent 11/30 partnering w/ACS

Ceridian www.comdata.com

Matt Spencer 801.903.7290 [email protected]

web meeting – 11/28 sent 11/29

CGI www.cgi.com

Holli Ploog [email protected]

12/2 11a phone call b/w 12/14 & 12/21

sent 12/1 [email protected] 703.267.5043 lobbyist – Jim Carpenter

Connecture www.connecture.com

Dana Leopold 404.964.4098 [email protected]

Web meeting – 11/10 CHI –12/6

sent 12/1 partnering w/Maximus

Getinsured.comwww.getinsured.com

Sephy Hambaz 650.618.4609 [email protected]

CHI –12/13 sent 12/1 Chini Krishan 650.618.4609 [email protected]

eHealth www.eHealthinsurance.com

Sam Gibbs 202.290.3911 [email protected] 408.887.1488 (m)

TBD sent 12/5 Partnered on other projects with Deloitte and/or Curam (sp)

BenefitMall www.benefitmall.com

Benjamin Waters 720.837.6726 [email protected]

web meeting – 12/8 sent 11/30

http://www.choiceadmin.com/

mailto:[email protected]

http://www.comdata.com/


http://www.cgi.com/



http://www.connecture.com/


http://www.getinsured.com/



http://www.ehealthinsurance.com/

http://www.ehealthinsurance.com/


http://www.benefitmall.com/


Solution Cost Estimate

8

Exchange Enrollment

200

400

600

800

'13 '14 '15 '16 '17 '18

(000

's)

Solution Cost EstimateKey Cost Drivers for SAAS model: • Enrollment

• Combination of Wakely/Gruber #’s; • “moderate” Wakely #’s in ’14 & ’15 • Gruber: ultimately 540K – 960K in exchange; used 750K (midpoint)

• SaaS PMPM (per member per month) rate • Rate depends on:

1) Vendor 2) Breadth of functionality and services, i.e. “thick” vs. “thin”

exchange

9


10

SaaS – Software-as-a-Service PMPM – per member per month

Slide 17

SaaS model yields annual costs of $20M – $60M at 750K enrollment.

* Rates remains flat over the years for these scenarios.

SaaS pmpm scenariosannual costs

$20

$40

$60

$80

'13 '14 '15 '16 '17 '18

($ M

per

yea

r)

$ 6.50*

$ 5.00

$ 3.50

$ 2.00

Enrollment 550K 650K 720K 750K 760K 770K

Solution Cost Estimate• Key Cost Drivers for acquisition model:

• Software license acquisition

• Monthly operating costs depends on:• annual maintenance and support (% of license)• application support and hosting (fixed cost/mo)• administrative service (per member per month) rate

• Administrative services linked to enrollment and likely to be 10-50x system costs

11

$200

$400

$600

$800

'12 '13 '14 '15 '16 '17 '18

($ 0

00's

) per

yea

rSolution Cost Estimate

12

Slide 18

Acquisition model estimates by component.

Enrollment (December) 550K 650K 720K 750K 760K 770K

Implementation – $2M

software – $3M $30M

$25M

$20M

$15M

$10M

$5M

$5M

maintenance/support hosting operations ~$3.00 pmpm

Solution Cost EstimateKey Cost Drivers of SaaS and acquisition model are administrative and customer services:

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• Eligibility• MAGI eligibility• SHOP Exchange

• Plan Management/Shopping• Interfaces and services for carriers to load approved plans into COHBE• Search criteria, multi-dimensional• Track plan mandate costs • Reimbursement system for exchange enrollees for additional mandated costs • Broker tools for quotes/comparisons

• Financial Management • Full A/R disbursement, collections, online presentation & billing customer service • automated billing aggregation for employers, individuals, families, insurance companies, & agents • Online payment service Integration for individuals and employers to include ACH, credit card, • Account management, view, search, adjust • Electronic and paper invoices • Automated notification to manage delinquent, late payments • Support for web advertising • Collect and maintain data to calculate billings determined necessary to compensate • Integrate with general ledger/accounting systems • Cafeteria plan integration for payments• Billing help desk support


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• Customer Service • Multilingual online system for specified languages • Multilingual help desk/enrollment support for specified languages • Promotion of health management and wellness initiatives • Flexible spending account, health reimbursement account and health saving account support • Sponsorship/assistance for state exchange outreach programs • Simultaneous online access for agent/navigator and consumer from different sites • Wellness Programs enrollment, monitoring and portability

• Communications • Classroom and/or online training programs for agents and navigators • Resource library for consumers, agents, brokers, employers and providers • Associated document management to store and access electronic and paper communication • Complete forms library for all plans

Key Cost Drivers of SaaS and acquisition model are administrative and customer services:

$10

$20

$30

$40

$50

'12 '13 '14 '15 '16 '17 '18

($ M

per

yea

r)

Acquisition

SaaS


15

Acquisition model results in $14M – $18M annual savings based on the assumptions below.

