Level 1 Grant Application Project Narrative - Idaho Health Insurance ...

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Oct 31, 2013 (3 years and 9 months ago)

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Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

1


E. Project Narrati ve

i.
Level One Establishment

a.

Demonstrati on of Past Progress i n Exchange Pl anni ng Core Areas



Background Research:

Quarter 1
: Ini ti al data research has begun by compari ng Kai ser Commi ssi on on Medi cai d and the
Uni nsured for 2008 wi th the

current 2009 publ i shed data. Thi s wi l l be one source of data that wi l l be
used i n determi ni ng the number of i ndi vi duals that may be el i gi bl e for coverage through the Exchange
and al so el i gi ble for Medi cai d and other state assi stance programs.

Quarter 2
and 3
: Conti nued data research contrasti ng and compari ng other states’ pl ans for Heal th
Insurance Exchange. Conti nued revi ewi ng opi ni ons, gui dance and recommendati ons from U.S.
Department of Heal th and Human Servi ces (HHS), Centers for Consumer Informati on

and Insurance
Oversi ght (CCIIO), Centers for Medi care and Medi cai d Servi ces (CMS), Robert

Wood Johnson Foundation
(
RWJ), Kai ser Fami l y Foundati on (Kai ser) , Ameri ca’s Heal th Insurance Pl ans (AHIP), Nati onal Academy
for State Heal th Pol i cy (NASHP), Nati ona
l Associ ation of Insurance Commi ssi oners (NAIC), Nati onal
Academy of Soci al Insurance (NASI), Ameri ca’s Heal th Insurance Pl ans (AHIP), Idaho Associ ati on Of
Heal th Pl ans (IAHP), Nati onal Associ ation of Heal th Underwri ters (NAHU) and the Nati onal Associ ati on

of Medi cai d Di rectors (NAMD). The fi ndi ngs are i ncl uded i n core area pl anni ng and devel opment of
recommendati ons.

We al so l everaged research compl eted by exi sti ng sources (studi es compl eted and stati sti cal
i nformati on compi l ed by a wi de vari ety of source
s i ncl uding nati onal thi nk tanks, uni versi ties, pol icy
anal ysis groups, state and federal agenci es, professi onal associations and non
-
profi t enti ti es.)
Interacti ons between Heal th Insurance Exchange Pl anni ng Project Managers and exchange staff i n other
sta
tes have i ncl uded the conducti ng of i nformal i ntervi ews, si te vi si ts and the revi ew of Impl ementati on
grant appl i cati ons.

As a resul t we have determi ned that addi ti onal, focused anal ysis wi ll be needed i n Level One. The
associ ated tasks can be found i n ea
ch Core Area wi thi n the
Project Work Pl an
.



Stakehol der Invol vement:

Duri ng the m
onths of March and Apri l 2011, si x publ i c stakehol der meeti ngs and focus groups were
conducted to gai n publ i c i nput on a proposed Heal th Insurance Exchange i n Idaho. We were successful
i n engagi ng 92 organi zati ons, i ncl uding 5 tri bal members, medi cal prov
i ders, consumer advocates,
i nsurers, producers, government enti ti es, and busi ness groups, i n stakehol der meeti ngs from three
major areas of Idaho (Boi se, Cal dwel l and Coeur d’Al ene). The Stakehol der meeti ngs resul ted i n
val uabl e i nformati on that was used
i n devel opi ng thi s i mpl ementati on grant for an Idaho Heal th
Insurance Exchange. The fol l owi ng three work groups were al so formed from members representi ng a
wi de vari ety of stakehol ders to ensure stakehol der i nvol vement wi th ongoi ng desi gn and deci si ons:


o

Governance and Legi sl ati on

o

Medi cai d Integrati on

o

Informati on Technol ogy

An addi ti onal Tri bal meeti ng was hel
d

where 24 tri bal members, representi ng fi ve tri bes, di scussed
Exchange i ssues i mpacti ng the tri bes.

F
eedback from these stakehol der meeti ngs h
el ped i denti fy addi ti onal stakehol ders and pl an for future
meeti ngs throughout the l i fe of the project.



Legi sl ati ve and Regul atory Acti on:

Quarter 1
: Governor Otter’s Executi ve Order 2010
-
15, dated December 14, 2010 establ i shed the Idaho
Heal th Care Counci
l.

Quarters 2 and 3:

Duri ng the second quarter of the pl anni ng grant peri od, a nul l i fi cation governance bi
l l

(
HB298
)

was passed by the House and the Senate, but was vetoed by the Governor. Al though the bi l l
was vetoed, the Governor i ssued an Executi ve Orde
r Number 2011
-
03, Prohi bi ti ng Executi ve Branch
Departments, Agenci es
,

and Insti tuti ons of the State from Impl ementi ng the Pati ent Protecti on and
Affordabl e Care Act.

A draft of Exchange l egi sl ati on was compl eted, wi th on
-
goi ng revi si ons by the Governance W
orkgroup
for the 2012 l egi sl ative session.

Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

2


Idaho has engaged a gap anal ysis consultant to assi st state l eaders by provi di ng addi ti onal i nsi ghts and
gui dance on pol i cy acti on rel ated i ssues. The consul tant wi l l oversee the pol i cy i ssues across all
functi ons

of the Exchange and devel op necessary pl ans to address each i ssue.

Quarter 4
:
An announcement was formal l y made by
Governor Otter
, al l owi ng the Department of Heal th
and Wel fare to appl y for the Impl ementati on Grant
.



Governance:

A Governance Workgroup and
Charter was establ i shed, whi ch gathered and studi ed other states
i nformati on on the opti ons for a
state
-
run exchange and an e
xchange run by an i ndependent enti ty.
The workgroup engaged representati ves from the Department of Insurance, i nsurance provi ders,

smal l
busi ness, Di vi sion of Medi cai d, Associ ati on of Counti es
,

and the Idaho l egi sl ature. The workgroup
returned a recommendati on for a State
-
based Exchange.



Program Integrati on:

Researched the possi bi lity of usi ng Medi cai d’s new web
-
based and bi l l ing sy
stems as a l aunching pad
for the Exchange system, whi ch woul d enabl e easi er i ntegrati on.

Current
-
state process mappi ng of Medi cai d el i gi bility, Medi cai d benefi ts, and i ndi gent care was
compl eted. Draft

of

future
-
state Medi cai d el i gi bility process map

was
compl eted
.

Wel l
-
establ i shed communi cati ons between the Department of Heal th and Wel fare, Medi cai d, and the
Department of Insurance have been on
-
goi ng. A workgroup i s
establ i shed wi th representati ves from
each area, and meets weekl y. Thi s workgroup has be
en i ntegral i n surfacing i deas for i ntegrati ng
Medi cai d el i gi bili ty and exchange functi ons and l everagi ng exi sti ng technol ogy to support exchange
functi ons.



Exchange IT Systems:

An IT Gap Anal ysi s, whi ch provi des a work pl an and ti mel i ne, was compl eted.
T
hat anal ysis i s detai led
secti on
E.c
.

A publ i c web page was bui l t and i s functi onal. It i s used for stakehol der meeti ng regi strati on and
knowl edge shari ng. The si te can be accessed at
http://www.heal thexchange.i daho.gov
.

The State of Idaho has several consol i dated customer servi ce and el i gi bi lity determi nati on uni ts that
serve the enti re state. Investments have been made i n technol ogy and system i mprovement to al l o
w
work to
be done from any state l ocati on;

thi s experi ence wi l l be val uabl e as potenti al model s for
customer servi ce efforts i nvol vi ng the Exchange.



Fi nanci al Management:

Began research on pathways to devel opi ng accounti ng and audi ti ng standards; mechani s
ms of
transparency to the publ i c; and procedures to faci l itate reporti ng to the Secretary. Recommendati ons
and fi ndi ngs are bei ng compi l ed at thi s ti me.



Oversi ght and Program Integri ty
:

No project work was conducted i n thi s area due to l egi sl ati ve pri orit
ies.



Heal th Insurance Market Reforms
:

No project work was conducted i n thi s area due to l egi sl ati ve pri orities
.



Provi di ng Assi stance to Indi vi duals and Smal l Busi nesses, Coverage Appeal s, and Compl ai nts
:

No project work was conducted i n thi s area due to l e
gi sl ati ve pri orities.




Busi ness Operati ons
:

Quarter 1
:

Began di scussions wi th i nsurers and Medi cai d for el i gi bility determi nati ons, pl an
qual i fi cation, pl an bi dding, appl icati on of qual i ty rati ng systems and rate justi fi cati on, admi nistrati on of
premi um cr
edi ts and cost
-
shari ng assistance, and ri sk adjustment. It was determi ned that addi ti onal,
focused di scussions are needed. Pl ans are i n pl ace to conti nue these di scussions as the project moves
forward.



Quarters 2 and 3
:
Idaho has begun l ooki ng i nto possi
bl e busi ness operati on processes (future state) for
el i gi bi lity determi nati on and enrol l ment. There are several ways one coul d i nteract wi th the Idaho
Heal th Insurance Exchange that wi l l create the need for speci fi c processes for i ndi viduals, empl oyees,
sm
al l busi ness empl oyers, navi gators, or Exchange pl an
admi ni strators. Attachment
B

contai ns process
mappi ng for
El i gi bi lity and Enrol l ment (Ti er 1 thru Ti er 4 l evel s)
.

Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

3


In addi ti on, an anal ysis of current
-
state and potenti al f
uture
-
state
busi ness operati ons
was conducted
wi th Medi cai d El i gi bility and the Department of Insurance. Thi s effort wi l l be i ntegrated i nto defi ni ng
busi ness operati ons i n more detai l.

IT wi l l establ ish work groups that wi l l col laborate wi th the busi ness
as they dri l l down i nto the next Ti ers
of the process mappi ng. Thei r rol e wi l l be to research, anal yze
,

and devel op the gap anal ysis and
technol ogy requi rements as they affect each busi ness process.


b.


Proposal to Meet Program Requi rements

In order to more
effecti vel y support the popul ati on of Idaho and to meet the Federal gui dance and
requi rements of the Affordabl e Care Act, the Idaho Heal th Insurance Exchange Project and resul ti ng
Impl ementati on wi l l be dri ven by these pri nci pl es and pri orities:



Establ i shi
ng a state
-
based exchange



Promoti ng effi ci ency and effecti veness



Avoi di ng adverse sel ecti on



Streaml i ni ng access and conti nui ty of care



Publ i c outreach and stakehol der i nvol vement



Publ i c accountability and transparency



Fi nanci al accountabili ty



Sel f
-
sustai na
bility

Whi l e consi deri ng the fol l owi ng hi gh
-
l evel mi l estones:



January 2013


Certi fi cati on of Idaho Heal th Insurance Exchange



June 2013


Open enrol l ment for Idaho Heal th Insurance Exchange cl i ents



January 2014


Ful l y functi onal Idaho Heal th Insurance Exc
hange and supporti ng organi zati on



December 2014


End of Federal fundi ng for Idaho Heal th Insurance Exchange i mpl ementati on and
supporti ng changes

Idaho’s approach to i mpl ementati on of the exchange wi l l consi st of two major Ini ti ati ves: the Prel i mi nary
Des
i gn Ini ti ati ve supported by thi s Level 1 Impl ementati on Grant and the Fi nal Impl ementati on Ini ti ati ve
supported by the Level 2 Impl ementati on Grant. The Prel i mi nary Desi gn Ini tiative wi l l address or refi ne
many of the functi onal, busi ness, organi zati onal
,

and techni cal questi ons that remai n.

