February 18, 2014
Mr. William Watson 1401 Capitol Avenue Suite 300, Victory Building Little Rock, AR 72201
Subject: First Data’s proposal in response to the Arkansas Health Insurance Marketplace (AHIM), Professional Consulting Services RFP
Dear Mr. Watson
In response to the Request for Proposals referenced above, First Data Government Solutions, LP is enclosing our proposal for the Arkansas Health Insurance Marketplace Project. First Data is providing the required number of copies and CD's of its response. First Data Government Solutions, LP is a government-facing business component of First Data Corporation, a large Fortune 500 company that drives the business of private and public sector enterprises through our processing and consulting capabilities. First Data recognized the unique needs of government and developed resources to help government clients effectively perform their mission by providing a seamless approach to business, technology, and professional services. Not only are we industry leaders in project management, planning and quality assurance, we have diligently performed these services for many of the nation’s largest health and human services information technology projects. Since 2011, First Data has been advising Arkansas on options to implement a state exchange. We understand and share your vision for an Arkansas Health Insurance Marketplace. We look forward to continuing our relationship and helping AHIM drive to the finish line. First Data welcomes the opportunity to discuss our approach, answer any questions and negotiate any terms and conditions of the contract resulting from this RFP that may arise. Mr. David Sodergren will serve as the primary contact for this response. He can be reached at (518) 618-5830.
Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 1.0 Company Profile 1. Company Profile
First Data Government Solutions, LP is wholly owned by First Data Corporation, a global payment processing leader, headquartered in Atlanta, Georgia. First Data Government Solutions, LP was formally established in 2004 by combining four companies - govONE Solutions, GovConnect, Frank Solutions, Inc. and Taxware. GovConnect was originally formed by the merging of Eligibility Management Systems (EMS), started in 1989, and International Public Access Technologies (IPAT), started in 1978. In 2007, First Data was acquired by Kohlberg Kravis Roberts & Co. (“KKR”). First Data Government Solutions, LP became a wholly owned subsidiary of First Data Corporation. As such, First Data has been performing strategic planning, procurement, Quality Assurance, and Independent Verification and Validation (IV&V) services for large government systems projects for more than 30 years. First Data Government Solutions, LP has the following major office locations:
First Data Government Solutions, LP Office Locations Office Address Telephone Atlanta, GA 5565 Glenridge Connector NE, Ste. 1600 (404) 890-2285 Atlanta, GA 30342 Cincinnati, OH 11311 Cornell Park Drive, Suite 300 (513) 489-9599 Cincinnati, OH 45242 Omaha, NE 7305 Pacific St. (402) 222-5701 Omaha, NE 68114 Denver, CO 6200 S. Quebec Street (303) 967-6159 (Headquarters) Greenwood Village, CO 80111 Table 1.1 – First Data Government Solutions Office Locations
The primary point of contact for this proposal is:
David Sodergren Director, Government Accounts 5565 Glenridge Connector NE, Suite 1600 Atlanta, GA 30342 (518) 618-5830 [email protected].
Page 1 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 2. Qualifications 2. Qualifications
First Data is excited to offer our consulting services and expertise with health insurance exchanges to assist the State of Arkansas in dissecting the decisions and actions on its Health Insurance Marketplace and to make recommendations for moving forward. First Data does not just have a theoretical understanding of the challenges facing Arkansas; we have a practical understanding of those challenges, rooted in existing relationship with the State as well as more than 30 years of experience helping other states plan and implement large, complex health and human services programs and systems. The Affordable Care Act (ACA) changed the landscape of the health and human services industry. There are new hills to climb to meet the seven standards and conditions; new valleys of despair; and new heights to achieve towards improving access to health care whether it is through insurance exchanges or enhanced Medicaid eligibility and claims processing systems. First Data has not been on the sidelines. We have been actively assisting our clients as they seek to understand and then successfully implement the provisions of ACA. These efforts initiated with the early Planning Grant efforts all the way through the implementation and current maintenance initiatives for the first year of Exchange operations. First Data has established a Center of Excellence to explore and educate ourselves and our clients on changes to cost allocation resulting from new ACA- related guidelines. In addition, our health care consulting team has been closely engaged with several states on the impact to eligibility and MMIS projects and has become not only a trusted advisor, but a reliable source to help navigate through the challenges of staying on time and within budget despite the unknowns associated with this sweeping legislation. Specifically in the past year we have performed the following consulting services on health insurance exchanges: State Exchanges
California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) – RFP development, Evaluation Planning, Project Management Support and Oversight, APD Development and Maintenance, Technical Architecture Review and Business Analysis Testing.
Colorado Health Benefit Exchange (COHBE) – Review of policies and procedures, Business Process Analysis, Monitor Project Work Plans, Requirements Analysis, Design Analysis, and Testing.
Connecticut Health Insurance Exchange (HIX) – Independent verification and validation (IV&V) including monitoring testing activities and reviewing test results, quality assurance, project management, status meetings, and monthly executive briefings.
Oregon Health Insurance Exchange (HIX) Assessment – Assessment of website planning and implementation through stakeholder interviews, review of vendor services, and review of project documentation and artifacts.
Page 2 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 2. Qualifications
Partnership Exchanges
Arkansas Insurance Department Health Insurance Marketplace Partnership (AHIMP) – Governance Model Development, Marketplace Analysis, Financial Modeling, Project Management, Quality Assurance, Integration Planning, Business Model Planning, Outreach Planning, and Procurement Support. Subsequently, initial planning for migration from the Partnership Marketplace model to the State Marketplace model.
Illinois Health Benefit Exchange (HIX) – In support of the State of Illinois’ Governor’s Office - Project Management, Design Management, and Quality Assurance.
In each of these projects, First Data has worked closely with our state customers and CMS representatives to understand and implement the federal guidance and to help achieve a successful project. This experience has afforded our team significant insight into the IT challenges introduced by the Affordable Care Act, as well as familiarity with numerous Health Insurance Exchange solutions available in the marketplace today. As a result, we are able to provide our clients a comprehensive perspective on their projects and bring best practices and lessons learned from other states that can help them succeed. First Data has selectively chosen to partner with Seema Verma Consulting, Inc. (SVC) to supplement the First Data Team with additional Health Insurance Exchange experience. First Data has also previously partnered with SVC in other state health initiatives. With over 30 years of combined health care experience and knowledge of government health programs on the local, state and federal level, SVC offers its clients comprehensive policy research, analysis, and program development options. SVC has a range of clients, working directly with states such as Indiana, Nebraska, Iowa, Idaho, Maine, and South Carolina around topics including Medicaid strategy, Affordable Care Act (ACA) implementation, state Department of Insurance and Exchange issues. In addition, First Data is pleased to partner with Arkansas Foundation for Medical Care (AFMC) to provide specialized support for AHIM. In addition, we will leverage their extensive experience with many of the Exchange stakeholders and Arkansas consumers to develop strategies for the Marketplace. AFMC, which was incorporated in 1972, is a nonprofit educational organization dedicated to the clinical evaluation and improvement of health care in Arkansas and throughout the country. To complete our partnership, we have included Santa Barbara Actuaries Inc., (formerly Solucia Consulting). SB Actuaries was founded in 2012 by Ian Duncan. The firm’s principals have experience with pricing, reserving, rate filings, exchange design, and implementation and risk adjustment. Recent experience includes significant actuarial and analytical work in support of ACO and Bundled Payment initiatives for providers.