$5 pmpm

$17M—$18M/yr; $ 1.88 pmpm


$50

$100

$150

$200

$250

'12 '13 '14 '15 '16 '17 '18

($ M

)

Acquisition

SaaS


16

Cumulative cost savings based on estimate assumptions.

$50M

$87M


$2

$4

$6

$8

$10

'13 '14 '15 '16 '17 '18

per p

olic

y pe

r mon

th

AcquisitionSaaS

Solution Cost EstimateAssuming 1.8 members/policy (Wakely), $5—$9 per policy per

month required to fund ongoing exchange operations.

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Enrollment 550K 650K 720K 750K 760K 770K

$5.43 $8.82

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Acquisition Process

Acquisition Process

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Define Acquisition Strategy and

Gather Requirements

Evaluate:• Software solution• Hosting• Services• Costs• Skills/qualifications of vendor• Skills/qualifications of proposed team• Implementation approach and methodology

Release RFP

ConductReference Checks for 2-4 Vendors

Develop BAFO Guidance (for each vendor) & Transmit to Finalists

Approx 30 days

Negotiate w/PreferredVendor(s)

RFI and OtherInformationGathering

Draft RFP Review RFP(Board)

RFPApproved

for Release?

Develop VendorList

VendorsPrepare & Submit

Proposals

EvaluateProposals

(Technical & Cost)

Down Select to 2-4 Finalists &Notify Vendors

Finalists DevelopBAFOs

EvaluateBAFOs

Select PreferredVendor(s) Award

Conduct System Demos and Orals

w/ Finalists

Draft Statement0f Work Project Kick-off

12/01 01/23 03/0902/27

Approx 15 days

A

A03/19

Approx 10 days Approx 5 daysApprox 5 days Approx 5 days

04/02 05/0704/15

Begin formalAcquisition Process

Iterative w/ CCIIO for Review and Comments

12/15

Timeline for COHBE Solution Selection Process

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Acquisition ProcessKey Elements of Acquisition Strategy:

• Three core areas (system, hosting/IT ops, administrative services) w/ system acquisition as an option

• Teaming OK but single point of accountability, i.e. “prime” contractor

• Fixed-price by scope element

• Strict adherence to SLAs w/ material penalties for non-performance

• At least one team member in healthcare exchange business for five years

Need direction from Committee:• Asset acquisition as an option for COHBE (is this a “must” for bidders,

i.e. if they will not agree to license solution will proposal be rejected?)

• Three-year operating agreement with five (5) one-year options?

• Call center operations (and jobs) shall be located in CO?

• Other TBD

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Acquisition ProcessAnalysis and Scoring of Proposals• Solution Fit/Coverage and Gaps – single vendor or teaming arrangement must

provide required system and services that constitutes entire solution

• Experience and Wherewithal of Vendor in Exchange Space and Knowledge of Healthcare Reform

• Company Qualifications and Resources (Corporate and Proposed Project Team)

• Cost (implementation, 3-Year, Option Years)

• Strategic Fit

• Partnership Fit

• References

• Exceptions to Proposed Contract Ts & Cs

• Other Factors TBD

Beyond meeting minimum requirements, weighting matters; will propose approach to weighting later, i.e. during evaluation team orientation (mid-Feb)

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Acquisition ProcessOutline of RFP:1. Purpose of RFP, Vision, Concept of Operations2. COHBE Background3. General and Administrative Procurement Information and Timeline4. Scope of Implementation and On-going Services5. Proposal Response – System, Implementation Services, On-going

Operations and Administrative Services:• Solution Proposal (business, technical)• Cost Proposal (cost model will be provided ; line items broken down between

implementation and on-going costs to insure ability to accurately compare costs)6. Proposed Contract Terms and Conditions7. Appendices:

• Appendix A – Business Process Models• Appendix B – Business Requirements (functional, technical)

