McKinsey CMS HealthCare.gov review

8/13/2019 McKinsey CMS HealthCare.gov review

1/15

. . : ... . . -; . . .. . ,, .; .> . . . ... . >i


2/15

Red Team overview, objectives, and approach

: =

::

l'.r -.u ' ' ' ' ' ''' ; ' ' ;; - , , . ...... P _ . ,o N . ' N ' ~ W ... . .... , . ~ ... 1 ' > - V U ' \ o ' > > J I < ' ..,..,__ . .,_ , ~ H - , r . . , . r , - , , .,.,..., .... .,,.,,.. 1 ~ ; _ , . _ , , . . . . . . , , _ , , , .,, .. . , .... o ,, ' ' ' ' , , . , . , , ,-, . , . ,, J ' . , ,,_,_,,..,_ .. ,,,_.,,;.,I - o . . . . . . . . , , . ._ N . ~ .. ._...,_ ,, . ' ' ' '' ....

1The Red Team is:1 An independent team charged with pressure testing existing trajectory of thefederal marketplaces1 Not a backwards looking effort or audit

L . w ~ ~ ~ ~ ~ w ~ v . w ...> n w ;. ' v - - ' . . v ~ v .. _ . . ,_. , . , , . . .. v . .,. ._. , ._, . , .- v n . - . w . ~ - ' ..._ .. . ~ - ~ ' - ' * - ' W W v . ~ ~ v n h -Objectives _A : p : p_ro_a_c_h_______ ___8 Develop a picture of the ~ ~ ~ ; ~ ' : ~ : ; ' : ' : ' . : : ' Identify consumer paths;planned consumer experience ~ ~ ~ review and modify vignettes.. - .over the fi rst year ._,:=- ;. - ...8 Identify risks and threats to thatpicture

0 Identify current and possibleadditional risk mitigationoptions .. .

w . .

Define stages of the journeyand risks to each stage

Identify mitigation stepstaken and other options toconsider

Confidentialand Proprietary Pre decisionallnfonnation. ,_ ... .1

EC/0002


3/15

O v e r v i e w of the Red Team sources of insight- ~

:.::

/

~ M s.'0.'\ \' ' 01V oo ... U o .. ,.,.ov , , , , , \ . , , .V

.;;. , .

- - - - - - - - ~

I.V ; . .. . _ . _ . ~ - . . ................ , . ...... . ...,...-.. ~ , . , . , . , . ~ - ,_ . . , . ,,, , , . . , ,. '' . ,_,, , . , . ,i Reviewed 200+ documents and artifacts, includingr operational designs and reports, implementation plans,;i workload forecasts, contract-related documents, andmanagement reports and schedules}

I Interviewed 40 people across 6 CMS/HHS Offices,1Centers, and FFRDC and Federal partner agenciesi Participated in select meetings and working sessions,i including weekly operations meetings and OIS workingi sess1onsj

., . ' . . Y . ? - ' ' - ; . r . ~ N < ~ . . , , : ; _ w . w , , v u , . . , . , . r , v . . . , . . . . v l . ' . - . ( ' , . , ,..,..,., ,. ' ' ........ . .. -.,.,,_. Yo y . ..... ~ . - . ...... , ,.-. ' .,,.,.., . ., .. .... , . , . ,.,. , ......... ,,.,.,,.,., . ., . ' ,, .., .

ConfidentialandProprietary Pre decisional Information. ; .... ... .;2

EC/0003


4/15

..... . .: ,.,. ..

plementing the health i ~ s u r a n c e marketplaces is a un iquechallenge in magnitude and complexity: _..... _ . lo ~ ~ ...... ... . ._ ._ _ ____ __. . ~

Buyers and sellers

Emp loyers : . .j: ::: : : ;i : : .. ' :.. .............. = ~ ~ .................J . i 1

Assistors

4 . ,; Example influencers and partner agencies : : : ..

