State-Based Marketplace and Medicaid Information Technology (IT) System Contracts Update

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State-Based Marketplace and Medicaid Information Technology (IT) System Contracts Update Jessica Kahn, MPH Centers for Medicare & Medicaid Services Jay

1 State-Based Marketplace and Medicaid Information Technology (IT) System Contracts Update Jessica Kahn, MPH Centers for Medicare & Medicaid Services Jay Himmelstein, MD, MPH UMass Medical School Co-Author: Scott Keays, MPH - UMass Medical School Medicaid Enterprise Systems Conference Charleston, SC., September 10, 2013

2 Agenda Background: Technology Infrastructure for Insurance Exchange 1.0 Affordable Care Act (ACA) Information Technology (IT) Vision ACA Marketplace Options and State and Federal IT System Approaches and Contracts Implications for Future ACA IT System Development 2

3 Chapter 58 of the Acts of Signed Into Law - April 12,

4 2006 Framework for Massachusetts Health Reform Similarities with ACA Medicaid Expansion to 133% FPL Subsidized private insurance coverage for lowincome ( % FPL) adults Requirement to obtain and maintain health insurance or face a tax penalty the so-called individual mandate Requirement for employers to contribute to employees health insurance or make a fair share contribution to the state the employer mandate Insurance market reforms, including establishment of a state health insurance exchange The Health Connector 4

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14 Referred to Paper Process 14

15 Agenda Background: Technology Infrastructure for Insurance Exchange 1.0 Affordable Care Act (ACA) Information Technology (IT) Vision ACA Marketplace Options and State and Federal IT System Approaches and Contracts Implications for Future ACA IT System Development 15

16 National Health Reform Signed Into Law - March 23, 2010

17 ACA Vision: Single Application, Simplified Eligibility & Enrollment Process User Seeks health care coverage HIX/IES Web Portal Initial Eligibility Screener Questionnaire User may browse for health plans before completing an application Applicant browses for health plans without subsidy No Applicant appears eligible for subsidized coverage Yes Single Yes Streamlined Application Verification Rule-based Eligibility Engine Unsubsidized QHP Application MassHealth (Medicaid, CHIP) QHP (with APTC) Health Plan Shopping & Enrollment Federal Data Hub SSA, IRS, DHS etc. 17

Modern Web-enabled Communications Other Data Sources Other Qtrly

Assistors DHS Citizenship Immigration Verification SSA SSN

Request/Response Citizenship/ Immigration Status Request/Response

Request/Response Other Coverage Verification Enrollment Request &

& Logs QHP Plan Data & Enrollment History Citizenship Verification

Computational Engine PTC Reconciliation Plan Benefit Data

18 Modern Web-enabled Communications Other Data Sources Other Qtrly Wage Attestation Consumers Individuals Household Employers Assistors DHS Citizenship Immigration Verification SSA SSN Validation Response Exchange/Medicaid/CHIP SSN Validation Request/Response Citizenship/ Immigration Status Request/Response Income Verification Request/Response APTC Calculation Request/Response Other Coverage Verification Enrollment Request & Response CMS Data Services Hub Request & Response Services Routing & Logs QHP Plan Data & Enrollment History Citizenship Verification IRS Income Verification Response APTC Calculation Response Computational Engine PTC Reconciliation Plan Benefit Data Enrollment Response/ Confirm QHP Plan Benefit Data Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Other Information Source TBD 18

19 CMS Guidance for Exchange and Medicaid IT Systems Shared services and IT components Federal Data Services Hub Seamless coordination between Exchanges, Medicaid and CHIP High level of service, support, and ease of use regardless of coverage type Real time eligibility and enrollment (15 to 20 minutes) Seven conditions and standards 19

20 Enhanced Funding Requirements: Seven Conditions and Standards Modularity MITA alignment Leverage and reuse within and among states Industry standard alignment Support of business results Reporting Seamlessness and interoperability 20

21 Key Challenge: Integration of HIX and Medicaid Eligibility and Enrollment Coordination between multiple programs and agencies Complex new functionality New modified adjusted gross income (MAGI) standards used to determine eligibility New linkages to federal and state data sources Timelines are tight! Open Enrollment Oct. 1, 2013 thru March 2014 Coverage Effective Jan 1,

22 Agenda Background: Technology Infrastructure for Insurance Exchange 1.0 Affordable Care Act (ACA) Information Technology (IT) Vision ACA Marketplace Options and State and Federal IT System Approaches and Contracts Implications for Future ACA IT System Development 22

Review: ACA Marketplace Options STATE-BASED STATE- PARTNERSHIP FEDERALLY FACILITATED States Operate: Consumer Assistance (all IAP) Eligibility and enrollment for insurance affordability programs