The State of Idaho i s worki ng di l i gentl y to devel op a state
-
based heal th i nsurance exchange wi th the
ul ti mate goal of reduci ng the number of uni nsured. The Idaho H
eal th Insurance Exchange
wi l l certi fy and
make avai l ab
le qual ified heal th pl ans to i ndi vi duals and smal l businesses, and serve as a seaml ess gateway
to the Medi cai d and CHIP programs.

A heavy emphasi s duri ng the Pl anni ng Grant has been on background research for deci si on makers,
l egi sl ators
,

and the Governor
to ai d i n the deci si on to move to a state
-
based heal th i nsurance exchange.
Concurrent wi th those efforts was stakehol der i nvol vement and a pl an for assessing, desi gni ng, devel opi ng,
i mpl
ementi ng, and eval uati ng the Idaho Heal th Insurance Exchange
. We wi l l

seek opportuni ti es for
engagement wi th previ ousl y i denti fi ed stakehol der groups (tri bal members, medi cal provi ders, consumer
advocates, i nsurers, producers, government enti ti es, and busi ness groups) as wel l as representati ves from
the uni nsured popul ati on

i n consumer assi stance, pl an management, el i gi bi l ity, enrol l ment, and fi nanci al
management. We pl an to use stakehol der meeti ngs, focus groups, work groups, surveys and i ntervi ews to
obtai n the desi red engagement. Thi s wi l l i nclude face
-
to
-
face and vi rtua
l meeti ngs i n the three regi ons of
Idaho. These i nteracti ons wi l l conti nue wi th the extensi on of the Pl anni ng Grant and throughout the
Impl ementati on Grant. The resul ts of the targeted assessments wi l l di rect desi gn, devel opment and some
i mpl ementati on, w
hi ch wi l l be the focus of thi s Level One Impl ementati on Grant.

Idaho wi l l consul t wi th the earl y Innovator States throughout the process for i nformati on and avai lable
opportuni ti es, al l owi ng us to gl ean processes, systems, and i deas that may functi on for
Idaho. Compl eti on
Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

4


of these tasks wi l l enabl e Idaho to meet federal ti mel i nes for certi fi cati o
n and i mpl ementati on of the Idaho
Heal th Insurance Exchange
.

Project Management and Strategic Alignment

Idaho wi l l use an i terati ve method of determi ni ng requi rem
ents i n a hi ghl y fl exi bl e and i nteracti ve manner.
It wi l l requi re empowered i ndi vi duals from the rel evant busi ness, wi th suppl i er and stakehol der i nput. The
project i s di vi ded i nto smal l
-
scale teams focused on operati ons (appl i cati on, veri ficati on, el i gib
i lity,
enrol l ment, appeal s & noti ces) stakehol der i nvol vement & consumer assi stance (i nvol vement, outreach,
educati on, cal l center, navi gator) and structure (fi nanci al management, oversi ght & program i ntegri ty,
heal th i nsurance market reforms, governance
,

and l egi sl ati ve/regul atory). Cross
-
functi onal l eads wi ll
provi de opportuni ti es for conti nui ty of the overal l goal and i ntegrati on of objecti ves.

Goal:
Provi de di recti on and management of the project whi l e assuring core area i nterdependenci es to
achi eve a

sel f
-
sustaining, effi ci ent
,

and effecti ve Heal th Insurance Exchange by 2015 on ti me and wi thi n
budget
.

Overall Approach
: Throughout i mpl ementati on of the exchange, Idaho wi l l mai ntai n executi ve and project
l eadershi p. Executi ve Leadershi p wi l l consi st of

the Department of Heal th and Wel fare and the Department
of Insurance Di rectors and Deputy Di rectors. Thi s wi l l ensure conti nui ty and i ntegrati on through al l parts of
the Idaho Heal th Insurance Exchange. The Project Management Team wi l l consi st of two Pro
ject Managers,
two Project Coordi nators and
mul ti pl e

Project Leads. These l eads wi l l oversee and provi de conti nui ty across
al l Core Areas i n Pol i cy, Busi ness Process Reengi neeri ng, Informati on Technol ogy, Qual i ty and
Communi cati ons. Thi s structure wi l l a
ssure earl y i denti ficati on and i mmedi ate mi ti gati on of ri sks and i ssues
i n a defi ned escal ati on process. These resources wi l l be engaged i n al l of the Core Areas.
(See
Project Work
Pl an, Project Management and Strategi c Al i gnment
,

for more detai l s)

Core Areas: The fol l owi ng are the goal s and overal l approaches to each of the Core Areas

1
. Background Research

2. Stakeholder Consultation

3. Legislative and Regulatory Action

4. Governance

5. Program Integration

6. Exchange IT Systems

7. Financial Management

8. Oversight and Program Integrity

9. Health Insurance Market Reforms

10. Providing A
ssistance to Individuals and Small Businesses, Coverage Appeals, and Complaints

11. Business Operations of Exchange


Core Area 1: Background Research

Goal:
Conduct research and anal ysis and regul arly eval uate to i nform devel opment and i mpl ementati on of
the

Idaho Heal th Insurance Exchange.

Overall Approach:

Background research on heal th exchanges and i mpl i cati ons to stakehol ders was started
i n the pl anni ng grant. In addi ti on to these acti vi ti es
,

research wi l l be conducted on the popul ati ons that wi l l
i ntera
ct wi th the exchange and the market envi ronment that wi l l resul t from vari ous deci sions across the
exchange. There wi l l be a seri es of reports uti l i zed to make i ncremental deci si ons for the most effi ci ent,
effecti ve
,

and sustai nable I
daho Heal th Insurance

Exchange (
i ncl udi ng a study and other research to
determi ne the best approach for supporti ng an Exchange
)
. Other background research wi l l be associ ated
wi th the respecti ve core areas and wi l l be refl ected i n that work pl an.

The Level
1

Grant wi l l be use
d to conduct anal ysis of Idaho
’s

i nsurance market and devel op
recommendati ons for Exchange structure based on thi s anal ysis; conduct research on i ssues i mpacting
Idaho
’s

Heal th Insurance Exchange; present fi ndi ngs; and, i ntegrate fi ndi ngs i nto desi gn, deve
l opment
,

and
i mpl ementati on of
Idaho Heal th Insurance Exchange
. (
See
Project Work Pl an, Core
Area 1
,

for more detai l s)




Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

5


Core Area 2: Stakeholder Involvement

Goal:
Increase stakehol der i nvol vement and uti l i ze the resul ts to create the Idaho Heal th Insurance
Exchange.

Overall Approach
: Idaho wi l l conduct 12 stakehol der and work group meeti ngs thr
oughout Level 1
Grant

to
i nform groups of progress and obtai n feedback.
T
he Level 1 Grant emphasi s wi l l be to focus on the needs of
consumers, empl oyees, empl oyers, tri bes, producers, i nsurers
,

and l egi slators through a mul ti faceted
outreach to i nform the

publ i c of servi ces and coverage opti ons. Thi s wi l l devel op a strong rel ati onshi p wi th
stakehol ders as a vi tal component of a successful exchange. Thi s wi l l i nclude i nformati on sessions on the
progress of the project for key l eaders. Idaho wi l l al so enco
urage feedback i n vari ous formal and i nformal
processes. Stakehol ders wi l l conti nue to be i nvol ved i n Work Groups i n vari ous core area assignments.
Idaho wi l l conti nue to keep stakehol ders advi sed of progress; promote conti nued feedback and
i nvol vement;
and desi gn the outreach and educati on pl an requi red for
Core Area
11
-
16
.

A study wi l l be
conducted under the Pl anni ng Grant to determi ne stakehol der needs i n the three uni que regi ons of Idaho
for al l stakehol der types. The pl an

that resul ts i n t
hi s assessment wi l l gui de the Level 1 Grant

acti vi ti es to
maxi mi ze engagement. Thi s i ncl udes establ ishment, i mpl ementati on
,

and documentati on for consul tati on
wi th the fi ve federal l y recogni zed tri bes i n Idaho.

Al so i ncl uded i n the Leve
l 1 Grant i s for the establ i shment of a Communi cati ons and Outreach Lead who wi l l
be responsi bl e for management of the Exchange’s communi cati ons wi th members of the publ i c and the
medi a, and the devel opment of outreach and educati on campai gns to ensure emp
l oyers, government
agenci es
,

and members of the publ i c are aware of l aws pertai ni ng to heal th care reform and the benefi ts
avai l able throughout the Exchange. (
See
Project Work Pl an, Core Area 2
,

for more detai l s)


Core Area 3 Legislative and Regulatory Action

Goal:

Establ i sh suffi cient State and Federal authori ty for the Idaho Heal th Insurance E
xchange for i ts
programs and operati ons that compl i es wi th appl i cable State and Federal rul es and requi rements.

Overall Approach:
The Legi sl ature for the State of Idaho i s schedul ed to reconvene i n earl y January 2012
and the
Department of Insurance

i s prep
aring to fi nal i ze and recommend the Legi sl ature adopt the draft
Exchange enabl i ng l egi sl ati on. At thi s ti me the Idaho Heal th Insurance Exchange project i s conducti ng a
revi ew and eval uati on of regul ati ons that may affect the exchange; i denti fyi ng speci fi c

state requi rements
for the exchange; drafti ng the needed exchange l egi sl ati on; advi sing the Legi sl ators; and obtai ni ng
l egi sl ative support for the exchange l egi sl ati on. As we move i nto the next l egi sl ati ve session, we wi l l
conti nue to research al l perti ne
nt State l aws and regul ati ons. The research wi l l determi ne
the

steps Idaho
must take to have the necessary l egal authori ty to establ i sh and operate an exchange that compl i es wi th
Federal requi rements. Thi s wi l l ensure the proposed and adopted l egi sl ation w
i l l permi t the State to
establ i sh and operate an exchange, as wel l as provi di ng for the establ i shment of governance and exchange
structure. The research wi l l be revi ewed for i nput from the Governor’s Heal th Care Task Force, Senate
Commerce and Heal th Comm
i ttees, House Busi ness and Heal th Commi ttees, and other groups deemed
necessary by executi ve l eadershi p.

(See
Project Work Pl an, Core Area 3
, for more detai l s)

The Level 1 Grant funds are not needed beyond Exchange Project staff to conti nue to meet program
requi rements for State l egi sl ati ve and regul atory acti ons.


Core Area 4 Governance

Goal:

Establ i sh an accountable and transparent governance structure for the Idaho Heal th Insurance
Exchange that i s staffed wi th competent l eadershi p and i s i n compl i ance wi th appl i cable confl ict
-
of
-
i nterest
provi si ons.

Overall Approach:
The enactment of an Idah
o Heal th Insurance Exchange and the appoi ntment of a Board
of Di rectors wi l l be a major mi l estone i n the l ong
-
term success of the exchange. The Board of Di rectors wi l l
conform to the Federal requi rements. Several al ternati ves have been di scussed and more

anal ysis needs to
be done i n speci fi c areas. These areas are: obtai ni ng addi ti onal stakehol der i nput i nto the process;
devel opi ng a pl an to hi re the necessary program staff and determi ni ng on
-
goi ng staffi ng needs; determi ni ng
confl i ct
-
of
-
i nterest requi re
ments for the governi ng body; and adopti ng the governance structure when the
State adopts the Legi sl ati ve authori ty descri bed i n
Core Area 3

of thi s document
.