Page 3 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 2. Qualifications
Drawing on our collective experiences, the First Data Team is prepared to continue in the assessment of Arkansas’s Health Insurance Marketplace. We will work with State staff and vendors to factually document what transpired throughout the Arkansas’s Health Insurance Marketplace project that resulted in the delayed implementation and to develop recommendations for the future. We understand there is a tremendous amount of media attention and focus on the Exchange, and there is a high degree of sensitivity regarding decisions that were made. We understand that our task will be difficult and that some of the challenges include: Staff and vendors will be guarded - We understand that State staff and vendors may feel threatened by questions regarding the decisions made throughout the Arkansas’s Health Insurance Marketplace project.
Understanding project efforts with many stakeholders involved - Because we have worked with other states on equally complex projects, we appreciate that we need to understand the intricacies of the roles and responsibilities for each agency and vendor involved.
Overseeing a statewide program planning effort – We have direct experience identifying, developing and managing the relationships and dependencies between Exchange Core Areas including the development of a comprehensive State Exchange transition plan. Recognizing the key related strategic and policy decisions and their impact on implementation and operations is the fundamental element to strong risk management in an Exchange plan.
First Data has established a sound approach for addressing these challenges. This assurance comes from the knowledge and experience that can only be acquired by having succeeded previously in similar projects in equally challenging environments. Meeting these challenges requires a partner with a proven record in helping government agencies plan and implement large systems successfully. It requires a partner that understands the unique risks the Arkansas’s Health Insurance Marketplace Project faces, and an ability to help Arkansas correct its course and deliver project success. Most importantly, it requires a partner that shares both the State’s vision for the Arkansas’s Health Insurance Marketplace Project and its commitment to making it happen. First Data is that partner. 2.5 Financial Stability
First Data Government Solutions, LP is the government facing business component of First Data Corporation, a Fortune 500 company ranked #1 in Financial Data Services. As the global leader in transaction processing and services for financial institutions, retailers, and government organizations, Arkansas can be rest assured that in addition to being a well- rounded and highly qualified company, First Data is also a financially stable organization. In 2007, First Data was acquired by Kohlberg Kravis Roberts & Co. (“KKR”) in a highly leveraged buy-out. The company has strong financial backing, solid revenue growth and substantial available liquidity to fund all its operations. The company continues to be confident in its business model, well-balanced revenue base and market-leading position.
Page 4 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 3. Approach 3. Approach
The Arkansas Health Insurance Marketplace (AHIM) Board has requested the assistance of a professional services firm to assist it in executing its responsibilities under Act 1500 of 2013. To meet Act 1500, the AHIM Board will need to gather exchange related data so it can assess the strategic options for an Arkansas Marketplace as the state considers the path for its transition from a State Partnership to a State-based exchange. The legislation also requires the Board to put the staffing and funding in place to support the transition, both in terms of defining and implementing strategies, and assessing and managing costs to ensure the exchange sustainability desired.
First Data has managed health insurance exchange projects in a number of states over the past several years. As a result of this intensive work with state-partnership and state- based exchanges, including work in Arkansas, we understand the challenges facing the Arkansas Marketplace, especially the incredibly tight timelines facing the AHIM Board in meeting the many complex, overlapping exchange deliverables. The First Data Team plans to utilize its understanding of these current issues to “hit the ground running”, capturing essential action items and using them to outline strategic decisions for the Board and any senior staff to deliberate. These steps will help the Board manage their deadlines and deliverables more quickly to shape the best Key First Data Health Insurance Exchange Project future for the AHIM. First Data will State-based Marketplace (16 states and DC) provide assistance through: Partnership Marketplace (7 states) Federally-facilitated Marketplace (27 states) Strategic analysis, planning and assistance with decision making on key areas involved with the implementation of state-based marketplaces - As illustrated, First Data possesses extensive experience working with a broad variety of health insurance exchanges, including setting up state-based marketplaces. We have partnered with California, Oregon, Indiana, Colorado and Connecticut, and we are supporting Illinois’ transition from state partnership to state-based exchange. We also can draw on our experience working in Arkansas as well as from other, general health and human services projects. Analysis and Research - The First Data Team works closely with the AHIM Board and its members to build on existing work and action plans done in support of the marketplace. First Data also will draw on the database of best practices and lessons learned from work on exchanges, including Arkansas, presenting the current and future decisions the Board and/or staff must make. The Board must weigh all possible alternatives while understanding the impacts and costs of those decisions.
Page 5 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 3. Approach
Governance - First Data assists with the planning and implementation of communication, decision making and project management processes. First Data manages all projects according to industry standards and has developed policy and operational procedures as part of our exchange-based projects. In addition, we utilize formal communication and project management processes, tools and templates to enhance the AHIM Board’s strategic decision making and communications, increasing project effectiveness and supporting federal documentation requirements. The goal is for the First Data Team to craft actionable items from which the Board can quickly deliberate and make decisions. Liaison between the AHIM and Federal and State agencies’ representatives, health insurance marketplace partners, and other vendors - First Data focuses on building positive, collaborative relationships on all projects. As noted, First Data can draw on experience working with other exchanges to identify and contact those who will need to participate in the marketplace process. Our current working relationships and understanding of who needs to be involved from within Arkansas, from CCIIO, and from many other supporting areas, will provide the ability to draw on resources more quickly and efficiently to meet exchange goals and milestones. Grant Management - First Data creates practices that meet the federal and state processes to collect available 2014 exchange funding. This includes: (1) the planning, preparation, submission and management of the May 15, 2014 Level I “G” Exchange grant; (2) completing CCIIO reporting requirements for the Level I “E” Grant procured; and (3) the possible completion of the Level II Exchange grant due November 15, 2014. First Data has worked closely with CCIIO and states to establish grant management governance and processes, successfully submitting Level I and II Establishment Grant documentation on time and resulting in federal and state approval to collect all available exchange funding. Exchange Areas. Assistance with completion of the Blueprint and in understanding and meeting all requirements of the eleven state-based Blueprint “Exchange Areas,” defined by the Center for Consumer Information and Insurance Oversight (CCIIO), with the Blueprint due for submission May 15, 2014. First Data has submitted Blueprint documentation successfully in Arkansas and for other states’ exchanges. As a result, the First Data Team possesses a uniquely acute understanding of the Blueprint areas as they pertain to the AHIM, where and how information may need to be adapted or added, and how to quickly identify and reach contacts who may provide additional information, putting the Team in a strong position to complete the detailed Blueprint process in the incredibly limited time available. First Data will use the submitted Blueprint to design, develop and implement the eleven exchange area, complete business analysis planning, and ensure that system integrator development and procurement are completed.