. . '

Federally facilitated marketplace . .'Channels:

t4: ;; .. .

Website

Call-center

~ ~ jMan

Infrastructurei ~~ ~Dataexchange

Identitymgmt

Manualprocessing

Planmgmt

Privacy&security

Call centeroperations.. ' :... ,. :

. Navigators Brokers/ Certified Educating and certifying Launching at scale from agents counselors ~ assistors for enrollment day one in all 50 states;' .. .. , . . ConfidentialandProprietary Pte-decislonallnfonnation

.. ..... . . .

Interacting, aligning, andintegrating multiple verylarge organizations withpotentially differentdefinitions of success

. ; State.::.; ' managed 1marketplaces j.

Statepartnershipmarketplaces

. :;t State: . :x departments~ j of insurance ' ~ ~ . : ~ ~

Supporting a complexand flexible statemarketplace andpartnership model

3

EC/0004

..


5/15

. I '

P r o g r a ~ s of this type ideally have a e q u e n ~ a l planning_design, a n ~-- implementation process with significant testing and revision

. ...... _ , _ ....... . . . , .. . ; . . . . i

; ~ ~ Ideal large-scale program development . , . Characteristics of this program .:: j;; _t.fJ.rt ...... ....... - ~ - - - - - - - E J l ~ J l tc:Jr.t ___. - - - - - .. . f r J . t . ~j Define Define .. ...l policy I i po licy I. \ requirements 1 requirements

1i .. . . .. Desagn 1 Design r r ~ ~ : l . .r imiieci n i : J ~ i O : .1 1 l end testing. \

: ~ .I Testing will,, j Build [ Build Icontinue to be: l l p e r f o r m e d j

. .._ I ~ - - ~ f ~ r . ~ Y f J; Il liest Gradua 1 :_ liest ; t f l : > f - 1 : ., Launch : ; ' (,.//.: .-.: > i' [ launch t c / . - : . . / . ~ , - : . ......'l:-- at scale l' l,.., . . ._ , .,.,,.. , ........ ... .. .... ... , . . . , . . , , . , , . , . , . . . . . v , ._. . _.. ., . . . . . . . . .. . . . .. . . . . , .... _ ; . . ....... ..... ... ..... ... ., ... .. . . . . . . .. . . . .. ... ... ... .. ; ._ .. ., . ..... . . . ; ., . . . .. . . . . . . ... . . . . . .. . . . . . . . . . .. . .. . . . . . .. .......................... ., . . . . . .... . . . .. . . . . . .. .. . . . . . . . . . . . . .. . . . . .. . ........ . .. . . . . .. ... ;

n Description of ideal situation: Current situation: Clear articulation of requirements & success metrics Evolving requirements Minimized dependency on third parties Multiple definitions of successSequential requirements, design, build, and testing Significant dependency on external parties/ Iteration and revision between phases End-to-end integrated operations and IT testing Limited initial launch

contractors Parallel "stacking" of all phases Insufficient time and scope of end-to-end testing Launch at full volume

: ... ~ _ V I S..... . . ... .. . _.., ...CMS has been working to mitigate challengesresulting from program characteristics 4ConfidentialandProprietary- Pre decisiona l Information

EC/0005


6/15

Example Fully automated:, :' ' o ' a , o o ''''' . . , ' ' , ' ' , . " Y ~ < - '' ' ' ' '' ,.,..,,,, ' ' ' ' ' ' ' ' ,., O . " ' ' ' ' 'o t tl h ~ I : < ~ : ' ' - : ' ' ~ ' '" ' " ' '' f o ': ' 'U 'f ., ' ' ' ' ' ' ' ''' ,.' ' ' '' ' ' ' ' ' .' ' "

Hypothetical consumer profile: Mike Mike is married with a two year old son, lives in Maine, and wants to enroll his family in insurance He works at an engineering company with 30 employees that does not offer employer sponsoredcoverage and his household income is $49,000 (-250% of FPL) Mike has worked for the same company for 3 years and his household income has not changedsignificantly in that period