The exchange wi l l be
publ i cl y accountabl e, transparent, and have tec
hni cal l y competent l eadershi p, adheri ng to Idaho’s confl i ct
-
Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

6


of
-
i nterest requi rements, wi th the capaci ty and authori ty to take al l acti ons necessary to meet Federal
standard, i ncl uding the di screti on to determi ne whether heal th pl ans offered through the exc
hange are i n
the i nterests of qual i fied i ndi viduals and qual ified empl oyers. (
See
Project Wor
k Pl an, Core Area 4
, for more
detai l s).


The Level
1

Grant funds wi l l be used to defi ne and establ i sh the governance structure by November 2012.


Core Area 5 Program Integration

Goal:
Col l aborate wi th the Department of Insurance and the Department of Hea
l th and Wel fare (Medi cai d)
by cl earl y defi n
i ng

rol l s and
creati ng
synergy
through

acti vi ti es that promote program i ntegrati on.

Overall Approach:
The Idaho Heal th Insurance Exchange project wi l l conti nue col l aborative pl anni ng wi th
the State Medi cai d and CH
IP programs to achi eve streaml i ned appl i cation, veri fi cati on, el i gibility and
enrol l ment processes through
out the exchange. The Idaho Heal th Insurance Exchange
’s partnershi p wi th
D
epartment of Heal th and Wel fare (Medi cai d)
wi l l focus on systems devel opment
, operati onal procedures,
i nteroperabi l i ty coordi nati on, referral s and other functi ons deemed necessary. The Idaho Heal th Insurance
Exchange wi l l work cl osel y wi th the Department of Insurance who wi l l oversee the regul ati on and l i censure
of heal th i nsuran
ce i ssuers, i ncludi ng those that offer qual i fi ed heal th pl an coverage through the exchange.
In addi ti on, the Department of Insurance may process consumer coverage appeal s and compl ai nts. The
exchange wi l l work cl osel y wi th the Department of Insurance to
moni tor the fi nanci al stability of i nsurance
compani es, certi fi cati on of pl ans, rate revi ew, State l i censure, sol vency, adverse sel ecti on
,

and market
conduct.

The Level
1

Grant wi l l be used to i mpl ement agreements wi th the Department of Insurance and the
D
epartment of Heal th and Wel fare as wel l as to col l aborate on procurement and devel opment of Exchange
and Medi cai d IT systems needed to faci l i tate “no wrong door” for el i gi bi lity requi rements. (
See
Core Area 6

for

detai l s on arc
hi tecture and i nfrastructure, and
Core Area 11

for

appl i cation, veri fi cati on, el i gibility and
enrol l ment tasks and IT detai l s.) (
See
Project Work Pl an, Core Area 5
,

for

addi ti onal detai ls)

Core Area 6


Technical Infrastructure/Information Technology

Goal:

Defi ne the Idaho Heal th Insurance Exchange archi tecture, i ncl
uding rel ated systems, and procure the
necessary components and provi de a techni cal demonstrati on.

Overall Approach:
Idaho wi l l use an agi l e approach to system devel opment process to capture updates and
changes to busi ness and system requi rement, devel opme
nt, testi ng, and i mpl ementati on of exchange
i nformati on technol ogy systems. After the i ni ti al Informati on Technol ogy (IT) Gap Anal ysi s and deci sion
maki ng has been establ i shed, the Idaho Benefi ts El i gi bi lity System (IBES) wi l l provi de Medi cai d El i gibil ity
Determi nati on to the Idaho Heal th Insurance Exchange.

The Level 1 Grant wi l l be used for the fol l owi ng:



Conduct a more i n
-
depth defi ni ti on

of the Idaho Heal th Insurance Exchange
-
IBES
-
MMIS rel ati onshi p.



Use the
Idaho Heal th Insurance Exchange Conceptual IT Archi tecture

di agram

to dri ve the techni cal and
i ntegrati on requ
i rements of the supporti ng systems and the Idaho Heal th Insurance Exchange and assist
i n the eval uati on of exchange sol uti ons.



Moni tor and l everage the resul ts of earl y i nnovator grantees for appl i cability i n the Idaho Heal th
Insurance Exchange



Create a P
rel i mi nary Desi gn Ini ti ati ve that wi l l consist of the fi rst three Exchange Li fe Cycl e (ELC) phases as
defi ned i n the Col l aborati ve Envi ronment and Li fe Cycl e Governance
-
Exchange Reference Archi tecture
Suppl ement, i ncl udi ng: ELC Phase


Ini ti ati on, Concept,

and Pl anni ng; ELC Phase


Requi rements,
Anal ysi s, and Desi gn; and ELC Phase


Devel opment and Test. It i s l i kel y that wi thi n the Prel i mi nary
Desi gn Ini ti ati ve there wi l l be at l east two i terati ons of the three ELC Phases (the i terati ons refi ni ng
what was
l earned i n the previ ous i terati on). The ELC Phase pl an wi l l be adapted to the Agi l e method
that Idaho has used successfully. The method wi l l i nclude the Project Startup Revi ew (PSR), Archi tecture
Revi ew (AR), Project Basel i ne Revi ew (PBR), Prel i mi nary Des
i gn Revi ew (PDR) and Detai l ed Desi gn
Revi ew (DDR) mi l estones. The pl anni ng acti viti es i n the Prel i mi nary Desi gn Ini tiative wi l l establ ish the
number of i terati ons. (
See
Project Work Pl an, Core Area 6
,

for more detai l s)


Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

7


The Fi nal Impl ementati on Ini ti ati ve (supported by the Level 2 grant) wi l l i nclude i terati ons of the fi rst three
ELC Phase
s wi th the i ncl usion of the ELC Phase


Impl ementati on and wi l l address the Fi nal Detai l ed Desi gn
Revi ew (FDDR), Pre
-
Operati onal Readi ness Revi ew (PORR) and Operati onal Readi ness Revi ew (ORR).

Core Area 7


Financial Management

Goal:

Establ i sh a fi nancial

management structure that adheres to general l y accepted accounti ng pri nci ples,
ensures sound fi nanci al management of exchange funds, compl i es wi th cost al l ocati on requi rements, and
ensures l ong
-
range sustai nability of the exchange as requi red by federal l
aw.

Overall Approach:
The Idaho Department of Heal th and Wel fare wi l l serve as the Grantee of Record for the
Level I grant program and wi l l manage the funds and reporti ng requi rements. Idaho wi l l focus on several
areas of speci fi c i nterest, namel y: cond
ucti ng a cost anal ysis of the di fferent exchange model s; i denti fyi ng
and esti mati ng the on
-
goi ng fundi ng requi rements to sustai n the exchange over the l ong
-
term; i denti fyi ng
the cost for i ntegrati ng exchange el i gi bi lity and enrol l ment processes; adopti ng a
nd i mpl ementi ng general l y
accepted accounti ng requi rements and ensure sound fi scal management of exchange funds; and, ensuri ng
l ong
-
range sustai nability of the exchange as requi red by federal l aw.

The Level 1 Grant wi l l be used to devel op and compare al t
ernati ve fi nanci al model s for sustai ning the
Exchange that adhere to HHS fi nanci al moni tori ng acti vities; defi ne fi nanci al management structure and
scope of acti vi ti es requi red to compl y wi th requi rements; establ i sh a fi nancial management structure and
hi r
e experi enced accountants to support fi nanci al management acti vi ti es of the exchange; devel op a pl an to
ensure suffi ci ent resources to support on
-
goi ng operati ons and determi ne i f l egi sl ati on i s necessary to
assess user fees; assess adequacy of accounti ng
and reporti ng systems; and, conduct a thi rd
-
party objecti ve
revi ew of al l systems of i nternal control. (
See
Project Work Pl an, Core Area 7
, for

more detai l s)


Core Area 8


Oversight and Program Integrity

Goal
: Impl ement effecti ve oversi ght and program i ntegri ty to prevent waste, fraud, and abuse of funds used
to start up and operate the Excha
nge.

Overall Approach:
The Idaho Heal th Insurance Exchange wi l l i ncorporate as many of the State’s exi sti ng
Waste Preventi on, Fraud, Abuse, and Audi ti ng procedures as possi bl e i nto the exchange program i n addi ti on
to i nsurance i ndustry standard fraud and a
buse procedures and adopti ng and i mpl ementi ng fi scal
management procedures to ensure program i ntegri ty.

The Level 1 Grant wi l l be used to devel op a pl an to ensure preventi on of waste, fraud, and abuse rel ated to
the expendi ture of grants; assess i nternal p
ol icies and procedures to compl y wi th State and Federal
requi rements rel ated to Exchange operati ons; assess the aspects needed to ensure the preventi on of waste,
fraud and abuse i n Exchange programs; desi gn and devel op i nternal pol i cies and procedures to c
ompl y wi th
State and Federal requi rements; establ i sh procedures for external audi t by a qual i fied audi ti ng enti ty to
perform an i ndependent external fi nanci al audit; and, i mpl ement fraud detecti on procedures and reporti ng
to HHS on efforts.
(See
Project Work Pl an, Core Area 8
, for more detai l s)


Core Area 9


Health Insurance Market Reforms

Go
al:

Moni tor and demonstrate state compl i ance wi th and enforcement of Federal heal th i nsurance market
reforms.

Overall Approach:
The Idaho Heal th Insurance Exchange wi l l track and moni tor state l egi sl ation, regul ati ons
and i mpl ementati on of heal th i nsurance

market reforms by worki ng wi th the Legi sl ature, Department of
Insurance and Department of Heal th and Wel fare. Level 2 Impl ementati on wi l l i nclude passing Idaho
l egi sl ation or i ssui ng appropriate regul ati ons i mpl ementi ng the heal th i nsurance market reforms
;
stakehol der consul tati on on these i ssues; devel opment of a pl an to i mpl ement the reforms; as wel l as
moni tori ng and consi deri ng enforcement of consumer protecti ons and speci fi c requi rements that i mpact
the exchange.

The Level 1 Grant wi l l be used for as
sessing State l egi sl ati on, regul ations and i mpl ementati on of heal th
i nsurance market reforms, and to desi gn
,

devel op
,

and i mpl ement a pl an to moni tor markets reforms and
consumer protecti ons, i ncl udi ng speci fic requi rements that i mpact the Exchange. (
See
Project Work Pl an,
Core Area 9
,
for

more detai l s)


Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

8


Core Area 10


Providing Assistance to Ind
ividuals and Small Businesses, Coverage Appeals and
Complaints

Goal:

Create a system to assure that servi ces are avai l able and suffi cient to meet the needs of i ndi vi duals
and smal l busi nesses for assistance i n determi ni ng el i gi bi lity, fi l ing
compl aints

an
d appeal s, and provi di ng
i nformati on about consumer protecti ons. Col l ecti on of data through consumer assi stance programs on
i nqui ri es, probl ems, and resol uti ons.