Appendix C – Interoperability with State Medicaid Systems and Business Processes

• Appendix D – Reporting and Business Intelligence• Appendix E – Technical Architecture• Appendix F – Operations, SLAs, and Continuity of Operations• Appendix G – Interfaces• Appendix H – Conversions• Appendix I – Deliverables• Appendix J – Turnover

•Procurements will b

e:

•Well-structured

•Efficient

•Competitiv

e

•Fair

•Transparent

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Acquisition ProcessEvaluation Committee

• Seeking volunteers to participate in COHBE vendor selection; crucial decision which can only be made once (for several years); leverage experience and perspective of diverse group will lead to better decision

• Duties and time commitment:• Review and rank proposals using evaluation sheets provided; note areas

of concern, be available to discuss evaluation and proposal rankings (need to be able to review all qualified proposals)

• Depending on number of quality proposals received likely 40 hours during first two weeks of March

• Demonstrations/orals likely 20 hours in late March

• BAFO review and recommendation 16 hours in early April

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Acquisition ProcessLegal services needed to support acquisition process and timeframes services will be required

• Develop initial contract for acquisition of Exchange system and services to include in RFP – 01/03 – 01/13

• Review and advise re vendors’ responses/exceptions to proposed contract – 03/03 – 03/09

• Advise on how to ensure information provided during demos/orals/discovery sessions and BAFO becomes binding – 03/19 – 03/24

• Participate in contract negotiations 04/06 – 04/15

• 200 – 300 hours estimated for legal services to support acquisition process

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

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

CBMS/PEAK &Medicaid/CHIP Eligibility & EnrollmentBusinessProcesses

COHBEEligibility & EnrollmentSystemsand BusinessProcesses

InteroperabilityBetween COHBE& State Medicaid/CHIP Systemsand Business Processes

Extent of “interoperability” (i.e. amount of overlap) between COHBE system and business processes and CBMS/PEAK

and associated State eligibility and enrollment business processes increase s complexity and schedule risk but improves

some consumer populations’ experience


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Small Business Owners& Employees(% and # expected)

IndividualHouseholds &Small BusinessEmployees(% and # expected)

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

(% and # expected)

Pre-screening

SHOPExchange

PEAK

IndividualExchange

Account Mgmt & MPI

EligibilityDetermination

Plan Selection &Enrollment

MAGI(including interfacing w/ federal data hub)

Set-up Employee Roster

Create Account

MMISCBMS

Should Pre-Screening Step be

Included?

Enrollment inCarrier Systems

Create Account

Review Subsidy/Out-of-Pocket Costs

Select Plan & Enter Enrollment Information

Interface Enrollment

Information to Carriers’ Systems

Review Out-of-Pocket Costs


Eligible for Employer Plan &

Amount of Coverage


Information to MCO Systems

Moderate Interoperability – MAGI & MMIS Interface

Does CBMS Need Enrollment Data?

Enroll Eligible HouseholdMembers into Family

Medical Program into MMIS

HouseholdMember(s) Eligible for Other

Medical or HS ProgramsState Systems

COHBE Systems

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

Gather business requirements

Gather technicalrequirements

Define interoperability “musts”” for 2013

including ACA

Prioritize all interoperability

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

Develop 3 options with increasing levels of

interoperability, complexity, risk, costs, etc.

Define design alternatives (functions and feature sets

for each option)

Evaluate feasibility of design alternatives

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

Compare feasible alternatives against criteria;

make recommendation

Draft/Negotiate Deloitte SOW

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

Prioritization of RequirementsRequirements Option 1 Option 2 Option 3

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

Tiered Sets of Requirements

“Musts”

Strong “Wants”

Nice “Wants”

Draft & Submit IAPD

Small Business Owners& Employees(% and # expected)

IndividualHouseholds &Small BusinessEmployees(% and # expected)

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

(% and # expected)

Pre-screening

SHOPExchange

PEAK

IndividualExchange

Account Mgmt & MPI

EligibilityDetermination

Plan Selection &Enrollment

MAGI(including interfacing w/ federal data hub)

Set-up Employee Roster

Create Account

MMISCBMS

Should Pre -Screening Step be

Included?

Enrollment inCarrier Systems

Create Account

Review Subsidy/Out-of-Pocket Costs



Information to Carriers’ Systems

Enroll Eligible HouseholdMembers into Family Medical

Program Into MMISWho pays for this interface ?

Review Out-of-Pocket Costs


Eligible for Employer Plan &

Amount of Coverage


Information to MCO Systems

Moderate Interoperability – MAGI & MMIS Interface

Does CBMS Need Enrollment Data?

