IT and Implementation Committee Strategic IT Decisions December 21, 2011 1

1

Colorado Health Benefits Exchange

IT and Implementation Committee Strategic IT Decisions

December 21, 2011

Overview

• On-going Activities

• SHOP Business Development and Operations

• Option for Ownership of Call Center/Customer Support Assets

• Plan Shopping and Enrollment Interoperability

• Additional Information from RFI Process

• Evaluation Committee

• Next Steps

2

3

On-going Activities

4

On-going Activities

• Additional IT Resources• Eventus – call center/customer support and legal support• Provided Patty with options for increasing COHBE capacity

• Progress on RFP• Working on first draft; expect to complete by 12/28 and begin first

review cycle• Additional dimensions of scope• Eventus providing input into RFP (customer support and legal)

• Continue Interacting with the Vendor Community; this week:• Infosys• CGI• eHealth

• Continue Working with HCPF• Use cases for interoperability eligibility processes• Defining interfaces and other interoperability requirements

5

SHOP Business Development and Operations

6


• Three risks associated with the SHOP:

• Market risk

• Performance risk

• Schedule risk

7


Market Risk: • Existing, competitive well-established market interests

• New competitors emerging now, before exchanges are formed

• Market inertia: protect current business (insurers, brokers, TPA’s)

• Adverse selection: trend toward self-insurance (among small firms)

8


Performance Risk: • Skepticism of state running an exchange

• Challenges of trying to compete in a public governance model

• Very small incentive to participate (tax credits) for a short time (2 years)

• No active purchaser model

• The only successful SHOP exchange models have been privately owned

• Employee choice and defined contribution operations are complex: premium payments, admin, customer service, marketing, Section 125 admin, etc.

• Voluntary insurer participation

9


Schedule Risk: • IT procurement is within reach for SHOP within our timeframes

• However, there is insufficient time to develop a team that can execute operations

10


Options:

a) Adjust expectations for SHOP

b) Find a partner to develop and operate it; pay for performance

Would the state require SHOP participation in order to participate in individual exchange? (insurer participation issue)

• Impact on RFP…• Unbundle SHOP (application, hosting and services, i.e.

development and operations) to provide flexibility for COHBE to select “best of breed” vendor to develop and operate the SHOP

• Mitigate identified risks (market, performance, schedule)

11


Solution Set Individual Solution Component Required Bundling

Individual Exchange1.A Individual Exchange Application, Maintenance and Support1.B Individual Exchange Application Hosting and Support

1.A, 1.B and 1.C must be bid together

Individual Exchange Development and Services

1.C Individual Exchange Services, Training & Outreach

SHOP Exchange2.A SHOP Exchange Application, Maintenance and Support2.B SHOP Exchange Application Hosting and Support

2.A and 2.B must be bid together

SHOP Exchange Development and Services

2.C SHOP Exchange Development, Administrative Services, Training and Outreach

If a bidder responds to 2A./2. B then the bidder must also respond to 2.C2.C may be bid independent of all other solution components

Proposed table for RFP showing bundling/unbundling of solution components

12

Option for Ownership of Call Center/Customer Support Assets

13

Option for Ownership of Call Center/Customer Support Assets

• Eventus (Craig Tobin) recommends that COHBE consider acquiring/retaining ownership of call center assets such as: • IVR• Help desk software• Knowledge base• Training tools

• Pros/cons+ Strategic assets+ COHBE will have more leverage in negotiating extensions since switching costs will be less+ Use federal funds to acquire assets to improve sustainability- Knowledge base and training content is IP that will be “owned” by COHBE- Unsure how much this will actually decrease operating costs- Unsure how vendors will react, i.e. most likely have processes, SOPs, training materials,

etc., used in their current call center/customer support - Call center technology changing rapid; why own rapidly depreciating assets - Ownership of assets may limit enhancements - Vendors less able to improve efficiencies

14

Enrollment “Interoperability”