Consumer Approximateexperience t ime required. . ... . . . .. _ ,_____.... .. . . . .... . . . . , ~ . . . , . - . - . . . ; - n . - ,_,, -- . ~ _ _ ... . .. . .......... t: ...,. ~ ~ :o Mike contacts an;I ft. i ; : n s u r a n c e agent to enroll

. l mcoverage; the agent. . . . - . . . . ~ of. begins an application

online on Mike's behalf.. ... ; Mike satisfies ID

verification, residency; status check, and1 income verification

30 mins

5 mins

Consumer Approximateexperience t ime required,,..,._,_,................ ...... .. . ._,_, , . . . . .... ._.,...,_.,.. .. . _ . ........ . - .. .......... . ...- . . . - ~ - ~ ' ~ ~ .... . ' 'i . - ~ ~ 1 ' ~ : - : ~ ~ . , . ; ; c ; . ~ ... ~ ~ , , The broker helps M1ke 30 minutes:r; , t. select a plan and.f i .: ,.,.- enroll ; M1ke makes an1 .. . ; ; r initial payment to issuer

~ - ~ - . . . ' ' ' ' ..................-............. ................. ...... . .._ _.............Total elapsed time fo rMike to enroll


7/15

Example: Manual high complexity) . < t . . . ; - - - ~ ~ - ' Y - ' Y I < . .. ....,...,W '__,.,__ _ 6 > 0 ~ .. o y - . , , - . , , . , _ . . . . n ~ . - 0 H - W - < # 0 / ' . _.N;,...,._.,.,... N - H Y ' ' ' ~ I I , .. - . - - . - - o . .... . . , . ~ - . . \ . _ . _ - _ l _ -.-._ ....... .1.. Hypothetical consumer profile: Charles .. . ,, l:: / t ~ ~ ~ ( ...... h ~ ~ i i ; - ~ i ~ 9 i ~ - - - ~ ; i ~ 5 ~ o ' ; ( : ; 3 5 o / ~ F P i ) ; ~ ~ k i ~ g part-time ; h ; ~ ~ y ~ a n . i 1 He recently left the military and no longer has insurance coverage through TRICARE Charles lives .n:Texas and would like to apply for insurance through the marketplace He has very little income budgeted for health care and wants to be sure he receives the fullamount of subsidy for which he qualiftes

' . - . . . . ........ _ . . . . . . _ . ~ , .... . . .c.onsume- . ...... ... X . . . . . . ... . . . . . . . . . .. .....AJ)I>.oxim.ate .. ................................................cofi ur:ne;:- ................................ ...,.;..........Approxi.mate ......~ ~ ~ t .. ........... .. ... . time required f . ) ( . P . t . : ~ ~ ~ ~ e v .. . .

.. .. .......... * ' ;.; # ~ ~ ~ ' ' ~ ~ Charles completes a paper

... : : : : : ; ~ ~ > ; : . ~ applicationc.w / ........ He receives a letter~ ~ r ' : .._ indicating he may qualify for -.: . . .:: --... l Medicaid; his information is

. : - - : : ~ . : : - ~ . - ' . : : . ~ : . ~ . : . : : . - : . : ' : . ' ~ : t : . sent to the Texas Medicaidprogram

: ~ E ~ I f E Charles receives . ; ; , \ ; ) ; ; ; : : , : ; : : ( { ( ; ' ~ ; . , ; ; ; ; ; ; i notification that upon state

' ' . ; ; . ; ' ~ : ; , " , ; : ' , ' : . : : L : . ' ~ ' ' .. ; review, he does not meet.. _ ~ ; ._ ,v_,_,. , .. state-specific Medicaidrequirements, which heforwards to the FFM.. ~ . . . .. ;; Due to a system lag, he.. . > ~ : receives notification that he isineligible to buy on the FFMbecause he appears to haveTRICARE1 coverage