Define scope for Exchange System(s) and Services

(RFP/RFQQ)

Define scope for modifications to PEAK &

CBMS

Begin Formal Exchange Acquisition

Process

Approach to Determining Optimal Interoperability Strategy

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

guiding principles and best practices):• Single/shared MAGI eligibility process for Private Insurance and Medicaid/CHIP• Single sign-on• Comprehensive MPI (Exchange and Medicaid/CHIP population)• Data only entered once• Request only information needed for determining eligibility for healthcare• Maximize “no touch” eligibility adjudications • Interface from PEAK to MAGI process to support “no wrong door” requirement• Provide links to non-medical eligibility processes and pre-populate with data

previously collected during medical eligibility processes

• Moderate level of systems interoperability:• Interfaces

• To MMIS for automatic enrollment for Family medical and CHIP• To CBMS for eligibility determinations for all other medical programs

• Maximum level of systems interoperability:• Shared rules engine• Single entry point (portal)

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Tiered Sets of Requirements

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Interoperability Feasibility Criterion Minimum Moderate MaximumCommon "no touch" MAGI eligibility X X XNo "wrong door" X X XShared MPI and Account Management X X XNo data entered more than 1x; re-use data X X XDo not ask for data not relevant to medical eligibility X X XMeet all minimum ACA reqs X X XShared call center XSame carriers for some private and public plans XInterface PEAK to Exchange for MAGI Eligibility X XLink and data population Exchange MPI to PEAK X XInterface Exchange to CBMS for other medical and human services X XInterface from Exchane to MMIS for no touch for Family Medical and CHIP enrollment X XShared rules engine * X* has other implications

Interoperability LevelImpact on Exchange RFP


Use Cases, expected populations and interoperability considerations

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System Entry Point

Use Case Construct

Household Composition

Use CasesPopulation

Account Mgmt/MPI/M

AGI

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

Call Center Rules Engine Other

COHBE Individual Household

Eligible for subsidy

TBD expected to be >200K

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

Not eligible for subsidy

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

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

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

Program Eligibility

PEAK/CBMSFamily Medical Eligible for

Family MedicalTBD expected to be > 300K

Y Y Y N Y Y Y

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

DisabilityTBD Y Y N Y Y not in COHBE Y Y

TNAF Eligible for TNAF What is intersecting population?

Y N N N N/A Y Future

SNAP Eligible for SNAP What is intersecting population?

Y N N N N/A Y Future

CHIPEligible

Eligible forSubsidizedPrivateCoverage

What is this population? CHIPEligible

Eligible forSHOPCoverage

What is this population?


• Storyboard shows moderate level option of interoperability

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Carrier Systems

Individual and Household w/ Income

Less than 133% PL

Individual and Household w/ Income between

133% and 200% PL


between 133% – 400% PL

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

Yes

Preliminary Eligibility Determination for Medicaid/SCHIP

(show potentially eligible programs)

May be Eligible for Medicaid/SCHIP

(Including Expansion)

Preliminary Eligibility Determination for Subsidized

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

Business Objective for Each Process

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

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

Likely Eligible for Medicaid/SCHIP

Individual Creates AccountIn COHBE

Likely Eligible for Subsidized Private

Coverage

Not Eligible for Subsidized Private

Coverage

SHOP Employee Presented Plans Based on Eligibility and Search CriteriaDisplay Benefit, Out-of-Pocket Cost, etc.Present Medicaid/CHIP plans if available (and provide search capabilities ) e.g.:

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

Based on application information

business rules make determination re eligibility for

Medicaid/CHIP or OtherLikely Medical Benefit

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

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

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

Initial Screening Account Management Eligibility Determination

Plan Management

Insurance Exchange Marketplace

Eligibility

Approval Fulfillment OperationsPremium

Collection/Aggregation

Determine if individual wants to see if he /she qualifies for financial assistance, i.e. Medicaid/CHIP or subsidized private coverageCollect minimal personal data and make preliminary determine if individual qualifies for financial assistance , i.e. Medicaid/CHIP or subsidized private coverage. No confidential information requested .

SHOP employers and brokers must create an account to proceed with SHOP coverage administration and account management .Individual must create account in order to enter personal data which will be stored and verified by interfacing with federal data hubIndividual enters required information , creates password , answers challenge questions , etc.