Overall Approach:
Work wi th exi sti ng consumer assi stance programs and stakehol der groups to co
l l ect and
anal yze data on provi di ng exchange i nformati on, probl em resol uti on, and i ntra
-
agency referral processes for
i ndi vi duals and smal l businesses. Stakehol der groups wi l l be i ntegral i n devel opi ng compl ai nt and appeal
process protocol s for the exchang
e. The Department of Insurance and Department of Heal th and Wel fare
have exi sti ng assistance programs that hel p resi dents resol ve probl ems, answer questi ons, fi l e compl ai nts
and appeal s
,

and enrol l ment appl i cations. The Idaho Heal th Insurance Exchange wi
l l provi de thi s assistance
through contracti ng enti ti es or i nteragency agreements and wi l l ensure the referral enti ty has capaci ty to
provi de assi stance that consumers need. The exchange wi l l bui l d a robust capacity for provi di ng assistance
for al l resi de
nts and smal l business owners by col l aborating cl osely wi th other enti ti es wi thi n Idaho who are
carryi ng out these acti vi ti es.

The Level 1 Grant wi l l be used to anal yze feedback from stakehol ders and other states’ i ndi vi dual and smal l
busi ness assistance
processes; analyze data col l ected by consumer assi stance programs and report on pl ans
for use of i nformati on to strengthen qual i fi ed heal th pl an accountability and functi on of Exchanges; desi gn a
pl an to provi de assi stance to i ndi vi duals and smal l business
es; establ i sh protocol s for appeal s on coverage
determi nati ons; and draft a scope of work for bui l di ng capacity to handl e coverage appeal s functi ons. (
See
Project Work Pl an, Core Area 10
,

for more detai l s)


Core Area 11


Business Operations

Goal:
Identi fy Exchange markets, products, programs
,

and detai l ed system and operati onal requi rements
f
or Exchange Impl ementati on.

11
-
1 Health Plan Certification and Administration

Goal:

Provi de an automated way to certi fy, recerti fy, and decerti fy qual i fi ed heal th pl ans.

Overall Approach:

The Idaho Heal th Insurance Exchange project wi l l devel op a streaml i n
ed process and
approach to certi fy, recerti fy, and decerti fy qual i fi ed heal th pl ans by open enrol l ment mi d
-
2013.

The Level 1 Grant wi l l be used to anal yze Heal th Pl an Certi fi cati on and asses the Exchange’s approach to
contracti ng wi th qual i fied heal th pl a
ns, i ncludi ng determi ni ng requi rements for a technol ogy pl atform, and
devel opi ng standards and pol i cies. Stakehol ders wi l l be engaged i n the devel opment of sol i citati on for
proposal s. A strategy, pl an, and ti mel i ne for i ntegrati on of staff and IT systems
wi l l be devel oped. (
See
Project Work Pl an, Core Area 11
-
1
,

for more detai l s)


11
-
2 Call Cen
ter and Toll
-
free Hotline

Goal:

Provi de meani ngful assi stance to i ndi vi duals and smal l busi nesses by operati ng a cal l center wi th a
tol l
-
free hotl i ne before open enrol l ment.

Overall Approach:
In addi ti on to provi di ng enrol l ment assi stance to i ndi vi duals
and smal l businesses, the
Idaho Heal th Insurance Exchange Cal l Center may faci l itate outreach to consumers and answer consumer
questi ons on how the ACA may affect i ndi vi dual access to heal th i nsurance. Consi derati ons for cal l
c
enter
acti vi ti es may i ncl ude

col laborating wi th the Department of Insurance Consumer Assi stance Program to
joi ntl y contract for
,

or to operate
, a cal l center (
si nce the acti vi ti es are cl osely rel ated
)
.

The Level
1 Grant wi l l be used to

assess Call Center and Tol l
-
free Hotl i ne tech
nol ogy and non
-
technol ogy
needs; col l aborate wi th
the Department of Insurance and the Department of Heal th and Wel fare

to
determi ne i f cal l center functi onal i ti es can be shared; desi gn and devel op a pl an to
meet the needs

i denti fi ed i n the assessment and m
arket research
. (See
Core Area 1

and the
Project Work Pl an,
Core Area
11
-
2
,
for more detai l s)



Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

9


11
-
3 & 4 Exchange Website and Calculator

Goal:

Provi de a websi te through whi ch appl i cants and enrol lees may obtai n standardi zed comparati ve
i nformati on on qual i fied heal th pl ans, appl y for coverage, and enrol l onl i ne (
i ncl uding premi um tax credi t
and cost
-
shari ng reducti ons).

Overall Approach
: The Idaho Heal th Insurance Exchange wi l l mai ntai n a websi te through whi ch appl i cants
and enrol l ees may obtai n standardi zed comparati ve i nformati on on qual i fi ed heal th pl ans, appl y

for
coverage, and enrol l onl i ne. The exchange wi l l provi de access to an el ectroni c cal cul ator that al l ows
i ndi vi duals to vi ew an esti mated cost of thei r coverage once premi um tax credi ts have been appl i ed to thei r
premi ums, and the i mpact of cost
-
shari ng

reducti ons, i f they are el i gi bl e. The websi te wi l l al so post requi red
transparency of cost i nformati on.

The Level
1

Grant wi l l be used to assess, desi gn and devel op a pl an to meet techni cal and non
-
techni cal
needs for the websi te, premi um tax credi t and
cost

shari ng reducti ons, as wel l as begi nni ng systems
devel opment.

(
See
Project Work Pl
an, Core Area 11
-
3&4
,

for more detai l s)

11
-
5 Quality Rating System

Goal:

Ensure a qual i ty rati ng i s assigned to each pl an i n accordance wi th the qual i ty rati ng system that wi l l
be i ssued by HHS. Al so, certi fi cati on of qual i fied heal th pl ans wi l l i nclude c
onsiderati on of qual ity data.

Overall Approach:

The approach for qual i ty rati ng systems wi l l be determi ned through an i ni ti al assessment
and gui dance provi ded by HHS.

The Level
1

Grant wi l l be used to assess and desi gn qual ity rati ng systems by conducti n
g a study on the
Exchange’s approach to qual i ty rati ng systems. (
See
Project Work Pl an, Co
re Area 11
-
5
,

for more detai l s)

11
-
6 Navigator Program

Goal:
Establ i sh a Navi gator program to assi st consumers i n the sel ecti on and enrol l ment of heal th i nsurance.

Overall Approach:
The Idaho Heal th Insurance Exchange project wi l l establ i sh a Navi gator pr
ogram by
determi ni ng Navi gator grantee organi zati ons and awardi ng contracts or grants to enti ti es that wi l l assist
consumers i n navi gati ng thei r choi ces i n the heal th i nsurance marketpl ace. Thi s i ncl udes facilitati ng
enrol l ment i n qual i fi ed heal th pl ans.

The Navi gator program wi l l be funded from the operati onal funds of
the exchange.

The Level
1

Grant wi l l be used to assess needs i n a navi gator program by revi ewi ng other states’ pl ans,
gui dance, i ntervi ews and other research; formul ate work group(s) to r
evi ew resul ts; desi gn and devel op a
pl an for the navi gator program, i ncl udi ng determi ni ng targeted organi zati ons i n the state who woul d qual i fy
to functi on as navi gators. (
See
Project Work Pl an, Core Area 11
-
6
,

for more detai l s)

11
-
7 Eligibility Determinations for Exchange Participation, Advance Payment of Premium Tax Credits,
Cost
-
Sharing Red
uctions, and Medicaid

Goal:

Provi de el i gi bi lity determi nati ons for exchange parti ci pation, advance payment of premi um tax
credi ts, cost
-
shari ng reducti ons, and Medi cai d.

Overall Approach:
Key operati ons of the exchange wi l l be veri fi cati ons and determi nat
i ons of el i gi bi lity for
qual i fi ed heal th pl ans. Key functi ons wi l l i nclude el i gibi lity determi nati ons for advance payment of premi um
tax credi ts; cost shari ng reducti ons and Medi cai d; and appeal s of el i gi bility determi nati ons for enrol l ment i n
a qual i fi ed

heal th pl an and premi um tax credi ts and cost
-
sharing reducti ons.

The Level One Establ i shment Grant wi l l be used to assess, desi gn and devel op processes and components
for al l aspects of el i gi bility determi nati on i ncl udi ng Medi caid, CHIP and i nsurers usi n
g CMS Gui dance; refi ne
requi rements and begi n system devel opment. (
See
Project Work Pl an,
Core Area 11
-
7
,

for more detai l s)

11
-
8 Seamless Eligibility and Enrollment Process with Medicaid and Applicable State Health Subsidy Programs

Goal:

Provi de seaml ess el i gi bility determi nati ons for Medi cai d and CHIP programs through the exchange.

Overall Ap
proach:

The Idaho Heal th Insurance Exchange wi l l determi ne an i ndi vi dual’s el igi bility for
Medi cai d, CHIP
,

and other appl i cable state heal th subsi dy programs. The exchange wi l l al so ensure that
such i ndi vi duals are seaml essly enrol led i n the program for w
hi ch they are el i gi bl e wi thout need for further
determi nati on by other programs. The exchange el i gi bi lity system wi l l be i ntegrated wi th the Medi cai d
system si nce the el i gi bi lity functi on i n the exchange has si gni ficant si mi larities to el i gi bi lity determi
nati ons i n
Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

10


other programs. Steps necessary to achi eve i nteroperabi l i ty wi th other heal th and human servi ces programs
for the purposes of coordi nati ng el i gi bility determi nati ons, referral s, veri fi cations, or other functi ons wi l l be
consi dered. The seaml ess
el i gi bi lity and enrol l ment process wi l l be carri ed out through the devel opment of
i nformati on technol ogy systems i n cl ose partnershi p wi th Idaho’s Medi cai d program.

The Level
1

Grant wi l l be used to assess process
es

and components to create seaml ess el i gi
bility and
enrol l ment between the Exchange and other state heal th subsi dy programs; desi gn and devel op a pl an to
meet the needs

i denti fi ed i n the assessment
; and begi n systems devel opment.

(
See
Project Work Pl an, Core
Area 11
-
8
,

for more detai l s)

11
-
9 Enrollment Process

Goal:

Faci l i tate pl an sel ecti on for an i ndi vi dual who i s el i gi ble to enro
l l i n a qual i fi ed heal th pl an, i ncludi ng
provi di ng i nformati on about customi zed qual i fied heal th pl ans.

Overall Approach:

The Idaho Heal th Insurance Exchange wi l l provi de i nformati on about avai l able qual ifi ed
heal th pl ans that i s customi zed accordi ng to an

i ndi vi dual’s preferences, recei vi ng an i ndi vi dual’s choice of
pl an, and provi di ng enrol l ment transacti ons to qual i fied heal th pl an i ssuers using appl icable standards that will
be set forth by HHS.

The Level
1

Grant wi l l be used to desi gn and devel op a pl
an to faci l itate pl an sel ecti on for an i ndi vi dual who i s
el i gi bl e to enrol l i n a qual i fi ed heal th pl an, and begi n systems
devel opment. (See
Project Work Pl an, Core Area
11
-
9
,

for more detai l s)

11
-
10 Applications and Notices

Goal:

Provi de a si ngl e, streaml i ned appl i cation, (i ncl uding noti ces) that supports the consumer’s abi l ity to
carry out en
rol l ment through the exchange.

Overall Approach:
The Idaho Heal th Insurance Exchange project wi l l i mpl ement al l requi rements for
appl i cations and noti ces consi stent wi th Federal requi rements, i ncl udi ng faci litating the use of a si ngl e,
streaml i ned appl i c
ati on. Appl i cati ons and noti ces wi l l i nclude mechani sms for consumers to carry out
enrol l ment steps (screeni ng, enrol l ment forms, and veri fi cati ons) both i n person or onl i ne. Appl i cati ons and
noti ces wi l l faci litate the appl i cation, el i gi bility determi nati
on process, and enrol l ment of i ndi vi duals i nto
qual i fi ed heal th pl ans. The Exchange wi l l al so i ssue noti ces to faci l itate program operati ons and
communi cati ons wi th enrol l ees.