1 hour

3-4 weeks

3-4 weeks

1 month

-.: He calls the call center tochallenge the notification: and is asked to senddocumentation that he nolonger has coverage

t V. _;.;;l The FFM confirms his; 5 i ' ~ , 1eligib ility and makes a

~ ~ " : ' : .. : ..... . ... inal subsidy determination- : . ~ ... ... . : : : : : , : . : ; ... .. ::: . ::::: :

Call center operatorhelps Charles enroll in aplan and he makes initialpaymentTotal elapsed time forCharles to enroll

... ' Charles receives a letter-==--- rom the insurance company; indicating his date of initial1 TRICARE real-time checks may not be available on Day 1 coverage

Confidential nd Proprietary Pre decisional Information

Real time

3-4 weeks

Real time

13 16 weeksGoat: 1 - 2 weeks

6

EC/0007


8/15

:Complexities of the marketplace a n ~ its implementation drive four L ~ ~ ~ A ~ ~ ~primary experiences for consumers enrolling on MJo V..._ N.... .____ ~ - N V ~ - - o - - - - - . . . . . . . - . . - 1 - . o - ..... .----- _...___ . . _.. . .... . . . ~

Descript ion

Anticipatedtime to. enrollment

Assumed volume

' 90 days

25% or less, .. . . . . . .... .. . ... .... ... ... .... . . . ........... . . .. . . ... .. ..... ......

60/o or more' . . . ... . . ' .. ... ' ' ... .... .... . . . .... . . ' . ... . ... . .. .. ' ...

Note: Volume assumptions based on CBO estimates with adjustment for FFM share, resulting in 5M enrollees in individual market and 1.2M.. .enrollees in SHOP. Volume numbers do not include expected Medicaid enrollees or exemptions. See appendix for methodology.

r --r ( CI\JIS c d . I d ft ta p d . . 6. , . 7' ~ - - - - < w ..N . Oml en 1a an rroprre y re ec1sJona nrorma 1 n

EC/0008

..:.;


9/15

iskprioritizatio_n approach.. . ._ ....__ - - , . ; y - - o - O . . y . o _ . ___ _. N N o / ~ - - - - __ _ o - - H ... . . . , - . , . . . , _ T . . . . , _ ~ - - - - ~ ~ - . v ~ - - - - _ . , , ._.__._....... _ _.. . ._.Jn

:: Ini tial set of risksgenerated from: -200 artifactsreviewed 40 interviewsconducted

Baseline expectations:Refine risks in the context ofexpectations for plannedconsumer experienceClassify risks: Classify risks as eitherV targeting a specific component of theconsumer journey systemic/cross cutting,or organizational/governance in nature

40 targeted5 systemic 13 most criticalrisks5 organization/

Prioritize risks Identity top risks against thefollowing criteria: Limit ability to offer core marketplacecapabilities Significantly reduce consumer participationor experience Absence of key cross-cutting enablers

ConfidentialandProprietary Pre decisionallnfonnation 8

EC/0009

::.

..:


10/15

. . .Most critical risks to marketplace implem entation fforts: ore marketplace functionality I Experience nd participation :

... w " N_ . A - . A - - - ~ . . . . _ _ f O M . . . _ ; o . , ~ _ , . _ , _ , , . , _ > N ~ O O . - - . . . , _ ; _ _ __ OI l 'N. . . . - . . . . . . . . - " " " " ' ' ' ' ' .. ---..,.--.......,....., .......,._ .._., _o;Moo j> N -o ..__,.-,,,O._.,_,.,.._,,_.., ..________ .. .... , ~ , . , . , , . , . , . .. .....,._..., ;: Risk Root cause drivers.r--e .~ ; ~ ~ ~ ~ ~ ~ ~ ~ ~ s ~ ~ ~ ~ ~ ~ ~ ~ ~ , :: ' ; N ,Y h N ' W o ... ' . . , \ .0 1< ,, h .; . , . r ' o- ... r _. A . . , n.., I .. y _, .... ' .,. '; ,, " , , ._ ' , ., ... .,..., . . . . . . . . . . ,, , . . . , , . . . . , , . . , . . .. ,,,,..,,, . , , ;, , o . ;H ,VU '- '' ' ' ' ' '- ' ' ' - ... , , , . . , . . . , , ,_. , ,_ ,,,..,,.. .,.,.. , , . , . .. ,,,,,,.,.,..