RenewalPlanSelection

Business Processes

Core ExchangeFunctions

Enrollment

Interface to HHS Data Hub SSA, IRS, HHS,

DHS

Individual Selects Plan /

Coverage Type

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

Eligibility Determination #2 is the determination if and to what extent an individual meets the criteria for a given category or categories of medical coverage . This will be performed by applying business logic to a set of data the required data will be different depending on the type of coverage , it may include but is not limited to : age, smoking, disability status , income, assets [resources], medical expenses , etc .)

Enrollment is the assignment of eligible individuals to health care plans that are available to that eligibility category. Plans may be restricted to eligible beneficiaries based on geography , funding stream , or other criteria. ( Enrollment generally includes options to choose a plan , but may also have a time -driven default assignment based on a fairly sophisticated algorithm that could include geography and funding streams , but also could include patients previous care providers , an agreement for the exchange to allocate default assignments according to some percentage across plans , or other criteria to be determined, etc.)

Insurance Exchange Marketplace is a presentation of plans for which the user is eligible . Tools to search, sort and compare plans along a variety of dimensions such as price, deductable, location/availability of network and out of network providers

Send Subsidy Transactionsto US Treasury and Carriers

Approve AssignmentsAssign Individual /Family Members to Pools

SHOP Employee

Selects Plan/Coverage Type

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

Enroll Individual/Family Members in MMIS

Provide medical card /proof of insurance when needed

Approve and process allowable claims on behalf of enrollee

US Treasury Systems/Subsidy Payments to Carriers

and Tax Credits for SHOP Employers

Call Center and Customer Assistance Track Enrollment and Changes to Enrollment

Effective as of 2014Main article: Patient Protection and Affordable Care Act #Effective by January 1, 2014

· State health insurance exchanges for small businesses and individuals open . · Individuals with income up to 133% of the federal poverty level qualify for Medicaid coverage. · Healthcare tax credits become available to help people with incomes up to 400 percent of poverty

purchase coverage on the exchange . · Premium cap for maximum "out-of-pocket" pay will be established for people with incomes up to 400

percent of FPL.[10][62] Section 1401 of PPACA explains that the subsidy will be provided as an advancable , refundable tax credit[63] and gives a formula for its calculation .[64] Refundable tax credit is a way to provide government benefit to people even with no tax liability [65] (example: Child Tax Credit ). According to White House and Congressional Budget Office figures , the maximum share of income that enrollees would have to pay for the "silver" healthcare plan would vary depending on their income relative to the federal poverty level , as follows:[11][66] for families with income 133–150% of FPL will be 4-4.7% of income , for families with income of 150–200% of FPL will be 4.7-6.5% of income, for families with income 200–250% of FPL will be 6.5-8.4% of income, for families with income 250-300 % of FPL will be 8.4-10.2% of income, for families with income from 300 to 400% of FPL will be 10.2% of income. In 2016,the federal poverty level is projected to equal about $11,800 for a single person and about $24,000 for family of four.[66] See Subsidy Calculator for specific dollar amount.[67]

· Most people required to obtain health insurance coverage or pay a tax if they don 't. · Health plans no longer can exclude people from coverage due to pre -existing conditions . · Employers with 50 or more workers who do not offer coverage face a fine of $2,000 for each employee if

any worker receives subsidized insurance on the exchange . The first 30 employees aren't counted for the fine.

· Health insurance companies begin paying a fee based on their market share .

Guaranteed -issue health insurance coverage – which ensures that individuals are not denied coverage or forced to pay higher premiums because of pre -existing conditions or poor health status may , require the gradual elimination of medical underwriting due to the restrictions outlined in the bills on rating practices and the requirement that all individuals have access to coverage regardless of their health conditions .

Rqmt # Requirement Requirement Description

CUE

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

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

CUE3 Calculator Make an online calculator available so that people can see the actual costs of their coverage after account ing for the premium tax credits they may receive;

CUE4 Medicaid/CHIP Eligibility Screening

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

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

CUE7 Navigators Establish “navigators”—individuals or ent ities that help consumers and employers learn about , and enroll in, coverage options .

CUE8 Consumer Information Inform consumers of plan quality and enrollee sat isfaction ratings.

CUE9 ExemptionsHave the capability to identify , and inform the U .S. Treasury , about consumers who are exempt from the law’s individual responsibilit y requirements.