Page 6 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 3. Approach
April 2014 May 2014 June 2014 July 2014 August 2014 September 2014 Initiation Phase Strategic Planning/Operational Phase
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t Analysis and Research S Establish AR SEM Foundation
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v Support Recruitment/Administrative o Functions G
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e Preparation of applications for Level I and/or Level II Exchange Grants m e Establish Grant Management g Level 1G Grant Due 5/15/2014 a Governance n a Establish Grant Management Process/Procedure Grant Management M
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r Management and submission of Level 2G Grant G
Assistance with meeting the requirements of Eleven Exchange Areas s t n e Arkansas State Based Marketplace Blueprint Initial Blueprint due 5/15/2014 m e r i Business Analysis Planning u q e
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i Other responsibilities as assigned t a r t
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d Procedure A The following sections expand on First Data’s approach to completing the many March – May 2014 project initiation deliverables (i.e., strategic analysis, Blueprint submission and
Figure 3.1 – First Data’s approach to supporting Arkansas Exchange Planning Level One ‘G’ Grant preparation, and senior staffing support), as well as the strategic planning and operational activities that will begin approximately June 2014 and continue through the end of the project (e.g., Level I and II grant management, business planning and implementation based on exchange areas, and working with AHIM on supporting policies and legislation). The key activities and deliverables in each of the phases are detailed in the following sections. 3.1 Project Initiation Phase (March – May 2014)
During the Project Initiation Phase, which runs from the mid-March project start date through mid-May, the AHIM Board must: Build off the existing AHIM Board policies to formalize project management, risk, communication and decision-making processes. Review action items presented by First Data covering marketplace issues and gaps in the eleven Exchange areas, and make decisions outlining strategies for implementing a sustainable state-based exchange representing the ‘right’ future for Arkansas. Based on the strategic decisions, complete and submit a Blueprint for a State-based Exchange to CCIIO by May 15, 2014.
Page 7 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 3. Approach
Establish the Marketplace physical presence and Staffing plan, as well as, required Administrative and Operational processes/procedures. • Review the Level 1 “E” Grant, identifying additional needs and submitting a Level 1”G” Grant to CCIIO for funding based on defined AHIM-AID agreements.
3.1.1 Establish Program Management for the AR Exchange
As an initial step, the First Data Team will identify and position resources in collaboration with the AHIM Board and any AHIM staff. As illustrated in Figure 3.2, program management includes:
Project Management tools and templates to plan and organize work, estimate effort, track progress and provide a process for change. DYNAMIC Risk Management to identify and track risk, PROJECT MANAGEMENT and to develop mitigation strategies. EFFECTIVE Communication Management to identify COMMUNICATION meeting and reporting needs, communication processes, and escalation procedures. PROACTIVE COMPREHENSIVE ACTION RISK Action Planning to execute responsibilities PLANNING MANAGEMENT and meet all required federal and state timelines. Figure 3.2 – Key Aspects of First Data’s Program Management First Data understands the importance and significance of the decisions that are required of the Board. We realize that a tremendous amount of work has already been accomplished, but there are still hurdles to go through to meet the quickly approaching deadlines. First Data will document the decisions and actions required of the Board, and help the Board prioritize the work. We will create a series of action plans and questions for the Board to address based on existing data and information gathered. We will support the AHIM Board in identifying gaps and issues that need to be addressed, and escalated. The First Data Team will collect the decision points and responses to create the Blueprint and grant strategies to move the Arkansas Exchange toward sustainability. First Data also will provide assistance with the development of rules, regulations, policy and operational procedures governing the state-based marketplace. Throughout this initial phase of the project, First Data will provide project leadership and support to the Board staff as required. Additionally, we will assist with the continued sourcing of key staff positions. The First Data Team has experience with national sourcing, and is adept at using popular national internet sites such as LinkedIn or theLadders to efficiently source potential candidates.
Page 8 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 3. Approach
3.1.2 Complete and Submit AR State-based Exchange Blueprint
First Data will complete the initial AR State-based Exchange Blueprint for the AHIM Board to review and submit, with Center for Consumer Information and Insurance Oversight (CCIIO) requirements. The Blueprint is due May 15, 2014. First Data has experience preparing state-based and state-partnership Blueprints in a number of marketplaces. It also is preparing a Blueprint for another state that is planning a transition to a state-based exchange. First Data’s prior experience working with CCIIO on Blueprints and the existing relationships developed, particularly in Arkansas, will prove Able to leverage content for: helpful and necessary to meet this tight Legal Authority & Governance deadline. Consumer & Stakeholder Engagement and Support In order to complete the Blueprint, First Plan Management Privacy and Security Data will review and leverage existing data for possible re-use or revision. In Arkansas, CCIIO has already reviewed More information needed for: work done in some areas, which may help Eligibility and Enrollment facilitate reviews with the current Financial Management, Risk Adjustment & Reinsurance submission. Small Business Health Options Program (SHOP) Organization and Human Resources The First Data Team will additionally Technology/IT Systems focus on the Sustainability Model as a way Oversight and Program Integrity to pare down potential Blueprint Contingency Planning Re-use approaches, leverage initial strategic analysis, build on the best practices and input already collected from the Board. We will facilitate action item resolution Submit Blueprint To CCIIO and update areas currently in flux in May 15, 2014 Arkansas due to pending legislative decisions to complete the Blueprint in Figure 3.3 – Arkansas Blueprint Inputs these core areas. 3.1.3 AR SEM Finance/Grant Management/Governance
State exchanges may apply for Federal Establishment Grants through 2014, which provide an important source of funding for assessing and building state exchanges. Arkansas has consistently applied for and received grant support for the state partnership and AHIM through multiple Level 1 Grants; to-date, Level 1 “A”, “B”, “C”, “D”, “E” and “F” have been submitted. The AHIM Board applied for and received initial funding through the Level I “E” Grant. The Board may apply for additional funds through submission of the Level I “G” Grant, due May 15, 2014, as a result of its current agreement with the Arkansas Insurance Department.