15

CBMS/PEAK &Medicaid/CHIP Eligibility & EnrollmentBusinessProcesses

COHBEEligibility & EnrollmentSystemsand BusinessProcesses

InteroperabilityBetween COHBE& State Medicaid/CHIP Systemsand Business Processes

• Single/shared MAGI eligibility process for Private Insurance and Medicaid/CHIP

• Single sign-on• Comprehensive MPI (Exchange and Medicaid/CHIP population)• Data only entered once• Request only information needed for determining eligibility for

healthcare• Maximize “no touch” eligibility adjudications • Interface from PEAK to MAGI process to support “no wrong door”

requirement for medical eligibility• Provide links to non-medical eligibility processes and pre-populate with

data previously collected during medical eligibility processes

Plan Shopping and Enrollment Interoperability

Minimum level of interoperability as discussed at last meeting

16


• Plan shopping and enrollment interoperability is the ability for consumers to shop in the Exchange for and enroll in plans for which they are eligible

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

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

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

eligible for subsidized private coverage and children eligible for CHIP

17

Small Business Owners& Employees

IndividualHouseholds &Small BusinessEmployees

IndividualHouseholds(seeking public assistance,i.e. Medical, Food

or Cash Assistance)

Pre-screening

SHOPExchange

PEAK

IndividualExchange

Account Mgmt & MPI

EligibilityDetermination

Plan Selection &Enrollment

MAGI(including interfacing w/ federal data hub)

Set-up Employee Roster

Create Account

MMISCBMS

Should Pre-Screening Step be

Included?

Enrollment inCarrier Systems

Create Account

Review Subsidy/Out-of-Pocket Costs

Select Plan & Enter Enrollment Information

Interface Enrollment

Information to Carriers’ Systems

Review Out-of-Pocket Costs

Select Plan & Enter Enrollment Information

Eligible for Employer Plan &

Amount of Coverage

Interface Enrollment

Information to MCO Systems

Minimal Interoperability

HouseholdMember(s) Eligible for

Medical or HS Programs

Boundary between COHBE and State Systems

Boundary between COHBE and State Systems


Eligibility Interoperability

Shopping and Enrollment Interoperability

18


Coverage of the Spelmer household requires three different plans

In the example on the right all members of the household enroll via the Exchange

Spelmer’s only see plans for which they are eligible to see, i.e. only Medicaid “eligibles” see Medicaid plans/MCOs

19


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

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

20

Call Center Interoperability – TBD

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

21

Alternative Description/Approach

CostConsumer Experience

Impact of Change on Workforce

Reliability/Maintainability/

Scalability

State of System after

Investment (MITA/Tech

Arch/Platform)

Impact on COHBE

Operations and Systems

State’s Strategic

Direction and Latitude

Stakeholder Acceptance

Implementation Costs

(federal & SGF)

5-Year Operational

Costs (federal & SGF)

Minimum 2013 Interoperability

Moderate 2013 Interoperability

Maximum 2013 Interoperability

2015 Interoperability

Analysis of Interoperability Alternatives – feasibility of alternatives versus critieria

22

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

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

23

Additional Information from RFI Process

24

Company Respondents

End-to-EndSolution

Exchanges OperatingModel

Current Clients

Partners MAGI Rules engine

ACS/Choice/Benefitfocus Yes Individual &

SHOPSaaS only

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

systems

Choice Admin Benefitfocus

Implements with an

independent rules engine

custom – proprietary

Connecture/MAXIMUS

Yes Individual &SHOP

license & SaaS

CA, TX, CO, IA, NY MAXIMUS (prime) designing for MN

prototype

open source

Getinsured.com Yes Individual &SHOP

license & SaaS

MS Accenture No Drools Flow (jBPM5)

CGI Yes Individual & SHOP

license & Saas

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

hCentive, Exeter, Policy Studies

(PSI)

Yes COTS – HIE360

Vendors w/ partial solution

BenefitMall No SHOP

SaaSpmpm

CO – Anthem BCBS MD – CareFirst BCBS

CO broker – Jim Sugden

MD – Dell, Oracle, Cognascante

No No

Ceridian No TPA, premium

aggregation

pmpm 130,000+ using payroll & benefit mgmt services

Solution works with a number of

structures

No custom

eHealth No Individual SaaS only Mass HealthConnector Florida w/Ceridian

Deloitte (MN, WA)Support–Ceridian

No No

COHBE RFI Summary

25

Evaluation Committee

26

Evaluation Committee

Proposed Committee members:

1. Patty Fontneau COHBE - ED2. Shawn Raintree COHBE - Staff3. Myong KimCOHBE - Staff4. Nathan Wilkes COHBE - Board5. TBD Technology Company Executive6. TBD OIT7. TBD HCPF8. TBD DOI

Support Staff:

• Gary Schneider COHBE – GMS • Chuck FishCOHBE – GMS • Larry Redd COHBE – GMS • Craig TobinEventus• Kevin Appleton Eventus

27

Next Steps

28

Next StepsRFP

Work with Eventus:• Sample contract terms and conditions• Call center/customer support scope, SLAs, etc.• Pricing worksheets

Work with HCPF:• Interoperability (interfaces, security)

Complete Appendices• Appendices (business processes, requirements, volume metrics, BI)

Reflect decisions from today in RFP

Plan to complete first draft 12/28 and make available for 1st review cycle

Wrap-up vendor demos & RFI

29

Background Material

COHBE Implementation and Start-up Timeline

30

Note: Accompanying timeline for required enhancements to PEAK & CBMS not shown

Analysis/Confirmation of Current Approach & Prel

RFP

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

Procure IT Systems & Services for HIX

COHBE Certificationby HHS

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

2011 2012

HIXIntegration Testing

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

2013

Policy & BusinessDecisions and Activities

HIX - IndividualPilot Phase06/13 – 10/13

HIX Deployment

Policy & Business Decisions

Impacting IT

Supreme CourtRuling on Mandate

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

Start-up and Operational Decisions

Start-up Activities

Operational Activities

Analysis/Confirmation of Current Approach & Prel

RFP

IT/Systems

Procure IT Systems & Services for HIX

HIX SHOPIntegration Testing

Design/Build/Test HIX Systems for SHOP

HIX - SHOPPilot Phase04/13 – 10/13

HIX Deployment

Establish PMO

Draft COHBE Guiding Principles for Systems and Implementation

Category Guiding Principle

Exchange Functions, Features and Business Processes

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

Exchange Customers and Business Lines

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

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

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

Integration with Medicaid

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

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

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

Inter-agency Partnerships

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

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

31

32

Exchange Capability and/or Service Category

Exchange Capability and/or ServiceStrawman Priority for 2013

(depends on “who” is asked)Impact on

Implementation and Operational Costs

High Moderate LowImpact on

Implementation Cost

Impact on Operation

al Costs

Eligibility, Plan Shopping and Enrollment (System)

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

XHigh Moderate

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

XModerate Moderate

Multi-lingual on-line system High Moderate

Broker-Related Features & Tools (System)

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

X Moderate Low

Plan Management

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

X Moderate Low

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

X Moderate Moderate

Solution Cost Estimate – Cost Drivers 1 of 3

33



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

Operational Costs


Implementation Cost

Impact on Operational Costs

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

X Moderate High

Call center support for SHOP employers and brokers X Moderate High

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

Financial Management

A/R management (including billings) for premiums from SHOP employers and consumers; A/P management for payment to carriers (system and support) including electronic and paper notifications, invoices and receipts (systems and services)

X High High

Aggregated premium billing for SHOP employers X High Moderate

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

X High High

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

X Moderate High

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

X Moderate High



34



(depends on “who” is asked)Impact on

Implementation and Operational Costs


Implementation Cost

Impact on Operation

al Costs

Other Exchange Features

Data repository of all plan/carrier ratings, transactions, enrollments, disenrollments, trend reporting, performance indicators/metrics to support COHBE improvements and to provide useful information to navigators, agents, brokers, carriers, regulators, consumers

X High High

Track all consumers/enrollees into and out of plans

Individual homepage and account management (system and services)

X Moderate Low

Wellness program functionality (system and services) X Moderate Low

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

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

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

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

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

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

X Moderate Moderate

Role of IT and Implementation Committee

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

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

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

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

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

35

Documents

IT and Implementation Committee Strategic IT Decisions December 21, 2011 1