The Level
1

Grant wi l l be used to revi ew Federal requi rements for appl i cations
and noti ces; begi n
customi zi ng Federal appl i cations and noti ces; begi n devel opi ng requi rements for Exchange
-
created
appl i cations and noti ces; and desi gn and devel op functi onal i ty wi th IT for appl i cations and noti ces
consi stent wi th Federal requi rements, i n
cl udi ng faci litating the use of a si ngl e, streaml i ned appl i cati on and
mechani sms for consumers to carry out enrol l ment steps and forms. (
See
Project Work Pl an, Core Area 11
-
10
,

for more detai l s)

11
-
11 Individual Responsibility Determination

Goal:

Establ i sh a process for recei vi ng, adjudi cating, and reporti ng on requests for exempti ons to i nd
i vi dual
responsi bi lity requi rements.

Overall Approach:

The Idaho Heal th Insurance Exchange wi l l have i n pl ace a process to recei ve and
adjudi cate requests from i ndi vi duals for exempti ons from the i ndi vi dual responsibi lity requi rements of the
Affordabl e Car
e Act, and to communi cate i nformati on on such requests to HHS for transmi ssion to the IRS.

The Level
1

Grant wi l l be used to desi gn and devel op functi onal i ty wi th IT to automate processes to recei ve
and adjudi cate requests from i ndi vi duals for exempti ons
from the i ndi vi dual responsibility requi rements;
devel op requi rements for systems and program operati ons; and begi n systems devel opment
. (See
Project
Work Pl an, Core Area 11
-
11
,

for more detai l s)

11
-
12 Administration Premium Tax Credits and Cost
-
Sharing Reductions

Goal:

Perform and report on admi ni strative acti vi ties rel ated to premi um tax c
redi ts and cost
-
shari ng
reducti ons.

Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

11


Overall Approach:

The exchange wi l l perform admi ni strati ve acti viti es rel ated to premi um tax credi ts and
cost
-
shari ng reducti ons. The exchange wi l l be the fi rst poi nt of contact for prospecti ve enrol l ees who wi l l be
i nt
erested i n l earni ng more about premi um tax credi ts and for seeki ng assi stance when needed.

The Level
1

Grant wi l l be used to begi n devel opi ng requi rements for systems and program operati ons;
desi gn and devel op functi onal i ty wi th IT for Exchange to perform

and report on admi ni strative acti viti es
rel ated to premi um tax credi ts and cost
-
shari ng reducti ons; and begi n systems devel opment.

(See
Project
Work Pl an, Core Area 11
-
12
,

for more detai l s)

11
-
13 Adjudication of Appeals of Eligibility Determinations

Goal:

Establ i sh a process for i ndi vidual s to contest the el i gi bi lity determi nati ons made by
the exchange for
premi um subsi dies and exchange parti ci pation.

Overall Approach:

The exchange wi l l i mpl ement a process for processi ng appeal s i f an i ndi vidual seeks to
contest the el i gi bi lity determi nati on made by the exchange for premi um subsi di es or exc
hange
parti ci pation. Thi s process wi l l coordinate wi th Medi cai d and CHIP programs.

The Level
1

Grant wi l l be used to desi gn and devel op IT and non
-
IT functi onal i ty for i ndi viduals to contest
the el i gi bi lity determi nati ons made by the exchange for premi um
subsi di es and Exchange parti ci pation,
whi ch i ncl udes devel opi ng busi ness processes and operati onal pl an for appeal s functi on.
(See
Project Work
Pl an, Core area 11
-
13
,

for more detai l s)

11
-
14 Notification and Appeals of Employer Liability

Goal:

Provi de noti fi cati ons to empl oyers when one or more of thei r empl oyees i s determi ned to be el i gi bl e

for advance payment of a premi um tax credi t.

Overall Approach:
The Idaho Heal th Insurance Exchange wi l l noti fy empl oyers when one or more of thei r
empl oyees i s determi ned to be el i gi bl e for advance payment of a premi um tax credi t because the empl oyer
does

not offer mi ni mum essenti al coverage or the coverage i s not affordabl e or does not meet the mi ni mum
val ue requi rement. The exchange wi l l al so offer the empl oyer an opportuni ty to appeal.

The Level
1

Grant wi l l be used to desi gn and devel op mi ni mum funct
i onal i ty wi th IT to noti fy empl oyers
when one or more of thei r empl oyees i s determi ned to be el i gi bl e for advance payment of a premi um tax
credi t because the empl oyer does not offer mi ni mum essenti al coverage or the coverage i s not affordabl e.
These requi
rements for systems and program operati ons wi l l i nclude coordi nation of empl oyer appeal s wi th
appeal s of i ndi vi dual el igi bility and submi ssion of rel evant data to HHS. System devel opment and
preparati on for fi nal user testi ng wi l l al so be covered i n thi s g
rant request. (
See
Project Work Pl an, Core
Area 11
-
14
,

for more detai l s)

11
-
15 Informati
on Reporting to IRS and Enrollees

Goal:

Report requi red coverage data to the IRS and enrol l ees each year.

Overall Approach:

The Idaho Heal th Insurance Exchange wi l l report to the IRS and enrol l ees each year
certai n i nformati on regardi ng the enrol l ee’s cov
erage provi ded through the exchange.

The Level
1

Grant wi l l be used to desi gn and devel op functi onal i ty wi th IT to report to the IRS and enrol l ees
each year certai n i nformati on regardi ng the enrol l ee’s coverage provi ded through the Exchange.
Requi rements

for systems and program operati on wi l l i nclude capturi ng data used i n the enrol l ment
process; submi tti ng rel evant data to HHS; and capaci ty to generate i nformati on reports to enrol l ees.
System devel opment wi l l al so be covered i n the grant
request. (See
Project Work Pl an, Core Area 11
-
15
,

for
more detai l s)


11
-
16 Outreach and Education

Goal:

Provi de a robust educati on and outreach program to heal th care consumers a
bout the exchange
(pri mari l y

new coverage opti ons and the benefi ts of purchasi ng heal th care through the exchange).

Overall Approach:
The exchange wi l l educate consumers about the

benefi ts of purchasi ng heal th i nsurance
coverage through the Idaho Heal th Insurance Exchange, i ncl udi ng access to heal th pl ans that meet State and
Federal certi fi cati on standards and access to assi stance wi th payi ng thei r premi ums and cost
-
shari ng. Thi s
i nformati onal and educati onal outreach wi l l be uni que to the di verse stakehol der types i n the
three
geographi c regi ons of Idaho
. The outreach wi l l coordi nate wi th
Core Area 2
,

Stakehol der Invol vement.

Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

12


The Level
1 Grant wi l l be

used to

desi gn and devel op a pl an for communi cati ons, outreach
,

and educati on
based on the assessment conducted i n the Pl anni ng Grant; di stri bute outreach and educati on pl an to
stakehol ders and HHS for i nput and refi nement; devel op a “tool ki t” for outreac
h to i ncl ude educati onal
materi al s and i nformati on; devel op performance metr
i cs and an eval uati on pl an; and

submi t a fi nal
outreach and educati on pl an (i ncl uding performance metri cs and eval uati on pl ans) to HHS.
(See
Project
Work Pl an, Core Area 11
-
16

for more detai l s)


11
-
17 Risk Adjustment and Transitional Reinsurance

Goal:

Impl ement and s
upport a ri sk adjustment program and a transi ti onal rei nsurance program i n
accordance wi th Federal standards.

Overall Approach:

The ri sk adjustment program and transi ti onal rei nsurance program wi l l meet Federal
standards. Data col l ecti on wi l l support ri sk

adjustment and transi ti onal rei nsurance i ncluding demographi c,
di agnosti c, and prescri ption drug data. Qual i fi ed Heal th Pl ans may be requi red to submi t encounter data
and therefore, wi l l need to devel op data and other systems to support ri sk adjustment.

The Level
1

Grant wi l l be used to assess components of a system needed to col l ect data to support ri sk
adjustment, i ncl udi ng demographi c, di agnosti c, and prescri pti on drug data as wel l as capture qual i fied
heal th pl an encounter data.
(See
Project Work Pl an, Core Area 11
-
17
,

for

more detai l s)


11
-
18 SHOP Exchange specific functions

Goal:

Esta
bl i sh and operate a Smal l Busi ness Heal th Opti ons Program (SHOP) Exchange that i s i ntegrated
wi th the Indi vi dual Heal th Insurance Exchange.

Overall Approach
: The Idaho SHOP Exchange wi l l faci litate the purchase of coverage i n Qual i fied Heal th
Pl ans for emp
l oyees of smal l busi nesses that choose to purchase coverage through the exchange. Idaho wi ll
deci de whether to merge the operati ons of the SHOP Exchange wi th the i ndi vi dual market exchange.
Impl ementati on wi l l be i ntegrated wi th outreach and educati on act
i vi ti es.

The Level
1

Grant wi l l be used to desi gn and devel op sel ecti on cri teri a that wi l l i nclude the abi l ity to provi de
basi c functi onality to sui t a Smal l Busi ness Heal th Opti ons Program (SHOP) Exchange i ncl udi ng devel opment
of requi rements for systems

and program operati ons. The Grant wi l l al so be used for systems devel opment.
(
See
Proje
ct Work Pl an, Core Area 11
-
18
,

for more detai l s)

c.

IT Gap Anal ysi s Summary

Introduction

In a tradi ti onal gap anal ysis, the “to
-
be” i nfrastructure i s normal ly wel l defi ned so that the “as
-
i s” to “to
-
be” gap
can be cl earl y speci fied; however, the “to
-
be” i s s
ti l l bei ng researched. Therefore
,

Idaho's pl an i s to use the
remai ni ng pl anni ng grant funds and part of the Level
1 G
rant fundi ng to compl ete the necessary assessments
and devel op a more comprehensi ve detai l ed gap anal ysi s.


Technical Architecture

T
echni c
al archi tecture i s cri tical i n supporting the necessary busi ness functi ons of the heal th i nsurance exchange.
Idaho understands that the techni cal archi tecture must be:



Fl exi bl e so that the techni cal i nfrastructure can support and easi l y adapt to the autom
ated systems that
support the changi ng busi ness needs
.



Based on open standards such as Nati onal Informati on Exchange Model (NIEM) to support i nter
-
system
and extra
-
system i nteroperabi l ity
.



Secure and adhere to HIPAA gui del i nes i n order to provi de a safe an
d pri vate exchange of i nformati on
.

Idaho's current techni cal i nfrastructure has evol ved based on the changi ng busi ness needs and the avai l ability of
automated systems that support the busi ness. The heal th i nsurance exchange wi l l be another opportuni ty for

Idaho's techni cal i nfrastructure to evol ve and support the needs of the busi ness.

Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

13


Current Technical Architecture

Idaho has a heterogeneous techni cal i nfrastructure consi sti ng of .NET and J2EE technol ogi es, and x86 and RISC
-
based server hardware. Seni or I
daho IT Management recogni zed the need to support a heterogeneous IT
i nfrastructure so that the busi ness can focus on sel ecti ng the best sol uti on for the busi ness' compl ex and ever
changi ng busi ness needs
.

