Request for California Healthcare Eligibility, Enrollment, and Retention System Development and Operations Services

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Request for California Healthcare Eligibility,
Enrollment, and Retention System Development and
Operations Services
Yolanda Richardson, California Health Benefit
Exchange Dianne Koelzer, CalHEERS Acting Project
Director Overview of Draft Solicitation Health
Benefit Exchange Board Presentation
December 20, 2011
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Agenda

• Solicitation Overview
• Examples of Inclusion of Stakeholder Input
• Draft Solicitation Section Review
• What You Will See in Draft Solicitation
• Review of Sections
• Solicitation Development Timeline
• Public Submission of Comments

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CalHEERS Partnership

• The California Healthcare Eligibility,
  Enrollment and Retention System (CalHEERS)
  project is jointly managed between the California
  Health Benefit Exchange, the Department of Health
  Care Services, and the Managed Risk Medical
  Insurance Board, with the assistance of the
  Office of Systems Integration. The Exchange will
  serve as the point of contact for the
  solicitation.

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CalHEERS Solicitation Overview

• Seek to assure the information technology system
  will support the common aspiration of the
  Exchange, Department of Healthcare Services, and
  the Managed Risk Medical Insurance Board to have
  maximum possible enrollment of the eligible
  individuals in the Exchange, Medi-Cal, and
  Healthy Families.
• Listen and learn from partners expertise in
  California and nationally.
• Build on existing capacity whenever possible.

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CalHEERS Solicitation Overview

• Policy and Business Approach to Developing
  CalHEERS
• Policy drives IT design
• Solicitation reflects current policies and
  includes requirements reflecting policies still
  under consideration
• Policies and business approaches will be
  finalized
• Federal regulations forthcoming
• State policy issues that are specific to the
  Exchange, Medi-Cal and/or MRMIB in process (e.g.,
  roles and compensation of Assisters, Basic Health
  Program, employer/employee choice in the SHOP and
  staffing of a call/service center)

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CalHEERS Solicitation Overview