' ,[ G long manual processing times Potentially undersized contractor eligibility support team o f Potential protest of une st contract ::gc Higher than expected manual processing volumes: l . ' . ' ' . . ' '

1 Failure to resolve post-launch issues rapidly Compressed testing window and volume uncertainty''I .. l ... ..................._........................... .... ................... ...................... ... _... .... .... . ~ ~ ~ r an_d intra-agency response teams not yet in place9 .. . . .. .............. .................. .......... . ' ..... .... ........ ' ' ......." . ' ~ Q No viable marketplace in large-volume SBM Large-volume SSM states (i.e., NY, CA) too big to fail1 states High risk of federaiiT/Ops resource overload if pivot 42 , needed.... , . .. ...... .. .. - .. . . .. .... ...... - - ..... ' ' . ..... .. .. .... .. .... - ' . ....... .. " .. " .. " . ' ' .. . ....1

18 j G Plans not approved and loaded in selected m a r k e t ~ ...... ......... . . - ~ ~ k - ~ ~ - t i ~ ~ i ~ ~ ~ ~ ~ ; ~ ~ ~ S t ~ t ~ ..[)'()j ...-. .. ............ - -

SBM pivots may miss 4/30 data load deadline ~ ~ J, _ .J Issuers may not design and offer plans

Data Hub I FEPS are single points of failure Limited end-to-end testing prior to launch

:

....... ~ ~ ~ ; ~ ~ ~ ; ~ ~ ~ ; ~ i ; ; ~ ~ i ~ ~ ..................................... -.......: ---.. ; ~ ~ ~ ~ ~ ~ ~ ~ t - - - -standards results in unexpected tax debt to Subsidies calculated with less accurate income; consumer and unrecoverable excess federal Accepting business risks to meet deadlinessubsidies in 2015l 't : ' . .. ... ' ' " .. .. .......... ' ' ' ' ' ............- ...... . ' ' ' ' .. . " ............ ' ' .. .. ...... "' ........ . . ' ......... " ... " ..... ' . ' ... " . .... ............... .. .. " ... .. - .... ' ' ' . ' " . "" ........ .. ' ............ .; ;e Inaccurateor incomplete financial management systems Financial management system release in December Limited testing time and resources prior to launch i ; Due to focus on enrollment, limited focus on financial

;j .. ,. _. ' -" . " ' - '' ' '- ., .. " ..... " '' " ov ' '' " .. .. " " , ._. , '' ' 1 ~ ~ ~ Q . ~ " : ' ~ ""' ., " .. ' ' " , : _j i No call center enrollment channel or long waits Call center tools linked to enrollment IT systems - - Minimal integration/testing time prior to 10/11aunch: (. f . V I S Significant risk of higher call volumes - ..., Conf idential and roprietary Pre decisional nformation 9

EC/0010


11/15

.. . : - ~ : .-. .

Most critical risks to marketplace plementation effot -. Cross cutting enablers

.___ ........._ _ ___ _ . ........ . ...._ . .______...._____ __ _...: Risk Root cause drivers. ..... ~ ~ ~ : ~ ; ~ ~ ~ ~ ~ .. ; ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ .. ..... .....-..... ...... .. ~ ~ ~ ~ ~ ~ ~ .. .. ~ ~ ~ .. .. ......

needed for implementation effort No clear roles, responsibilities and processes formaking change No single empowered decision-making authority Lack of a shared definitionof success. . .. . ......... .. ....... ...... .. .... . . .. .... .. ...... . .............................. . . . _.......... .... . . ... ..... .. ........ .... ...... ........ ... .