Idaho's heterogeneous techni cal i nfrastructure tha
t wi l l be used for the heal th i nsurance exchange i s descri bed
i n the fol l owi ng secti ons
.

Current/Legacy Software

The tabl e bel ow descri bes Idaho's current/l egacy software appl i cable to the heal th i nsurance exchange:

Component

Description

IBES

The Idaho B
enefi ts and Eligibility System (IBES) is a J2EE based application
running on JBoss application server on Sun SPARC servers. All IBES data is
stored in an Oracle datab
ase. IBES is a modern, secure
,
and
easy to use
statewide eligibility determination and c
ase management platform for the
Self
-
Reliance (SR) benefit programs including food stamps, cash assistance,
and Medicaid.

Business Rules Engine

Eligibility business rules are documented and developed using a COTS rule
engine called ILOG JRules.

eCaseFile

eCaseFile is a client server VB.Net application. All eCaseFile data is stored in
a Microsoft SQL Server database using EMC ApplicationXtender. eCaseFile is
the electronic document management solution used by the Self Reliance
and Child Support programs.

eVerif
-
I

eVerif
-
I is a J2EE based application running on JBoss application server on
Windows servers. All eVerif
-
I data is stored in a Microsoft SQL Server
database. eVerif
-
I is used to validate and verify client information with
various internal/exter
nal partner applications.

Data Warehouse

The data warehouse stores data in Microsoft SQL Server. Data is extracted,
transformed, and loaded into the data warehouse using IBM InfoSphere
DataStage. BusinessObjects is used for reporting.

MMIS

The Idaho Me
dicaid Management Information System (MMIS) is comprised
of four major components that were supplied by three different companies.
The Base MMIS and Electronic Document Management System (EDMS)
components were supplied by Molina Medicaid Solutions. The P
harmacy
Benefit Management System (PBM) component was supplied by Magellan.
The Decision Support System/Data Warehouse (DSS/DW) component was
supplied by Thomson Reuters. MMIS uses Molina Medical Solutions' state
-
of
-
the
-
art Heal th PAS system. Heal th PAS
al i gns wi th the Medi cai d
Informati on Technol ogy Archi tecture (MITA). MMIS data i s stored i n a
Mi crosoft SQL Server database.

Payment Processi ng

Onl i ne payments are made through the Access Idaho websi te. Users are
redi rected to the si te to compl ete the p
ayment transacti on.

RDBMS

Two rel ati onal database management systems are used by Idaho to manage
the data for the automated systems. Oracl e Database 10g i s used by IBES.
eVeri f
-
I and eCaseFi l e use Mi crosoft SQL Server 2008.

Reporti ng

Reporti ng requi reme
nts are ful fi l led through a number of reporti ng products
l i ke Adobe Li feCycl e Form ES, InetSoft Styl eReport Pro, Oracl e Reports, and
Crystal Reports.

Securi ty

Securi ty i s provi ded by Mi crosoft Integrated Wi ndows Authenti cati on
servi ces and CA Si temi nder.


Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

14


Current/Legacy Hardware

The tabl e bel ow descri bes Idaho's current/l egacy hardware appl icable to the heal th i nsurance exchange:

Component

Description

Cisco UCS blade servers

Cisco UCS blade servers are replacing the Dell PowerEdge servers because of
the
smaller footprint and confi guration fl exibility. The Cisco UCS blade
servers run Windows 2003/2008.

Dell PowerEdge servers

A cluster of Dell PowerEdge servers running VMware vSphere is used to
create Idaho's virtual server infrastructure. Separate Dell
PowerEdge server
clusters are also available for applications that require the computing
resources of a non
-
virtualized environment. The Dell PowerEdge servers run
Microsoft Windows 2003/2008.

EMC Centera SAN

The EMC Centera SAN is used for scalable, hig
h
-
capacity data storage and
shared disk fi le systems.

f5 BigIP

f5 BigIP load balancing appliances are used to distribute web requests across
multiple web servers in the server farm and to route web requests to the
remaining operational web servers if one
of the servers fails.

Sun SPARC Enterprise
servers

Sun SPARC Enterprise servers are used to run the various components of the
IBES applications and the Oracle 10g RDBMS. The Sun SPARC Enterprise
servers run Oracle Solaris.


Technical Architecture Vision

Idaho techni cal archi tecture must be enhanced and modi fi ed to support the techni cal needs of the Idaho Heal th
Insurance Exchange. The overal l goal of the

to
-
be


techni cal i nfrastructure i s to l everage the exi sti ng
technol ogy as much as possi ble and enha
nce the components to meet the needs of the Idaho Heal th Insurance
Exchange. Modi fi cati ons to the exi sti ng i nfrastructure wi l l not jeopardi ze the i ntegri ty and rel i abi lity of the
current systems that use the i nfrastructure.


Target Software

The tabl e bel o
w descri bes Idaho's target archi tecture vi si on to support the heal th i nsurance exchange:

Component

Description

Business Rules Engine

A business rules engine will be used to capture and maintain eligibility
business rules for health insurance exchange. Th
e business rules engine
will make the eligib
ility decision based on the user
-
supplied information.

Communication
Software

Communication software will be used in conjunction with the
communication hardware to provide services like voice response, text
-
to
-
s
peech, and SMS functionality.

Data Verification
Interface

Interfaces with the Federal Data Services Hub and the eVerif
-
I Verifica
tion
Aggregator services. User
-
supplied information will be validated with the
Federal Data Services Hub and the eVerif
-
I Ver
ification Aggregator services
before the business rules engine is called to make an eligibility decision.

Data Warehouse

A data warehouse will provide the Idaho Health Insurance Exchange the
ability to analyze

insurance exchange information
.

EDI Translat
ion Software

Translation between standard transactions and code
-
sets to
communication between the Idaho Health Insurance Exchange and
insurance providers.

Internal/External
Partner Interface

Interfaces to the insurance providers and Idaho Department of In
surance
will use the EDI translation software to create HIPAA compliant X12
transactions.

Payment Processing

A payment processing gateway will be used to process online insurance
premium payments.

Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

15


Component

Description

Portal

A portal framework wi l l be used to devel op the fro
nt
-
end user experi ence
for users accessing the Idaho Heal th Insurance Exchange.

Securi ty

The exi sti ng securi ty i nfrastructure wi l l be enhanced to ensure that
encrypti on i s used for data transmi ssion, user i denti ty i s accuratel y and
qui ckl y determi ned, an
d correspondi ng securi ty pol i cies are i mpl emented
to support the securi ty i nfrastructure.

RDBMS

Rel ati onal database used to store i nformati on associated wi th the Idaho
Heal th Insurance Exchange.

Reporti ng

Idaho Heal th Insurance Exchange ADHOC and batch r
eporti ng wi l l use one
or more of the exi sti ng reporti ng tool s.


Target Hardware

The tabl e bel ow descri bes Idaho's target hardware appl i cable to the heal th i nsurance exchange:

Component

Description

Ci sco UCS bl ade servers

Addi ti onal Ci sco UCS

bl ade server
s wi l l provi de

added computi ng capaci ty
needed for the Idaho Heal th Insurance Exchange system. The Ci sco UCS
bl ade servers wi l l run Wi ndows 2003/2008.

Communi cati ons
equi pment

To address the communi cati on needs of users that do not appl y, enrol l, or
di s
-
enrol l onl ine, some addi ti onal equi pment wi l l need to be purchase to
support voi ce or SMS communi cati ons wi th the user.

EMC Centera SAN
hardware

The addi ti onal storage needs of the Idaho Heal th Insurance Exchange may
requi re addi ti onal SAN hardware and SA
N hard dri ves to be added to the
exi sti ng EMC Centera SAN i nfrastructure.

Applicable Standards

Empl oyi ng technol ogy and securi ty standards i n devel opi ng the Idaho Heal th Insurance Exchange wi l l i mprove
usabi l ity, accessibi lity, transparency, data securi ty
, customer pri vacy, and consi stency i n i ntegrati ng wi th other
systems. The fol l owi ng tabl e summari zes the l evel of compl i ance i n Idaho's current i nfrastructure to the
appl i cable stan
dards. Pl ease refer to
Attachment A

for a

detai l ed expl anati on of the eval uati on cri teri a use
d for
each appl i cable standard.

Standard

IBES

MMIS

eVerif
-
I

eCaseFile


Legend:

Functi onal i ty fi t






Support for
Standard

Rati ng

ACA 1561: Core Data






None


ACA 1561: Veri fi cati on Interfac
es






Limited


ACA 1561: Business Rules






Partial


ACA 1561: Transmission of Enrollment Data






Significant


ACA 1561: Privacy & Security: Timely &
Accurate Access to Information






Full


Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

16



Idaho's approach to the appl i cable standards i s descri bed bel ow:

Affo
rdable Care Act Section 1561 Recommendations

Al l four systems i n current i nfrastructure have vari ous l evel s of compl i ance to the ACA Secti on 1561
recommendati ons.

Idaho i s commi tted to i mpl ement the 1561 recommendati ons for human servi ces el i gi bility and e
nrol l ment
processes i n the Idaho Heal th Insurance Exchange. Thi s wi l l al low us to:

o

Create a transparent, understandabl e and user
-
fri endl y onl i ne process that enabl es consumers to make
i nformed deci si ons about appl yi ng for and mai ntai ning benefi ts

o

Provi de
a range of user capabi l iti es, l anguages, and access considerati ons

o

Offer seaml ess i ntegrati on between pri vate and publ i c i nsurance opti ons

o

Enabl e a consi stent and transparent exchange of data el ements between mul ti pl e data

users
(e.g., NIEM
standards)

o

Mai
ntai n strong pri vacy and securi ty protecti ons

HIPAA

Mai ntai ni ng appl ication securi ty and usi ng a standard EDI transacti on to communi cate wi th i nternal and external
partners i s i mportant to protect sensi ti ve user i nformati on and to ensure that communi cati on

wi th partners
occur i n a secure and standard method.

The Idaho Heal th Insurance Exchange wi l l compl y wi th the HIPAA
pri vacy, securi ty, and EDI transacti ons.


Idaho's MMIS i s one of the systems that i s HIPAA compl i ant and supports ASC X12N 834 Enrol l ment,
ASC X12N
270 El i gi bi lity Request, and ASC X12N 271 El i gi bi lity Response transacti ons because thi s system i s responsi ble for
i nterfaci ng wi th the Medi cai d provi ders.

The remai ni ng three systems i n the current i nfrastructure, IBES, eVeri f
-
I, and eCaseFi l e, a
re al so ful l y HIPAA
compl i ant.

Accessibility for Individuals with Disabilities

It i s a federal mandate that el ectroni c and i nformati on technol ogi es l i ke publ i c
-
facing websi tes must be
accessi ble to peopl e wi th di sabiliti es. Idaho's MMIS outward faci ng pro
vi der web portal i s Secti on 508
compl i ant. The remai ni ng three systems, IBES, eVeri f
-
I and eCaseFi l e are not compl i ant to the Accessi bi lity for
Indi vi duals wi th Di sabiliti es standard.


The Idaho Heal th Insurance Exchange portal wi l l compl y wi th Secti on 50
8, Secti on 504, and Ti tl e II of the
Ameri cans wi th Di sabi liti es Act gui del i nes so that i ndi vi duals wi th di sabilities, i ncluding those who use assi stive
technol ogi es, can access the system.

