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Transcript of Preliminary Discussions with IT and Implementation Subcommittee – Strategic IT Decisions November...
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
2
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
3
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
10
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