• Service Center Planning Process

Design business model and staffing alternatives January 3- February 15, 2012
Consultation with stakeholders February 15-28, 2012
Finalization of staffing approach Mid-April 2012
Release Solicitation (if required) April 2012
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Incorporating Input and Buildingthe Best
Possible System
Input/Issues How and where it is addressed
No wrong door service system that provides consistent consumer experiences for all entry points CalHEERS utilizes the no wrong door approach for all public entry points including by phone, online access, or in-office service, to Submit applications for healthcare coverage for enrollment and subsequent renewals with reduced consumer burden. Provide subsequent information to how to dis-enroll, renew, transition between coverage programs, update case information, or appeal an eligibility determination. Compare Health Plans whether in Exchange, Medi-Cal or Healthy Families and select the plan that best meets their situation. Section 1.4.1-Future Vision
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Incorporating Input and Buildingthe Best
Possible System
Input/Issue How and where it is addressed
No wrong door service system that provides consistent consumer experiences for all entry points CalHEERS will contain the Business Rules Engine and technical capabilities to do online, real-time eligibility for Modified Adjusted Gross Income Medi-Cal, Healthy Families, Access for Infants and Mothers, Advanced Premium Tax Credit, Cost Sharing Reductions, and the Basic Health Program (if enacted) based on verified application data Section 1.4.1-Future Vision Enables self-service consumers, Assisters, and Program Eligibility Administrators to gain access to information on Consumer Accounts via the CalHEERS Web Portal using role-based security Section 1.4.1-Future Vision
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Incorporating Input and Buildingthe Best
Possible System
Input/Issue How and where it is addressed
Culturally and linguistically appropriate oral and written communications which also ensure access for persons with disabilities Website Design, telephone systems, and forms will be designed to meet the needs of the full range customers, including non-English speakers and person with disabilities. The designs will conform to state and federal laws and regulations regarding accessibility. Section 4.3.8-Usability
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Incorporating Input and Buildingthe Best
Possible System
Input/Issue How and where it is addressed
First class user experience Vendors will be required to build a web portal that will provide a first class user experience and illustrate how they have evaluated solutions for this requirement including the UX2014 project. Section 4.4.4.3.6 Presentation Layer
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Incorporating Input and Buildingthe Best
Possible System
Input/Issue How and where it is addressed
Pre-population of data with consumer consent System requirements call for potential pre-population of application data from a range of sources that will provide information for eligibility and enrollment purposes. Requirements call for the applicant to consent to having their application form pre-populated with available data. Section 4.3.1.2.1 - Individual Eligibility and Enrollment
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Incorporating Input and Buildingthe Best
Possible System
Input/Issue How and where it is addressed
Enables real-time, accurate eligibility determinations CalHEERS will contain the Business Rules Engine and technical capabilities to do online, real-time eligibility for Modified Adjusted Gross Income Medi-Cal, Healthy Families, Access for Infants and Mothers, Advanced Premium Tax Credit, Cost Sharing Reductions, and the Basic Health Program (if enacted) based on verified application data Section 1.4.1-Future Vision
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Incorporating Input and Buildingthe Best
Possible System
Input/Issue How and where it is addressed
Consistent rules applied among programs The rules engine shall provide a consistent determination of eligibility based upon verified data. The eligibility determination from the rules engine shall be provided to the applicant along with simple language explaining the results. In addition, the results of the rules engine determinations shall be provided, as needed, to the Exchanges interface partners. Section 4.4.3.3-Business Rules Externalization
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Incorporating Input and Buildingthe Best
Possible System
Input/Issue How and where it is addressed
Reduce consumer burden to establish and maintain eligibility Automatic redetermination of annual eligibility based on current data. Key functionality to include supporting field-level validation and verification and interfacing with federal and/or state systems. Section 4.3.2. Eligibility and Enrollment
Ensure transparency and accountability to decrease errors and improve service CalHEERS shall produce transaction data, reports, and performance information that would contribute to program evaluation, continuous improvement in business operations, and transparency and accountability. Requirements call for a single rules engine to determine eligibility. Section 4.4.Technical Scope
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Incorporating Input and Buildingthe Best
Possible System
Input/Issue How and where it is addressed
Minimize administrative tasks for employers, including tools for on-line processing and access for employees to self manage accounts Requirements call for the employers to have the ability to create and update an employee roster through an on-line application process. CalHEERS will enable employees to update their accounts. Section 4.3.7 SHOP Eligibility and Enrollment
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CalHEERS Solicitation Overview
Functionality to be implemented by 2014
Eligibility and Enrollment
Plan Management
Service Center Hardware, Software, Facilities
Customer Service and Education via Web Portal (English and Spanish)
Forms, Notifications, and IVR in Threshold Languages
Eligibility Transfer (i.e., pre-enrollment, pre-notification, and pre-population)
Financial Management
Case Data Management (two approaches solicited)
Organizational Change Management
includes Modified Adjusted Gross Income (MAGI)
Medi-Cal, Childrens Health Insurance Program
(CHIP), Access for Infants and Mothers (AIM),
Advanced Premium Tax Credit (APTC), Cost Sharing
Reductions (CSR), if enacted, the Basic Health
Program (BHP) based on verified Application data
and non-subsidized individual exchange coverage.
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CalHEERS Solicitation Overview
Functionality to be priced separately
Provider Directory Linkage to Plan Choice
Individual Premium Aggregation
Incorporation of other Health Care Services Programs (e.g., CDHP, BCCTP)
Incorporation of other Non-Health Care Services Programs (e.g., CalFresh)
Incorporation of MEDS Functionality (central Medi-Cal eligibility index)
Translation of Web Portal to support other threshold languages
Small Business Health Options Program (SHOP)
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CalHEERS Solicitation Overview

• A FIRST DRAFT of
• Section 1 Introduction and Background
• Section 2 Solicitation Process and Schedule
• Section 3 Vendor Qualifications
• Section 4 Vendor Scope of Work
• Section 5 Proposal Submission Instructions
• Section 6 Evaluation Criteria
• Appendices
• Appendix A Glossary
• Appendix B Collaborative Environment and Life
  Cycle Governance
• Appendix E CMS Cloud Computing Standard
• Appendix F Gap Analysis Matrices
• Appendix G MEDS Functionality
• Appendix H CalHEERS Architecture Diagrams and
  Technical Reference

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CalHEERS Solicitation Overview

• A FIRST DRAFT of
• Attachments
• Attachment 1 Vendor Notice of Intent to Respond
• Attachment 2 Confidentiality Form
• Attachment 3 Requirements
• Attachment 4 Certification Checklist
• Attachment 5 Corporate Experience Matrix
• Attachment 6 Key Personnel Experience Matrix
• Attachment 7 Client Reference Form
• Attachment 8 Resume Form
• Attachment 9 Cost Schedules
• Attachments 10 Comment Matrix
• Attachments 11 - 19 Other Administrative Forms