The First Data Team has completed and submitted numerous grants for its exchange clients, including those in Arkansas. As part of its project management best practices, the Team will build off current processes and agreements to prepare policies and procedures
Page 9 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 3. Approach for financial and grant management going forward. This will apply to both the Level 1 and Level 2 grants. First Data will work with the Board to review current funding and additional needs based on the strategies that have been identified during strategic/action planning and the Blueprint submission process, and to prepare the Level 1 “G” grant documentation required. 3.2 Strategic Planning/Operational Planning (May – September 2014)
As shown in Figure 3.4, First Data will build on the demands of the Initiation phase activities to begin the strategic and operational planning to create a sustainable Marketplace for Arkansas. This will consist of ongoing support for research, business analysis, further refine the sustainability matrix, technical analysis, assessments, alternative analysis, procurement support, facilitating/ collecting business and technical requirements, IT solution RFP development, initial Call Center strategic development and project management support. The Strategic and Operational Planning phase will begin after the submission of the Blueprint and Level 1 “G” Grant and will include:
Business Analysis Planning, including beginning to strategize and operationalize the 11 Exchange elements Managing the Level 1 Grant process and Planning for the Level 2 Grant Functioning as a liaison between the AHIM and Federal and State agencies’ representatives, health insurance marketplace partners, and vendors, manage relationships, and identify necessary agreements and legislation required to implement strategies and operations Completing any necessary RFPs for supporting Vendors
Business Planning May 15, 2014 Establish Program Management Business Analysis Submit Research & Analysis Operationalizing Level 1G Blueprint Assessment Grant & Blueprint Planning & Strategic Decision-Making Procurement Level 1 & 2 Grants
Strategic Planning/ Initiation Phase Operational Phase
Figure 3.4 – First Data’s process to support Exchange Planning
Page 10 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 3. Approach
3.2.1 AHIM Business Planning
During Business Analysis Planning First Data will assess the eleven exchange activities and the decisions that have been made thus far based on the Blueprint and Level 1 “G” Grant. These decisions will function as the foundation to begin to operationalizing the Arkansas Health Insurance Marketplace. First Data will work with the AHIM Board, identified federal and State partners and any vendors in further defining and meeting the requirements of the eleven “Exchange Areas” defined by the Center for Consumer Information and Insurance Oversight (CCIIO):
Legal Authority and Governance Organization and Human Resources Consumer and Stakeholder Engagement Small Business Health Options Program and Support (SHOP) Eligibility and Enrollment Technology/IT Systems Plan Management Privacy and Security Financial Oversight and Program Integrity Management, Risk Adjustment and Organization and Human Resources Reinsurance
First Data will need to collaborate with and manage business partner specialists who can provide supporting analysis in areas such as financial planning modeling, reinsurance, risk corridors and risk adjustment (the “3Rs”). First Data will incorporate this into strategic planning process with the Board.
The Market Analysis/Business Financial Model Vendor is funded by the Level 1 “E” grant. It will leverage the previous actuarial analyses and market predictions, adding updated 2014 market behavior to predict future exchange participation and related insurance rates. This data must be utilized to devise a future Business Financial Model to define the self-sufficiency model for the State Based Marketplace, required by calendar year 2017. The 3Rs Analysis Vendor is responsible for researching the nation and the State of Arkansas insurance marketplace 3Rs tools. The research of risk management tools must be conducted to produce an alternatives analysis and recommendations to the AHIM Board to define the future State of Arkansas Insurance Marketplace Risk Management methods. This analysis will provide input and direction for this activity for the Level 2 grant in October 2014. The IT Vendor will provide alternatives and plans for systems integration going forward.
Because the First Data Team has worked in many other states, First Data can provide the AHIM Board/staff with a variety of proven procurement strategies and options for acquiring any of the vendor options. However, we understand that the final procurement methodology will be determined by the Board.
Page 11 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 3. Approach
Once hired, the First Data Team also can assist the AHIM Board as to whether vendors are in compliance with all contract terms and conditions. Based on experience with exchanges and other projects, First Data understands all aspects of managing such agreements, from work product and deliverable reviews, approval processes, invoicing, tracking equipment and software purchases and associated license and maintenance agreements. 3.2.2 Finance/Grant Management Governance
The First Data Team will offer continued financial and grant management to the AHIM Board. First Data clearly understands how the Level 1 “E” grant was intended to be used to support the Arkansas Marketplace, given its role in submitting the grant. The Team will apply that knowledge and the experience from the Level 1 “G” Grant, along with subsequent directional strategic guidance from the Board, to ensure federal and state guidelines are met, including providing CCIIO required semi-annual reports. Based on the direction outlined by the Blueprint and strategic planning, First Data will work with the Board to create a Level 2 Grant Submission focused on funding the transition to the State-Based Exchange. The First Data Team understands, based on the needs of the Arkansas Marketplace and its experience with other exchanges, the importance of maximizing all available funding to ensure successful transition and implementation of the health insurance marketplace. 3.3 Conclusion
First Data brings a unique perspective to the Arkansas Health Insurance Marketplace project, the only vendor with that has both the detailed knowledge of the State coupled with deep market and industry experience. This makes us the best candidate for the professional services vendor role. The First Data Team has done extensive work with state-partnership and state-based exchanges in a variety of states across the county. We understand the Arkansas marketplace and its complexities (e.g. Medicaid Private Option), we have already established key relationships; we know the current landscape of work that has been accomplished as well as what is required to meet future milestones.
First Data plans to utilize these strengths to summarize data and information into actionable items the Board may deliberate and address, allowing AHIM to provide expected work such as the Blueprint and Grants to CCIIO within the deadlines that are quickly approaching. Our experience and relationships will bring together the federal and local parties necessary for the transitioning Arkansas to a sustainable State-Based Exchange as early as possible.
Page 12 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 4. Staff 4. Staff
First Data crafted our proposed organizational structure for this project very thoughtfully and carefully. We understand the constricted timeframes Arkansas has for completing the Level 1G Grant and the Initial Blueprint by May 15, 2014, in addition to Governance Planning and preparing for System Integrator Planning and Procurement. We feel that in order to successfully deliver the services and deliverables outlined in the scope of work the team must have knowledge of AHIM, understand the political landscape, are well-informed of the decisions made thus far regarding the State Based Marketplace, and the decisions that remain undecided. First Data is the partner who can effectively provide AHIM with the resources with both the familiarity of the Arkansas Health Insurance Exchange and expertise in Planning, Procurement and Implementation. First Data is committed to providing AHIM with resources that can assist you with meeting the goals and objectives for implementing a state based marketplace. First Data is partnering with SVC Inc., AFMC and Santa Barbara Actuaries to augment our team of talented consultants. Our goal is to help the State successfully transition to the State Based Marketplace, and we can best position ourselves to support AHIM through having resources readily available to meet the needs as they arise. Our partners will be providing As Needed staffing services as required. The First Data Team organization is demonstrated below.