Indecision about Version 1.0 requirements in select areas

,

Less than 180 calendar days - design still presumed tobe open Drives development churn and compressed t imelines Materially higher risk of system instability ~ ~ ~ ~ ~ ~ ~ t ~ t ; ~ ~ ~ ~ ~ ~ .. ...... ... .. .... .. ....-. .. a p ~ ~ ~ t i ~ ~ ~ i ~ ~ ~ d ~ P ~ ~ d ~ ~ ~ ~ ~ ~ 9 . .. .. .interdependencies No end-to-end business process view across agencies .

No critical path transparency (inter- and intraagency)

C Budget uncertainty and timing prevents executionof plan

.. ... .

or fully within agency Difficult to identify/address critical integration gaps Lack of transparency and alignment on critical issues Critical path drives coordination of end-to-end efforts Lack of visibility into critical milestones across agencies .. Staff still engaged in program design Many functions are contractor dependent Core contracts not awarded due to budget Hampers ability to hire/resource critical path activities

.@ .. ..C V S...... ~ n f i d _ ~ a l andProprietary Pre decisional Information 10EC/0011


12/15

Options that could be_mplemented to help mit igate key risks

) Align on ini tial release and transition to

::

solving for stability

Take tactical actions intargeted areas

Prioritize and lock down scope for version 1.0 Conduct fully integrated end-to-end test of version 1.0 Continue to enhance plan to develop an operations command

center and response team Determine readiness of SBM implementations Mitigate risks related to Call Center and l igibility support contracts Define broker/agent and issuer direct enro llment model Manage demand through targeted outreach Accelerate decision-making on using IRS tax data for verification of

income , , , , , , o4 o , ,, ,, ,, ,, ,, , , 0 , ,4 , , ,, ,, ,, , , , . ,, , ,, 0 , o ,. , oC ,, ,, ,, , , , , , , , ,, , . ,, , , I , 1o , o o , , , , , , ,, , , o o o o - ' .. ' ' .. ' ' ' ' ' ' ' ' ' ' ' ' '''i Streamline decision

~ - , ~ making process andmanage critical path.... . .

; ; ; : _ ~ > : ; } ~ ~ ~ ~ ~, . . .:.

Name a single implementation leader (COO/DCOO) and implementassociated governance process to:

Manage critical pathCreate transparency on critical issues

Finalize budget and release funds

Confidentialand Proprietary - Pre-decisional Informati on 11

EC/0012


13/15

~ I ~ T o p areas where requirements need to be defined and lockede r ~ down by April 30 . .

Decision Description' ' ' ' ' , . ..... ' ' .... ., . .,. ... . . ... .. ... ..... .........-. . ' ......... .. .... ...... ' ..... . ... ...... ........ ' ..

;

10 proofing (IRS)1

Household consent(IR5)1Marketplaceoperating modelsIssuer directenrollment

Agent I brokerenrollment

Requiring AGI as a shared secret will likely increase the amount of timeneeded to complete an application for enrollment but will provide IRSwith more confidence in a user's identity when returning federal taxinformation

Current taxpayer privacy rules require identity verification for each taxreturn that is retrieved to construct the household income and fam ily size Determine how each marketplace operating model should function (i.e.,SSM and different flavors of partnership models, e.g., Utah) with specificdescription of business rules for each marketplace variation Define entire end-to-end business flow (registration, authentication,handoffs of information, types of data, SLAs) by which issuers willdirect enroll consumers into plans and Define process by which agents and brokers can enroll consumers AgenUbroker training and certification (for safeguarding Federal TaxInformation) need to be developed and implemented