PC

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

PC2 Plan Offerings

The offering of only specified tiers of coverage: bronze, silver, gold, and platinum. A bronze plan covers 60 percent of medical costs for covered services (excluding premiums) for an average enrollee population; silver covers 70 percent ; gold covers 80 percent; and platinum covers 90 percent.2 Any insurer participating in the exchange must offer at least one plan at the silver level and one plan at the gold level. Insurers may also offer “catastrophic” plans for people under 30 and people who are exempt from the individual responsibility requirements (see Section 1302 of the Affordable Care Act ).

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

PC4 Marketing Standards Marketing standards.

PC5 Quality and Accreditation Specified quality, quality improvement, and accreditation standards.

PC6 TransparencyTransparency standards, such as disclosure of information on claims denials, plan finances, cost-sharing information, and enrollee rights in plain language.

PC7 Preimum IncreasesPrior justification of any premium increases (which will be made public, and which exchanges are asked to consider when determining whether to allow an insurer to participate).

OR

OR1 Stakeholder Participation

Consumer and public input: Exchanges must consult with stakeholders, including educated health care consumers, enrollment experts, small business representatives and self-employed individuals, and advocates with experience enrolling hard-to-reach populations.

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

OR3 Financial StabilityExchange administ ration must be self-financing by January 1, 2015 (through premiums or other sources). Until 2015, federal grants will be avaialable to help states implement exchanges.

Actual Source1 Implementing Health Insurance Exchanges, A Guide to State Activities and Choices, Familes USA October 2010

LegendCUE Consumer Usability and Enrollment

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

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

Additionally, Exchanes must meet these additonal requirements.

High-Level Requirements

Paper Application

Rules EngineCascading Eligibility


Carrier Operations and Backoffice Functions

Aggregate information and transactions

Enroll Individual /Family Members in Carrier Plans

COHBE Only COHBE or State MMIS

Call-in

CUE 1

CUE3

CUE 3

CUE4

CUE 6

CUE7

CUE 8

CUE 9

CUE2

Individual

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

SHOP

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

Account ManagementMaster Data Management

Send MedicalCards

Send MedicalCards

KEES Integration with Federal Exchange

Version 2.0 September 25, 2011

Gary Schneider

Individuals/Households


greater than 400% PL

Enrollment Financial Management

Tax Credits and Advance Payment of Premiums

Aggregation of Premiums

Plan Management

Approve and Load QHP

Aggregate information and transactions

PC2

Federal Data Hub

Boundary between CHOBE and PEAK/CBMS

SHOP Employers Brokers and

SHOP Employees

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

PC 2

SHOP

Small Employersand Employees

SHOP EmployerBroker or

SHOP Employee Employers

Employees

SHOP Employer Creates anAccount or Logs In

Brokers

Broker Creates anAccount or Logs In

Broker Accesses CHOBE Broker Tools and Authorized SHOP Employer Information

SHOP Employer AuthorizesBroker to Access Employee

Information

Manage SHOP Employee Roster & Benefits and

Admin ToolsManage SHOP Employee Roster and Benefits is accessed only in the COHBE. It is for establishing and administering benefits for SHOP employees. It defines who is eligible for what Metal of coverage . This process is not applicable to SHOP employees , individuals or households .

Broker Accesses CHOBE Broker Tools and Authorized SHOP Employer Information

COHBE & State SystemsCOHBE & State Systems

SHOP Employee Creates anAccount or Logs In

SHOP Employer and /or Broker Administer

Benefits and Account

Does Employee have

Household Family Members Who are

Not Covered?

COHBE and PEAK Entry Points

(Portals)

Yes

Does EmployeeWant to Check

Eligibility for CHIP or Subsidized Private

Coverage?

No

Yes

Individual completes on -line application

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

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

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

Based on application information

business rules make determination re eligibility for

Medicaid/CHIP or OtherLikely Medical Benefit


Yes

Does SHOP Employee /Individual

Want to Enroll Childrenin CHIP?

Automatically Enroll Eligible Children In CHIP

Yes

YesCHIP EligibleChildren?