Security

Securi ty i s extremel y i mportant when deal i ng wi th confi den
ti al

i nformati on

rel ated to i ndi vi duals and heal th
care programs. Idaho currentl y empl oys mul ti pl e l ayers of securi ty to veri fy a user's i denti ty and to l i mi t the
ACA 1561: Pri vacy & Securi ty: Thi rd
-
party
Access








HIPAA








Accessi bi lity for Indi vi duals wi th Di sabiliti es








Securi ty








Federal Informati on Processi ng Standards
(FIPS)








Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

17


amount of i nformati on that a user can access.

Al l four systems i n current i nfrastructure ha
ve vari ous l evel s of
compl i ance to the recommended securi ty standards.


The Idaho Heal th Insurance Exchange wi l l i mpl ement mul ti pl e l evel s of securi ty to veri fy a user's i denti ty and to
l i mi t and protect Personal Heal th Informati on (PHI) and Personal Ident
i fyi ng Informati on (PII). Addi ti onal ly,
Idaho wi l l i ncorporate the Federal Fai r Informati on Practi ces (FIP) gui del i nes when col l ecti ng data, mai ntai ni ng
data i ntegri ty and qual i ty, and provi di ng transparency regardi ng data access and use.

Federal Informat
ion Process Standards (FIPS)

Al l four systems i n current i nfrastructure have l i mi ted or parti al compl iance to FIPS.

The devel opment of the Idaho Heal th Insurance Exchange wi l l fol low the Federal Informati on Process Standards
(FIPS) gui del i nes to hel p achi e
ve secure i nformati on systems. The FIPS gui del i ne i ncl udes:

o

Faci l itati ng a more consi stent, comparabl e, and repeatabl e approach for sel ecti ng and

speci fyi ng control s
for i nformati on systems.

o

Provi di ng a recommendati on for mi ni mum securi ty control s for i nf
ormati on systems categori zed i n
accordance wi th the Federal Informati on Processi ng Standards (FIPS) 199, Standards for Securi ty
Categori zati on of Federal Informati on and Informati on Systems.

o

Promoti ng a dynami c, extensi bl e catal og of securi ty control s for
i nformati on systems to meet the demands
of changi ng requi rements and technol ogi es.

o

Creati ng a foundati on for the devel opment of assessment methods and procedures for determi ni ng securi ty
control effecti veness.

Attachment A
-

Detailed Explanation of Applica
ble Standards for Current Idaho Systems
,
Explanation of
Evaluation Criteria

Four current Idaho systems were eval uated for compl i ance to the appl i cabl e standards. The four systems are:
IBES, MMIS, eVeri f
-
I and eCaseFi l e.

The fol l owi ng descri bes the eval u
ati on cri teri a used to summari ze the fi t
cri teri a:



Functi onal i ty

fit

o

What functi onal i ty needs are provi ded by the proposed system
?



ACA 1561: Core Data

o

NIEM standard i s used to devel op, di ssemi nate
,

and support exchange of data



ACA 1561: Veri fi cati on Interf
aces

o

Federal and state i nterfaces are used for data veri fi cati on



ACA 1561: Busi ness Rul es

o

Busi ness rul es are expressed usi ng a consi stent, technol ogy neutral standard format



ACA 1561: Transmi ssion of Enrol l ment Informati on

o

HIPAA adopted transacti on standar
ds are supported



ACA 1561: Pri vacy & Securi ty: Ti mel y and accurate access to i nformati on

o

Consumer shoul d have ti mel y el ectroni c access to el i gi bi lity and enrol l ment data, wi th

the abi l i ty to
update



ACA
1561: Pri vacy & Securi ty: Thi rd
-
party access

o

Consumer
shoul d be abl e to desi gnate
thi rd
-
party

access wi th appropri ate authori zati on



HIPAA

o

Consumer ri ghts to secure i nformati on wi th di scl osure of personal heal th i nformati on

for
i mportant servi ces



Accessi bi lity for i ndi vi duals wi th di sabili ties

o

System desi gned
to meet the di verse needs of users, i.e. Secti on 508, 504 and ADA Ti tl e

II



Securi ty

o

Fai r Informati on Practi ces (FIP) are fol l owed to safeguard consumer i nformati on; IRS

1075



Federal Informati on Processi ng Standards (FIPS)

o

ACA 1561 provi des overal l gui dance

augmented wi th FIPS

Idaho Benefits Eligibility System (IBES)

Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

18



Functi onal i ty fi t



IBES wi ll provide services related to Medicaid

o

El i gibility, Enrollment, Notices, Maintenance, Changes



Wi l l be modified to support new rules, coverage groups, automated verifi
cations and HIPAA
transactions


ACA 1561: Core Data



Does not use NIEM standard for data definition and exchanges


ACA 1561: Veri fi cati on Interfaces



Currentl y uses batch external interfaces for data validation


ACA 1561: Busi ness Rul es



Business rules
are defined and executed using a rules engine


ACA 1561: Transmi ssion of Enrol l ment Informati on



Enrol lment transactions are currently generated but not using HIPAA transaction standards


ACA 1561: Pri vacy & Securi ty: Ti mel y and accurate access to i nfor
mati on



Information access is provided to the consumer only through eligibility workers


ACA 1561: Pri vacy & Securi ty: Thi rd
-
party access



Thi rd
-
party access is supported by IBES


HIPAA



IBES was designed and built taking HIPAA requirements i nto account


Accessi bi lity for i ndi vi duals wi th di sabili ties



Not applicable as IBES does not provide servi ces directly to the consumer


Securi ty



FIP practi ces are followed; IRS not applicable


Federal Informati on Processi ng Standards (FIPS)



Parti ally addressed as

noted above but not to ACA 1561 standards

Medicaid Management Information System (MMIS)


Functi onal i ty fi t



MMIS wi l l provide services related to Medicaid

o

Enrol lment, Cl aims Processing



Wi l l be modified to support new coverage groups and HIPAA transaction
s


ACA 1561: Core Data



Does not use NIEM standard for data definition and exchanges


ACA 1561: Veri fi cati on Interfaces



El i gibility determination not performed i n MMIS


ACA 1561: Busi ness Rul es



El i gibility determination not performed i n MMIS


ACA 15
61: Transmi ssion of Enrol l ment Informati on



Enrol lment transactions are currently processed but not using HIPAA transaction standards


ACA 1561: Pri vacy & Securi ty: Ti mel y and accurate access to i nformati on



Information access is not provi ded directly to t
he consumer (only through eligibility workers)


ACA 1561: Pri vacy & Securi ty: Thi rd
-
party access



Thi rd
-
party access is supported by IBES


HIPAA



MMIS was designed and built taking HIPAA requirements i nto account


Accessi bi lity for i ndi vi duals wi th di s
abili ties



Onl y the provider portal is accessible to the consumer. Otherwise, MMIS does not provide servi ces
di rectly to the consumer


Securi ty



FIP practi ces are followed; IRS not applicable


Federal Informati on Processi ng Standards (FIPS)



Parti ally ad
dressed, as noted above with ACA 1561 Standards

Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

19


eVerif
-
I
-

Online verification system


Functi onal i ty fi t



eVeri f
-
I provides manual online verifications used i n Medicaid eligibility determination



Wi l l be modified to support automated verifications and new
federal data hub


ACA 1561: Core Data



Does not use NIEM standard for data definition and exchange


ACA 1561: Veri fi cati on Interfaces



Currentl y uses external online interfaces for data validation


ACA 1561: Busi ness Rul es



Does not use a rules engine


ACA 1561: Transmi ssion of Enrol l ment Informati on



Is not used for enrollment


ACA 1561: Pri vacy & Securi ty: Ti mel y and accurate access to i nformati on



Information access is not provi ded directly to the consumer (only through eligibility workers)


ACA 1
561: Pri vacy & Securi ty: Thi rd
-
party access



Does not support third
-
party access


HIPAA



eVeri f
-
I was designed and built taking HIPAA requirements i nto account


Accessi bi lity for i ndi vi duals wi th di sabili ties



Not applicable as eVerif
-
I does not provi de s
ervi ces directly to the consumer


Securi ty



FIP practi ces are followed; i nterfaces approved and certified by the IRS


Federal Informati on Processi ng Standards (FIPS)



Parti ally addressed, as noted above with ACA 1561 Standards

eCaseFile
-

Document imagi
ng and management system


Functi onal i ty fi t



eCaseFile provi des document i maging, i ndexing and retrieval servi ces



Wi l l be modified to support automated verifications and new federal data hub


ACA 1561: Core Data



Does not use NIEM standard for data defini
tion and exchange


ACA 1561: Veri fi cati on Interfaces



Does not use i nterfaces for veri fications


ACA 1561: Busi ness Rul es



Does not use a rules engine


ACA 1561: Transmi ssion of Enrol l ment Informati on



Is not used for enrollment


ACA 1561: Pri vacy & S
ecuri ty: Ti mel y and accurate access to i nformati on



Information access is not provi ded directly to the consumer only through eligibility workers


ACA 1561: Pri vacy & Securi ty: Thi rd
-
party access



Does not support third
-
party access


HIPAA



eCaseFile was d
esigned and built taking HIPAA requirements i nto account


Accessi bi lity for i ndi vi duals wi th di sabili ties



Not applicable as eCaseFile does not provide services directly to the consumer


Securi ty



FIP practi ces are followed; i nterfaces approved and certi
fied by the IRS


Federal Informati on Processi ng Standards (FIPS)



Parti ally addressed, as noted above with ACA 1561 Standards


Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

20



Attachment B
-

Eligibility and Enrollment

(Tier 1 through Tier 4) Process Mapping

Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

21



d.

Eval uati on Pl a
n

Idaho wi l l empl oy an eval uati on pl an that covers both the project and operati ons, i ncl udes both i nternal and thi rd
-
party eval uati ons, and correcti ve acti on pl ans for
i nterventi on i f targets are not met or i mmedi ate response i s needed. The eval uati on res
ul ts wi l l hel p gui de our conti nuous qual i ty i mprovement by i denti fyi ng opportuni ti es
to streaml i ne processes, enhance the consumer experi ence and al i gn the project and Exchange wi th the pri nci ples of:



Establ i shing a state
-
based exchange



Promoti ng effi ci en
cy and effecti veness



Avoi di ng adverse sel ecti on



Streaml i ni ng access and conti nui ty of care



Publ i c outreach and stakehol der i nvol vement



Publ i c accountability and transparency



Fi nanci al accountabili ty



Sel f
-
sustai nability

The basel i ne data wi l l be gathered as

i ndi cated i n the matri x bel ow.

Measure

Performance
Measure

Measure
Objective

Measurement
Frequency

Source of Data

Data Evaluated/Analyzed

Responsible
Person

Recipients of Results

Schedule
Progress



Actual progress v.
planned



Actual work
completed v.
plan
ned

Target variance:
92%



Ensure
acceptable
progress



Identify
problems
early

Project
:

Weekly, beginning 2
weeks after the grant is
awarded and
continuing through the
life of the project.

Project
:

ScrumWorks
Pro, CALT, MS
Project

Project
:



Backlog reports



Bu
rndown reports



Project Progress
reports

Project:


Scrum Masters

Project
:

Executive Project
leaders, Project
Managers, Project
Leads, Project Teams,
Exchange Website,
Others
-
as needed

Milestones
Reached



Date reached v. date
planned

Target variance:
90%



C
ommunicate
progress



Maintain
project
support

Project:


Monthly, beginning 30
days following grant
award and continuing
through the life of the
project.