Consumers can apply with Medicaid/CHIP for insurance affordability programs States may use federal services for: Maximum premium tax credit calculations Exemptions Risk Adjustment Reinsurance States

23 Review: ACA Marketplace Options STATE-BASED STATE- PARTNERSHIP FEDERALLY FACILITATED States Operate: Consumer Assistance (all IAP) Eligibility and enrollment for insurance affordability programs States Operate: Plan Management and/or Consumer Assistance (all IAP) Consumers can apply with Medicaid/CHIP for insurance affordability programs States Operate Consumer Assistance (Medicaid/CHIP) Consumers can apply with Medicaid/CHIP for insurance affordability programs States may use federal services for: Maximum premium tax credit calculations Exemptions Risk Adjustment Reinsurance States may use federal services for: Eligibility for insurance affordability programs and QHP enrollment Exemptions States may use federal services for: Reinsurance Eligibility for insurance affordability programs and QHP Exemptions Reinsurance/Risk Adjust. 23

24 ACA Marketplace Status Source: State Refor(u)m, August

25 Exchange and Medicaid IT System Contracts: Methods CMS/UMMS collected information and performed initial review of state HIX and IES RFPs, contracts and related announcements. Information collected included: System Integrator (SI) Vendors Other vendors Developer, COTS vendor, IV&V vendor, Customer service, Program/Project Management and other major sub-contractors Scope & approaches to system development See Exchange and Medicaid IT System Contracts Chart on State Refor(u)m 25

26 Findings: System Integrator Contracts Differ in Scope and Approach Scope: Enhancement of existing eligibility and enrollment systems vs. full or phased replacement States with modern systems may only require ACA enhancements might have a lighter lift Approach: For those replacing systems, options include porting system from somewhere else with ACA enhancements vs. creating entirely new system Reliance on state staff vs. vendors and subcontractors Degree of reliance on commercial off the shelf (COTS) solutions vs. custom build 26

27 Findings: All States Building New Systems are taking a Phased Approach to IT Development Phase 1 (Oct. 1, 2013): Marketplace & Medicaid/CHIP Eligibility & Enrollment based on Modified Adjusted Gross Income (MAGI) Phase 2 (Jan. 1, 2014): non-magi Medicaid/ CHIP Phase 3 (Jan. 1, 2015 and beyond): Other Human Service programs 27

28 State Based Marketplace (SBM) System Integrator SI Contracts Most SBM SIs are committed to building both Exchange and Medicaid Eligibility and Enrollment Systems Colorado is the only SBM to have different Exchange (CGI) and Medicaid Eligibility and Enrollment System (Deloitte) vendors for their eligibility system All SBMs are system replacements or significant enhancements All ported systems and COTS products for the ACA are being debugged and tested now- so they ll be even more valuable for other states to adopt post-2014 After 2014, there will actually be ACA tested and functioning systems and COTS solutions 28

29 State Partnership (SPM) and Federally Facilitated Marketplace (FFM) Contracts CGI is building the IT for the FFM to include MAGI determination, plan shopping and enrollment: QSSI is building the Federal Data Services Hub (FDSH) and interfaces SPM/FFM states have the opportunity and are modernizing their own Medicaid Eligibility and Enrollment IT Systems with enhanced federal funding through 2015 New SBMs will need to leverage what has already been built by the Medicaid/CHIP agency SPMs must also develop systems for Plan Management and Consumer Assistance Services 29

30 State-Based vs. State Partnership and Federally Facilitated Marketplaces State Based Marketplace: Marketplace and State Medicaid Program State Partnership and Federally Facilitated Marketplaces: Federally Facilitated Marketplace State Medicaid Program One Front Door Two Front Doors

31 SPM/FFM Contracts for State Medicaid E&E systems All states have an approved enhanced funding APD Will need to modernize E&E as replacement or update to accept new and renewal applications for Medicaid/CHIP and process and verify based on electronic data sources and accurate business rules. 46 states are either currently integrated or planning to integrate with human services

32 Agenda Background: Technology Infrastructure for Insurance Exchange 1.0 Affordable Care Act (ACA) Information Technology (IT) Vision ACA Marketplace Options and State and Federal IT System Approaches and Contracts Implications for Future ACA IT System Development 32

33 Implications for the next phases of ACA IT Development Federal and state governments are making huge investments in money and time to support technology infrastructure required by the ACA States receiving CCIIO Establishment Funding must include language in their IT contracts regarding their responsibility to ensure maximum opportunity for IT reuse Given the timelines dictated by the ACA, what can be done to accelerate system development and promote efficient system investments? 33

34 Potential System Accelerators Reuse: Involves one state leveraging some, most, or all of another state s previously created artifacts, code, software, or other products to accelerate the development of their own IT systems. Community of Interest Networks (COINs)/ Shared Vendor Groups: Peer groups for states that share the same vendor and/or COTS solution in order to facilitate reuse and knowledge sharing 34