Figure 4.1 – First Data AHIM Professional Consultant Services Team
We have provided a narrative of First Data’s staff member’s experience working on Arkansas or other healthcare related services projects. These individuals represent the
Page 13 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 4. Staff types of talent First Data will provide in fulfilling the requirements for Professional Consultant Services: David Sodergren, Executive Oversight – Mr. Sodergren is a certified Project Management Professional (PMP) and has over 18 years of extensive experience with public sector business solutions. This experience includes multiple business-driven, transformational initiatives within state government including ACA-related initiatives in Arkansas, Indiana, Illinois and Oregon. In Arkansas he has worked closely with Arkansas Insurance Department (AID) during planning and implementation of the Health Benefit Exchange and Department of Human Services for the Eligibility System IV&V Project. His leadership expertise includes managing complex, multi-team, multi-phased efforts. Paul Eichorn, Project Manager - Mr. Eichorn has 25 years of experience in Information Systems and Technologies and has functioned as a Director, Senior Manager and Administrator of business systems in all stages of their lifecycle. Mr. Eichorn has developed infrastructures and sound managerial business teams, formulated and effected long and short range strategic systems plans, created and enforced internal system methodologies reducing budgets and project resource outlays. He has also been involved in business and revenue management, applications and development, consulting and implementations of large multi- facility or global installations and Information Services in several key industries throughout the United States. Bob Casto, Senior Manager – Mr. Casto is an industry expert in Medical and Public Assistance Health Insurance Exchange Assessment because of his demonstrated leadership in multiple states with varied clients trying to tackle complex challenges. Mr. Casto has 19 years Project Management experience and is certified by PMI as a Project Management Professional (PMP). His experience has been gained within the Technology (commercial), Nuclear (federal government), Medical (state/federal/ commercial), and Laboratory industries (federal/commercial). Mr. Casto has successfully developed and implemented technology systems and processes for schedule development and maintenance, budget, requirements, cost estimating, earn value management and risk management. Mr. Casto is currently assisting AID in governance planning, Blueprint preparation, Level 1G Grant planning, plan management legislation and revenue legislation. Gary Lieberman, Senior Business Consultant - Mr. Lieberman is an organizational change management/organization development professional with experience successfully delivering measurable business improvement through strategic analysis, organizational change management and stakeholder management programs. He has focused on relationship building and engagement in order to help link "big picture" with immediate business needs. He is currently engaged on the Arkansas Business Team and helped manage both the implementation of a federally facilitated exchange and a state run private option.
Page 14 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 4. Staff
Sandra Harlow, Senior Business Consultant – Ms. Harlow has over 20 years of experience with Medicaid and other HHS programs and systems. This includes 14 years of experience as a consultant on eligibility/recipient management system projects performing business transformation and Quality Assurance (QA). Her background also includes 12 years of experience as a county eligibility case worker and project manager. She has excelled in roles including; QA Analyst for Medicaid and SCHIP projects in Colorado, Business consultant on a large enterprise wide eligibility/recipient management modernization efforts in Colorado, California, New York and Indiana, Manager on multiple PERM and Medicaid utilization/compliance review projects, Liaison, QA and SME for Exchange Projects to support Affordable Care Act (ACA) including supporting AHIM with completing its Level 1 Grant.
Premjeet Shergill, Business Consultant – Ms. Shergill is a proven consultant with over 16 years of county/state government experience in the areas of criminal justice, child welfare and eligibility. She is an astute, results oriented leader with experience managing multiple teams and business areas on large scale automation projects and mid-size government agencies. She has been instrumental in creation of unique software solutions for clients with demonstrated expertise providing superior public human services program knowledge, automation integration design, strategic application programming, Requirements Analysis and Management, Pre and Post Implementation support, System Testing, and TCL (Transition and Change Leadership). By providing solution oriented results, she has provided direction to the business with industry standards, acceptable solutions, and achievable results. Premjeet has most recently contributed on First Data’s CalHEERs Exchange PMO and Oregon HIX Assessment projects. Eric Zimmerman, Business Consultant - Mr. Zimmerman is accomplished in healthcare with over 23 years of experience in leadership and development of state, local, and federal healthcare policy and system development. Mr. Zimmerman has knowledge of all sectors of healthcare, including Project Oversight and UAT Management. His experience in MMIS and healthcare includes claims and encounter processing, eligibility, provider processing, managed care, program management, case management, pharmacy and CMS requirements. Mr. Zimmerman has experience in 15 Medicaid state MMIS systems, as well as being an HIPAA and MITA expert. He is currently engaged in Arkansas and is providing information about other state based Health Insurance marketplaces to the Arkansas Health Insurance Marketplace board of directors. This information is used so that the Arkansas Insurance Marketplace Board of Directors can make educated decisions on the direction of their Exchange.
As we are introducing Paul Eichorn to AHIM, and he is a senior resource to the First Data Team we wanted to provide you a greater glimpse in to the breadth of his experience. We have included a Summary Resume for Mr. Eichorn on the following page.
Page 15 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 4. Staff
Paul Eichorn Background Project Manager Mr. Eichorn has experience in Information Systems and Technologies and has functioned as a
First Data Director, Senior Manager and Administrator of business systems in all stages of their lifecycle. Government Solutions, LP Mr. Eichorn developed infrastructures and sound managerial business teams, formulated and Tel 850-212-5906 effected long and short range strategic systems plans, created and enforced internal system [email protected] methodologies reducing budgets and project resource outlays. He has also been involved in Function and business and revenues management, applications and development, consulting and Specialization Public Sector implementations of large multi-facility or global installations and Information Services in Business several key industries throughout the United States. Solutions Healthcare Mr. Eichorn possesses strong communication, mentoring, and presentation skills that expertise encompass sound open communication with Upper Management, Team Members and Clients. IV&V Expertise He objectively evaluates situations on their merit and produces mutually acceptable results. Education, Additionally, Mr. Eichorn establishes sound working relationships at all levels within diverse Licenses & and complex organizations. Certifications
B.S., Biology, Virginia Professional and Industry Experience Commonwea lth University, Program Director at Global Information Services, Florida Department of Revenue 1979 Director at Public Consulting Group, oversaw several healthcare related projects ITIL Certification, Solutions Engineer at Code X, provided Enterprise Infrastructure Planning, Delivery and 2006 Implementations Project Director at Ciber, oversaw large scale project development and implementation Senior Technical Consultant at Information Resource Associates, managed enterprise systems Relevant Experience Enterprise Project Management for a large project portfolio. Provided IVV oversight for multiple State MMIS and Eligibility projects. (MS)Health Information Exchange: Acted as Program Director to State of Mississippi Governor's office, State Information Technology and Department of Health HIE Board for creation and updates to APD, ONC quarterly reporting, communications, finance and sustainability, technology and policies for the implementation of statewide HIE. (IA) State of Iowa MMIS and Integrated Eligibility Systems projects: Conducted program oversight to both projects, met and interviewed all stakeholders, provided strategy and vision guidance. (TN) Office of Information Resources: Implementation and Governance for the State’s second largest modernization project for Department of Health and Human Services Eligibility System. (HI) MMIS and HIX Projects: wrote Solution Integrator vendor RFP, updated APD and wrote Connector RFP for HIX Solution Integrator. (TN) Department of Health and Human Services: Provided Program Management for the modernization project Vision Integration Platform Eligibility System.
