1 Access Health CT: Connecticut s Health Insurance Marketplace NASCIO 2014 State IT Recognition Awards Category: Digital Government: Government to Citizen Contact: Mark Raymond State of Connecticut Chief Information Officer (860) Project Initiation Date: 07/01/2012 Project Completion Date: 10/01/2013
2 Executive Summary In March 2010, President Barack Obama signed The Patient Protection and Affordable Care Act (ACA), requiring every state to implement an electronic Health Insurance Exchange with an open enrollment start go-live date of October 01, While the majority of states chose to defer this implementation to the federal government (http://healthcare.gov), the State of Connecticut made a decision to pursue a statebased exchange, creating a quasi-state entity with the requisite procurement and administrative flexibility to be able to coordinate and operate the Health Insurance Exchange, later named Access Health CT (AHCT). AHCT today is well on its way to fulfilling the ACA s mission of providing Americans with access to affordable quality healthcare. Through the AHCT Individual and Small Business Exchange systems, individuals and small businesses can shop, compare and purchase health insurance, determine their eligibility for tax credits or Medicaid and the Children s Health Insurance Program (CHIP). AHCT also operates a Call Center which provides consumers with answers to questions, offers guidance on choosing and purchasing health insurance, and assists with enrolling eligible clients. In addition, AHCT s Navigator and In-Person Assisters Program reaches out directly to members of Connecticut s communities, working with community and nonprofit groups to bring affordable health insurance coverage to Connecticut residents. AHCT, by all measures and accounts, has been an incredible success. Today, it is considered one of the most successful state-based exchanges. AHCT has exceeded federal enrollment targets by the largest percentage of any other state-based Exchange. As of May 2014, over 229,000 Connecticut residents have signed up for health coverage, more than doubling AHCT s target and even further surpassing initial estimates by the United States Department of Health and Human Services. AHCT s successes go beyond the record percentage of individuals enrolled in quality health coverage. The project had a consistent focus throughout its lifecycle on the public end-user experience, with unwavering commitment to the system s ease of use, access to in-person, electronic, or over-the-phone assistance, and flexibility in meeting public need. AHCT continues to refine the system, so that it now includes a mobile application optimized for smart-phone usage. AHCT also demonstrated rigorous conformity and attention to project management standards and methodologies, and stakeholder requirements and expectations, using an iterative rolling wave planning methodology to deploy a functional public-facing system online and on-time under an intense 15 month schedule. Furthermore, AHCT s open-standard system architecture vision created an infrastructure of hosted services that could be leveraged by other state agencies and technology projects in the future. This innovative and future-oriented approach has numerous benefits for future state technology projects, and is already bearing fruit as Connecticut pursues an Integrated Eligibility System for a major state agency that will use the same document management, security, and hosting solutions that were utilized for AHCT, among other services. For all of these reasons, AHCT is a prime candidate for NASCIO s 2014 State IT Recognition Awards in the Digital Government: Government to Citizen Category.