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CalHEERS Solicitation Overview

• There are placeholders for
• Text and requirements that are still in progress
• Decisions that are under discussion
• Final graphics/organization charts to be
  provided/completed
• Metrics and Estimated Service Volume Tables are
  under Development
• Show the type of information to be provided
• Anticipated to be completed before final
  solicitation is released

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Section 1 - Information and Background

• Purpose of the Solicitation of Proposal
• Project Background
• Business Need
• Future Vision
• Current Environment
• Gap Analysis
• Solicitation Instructions
• Interpretive Conventions
• General Vendor and Contract Information and Scope

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Section 2 Solicitation Process and Schedule

• Identifies Single Point of Contact
• Procurement Process and Schedule
• Submitting Vendor Questions
• Security and Confidentiality
• The Exchange Terms and Conditions Pertaining to
  the Solicitation Process

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Section 3-Vendor Qualifications

• Minimum Vendor Qualifications
• Vendor Key Staff Qualifications

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Section 4 Vendor Scope of Work

• Overview
• Business/Functional Scope
• Technical Scope
• Project Management Scope
• System Development and Implementation Services
• Deliverables
• Operations and Maintenance Support
• Alternative Approach

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Section 5 Proposal Submission Instructions

• Proposal Submission
• Subcontractor Agreements
• Proposing Realistically
• Proposal Organization and Format
• Proposal Content Requirements
• Proposal Submission Instructions

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Section 6 Evaluation Criteria

• Proposal Evaluation and Selection
• Evaluation Team
• Evaluation Process
• Proposal Scoring Methodology and Evaluation
  Criteria
• Corporate Qualifications
• Project Management and Staffing
• Business Proposals
• Technical Proposals
• Cost Proposals
• Best and Final Offer (BAFO)
• Vendor Selection and Notification

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Section 6 Evaluation Criteria
Evaluation Category Decision Considerations Subcategory Weight Overall Weight
Business/Technical Proposal 70
Corporate Qualifications Experience, references, financial strength and stability Proven experience verified by other state and government entities. Proven experience of subcontractors. 5
Project Management and Staffing PM Approach, Work Plan, Key Staff qualifications, references and interviews Demonstrated ability to perform the work in complex environment, complete deadlines timely, and lower project risks. Proven experience of key staff. 25
Functional Approach Compliance with program objectives, business requirements and Federal guidelines Emphasis on the consumer experience, no wrong door, robust support and the ability to make informed choices. 20
Technical Approach Compliance with technical requirements and Federal technology guidelines and standards Emphasis on modern technology as tools to support the business processes, consumers and operations helps ensure flexibility, scalability and sustainability. Seamless transition between health programs enabled by technology. 20
Cost Proposal Reasonableness of one-time and recurring costs to achieve program goals and maximize Federal funding. 30
Total Total Total 100
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Project Funding and Value

• The solicitation does not include an estimated
  cost.
• The solicitation makes clear the funding of
  contracted services will partially come from the
  Level I Grant and the not yet submitted or
  approved, Level II Grant and from program
  partners.
• The solicitation asks the vendor to take
  advantage of systems developed by other states or
  the federal government that can be used to
  provide the required services.
• The solicitation also requires the vendor to
  share the technologies developed at no cost to
  other states or the federal government.

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CalHEERS Solicitation Development Timeline
Task Date
Draft Solicitation for Comments December 20, 2011
Comments and Intent to Bid Due December 30, 2011
Release Solicitation January 18, 2012
Bidders Conference January 23, 2012
Bids Due February 24, 2012
Award Contract April 17, 2012
Pre-enrollment Implementation July 1, 2013
First day of Exchange and Expanded Medi-Cal Coverage January 1, 2014
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Commenting on the Draft Solicitation

• Draft solicitation will be posted today at
  www.hbex.ca.gov under the Solicitations tab
• Use the Solicitation Comment Matrix at
  www.hbex.ca.gov under the Solicitations tab
• Follow instructions on first tab for entering
  comments and submit comments to
  hbexsolicitation_at_hbex.ca.gov
• Combine Comments One set of comments per
  organization
• All comments are welcome and must be submitted by
• December 30, 2011 by 500pm
• All comments will be thoroughly reviewed by the
  CalHEERS partnership