Page 16 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 5. References 5. References
Arkansas Insurance Department , Health Benefit Exchange Planning Project (June 2011 – Present) Cynthia C. Crone, APN, Health Insurance Exchange Planning Director 1200 West Third Street, Little Rock, AR 72201 (501) 683-3634 - [email protected] First Data is serving as the planning vendor for the state’s health insurance exchange. This initially included performing the following activities that were successfully completed September 2011: Recommended Governance Model - Evaluated the benefits and constraints of various governance models and recommended one based on Arkansas’ environment. Marketplace Analysis and Exchange Models - Documented relevant data about the insured and uninsured, defined the Arkansas insurance marketplace, and created actuarial models to project exchange utilization. Financial Model - Identified models based on the Arkansas marketplace to achieve financial sustainability without state appropriations. Program Integration Plan - Identified opportunities for the Exchange to capitalize on systems currently used in Arkansas agencies. Discussed collaboration methods, needed agreements, policy changes, etc. to make it happen. IT Integration Plan - Evaluated existing State technology to identify opportunities to leverage systems in support of the Exchange. Recommended timeline, milestones for implementation and projected budget (start-up and operations). Business (Operations) Plan - Develop a plan for routine Exchange operation including a plan for financial sustainability. Defined key operational roles (i.e. navigators, brokers, etc.) and recommended staffing. Communication/Education/Outreach Plan - Defined strategy and cost for timely dissemination of information to all impacted stakeholders, including recommendations for Call Center operations and other customer service support. Evaluation Plan - Defined how Exchange operations will be evaluated, including use of data that must be provided routinely per ACA.
Subsequent contract extensions for First Data services for October 2011 – December 2013 have First Data continuing planning efforts for the Exchange as well as seen the evolution of First Data responsibilities to include Project Management, Procurement Support and Quality Assurance activities as described below: Planning Efforts- Ongoing integration of planning efforts including facilitation of Steering Committee meetings and other Executive level meetings as needed and supporting the HBEPD Planning team in further developing the integrated operational organization. Ongoing preparations of resource needs for the support of the Arkansas components of the Exchange (job descriptions, cost projections, etc.). Project Management- Coordinating, evaluating and managing the various planning efforts across the state staff and all vendors toward the development and implementation of consistent operating procedures. Procurement Support - Planning for the program and IT solutions, including drafting of procurement opportunities, development and implementation of procurement evaluation processes. Quality Assurance – Performance of (QA) tasks including, reviewing documentation, policies, procedures, etc. for consistency and appropriateness.
Page 17 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 5. References
Arkansas Department of Human Services (ADHS) Arkansas Eligibility Independent Verification and Validation (IV&V) Project, (March 2013 – Present) Richard Wyatt, Arkansas DHS, Chief information Officer (CIO) Donaghey Plaza North, Slot N101 P O Box 1437 Little Rock, AR 72203-1437 (501) 320-3993 [email protected] First Data monitors and assesses the Software Development Life Cycle (SDLC) and the products that define the Eligibility and Enrollment Framework (EEF) Project to make sure it fulfills Federal and State project requirements. First Data will work with DHS and the Enterprise Program Management Team (EPMT) to navigate the Center for Medicare and Medical Services (CMS) gate review process. Services provided include the following: Quality Assurance/IV&V Assess the quality of the product as it is developed by formal review and assessment of design deliverables to identify potential discrepancies from established requirements and standards. Review testing procedures and results from the DDI and State testing teams to determine completeness and compliance with pre-defined test criteria, identify deficiencies and ensure cohesive interaction between required project teams. Collaborate with ADHS and the EPMT to prepare for and navigate through the CMS gate review process successfully by following the CMS Enterprise Life Cycle.
Technical Quality Assurance Support First Data provides dedicated resources to observe the EEF project technical team operation by: Monitoring Affordable Care Act (ACA) compliance and attainment of ADHS functional requirements. Providing consultative input to the Project Management Office (PMO) and ADHS project leadership, as deemed necessary. Ensuring that risks are identified and managed in a timely manner. Providing specialized assessment focused on: 1) Security Compliance and 2) Test planning and test management.
Business Process Reengineering Quality Assurance Support First Data provides dedicated resources to observe the EEF project teams by: Concentrating on rapidly reengineering operational service delivery processes to monitor ACA compliance and adherence to the business architecture selected by the governance board. Providing consultative input to the PMO and ADHS project leadership, as deemed necessary. Ensuring that risks are identified and managed in a timely manner. Providing specialized independent assessment focused on: 1) Client and User Support Contact Center design and implementation and 2) Organization Change Management (OCM) implementation.
Project Integration IV&V / Quality Assurance Support First Data understands the importance of the implementation of the ACA and the enacted Arkansas health care legislation, including the Health Care Independence Act. Therefore, First Data provides dedicated resources to support IV&V and enhanced program management level Quality Assurance support to ADHS that: Monitors effective integration between the Eligibility and Enrollment Framework, Arkansas Health Insurance Partnership Exchange and the Health Care Independence Act Medical Frailty determination and Shopping Experience projects. Works collaboratively with CMS to ensure that federal and state stakeholder interests are addressed promptly.