Financial All financials system management processes and calculations need to bemanagement defined including: APTC and CSR aggregations across exchanges,internal accounting systems, monthly receipt and reconciliation ofenrollment reports , collection of marketplace fees, and payment of APTCf; 1 10 proofing and o u s e n c ~ n ~ e ~ t ~ e e to be finalized by April 12 ~ ~ ~ - - ~ ~ Confidential nd Proprietary Pre decisional Information ' . . : .... . ' ... ,, . . .. . .. . . . . . 12

EC/0013

: - ~

...:: ,


14/15

: . .. .. : .. . :. ......... .; . ..(3.--1 n implementation leadership team and a consum r'.... outreach team could drive implementation progress

. : ..:

:: : .; : .;::;: ; : > . ~: ,: .; . .: ::? : aesponsibil: itiW. ? : :>: .;: . . ; ::.. , : . .;. . .;::::,=-:-=.

Expedite decisions on critical path and Version 1.0- If consensus cannot be reached, the leader willdecide or escalate

Regulate issues affecting IT and Ops buildReduce number of governance bodies to oneAll decisions impacting bui.d must flow throughthis team

Report d irectly to the Administrator and Secretary Brief White House on implementation progress Requests f rom policy staff must flow through thepolicy liaison

Track project statusfrom all stakeholders Create an integratedmanagerial viewacross keymilestones Surface risks tofacilitate resolution Provide analyticcapability to supportrapid decision-making

Policycoordination

Coordinate with theimplementationleadership team Drive consumeroutreach Coordina teoutreach effortsacross CMS, HHS,the White Houseand partnerorganizations

,, . ...... .... . . . . - ' . . . . . ... .. .. . . . . . .. . .. .. . .. . . . . . . . . . > . . .. . . .. - . . . < < :. : 1 representative each (CMS Administrator to select : 3-4 dedicated FTEs Sr. Advisor to theNlfrnberehip - CCIIO Additional support as Administrator' < . .,:> .. . - CMCS needed OC Director '

' > ... = - - - _ g - ~ g H Q _____ ____ _____ __ __ ____ _____ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - r ~ . P ~ ~ ~ r . t ~ Y ~ ~ ~ ~ . ,,: L ___;:: __.QQ ~ m ~ - ~ - ~ - C . l J L Q ~ J J J ~ r L . ------------ _________..._ --- -------------------- --- ------ :: __ n t ~ r ____ .:OIS - Regional officesSSA - CCIIO...... .,.,. ' < =

13IRS ConfidentialandProprietary Pre decisionallnformation Others TBD. , .. .. . . ... .-. . ....... :.::: EC/0014


15/15

.'

.. CMS needs specific u p p o ~ from HHS and the White House tosuccessfully operationalize the marketplaces

. ..-. .-- ..... - -- - ~ - - ~ . _ .. . ,.,__ _.... ._.__ - - ~ - . . . . , . . _ _ . . .... . .___ ..___.. _ .. ._._ ...______......_...._. __ .. __ o A, (/.,. . , 0 . , . , . .. ... ....,. ...... . o ' ' . ~ , ,o,l .. . .. , . ., , o < o > , ,., , , ., . .., , ' ' , , ol o ., . ,. o '' N ... . N < r .,, ,._,,.. , ' , -- o , ,, '' o , , o ., o , , . , ,,. .,,.,\ ... ' o ' , ,,. ._ , , . , o ,., o' , \ : , v;,o, , , , ~ .. ' ' ' , , . , . , , . . , . . ... o ,o , , , , , , , - , ' ' , . , . . . .. , 'o o'./' o; , ,vo ,u . , ' ' , . , . , . , ,, ' - - - ... . ., .. -. . ... . . , .. _ .. w. , .'' , ,. . . ..., . . ~ - . . . . ~ .- ' ' ... . . N w.. . . ~ ..w- ' J

Documents

McKinsey CMS HealthCare.gov review