350K

SHOP/Financial

AssistanceYes or No

Eligible for SHOP

Individual

May be Eligible for Subsidized Private

Healthcare Coverage

CHIP

No

PEAKMMIS

CBMSCounty case worker entersapplication and interviews client

Individual and Household seeking public assistance for

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

Federal and State programs

Visit County Office

Mail ApplicationInto HCPF

Processing Center

MAXIMUS employee enters application and notifies client

Secure Interface to Exchange/MAGI Eligibility Process from PEAK

CBMS determine eligibility for non-MAGI population and other

human services programs

Visit County Office

Likely Eligible for OtherMedical or Human Services

Programs

Secure Interface from ExchangeMAGI Eligibility Process to CBMS

Exchange Only

Administer/Pay Claims

PrivateCoverage

Boundary between CHOBE and PEAK/CBMSBoundary between CHOBE and PEAK/CBMS

CUE4

Call Center and Customer Assistance Track Enrollment and Changes to Enrollment

Medicaid

180K

Individuals/Households

CUE2

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

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

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

• Should #1 and #2 be combined? (shared /consistent support processes, infrastructure, capacity management flexibility, consumer experience, need for specialization or separation)

• Carriers offering plans that bridge private and public healthcare coverage to enable household to be covered by one carrier/similar provider network, etc.

• Prevalence of “mixed” household populations being researched, e.g.1. Single parent eligible for subsidized private coverage and children eligible for

CHIP.2. One parent receives subsidized coverage from SHOP employer, spouse eligible

for subsidized private coverage and children eligible for CHIP

33


• Analysis of Alternatives – table showing feasibility against

34

In process


35

Alternative Description/Approach

CostConsumer Experience

Impact of Change on Workforce

Reliability/Maintainability/

Scalability

State of System after

Investment (MITA/Tech

Arch/Platform)

Impact on COHBE

Operations and Systems

State’s Strategic

Direction and Latitude

Stakeholder Acceptance

Implementation Costs

(federal & SGF)

5-Year Operational

Costs (federal & SGF)

Minimum 2013 Interoperability

Moderate 2013 Interoperability

Maximum 2013 Interoperability

2015 Interoperability

COHBE Implementation and Start-up Timeline

36Note: Accompanying timeline for required enhancements to PEAK

& CBMS not shown

Analysis/Confirmation of Current Approach & Prel

RFP

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

Procure IT Systems & Services for HIX

COHBE Certificationby HHS

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

2011 2012

HIXIntegration Testing

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

2013

Policy & BusinessDecisions and Activities

HIX - IndividualPilot Phase06/13 – 10/13

HIX Deployment

Policy & Business Decisions

Impacting IT

Supreme CourtRuling on Mandate

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

Start-up and Operational Decisions

Start-up Activities

Operational Activities

Analysis/Confirmation of Current Approach & Prel

RFP

IT/Systems

Procure IT Systems & Services for HIX

HIX SHOPIntegration TestingDesign/Build/Test HIX Systems for SHOP

HIX - SHOPPilot Phase04/13 – 10/13

HIX Deployment

Establish PMO

37

Interoperability Decision CriteriaConsumer Experience- Make enrolling in coverage for the individual/household as fast and as simple as possible- Balance administrative simplicity, efficiency and effectiveness- Enable continuity of care- Provide user-friendly access to all eligible CO citizens and small CO businesses that desire access- Leverage and integrate with State systems and business processes as appropriateReliability/Simplicity in Getting Consumer Enrolled- Make enrolling in coverage for the individual/household as fast and as simple as possible- Leverage and integrate with the State system(s) and business processesReliability/Backend Complexity of Having All Solution Components Fully Functioning- Leverage and integrate with the other systems w/o reducing reliabilityPrivacy and Security- Leverage and integrate security, i.e. account management and MPI- Minimize proliferation and transmission of PIICost- Minimize costs to the COHBE, consumers, employers and carriers

Risk to COHBE Project Deadlines- Minimize Risks of: 1) not meeting federal milestones, 2) delivering baseline scope and 3) completing the project within the baseline budgetStrategic Direction and Latitude- Maximize flexibility to change its direction; enable the state to go in a different direction in the future without COHBE or State incurring a large potential cost impact or disruption to end users; this could include a different Exchange solution provider (re-compete) or a different Exchange solution direction such as building or buying the HIX software and integrating with State system in futureStakeholder Acceptability- Recognize limitations of interoperability given political realities, funding constraints, etc.

• Scope and Key Elements of Procurement

• Acquisition Strategy – prime contract (hosting and administrative services) with option for COHBE to license exchange IT solution

• Recommended level of Interoperability w/ State Medical Systems and Business Processes

• Acquisition Process and Timeline

• RFP Outline and Proposal Evaluation Criteria

• Evaluation Committee Participation

• Release of RFP Prior to Award of Level 1 Funds

Affirmations and Agenda for 12/12 Board Meeting

38

Review of Gameplan Leading to Start of Formal Acquisition Process

39

Date Topic of Meeting Objective/Decisions/Issues Impact on Next Steps11/28 Board Meeting

Present decision, decision framework, approach and timeline to Board.