Page 18 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 5. References
California Health Benefit Exchange, California Health Benefit Exchange Procurement Assistance, Project Management and Technical Support (October 2011 – Present) Karen Ruiz, Project Director 2329 Gateway Oaks, Suite 100 Sacramento, CA 95634 (916) 999-3214 [email protected] In June 2012, Exchange contracted with First Data, to provide Project Management and Technical Support Consulting Services to support State project staff during the Design, Development and Implementation (DDI) of the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS). Procurement Assistance Services - Developed, under the direction of the Exchange, a solicitation document that was used to acquire the services of a private sector vendor to develop and operate certain functions of the Exchange. This included: Drafted an initial version of the solicitation document for state partners review and incorporated the changes to the draft as resulting from state partners review and make solicitation document available for public review and comment. Completed the Board-ready solicitation document Completed the evaluation and scoring documentation for use by the evaluation team Responsible for managing the compilation of the solicitation document components and for drafting most of the content, in collaboration with the Exchange. Introduction and Background Solicitation Process and Schedule Vendor Qualifications Vendor Scope of Work Evaluation Criteria Proposal Preparation Instructions
Project Management and Technical Support - First Data is providing a full-time, on-site team of project management, business analyst, and technical architecture consultants to assist in the management and oversight of the CalHEERS DDI. The First Data team functions as an integral component of the State's CalHEERS project management team, supporting the State in executing its responsibilities for managing the CalHEERS DDI, including: Ensure effective and efficient coordination of project management activities. Work collaboratively with the SI’s PMO to ensure that project management activities are conducted in a coordinated manner and that alignment of standards, methods and tools is maintained. Track SI DDI performance to plan. Monitor all SI plans and plan components, including schedules, for progress against plan, SI compliance with contractual obligations, plan modifications and effective integration of SI plan components. Develop the communication plan and manage stakeholder communications. Perform independent issue and risk management. Participate in DDI activities, including, requirements elicitation, Joint Application Design (JAD) sessions, reviews, workgroup participation walkthroughs, test planning, testing and test results review, assess quality of work, effectiveness of processes and other aspects of SI performance. Review and assess deliverables. Coordinate and facilitate periodic federal Gate Reviews throughout the DDI phase. Coordinate and facilitate all project activities, processes and expectations associated with federal Gate Reviews. Lead the planning, development and execution of User Acceptance Testing. Review system diagrams, models, technical workflows, technical specifications, technical design deliverables and other technical design artifacts developed by the SI for compliance with contract terms and conditions, conformity with applicable standards, quality of work and conformity with the Centers for Medicare and Medicaid Services, Federal, State, and DHCS enterprise architecture and MITA requirements for adaptable, sustainable, and integrated information technology management. Review technical components by performing code reviews and performing other technical assessments to support evidence-based findings, conclusions and recommendations.
Page 19 Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services 6. Cost 6. Cost
The AHIM Board has requested a Cost proposal including position titles and hourly rates. The costs for this proposal will be invoiced at an hourly rate. All hourly rates are inclusive of any travel or travel related expenses.
Role Estimated Hours Hourly Rate Executive Oversight 96 $165 Project Director 1040 $165 Senior Business Consultant 1440 $150 Business Consultant 2960 $125 ACA Policy Expert 240 $170 Business Planning/Actuarial Services 240 $170 Manager Total 6016
The proposed costs for this 6-month duration effort will be invoiced at an hourly rate and are not to exceed $857,440. 6.5 Executive Director Role
First Data is prepared to support the AHIM Board with the services of an Executive Director role on an interim basis if requested. First Data is proposing an experienced management team that is already prepared to lead the team through the AHIM Board’s requested approach. To accommodate the Executive Director role First Data would augment the team with the following roles.
Role Estimated Hourly Rate Hours/Month Project Management Consultant 160 $125/hour Administrative Support 320 $30/hour Total 480
The costs for this proposal will be invoiced at an hourly rate in addition to the base 6- month effort estimate. All hourly rates are inclusive of any travel or travel related expenses.
First Data is prepared and looks forward to an opportunity to discuss alternative staffing models and/or solutions per request by the AHIM Board.
Page 20
Proposal to Provide Professional Consulting Services
PRESENTED TO THE ARKANSAS HEALTH INSURANCE MARKETPLACE
- COPY -
FEBRUARY 18, 2014
Proposal to Provide Professional Consulting Services for the Arkansas Health Insurance Marketplace February 18, 2014
Table of Contents
ABOUT HEALTH MANAGEMENT ASSOCIATES ...... 2
QUALIFICATIONS AND PRIOR EXPERIENCE ...... 3 Overview ...... 3 State Marketplace Experience ...... 3 Federal Marketplace Experience ...... 4 Issuer Marketplace Experience ...... 4 The HMA Project Team ...... 5 HMA’s Breadth of Experience ...... 6 Evidence of Financial Sustainability ...... 7
PROPOSED APPROACH ...... 8 Overview and Project Timeline ...... 8 Phase 1: Strategic and Operational Assessment ...... 8 Phase 2: Designing and Establishment of State-Based Marketplace ...... 9 Project Staffing and Structure ...... 10
STAFF BIOGRAPHICAL INFORMATION ...... 12
REFERENCES ...... 16
COST PROPOSAL ...... 18
Page 1 Proposal to Provide Professional Consulting Services for the Arkansas Health Insurance Marketplace February 18, 2014
ABOUT HEALTH MANAGEMENT ASSOCIATES Health Management Associates (HMA) is a national consulting firm with a proven track record and expertise in every aspect of publicly financed health care, including but not limited to Medicaid and CHIP program design and implementation, Marketplace development and implementation at the state and Federal levels, health care delivery system and payment reform, insurance market analysis, health economics and finance, information technology (IT) planning and implementation, program evaluation, policy analysis and development, and data analytics. HMA is widely regarded as a leader in providing technical and analytical services with a special focus on addressing the needs of the medically indigent and underserved. Publicly financed health care is more than our focus — it defines us. Our people set us apart. We know the policy, programs, financing and what it takes to get the job done. Government agencies, public and private providers, health systems, health plans, institutional investors, and foundations all turn to HMA for advice, counsel, and support. HMA is a private, for-profit “C” corporation, incorporated in the State of Michigan in good standing and legally doing business as Health Management Associates, Inc. Founded in 1985, Health Management Associates has 15 offices from coast-to-coast as shown in the following map (Figure 1). FIGURE 1: HMA OFFICES HMA has clients across the country including local, state, and federal governments, major safety net health systems, and private sector providers. Moreover, HMA has extensive experience and expertise in the implementation of the Affordable Care Act (ACA) – in the manner that works best for states with different priorities and challenges – and the design and implementation of health care programs, particularly with respect to delivery system and payment reform, care integration, and management. The staff of HMA is composed of over 120 professional health care managers and analysts, most of whom have over twenty years of experience in the health and human services fields, including senior professionals with long experience in state and federal health programs. HMA brings a strong interdisciplinary expertise to clients. Staff backgrounds include program development, management, and evaluation; health economics; health system organization; public health policy and administration; health care finance and reimbursement; clinical services; managed care; pharmacy benefit design and management; social work, and information systems. Since the passage of the Affordable Care Act, HMA staff has been actively engaged in assisting states and other stakeholders develop the infrastructure to comply with the law’s requirements and optimize its opportunities.