3 Business Problem and Solution Description One of the key provisions of the 2010 enactment of the ACA was the requirement that every state implement an electronic Health Insurance Exchange or join the Federally Facilitated Exchange (https://healthcare.gov), with an aggressive open enrollment golive date of October 01, This was a system of significant complexity, with requirements constantly evolving in a diverse regulatory environment governed by CMS, CCIIO, IRS, the AHCT Board of Directors, and other Connecticut state and insurance regulations. Changes mandated by evolving requirements resulted in additional costs, re-work, and broadened scope as the project progressed. Compounding the multi-faceted needs of AHCT requirements is the fact that the entire idea of state-based Health Insurance Exchange was a relatively new one, and in many ways AHCT and its regulators were operating in uncharted waters. In addition to the complexity of the system itself, deployment of the AHCT solution required the development of a large number of business processes and operational policies between AHCT and its partner, the Connecticut Department of Social Services (DSS). From the need to establish a Call Center, Printing Center and Scanning Center, to bringing on board a wide variety of contractors, partners and advisors with unique experiences and perspectives (all necessary for a successful implementation). Furthermore, in 2011 it was estimated that over 365,000 Connecticut residents lacked health insurance coverage, representing perhaps the single largest problem that AHCT was created to address. The regulatory complexity, system complexity, and need to bring quality health coverage to hundreds of thousands of uninsured Connecticut residents represented the key problems that informed AHCT s mission. The AHCT solution uses a modular, service oriented architecture to provide a standards-based enterprise system. It provides a Java Enterprise Edition (JEE) basedweb application for Connecticut residents to anonymously shop and compare different health insurance plans offered through the exchange, create an account from which to formally apply for health insurance coverage, determine the tax credits available to them, or choose to enroll in social services programs such as Medicaid or the Children s Health Insurance Program (CHIP). Web based security, single-sign on and role based access control are managed using IBM s Security Identity and Access Management suite and multi-factor authentication for Brokers uses Symantec Validation and Identity Protection (VIP) services. Messaging services available through the Federal Data Services Hub help guard against fraud, waste and abuse of the offered AHCT services and provide real time access to verification services including identity proofing, tax information and other federal eligibility requirements. In addition to the solution itself, AHCT has a number of supporting business processes to assist consumers and support operations. It operates a Call Center which provides consumers with answers to questions, offers guidance on choosing and purchasing health insurance, and assists with enrolling eligible clients. AHCT s Navigator and In- Person Assisters Program reaches out directly to members of Connecticut s communities, working with community and nonprofit groups to bring affordable health insurance coverage to Connecticut residents, by being available over the phone, at
4 storefront locations, or the numerous special events hosted to raise awareness for AHCT throughout the state. In addition, the Small Business Health Options Program (SHOP) also allows Connecticut employers to provide their employees health coverage through AHCT that comes with certain tax benefits. These and many other business processes support the state-of-the-art AHCT solution and help drive the organization to meeting its mission. To manage the AHCT Board s expectations and its diverse interests, the Board meets on a monthly basis with AHCT key staff, and operating under Robert s Rules of Order, with a Call to Order, and methodically works through a pre-set agenda of priorities and initiatives. The Board meetings, in addition to dealing with pressing issues and initiatives, include regular updates from AHCT s Information Technology, Plan Management, Operations, Marketing and Finance staff, creating a venue to raise concerns and promote open discussion. As a result, Board meetings are very productive and have helped shape the AHCT vision and success seen today. All Board minutes and agendas are made available to the public and interested stakeholders (http://ct.gov/hix). From the perspective of internal control and management, AHCT executives and staff have access to a wide variety of performance and incident-monitoring applications, receiving real-time access to system statistics (even on their mobile devices) to respond to issues immediately. In addition, the AHCT office location includes three centrally placed television monitors providing staff with up-to-date information about website traffic, recently logged IT and operational incidents and a comprehensive Rollout Performance Monitoring Dashboard with key operational metrics. This information feed gives AHCT staff the ability to identify trends, address arising issues, and anticipate and monitor risks before they turn into issues. All open risks related to program Schedule, Resources, Quality and Scope are managed per the risk management plan, and maintained in AHCT s Risk and Issue Log and reviewed and updated weekly. Contingency planning for the deferred system functionality was often driven through the risk management process, where risks and issues served as a way to focus on some of the associated pressing issues of scope, cost and schedule. In addition to the formal Risk management process, AHCT performs a weekly Top 5 issues, risks and accomplishments process across all stakeholder groups. Significance AHCT has significantly improved government operations both through the functionality available through the system as well as the collaboration promoted between its stakeholders. Integrating eligibility determinations for multiple programs, insurance plans and subsidies in a single application has simplified citizen access to health insurance by promoting a No Wrong Door multi-channel solution. Linkages with existing Connecticut human service agency systems also promote a streamlined enrollment process, and helps maximize the services that can be utilized by any