Can Acquisition of Exchange system(s) and services proceed prior to award of the Level 1 grant?

Sequential process of issuing RFP/RFQQ after 02/15/12 will likely reduce implementation time by approximately 1 month.

Week of 11/28 Present Acquisition process (what/why/when), timeline, options and highlights from vendor in-depth demos and RFI process.

Concur with Acquisition process, options and timeline.

Plan out remaining activities leading up to issuance of RFP/RQQ.

Week of 12/05 Present preliminary results of analysis of SAAS vs. asset acquisition.

Informational. Ensure that Committee understands trade-offs.

12/12Board Meeting

Present results of analysis of SAAS vs. asset acquisition to Board and associated Acquisition strategies.

Key asset acquisition decisions. Strategy and detailed timeline for systems and services acquisition needed to proceed.

Week of 12/12 Present outline of RFP/RFQQ, key requirements, etc., i.e. Acquisition and evaluation guide.

Concur with direction of Acquisition. Will Board members serve on acquisition evaluation team(s)?

Draft acquisition documents.

Week of 12/19 TBD or catch-up or schedule adjustment.

Week of 01/02 Review draft acquisition documents. Will likely need turn-around in one week and approval to present to full Board. Can draft documents be provided to federal sponsors for review?

Incorporate comments and provide final draft to full Board.

01/09Board Meeting

Provide final draft of acquisition documents to full Board.

Will likely need turn-around in one week. Incorporate comments and finalize.

01/23Board Meeting

Motion to release RFP(s)/RFQQ(s). Approval of Board to release RFP(s)/RFQQ(s).

Week of 01/23 Release RFP(s)/RFQQ(s).

40

Background Material

Draft COHBE Guiding Principles for Systems and Implementation

Category Guiding Principle

Exchange Functions, Features and Business Processes

Meet the minimal requirements of federal regulations; enhanced functions, features and integration will be considered in the future. New business processes to execute Exchange business processes shall minimize the impact to other State agencies’ business processes or systems.

Exchange Customers and Business Lines

Customers of the Exchange are individuals and small business owners and their employees.There will be a single Exchange. The Exchange will have two business lines: 1) the SHOP Exchange and 2) the Individual Exchange

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

Continuity of Care Ensuring continuity of care is a personal responsibility; the Exchange will not pro-actively enroll or change enrollments of consumers (i.e. individuals and small employers and their employees).

Integration with Medicaid

Minimize integration with Medicaid eligibility in the near-term; consider tight integration (and possible upgrade of State’s eligibility system) in long-term (i.e. 3-5 years); make investments based on this strategy. Send consumers to the “right” door first but enable cross (MAGI) eligibility determination.

Federal Deadlines Work with State Medicaid agency but do not jeopardize meeting federal and state deadlines.

Solution Acquisition Leverage existing solutions and solution components from other states and federal partners to the maximum extent possible.

Inter-agency Partnerships

Work in concert with all State agencies, e.g. HCPF, DHS, OIT and Insurance Department.

Regulatory Authority Maintain the Colorado Insurance Department as the single regulator.

41

Role of IT and Implementation Committee

• Role is to provide guidance to COHBE executive leadership and early input into major strategic decisions such as IT investments, acquisition of services and Acquisition strategy

• These initial acquisition decision(s) will likely be in the order of tens of millions of dollars over the first 3 – 5 years

• Acquisitions will be structured to be competitive, fair and transparent

• Due to the political sensitivities and visibility surrounding the COHBE, it is important that there be no real or apparent conflicts of interest in Acquisitions activities and operational decisions

• Meet weekly leading up to the start of the formal acquisition process

42

1. Should the Exchange use a SAAS model or acquire (borrow/build/buy) the capital IT Exchange assets?

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

3. With respect to #2, does the State intend to upgrade or replace CBMS so that near-term investments to modify CBMS and PEAK to meet the requirements of healthcare reform are rationalized against the State’s strategic direction?

Three Strategic IT Questions that Need to be Answered over Next 30 – 60 days

43

colorado health benefits exchange

Documents

cohbe rficopy of vendors

cohbe strategy

exchange acquisition

meeting rfi

sgf action item

md action item

summarizing rfi process

review state of mo rfi