Colorado Health Benefits Exchange

Preliminary Discussions with IT and Implementation Subcommittee – Strategic IT Decisions

November 21, 2011

Charge for IT and Implementation Subcommittee

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

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

• Procurements 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 procurements activities and operational decisions

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

2. Should the Exchange consider the Federal partnership model? If so, for which of the core areas? – analysis framework provided

3. Should the State develop a vision and strategy for replacing or upgrading CBMS so that investments in modifying CBMS and PEAK to meet the requirements of healthcare reform are rationalized against the strategic direction? – Yes and analysis framework confirmed with HCPF

After analysis frameworks (alternatives and criteria) are confirmed with COHBE Board, analysis will be completed and presented in mid-December

COHBE “owns” #1 and #2State (HCPF, DHS) “owns” #3

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

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COHBE Timeline

4

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

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

• Schedule is extremely tight for a product release of this magnitude and complexity, i.e. 20 months until SHOP “go-live”

• Implementation dependencies with changes to CBMS and PEAK increase complexity and schedule risk

• Asset acquisition (with federal funds) likely to result in lower sustainability costs vs. SAAS model with lower upfront costs

• Three major components must be procured: • Exchange technology solution (acquire/license or rent)• Exchange technology solution hosting (outsource)• Exchange administrative and customer support services (outsource)

• Procurements will be:• Well-structured• Efficient• Competitive• Fair • Transparent

• Opportunities to coordinate solutions, procurements, etc., with other states is challenging and becomes more challenging daily; coordinating across states (and multiple state agencies for each state) in this political environment creates additional dependencies and increases execution risk

• Federal Exchange partnership model is not compatible with Colorado having its own Exchange

Introductory Comments

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Question #1: Should the Exchange use a SAAS model or acquire (borrow/build/buy) the IT Exchange asset(s)?

Exchange Alternatives• SAAS Model• COBHE Acquires Asset; Operated by 3rd Party

Criteria• Cost

• Implementation• 5-Year operations

• Risk• Schedule risk• Cost risk

• Consumer experience• Reliability/simplicity in getting consumers enrolled• Reliability/backend complexity of having all solution components fully

functioning• Ability to share solution components with CBMS• Privacy and security• Impact on COHBE operations/and alignment with ops plan• Strategic direction and latitude• Stakeholder acceptability

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Should the Exchange use a SAAS model or acquire the IT Exchange assets and have the asset operated by a 3rd party?

Proposed Analysis Framework

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Alternative Description/Functions

Cost RiskConsumer ExperienceEmployer/ Employee

(Richness of Features &

Functionality

Reliability/ Simplicity in

Getting Consumers

Enrolled

Reliability/Backend

Complexity of Having All Solution

Components Fully

Functioning

Ability to Share

Solution Componen

ts w/ CBMS

Privacy and

Security

Impact on COHBE

Operations/and

Alignment w/ Ops

Plan

Strategic Direction

and Latitude

Political Acceptability

Implementation

Costs

5-Year Operationa

l Costs

Schedule Risk

Cost Risk

SAAS Model

w/ or w/o shared rules engine

Acquire Asset Operated by 3rd Party

Other-TBD

Eligibility

Screening & Eligibility

DeterminationMA/CHIP/PTC/RCS

Interoperable Systems and Multiple Doors

Enrollment

HIXCustomer A

Plan Shopping & Selection

Enrollment

Carrier Systems

Carrier Systems

State Systems/Programs

Customer BPEAK

CBMSSNAP, TANF, MA/CHIP/MA

ABD/LTC

MMIS

Federal and State Real-Time Data

Exchanges

MA/CHIP Eligibility Rules &

Real-time Eligibility Decision

Interoperability LayerWhat interoperability is feasible?

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Considerations of Federally-facilitated Exchange:

• Cost of Federally-facilitated Exchange is TBD; likely to charge carriers

• HHS is responsible and accountable for ensuring the Exchange meets all of the standards; State role is limited

• Two proposed areas of partnership that can be operated by states as part of the agreement are Plan Management and some Consumer Services

• For Plan Management, State helps select plans and collects a standardized set of data on them to plug into Federally-facilitated Exchange's eligibility and enrollment functions.

• For Consumer Services, HHS coordinates with the State regarding plan oversight, including consumer complaints and issues

Question #2: Should the Exchange consider the Federal partnership model? If so, for which of the five core areas?

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2. Should the Exchange consider the Federal partnership model? If so, for which of the two optional areas?.

Strategic IT Issues that Need to be Resolved

YES NOAccept applications (web/phone/mail)

Conduct verifications of applicant information

Determine eligibility for enrollment in QHP and for insurance affordability programsConnect Medicaid and CHIP-eligible applicants to Medicaid and CHIPConduct redeterminations and appeals

Enromment of consumers into QHPs

Transactions with QHPs and trasmissions of information necessary to initiate advance payments of premium tax credit and cost-sharing reductionsPlan selection approach (e.g. active purchaser or any willing plan)Collection and analysis of plan rate and benefits package informationIssuer monitoring and oversight

On-going issuer account management

Issuer outrach and training

Data collection and analysis for quality

Consumer support assistors

Education and outreach

Navigator management

Call center operations

Website management

Written correspondence with consumers to support eligibility and enrollmentUser fees

Financial integrity

Support of risk adjustment, reinsurance and risk corridor programs

Operated and maintained by HHS? Need to Confirm

Partnership Model for Each Core Function

State helps select plans and collects a stardardized set of data on them to plug into Federally-facilitated Exchange's eligibility and enrollment functions.

HHS coordinates with the State regarding plan oversight, including consumer complaints and issues with enrollment reconcilliation.

Consumer assistnace functions that a State would operate under this propoposed partnership option include:- In-person assistance- Navigator management- Outreach and education

Consumer assistance functions that HHS would operate under this proposed partnership option include:- Call center operations- Website management- Written correspondence with consumers to support eligibility and enrollment

Operated and maintained by HHS

Operated and maintained by HHS

Eligibility

Which Functions Are Candidates to be Met via the Partnership

ModelCore

Exchange Functions

High-Level Exchange Requirements

Financial Management

Enrollment

Plan Management

Consumer Assistance

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Draft COHBE Guiding Principles for Systems and Implementation

Category Guiding Principle

Exchange Functions, Features and Business Processes

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

Exchange Customers and Business Lines

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

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

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

Integration with Medicaid

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

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

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

Inter-agency Partnerships

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

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

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…Discussion