35 Potential for IT Reuse States are exploring and CMS is STRONGLY encouraging reuse and multi-state collaboratives 35

36 HIX Deployment Tier 3 Example HIX portal, middleware and database are available in shared cloud. Rules Engine, BPMS, Application Server Rules Engine, BPMS, Application Server Rules Engine, BPMS, Application Server Database Database Database Federal Cloud MDM MDM Medicaid/CHIP MDM Medicaid/CHIP Shared Services Medicaid/CHIP Shared Services MassCloud Shared Services State Y Cloud State X Cloud 36

37 Community of Interest Networks COINs/Shared Vendor Groups: Current COINs CGI Connecture Deloitte IBM/Curam Oracle WebCenter Future COINs IV&V Oracle SOA 37

38 What To Expect Moving Forward Due to tight timelines, October 1 realities will include a mixture of temporary workarounds and new functionalities: Many states will need to utilize temporary workarounds while IT system development and testing continues Meeting the critical success factors and having an approved mitigation plan is tied to the 75/25 FFP for M&O States are still moving apace towards the north star of real-time, modernized and integrated eligibility determination and enrollment systems 38

39 Reuse of ACA-Compatible Systems Tested COTS solutions? Options for porting systems from other states that are already ACA compliant? Hosting might be a better option for the 2015 cohort because the hosting state s solution will have been live? This may be attractive for smaller states and territories 39

40 Discussion: Things we need to understand better about reuse Can we objectively quantify the reusability of components and/or services? Clarifying federal and state procurement options that support reuse opportunities Clarifying ROI and state implementation and operating expenses Clarifying vendor role and business models

41 Discussion Can the integrated eligibility systems (IES) being built today for FFM and SBMs states be leveraged for the next cohort of 2015 SBMs? States: Funding for late development states will likely be more limited. What if reuse is not a choice? Vendors: Can re-use be made to be compatible with your business model? Examples of non-health care cloud solutions? 41

42 Thank you! Jessica Kahn, MPH Acting Director, Division of State Systems Center for Medicaid and CHIP Services (CMCS) Scott Keays, MPH Project Associate MA HIX/IES Project UMass Medical School Jay Himmelstein, MD, MPH Principal Investigator MA HIX/IES Project UMass Medical School 42

43 ACA Funding Opportunities Funding Source Amount Description Dates Planning Grants $49m in grants to 49 states HIX research and planning Awarded 9/30/10 Early Innovator Grants Originally $241 million awarded to 7 states Reusable HIX IT components that can be leveraged by other states Awarded on 2/16/11 Establishment Grants Will vary according to states needs and progress Development and implementation of HIX operations; available regardless of HIX model L1 and L2 due by 10/15/2014 FFP for Eligibility and Enrollment development 90% or 75% (normally 50%) Design, development and installation or enhancement of eligibility determination systems Maintenance and operations (including eligibility workers) Through the end of 2015 for the 90% and no end date for 75% OMB Circular A-87 Cost Allocation Exception No amount; Exception to normal OMB Circular A-87 principles and standards Allows federally funded human service programs (i.e. TANF and SNAP) to benefit from investments in the design and development of state eligibility determination functions being made by Exchanges, Medicaid, and CHIP Expires 12/31/15 43

44 High Level Marketplace Systems (System Context) 44

45 ACA HIX Functional Requirements 1. Eligibility and Enrollment 2. Plan Management 3. Financial Management 4. Customer Service Employer enrollment in an Insurance SHOP Exchange Individual enrollment in a qualified health plan offered through the Insurance Exchange Integra>on with Medicaid and CHIP Plan cer>fica>on, recer>fica>on and decer>fica>on Issuer contrac>ng Plan ra>ng Premium determina>on including premium tax credits, vouchers, and cost sharing Plan assessment, reinsurance, risk adjustment, and risk corridors func>ons Individual and issuer reconcilia>on Manage responses to informa>on requests and requests for service Efficient distribu>on/management of requests across phone, web, paper and face- to- face 5. Communica?ons Communica>ons and outreach strategies; content and messaging Measurement/repor>ng of communica>on effec>veness 6. Oversight Federal oversight of Exchange opera>ons Insurance Exchange management and opera>ons 45

Agenda. 1. Federal Health Care Reform: Background and Overview. 2. Exchange Operations. 3. Exchange Establishment Funding

Agenda. 1. Federal Health Care Reform: Background and Overview. 2. Exchange Operations. 3. Exchange Establishment Funding Agenda 1. Federal Health Care Reform: Background and Overview 2. Exchange Operations 3. Exchange Establishment Funding Federal Health Care Reform: Background and Overview Affordable Care Act PPACA, Affordable