5 particular client. Messaging services available through the Federal Data Services Hub help guard against fraud, waste and abuse of the offered AHCT services and provide real time access to verification services including identity proofing, tax information and other federal eligibility requirements. The AHCT Board includes stakeholders from every major Connecticut agency related to healthcare and insurance that have played a major role in AHCT s successful deployment. From the Lieutenant Governor, to the Commissioners of the Department of Public Health (DPH), Department of Mental Health and Addiction Services (DMHAS), State Insurance Department (CID), to the Department of Social Services (DSS), and including the Office of Policy and Management (OPM), Office of the Healthcare Advocate (OHA), the Board has interests and priorities that span across the full landscape of public policy. Four advisory committees regularly serve as a venue to address complex and detailed issues in specific areas of AHCT s operations (discussed in detail below). Health Insurance Carriers, who offer Qualified Health Plans (QHPs) through the online marketplace, were also critical stakeholders, given that their goodwill and cooperation is critical for ensuring that individuals have access to health coverage. Connecticut s Department of Social Services also plays a critical role as a stakeholder, not only in processing the Medicaid and CHIP applications that come through AHCT, but also working with the organization to ensure that the business rules that eligibility criteria reflect the changes that came as part of the ACA. The Connecticut s Bureau of Enterprise Systems and Technology (BEST), part of the Department of Administrative Services (DAS), also plays an invaluable role in managing AHCT s technology infrastructure, and helping safeguard the security and privacy of sensitive client data. The federal government is also considered a stakeholder the Centers for Medicaid and Medicare Services (CMS s) Consumer Information and Insurance Oversight (CCIIO) bureau, and the Internal Revenue Service (IRS) also play a critical role in issuing and overseeing the implementation of regulations and directives that directly affect AHCT s day-to-day operations, in addition to playing a role performing regular financial, operational and security audits. Finally, and perhaps most significantly, the chief stakeholders of AHCT are the Connecticut residents themselves, who are the end-users of the solution and the customers for essential and quality health coverage it provides. Benefit of the Project AHCT s successful implementation has had a wide variety of benefits to the State of Connecticut and its residents. Consumers benefit through an easy-to-navigate application and enrollment process, which they can initiate through a variety of channels (in-person, over the phone, or online), and access to affordable quality health insurance coverage. The Connecticut Department of Social Services (DSS) benefits through another point of intake for potential Medicaid and Children s Health Insurance Program applicants, including a streamlined process that transfers application and enrollment information to its own systems and personnel. The Insurance Carriers offering Qualified
6 Health Plans (QHPs) through AHCT benefit from being able to draw on a new segment of the market that was previously unable to afford insurance coverage, or was unaware of their healthcare options. Connecticut s economy also benefits from AHCT s operation niche markets have been created for brokers and other helping hands that help connect Connecticut employers to quality insurance coverage for their employees, as well as tax breaks and credits to help make that happen. AHCT s open-standard system architecture consisted of a common infrastructure of hosted services, meant to help standardize technology platforms across state agencies, lower custom development and maintenance and operations costs across state agencies. This architecture promotes cost and schedule efficiencies among all Connecticut technological projects. Interoperability conditions, including the ability to integrate with other systems and models that utilize the National Information Exchange Model (NIEM) and National Human Services Information Architecture (NHSIA) also promote future collaboration and expansion opportunities. Today, AHCT s approach is bearing fruit as Connecticut pursues an Integrated Eligibility System for a major state agency that will use the same document management, security, and hosting solutions that were utilized for AHCT, among other services. While current savings estimates are difficult to gauge, it is clear that the benefits of such an approach will only grow over time. Perhaps the largest benefit of AHCT has been to the 229,000 Connecticut residents that now have access to quality, affordable health insurance that conforms to all federal and state standards. The enrollment of these individuals has significantly contributed to closing the insurance coverage gap that was identified as affecting 365,000 Connecticut residents in 2011, and AHCT stands to further close this gain in the coming year s open enrollment period. Apart from the benefits to the State of Connecticut, AHCT is a model of project management, operational effectiveness, and software development to other public technology implementation projects across the nation, having successfully met its mission on time, and having exceeded all set targets and expectations. As testament to this fact, the AHCT solution and operational model is in the process of being re-adapted to the needs of the State of Maryland, which has chosen to utilize the same system integrator and technical advisor services that helped AHCT drive to success. Furthermore, the news media has time and again drawn positive light to AHCT s accomplishments, repeatedly painting it as the model state-based insurance marketplace.
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