Project
:
ScrumWorks
Pro, Contraxx,
CALT, Project
Monitor Report

Project
:



Sprint reports



Contract repor
ts



Monitor reports

Project
:

Scrum Masters,
Contract
Monitors

Project
:

Executive Project
leaders, Project
Managers, Project
Leads, Board of
Directors, Exchange
Website, Others
-
as
needed

Progress
Barriers



Type and date of the
barrier



Core Area(s)
impacte
d



Project Team(s)
impacted



Milestones/Goals


Ensure
acceptable
progress



Identify
problems
early

Monthly, beginning in
the month the grant is
awarded and
continuing through the
life of the pro
ject.

Project
:
ScrumWorks
Pro

Project
:



Impediment report

Project:
Scrum
Masters, Team
Leads

Project
:

Health and Human
Services, Executive
Project leaders,
Project Managers,
Project Leads, Project
Teams

Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

22


Measure

Performance
Measure

Measure
Objective

Measurement
Frequency

Source of Data

Data Evaluated/Analyzed

Responsible
Person

Recipients of Results

i mpacted



Patterns and trends

Target: trend
reducti on
>25%/month

Project
Decision
Timeliness



Date deci si on need
i den
ti fi ed v. date
made



Ti me taken to make
deci si on v. deci si on
maker

Target vari ance:
90%



Ensure
deci si ons
ti mel i ness

Monthl y, begi nni ng i n
the month the grant i s
awarded and
conti nui ng through the
l i fe of the proj ect.

Proj ect
:
Decision Log,
Impediment
Log

Pr
oj ect
:



Deci si on Log report



Impedi ment Log report

Proj ect:

Proj ect
Coordi nator

Proj ect
:

Executive Project
leaders, Project
Managers, Project
Leads

Grant
Compliance



Actual costs v.
planned



Actual progress
made v. planned



Actual resources
used v. planned

T
arget variance:
90%



Compl y wi th
grant

Proj ect
:

Quarterly, beginning
the first quarter
following grant award
and continuing through
the life of the grant.

Project
:

FISCAL DB,
CALT

Project
:



Cost Allocation reports

Expenditure reports



Contractor Breakdown
r
eports



Budget Estimation
reports

Project:


Budget Analyst

Financial Analyst


Project
:

Health and Human
Services, Executive
Project leaders,
Project Managers,
Project Leads, Project
Teams

Board of Directors,
Exchange Website,
Others
-
as needed

Project Goa
ls



Actual date goal
achieved v. planned

Target
variance:<90%



Communicate
progress



Maintain
project
support

Project:


Quarterly, beginning
the first quarter
following grant award
and continuing through
the life of the grant.

Project
:

MS Project,
CALT, Gran
t
Proposal,
ScrumWorks
Pro

Project
:



Sprint reports

Project Progress
reports

Scrum Retrospective
reports

Project
:

Scrum Masters,
Contract
Monitors

Project
:

Health and Human
Services, Executive
Project leaders,
Project Managers,
Project Leads, Board
of Dire
ctors,
Exchange Website,
Others
-
as needed

Stakeholder
Involvement



% known
stakeholders v. %
attending meetings



Satisfaction level of
involvement for


Ensure buy
-
in and
support

Quarterly, beginning
the first quarter
following grant award
and continuing every
quarter thereafter.

Project
:
Stakeholders,
Consumers,
Small Business,
Health Care
Project
:



Stakeholder feedback



Consumer surveys



Agency feedback

Project:


Consulting Firm

Project
:

Health and Human
Services, Executive
Project leaders,
Project Managers

Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

23


Measure

Performance
Measure

Measure
Objective

Measurement
Frequency

Source of Data

Data Evaluated/Analyzed

Responsible
Person

Recipients of Results

stakehol ders



Number of
Stakehol der
meeti ngs by type



Resul ts of
Stakehol der
meeti ngs i ntegrated
i nto proj
ect
deci si ons

Target: trend
i mprovement >15%
per quarter

Counci l s
/commi
ttees,
Workgroups,
Project team
members

Project Leads, Board
of Di rectors,
Exc
hange Websi te,
Others
-
as needed

Inter/Intra
-
agency
Collaboration



Actual i nvol vement
v. pl anned



Actual resources
used v. pl anned

Target vari ance:
<90%



Sati sfacti on l evel
wi th col l aborati on
efforts

Target: trend
i mprovement >10%
per quarter



Ensure
i ntegr
ati on of
sol uti ons



Promote
col l aborati on

Quarterl y, begi nni ng
the fi rst quarter
fol l owi ng grant award
and conti nui ng through
the l i fe of the grant.

Project
:

Project
Calendar

Feedback
Collection Log

Stakeholder
Surveys

Project
:



Stakeholder feedback



Consum
er surveys



Agency feedback

Project:


Project
Coordinator,
Business Analyst

Project
:

Health and Human
Services, Executive
Project leaders,
Project Managers,
Project Leads, Board
of Directors,
Exchange Website,
Others
-
as needed

Delivery of
System
Functio
nality



Date promised v
actual

Target variance:
90%



Manage
expectati ons



I denti fy
dependenci es

At each rel ease,
begi nni ng wi th the fi rst
rel ease and conti nui ng
throughout system
devel opment.

Proj ect
: MS
Proj ect, CALT,
ScrumWorks
Pro

Proj ect
:



Spri nt reports,



proj ect reports

Proj ect:

Scrum Masters

Proj ect:


Executi ve Proj ect
l eaders, Proj ect
Managers, Proj ect
Leads, Proj ect Teams

Budget Usage



Actual month
expenses v. pl anned



Actual month pai d v.
pl anned



Actual monthl y
amount spent v.
pl anned



Manage
budget
usage

Proj ect
:

Monthly, beginning the
calendar month
following grant award
and continuing through
the life of the project.

Operations
:

Monthly, beginning the
Project
:


FISC
AL DB

Operations
:

tool to be
developed

Project
:



Expenditure reports



Contractor Breakdown
reports



Budget Estimation
reports

Project:


Budget Analyst

Operations
:
Financial Analyst

Project
:

Executive Project
leaders, Project
Managers, Project
Leads

Operatio
ns
:

Board of Di rectors,
Executi ve Di rector,
Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

24


Measure

Performance
Measure

Measure
Objective

Measurement
Frequency

Source of Data

Data Evaluated/Analyzed

Responsible
Person

Recipients of Results

Target vari ance:
90%

cal endar month
fol l owi ng operati onal
go
-
live of the Exchange.

Others
-
as needed

Risk
Mitigation



Risks mitigation v.
engaging
contingency plan



Risk Patterns

Target mitigation:
93%



Control/mi ti
gate
negati ve
i mpacts

Proj ect:


Monthl y, begi nni ng i n
the month the grant i s
awarde
d and
conti nui ng through the
l i fe of the proj ect.

Operati ons
:

Monthly, beginning in
the first month of
operations, with the
potential to move to bi
-
monthly or quarterly
after the first year of
operations (decision to
be made December
2014).

Project
:

Risk

matrix,
Board Meeting,
Minutes,
Feedback
Collection Log,
Evaluation
Findings Log,
ScrumWorks
Pro

MS Project,
Grant Proposal,
FISCAL DB,
Decision Log,
CALT,
Stakeholder
Surveys, Project
Calendar

Operations:


Risk matrix,
Board Meeting,
Minutes,
Feedback
Co
l l ecti on Log,
Eval uati on
Fi ndi ngs Log,
Stakehol der
Surveys

Project:



Backl og reports



Burndown reports



Spri nt reports



Project Progress
reports



Contract Moni tor
reports



Deci si on Log report



FISCAL reports



Grant reports

Operati ons:



Contract Moni tor
reports



Fi na
nci al reports



Stakehol der feedback



Consumer surveys

Project:


Busi ness Anal yst

Operati ons
:

Risk Analyst

Project:


Executive Project
leaders, Project
Managers, Project
Leads, Others
-
as
needed

Operations
:

Board of Directors,
Executive Director,
Others
-
as

needed

Evaluation
Plan
Compliance



Pl anned eval uati ons
v. actual l y done

Target
vari ance:<90%



Effi cacy of
eval uati ons



Meet grant
requi rements



Ensure
opportuni ti es
for
i mprovement
Proj ect:


Quarterl y, begi nni ng
the fi rst quarter
fol l owi ng grant award
and conti nui ng through
the l i fe of the proj ect.

Proj ect
:
Evaluation
Findings
Log,
Corrective
Action Plans

Operations
:
Project
:



Evaluation Completion
reports



Evaluation Criteria
reports



Evaluation Schedule
Project
:

Business Analyst,
Consulting Firm

Operations
:
Evaluation
Specialist,
Project
:


Health and Human
Services, Executive
Project leaders,
Project Managers,
Project Leads,
Idaho Department of Heal th and Wel fare

Cooperati ve Agreement to Support Establ i shment of State
-
Operated Heal th Insurance Exchanges CFDA: 93.525

25


Measure

Performance
Measure

Measure
Objective

Measurement
Frequency

Source of Data

Data Evaluated/Analyzed

Responsible
Person

Recipients of Results

Project Target: >90%

Operati onal Target:
>95%

are i denti fi ed



Improve
eval uati
on
process

Operati ons:


Quarterl y, begi nni ng
the fi rst quarter
fol l owi ng the fi rst si x
months of operati ons

Eval uati on
Fi ndi ngs Log,
Correcti ve
Acti on Pl ans

reports

Operati ons
:



Eval uati on Compl eti on
reports



Eval uati on Cri teri a
reports



E
val uati on Schedul e
reports

Consul ti ng Fi rm

Others
-
as needed

Operati ons
:

Board
of Directors,
Executive Director,
Others
-
as needed

Uninsured
Idahoans



Number of enrollees
in private insurance



Number of enrollees
in Medicaid

Target: Increase
enrollees 3% per
year until number of
uninsured <10%



Reduce the
number of
uninsured in
Idaho


A
nnually beginning
January, 2014

Project
:

The Kaiser
Foundation

Operations:
The
Kaiser
Foundation

Project
:

Kaiser Foundation reports

Operations
:

Kaiser Foundation reports

Project:


Business Analyst

Operations:

Evaluation
Specialist

Project
:

Health and
Human
Services, Executive
Project leaders,
Project Managers,
Project Leads, Board
of Directors,
Exchange Website,
Others
-
as needed

Operations
:

Board of Directors,
Executive Director,
Others
-
as needed

Operational
effectiveness



Operational plan v.
actual
operations

Target variance:
90%



Al i gn wi th
Exchange
pri nci pl es

Every
month
, begi nni ng
30

days after
operati onal
i mpl ementati on
wi th a
quarterl y revi ew of
fi ndi ngs; monthl y
fi ndi ngs may tri gger an
i mmedi ate revi ew of
cri ti cal i ssues
.

Operati ons
:
Evaluation
Findings Log,
Feedback
Collection Log

Operations
:



Reports from exchange



Stakeholder feedback



Consumer surveys



Evaluation results

Operations:
Consulting Firm,
Business Analyst

Operations
:

Health and Human
Services, Executive
Project leaders,
Project Manager
s,
Project Leads, Project
Teams, Board of
Directors, Exchange
Website, Others
-
as
needed