Page 2 Proposal to Provide Professional Consulting Services for the Arkansas Health Insurance Marketplace February 18, 2014 QUALIFICATIONS AND PRIOR EXPERIENCE Overview HMA has played an integral role in the planning, formation and establishment of Insurance Marketplaces through its work with the federal government and several states. HMA teams have been involved in comprehensive Marketplace planning engagements in 10 states and territories. Through foundation-funded projects, we have provided assistance to additional states. We have also worked with health plans and other private sector clients during the initial implementation process and provided support to a state legislature seeking to assess Marketplace planning. Finally, we have worked as a subcontractor on a technical assistance contract with the Center for Consumer Information and Insurance Oversight (CCIIO) within the U.S. Department of Health and Human Services (HHS). As a result, the HMA team is prepared to partner with the AHIM to identify and address the complex challenges of implementing a state-based insurance Marketplace (SBM) in Arkansas along with the requisite regulatory, operational, and system changes. Our experience will enable us to quickly and efficiently assess and describe options, identify key questions, access available knowledge sources, and create a Marketplace implementation plan that meets Arkansas’ needs. Additionally, our team will be able to “hit the ground running”, which we recognize is of utmost importance to the AHIM. Our Marketplace-specific experience spans the following: • Marketplace strategic and operational planning, particularly around identification of threshold decisions and policies, operations, and information technology (IT) architecture primarily focused on the eleven core areas of a Marketplace; • Comprehensive analysis of local insurance market dynamics including the impact of the Marketplace on the market; • Stakeholder engagement and “solution brokering” to address governance, business operations, program evaluation and reporting, and information technology; • Preparation of Marketplace establishment grant applications; • In-depth information system analysis and design work; • Implementation support including facilitation of interactions with CCIIO staff on the management of the SBM and eligibility and enrollment information systems projects – our team is versed in the enterprise life cycle stage/gate review process that CCIIO is using to oversee these projects; and • Ongoing consulting services to states and Marketplaces as the health care market evolves and new issues (e.g. IT functionality and performance issues) emerge.
State Marketplace Experience We have assisted Tennessee, South Dakota, Puerto Rico, New York, Nebraska, Michigan, Massachusetts, Iowa, Illinois and Connecticut in various dimensions of Marketplace formation and operation. Some of these states implemented SBMs, while others eventually decided to defer to the Federally-Facilitated Marketplace (FFM). Like Arkansas, Illinois is also in the process of transitioning from a state partnership
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Marketplace (SPM) to an SBM. In addition, we are currently under contract to work with the state of Washington’s SBM. Finally, we performed a detailed analysis of the proposed financing plan and the IT contracting and procurement plans of Vermont’s SBM for that state’s legislature. The following table summarizes HMA’s experience working on Marketplace projects in various states and territories: TABLE 1: HMA MARKETPLACE EXPERIENCE BY TOPIC AREA
cost cost
nge support analysis planning planning modeling Excha feasibility assessment operational operational Stakeholder Stakeholder applications engagement Marketplace and resource resource and Strategic and Strategic Marketplace Insurance market market Insurance IT implementation implementation IT IT architecture and architecture and IT establishment grant grant establishment Tennessee (multiple) South Dakota Puerto Rico Nebraska New York Connecticut Iowa Illinois Michigan Massachusetts Vermont
Our Marketplace planning engagements have been deemed unequivocally successful by our clients, and in states where contracting rules have permitted it - Michigan, Illinois and Tennessee - HMA remains an ongoing support resource to state Marketplace planners even after the end of the initial contract period.
Federal Marketplace Experience HMA has worked closely with CCIIO as a major subcontractor on a technical assistance contract. Under the terms of this contract, HMA assisted CCIIO in studying commercial insurance markets and quality promotion strategies. Following these studies, HMA helped CCIIO understand the most promising strategies for making quality-related information available to consumers and purchasers in a user- friendly and accessible platform. Currently, in the next phase of this engagement, we are surveying Patient Safety Organizations (PSOs) and leading providers on best practices to improve patient safety to assist CCIIO in implementing the quality requirements for QHPs.
Issuer Marketplace Experience HMA has also been deeply engaged in the process of implementing Marketplaces from the perspective of issuers. Throughout 2013, HMA led a number of complex and time-sensitive initiatives with issuers, including new Consumer-Operated and Oriented Plans (CO-OPs), and state and federal leaders (through state-based, partnership and federal Marketplace models) to effectively offer QHPs and to enroll
Page 4 Proposal to Provide Professional Consulting Services for the Arkansas Health Insurance Marketplace February 18, 2014
members in coverage for the 2014 open enrollment period. This collaborative work included creating and implementing outreach and education initiatives, assisting plans in fulfilling network adequacy requirements, particularly for Essential Community Providers, developing member-centric policies, leading the testing and implementation of enrollment, facilitating financial and provider data transactions between Marketplace entities and issuers, and resolving complex implementation challenges. HMA staff also worked with issuers that wanted to assess the feasibility of offering QHPs in their state’s Marketplaces; to that end we developed a capability assessment methodology and tool set which covered the key Marketplace-related business functions (eligibility and enrollment, plan management, financial management, customer service, communications and program management) and the IT functionality that issuers would need to perform these functions effectively. We believe that our extensive work with issuers will prove particularly useful to AHIM because our team gained considerable insight into how the initial implementation of some SBMs and the FFM were experienced “on the ground.”
The HMA Project Team HMA’s project leadership and staff who will work on the team include individuals with hands-on experience in designing, developing, budgeting for, and operating a health insurance Marketplace; expertise in healthcare coverage programs and the ACA; leadership in stakeholder engagement and governance; proven capacity in information technology systems assessment and architecture; sophistication in business process analysis; and proficiency in the development of operational procedures. • Project Director Tom Dehner, JD has led seven major Marketplace planning projects at HMA and was substantially engaged in work for other state Marketplaces. Before joining HMA, Mr. Dehner was the Medicaid Director of Massachusetts during the establishment of the Massachusetts Health Connector and was a member of its Board of Directors. Mr. Dehner is deeply involved with health reform and Marketplace planning issues on a state and national level. • Task Lead Barbara Smith, JD was a senior policy advisor on Exchanges in CCIIO before becoming founding director of the Consumer Operated and Oriented Plan (CO-OP) Program. In that capacity, Ms. Smith established 23 new insurance organizations based on stakeholder governance according to Marketplace requirements and policy goals. Having worked at the intersection of program creation and Marketplace implementation, Ms. Smith has an intuitive and informed sense of the federal dynamics involved in ACA implementation. • Task Lead Stephanie Chrobak, MHSA has worked very closely with health plans in the implementation of Covered California and was Director of Program Management and Director of Operations at the Massachusetts Health Connector before joining HMA. Ms. Chrobak has an in- depth understanding of the operational challenges of interfacing plans and an SBM and of the realities of running a Marketplace. • Task Lead Juan Montanez, MBA is an information technology planning, design and implementation expert who has helped several states develop IT strategies for their Marketplaces. Mr. Montanez led the IT capability assessment phase of Connecticut’s
Page 5 Proposal to Provide Professional Consulting Services for the Arkansas Health Insurance Marketplace February 18, 2014
Marketplace planning project and led the team of Illinois officials that developed data flows and system interfaces for the future Marketplace in that state. Mr. Montanez also led the Marketplace feasibility assessment and planning project for the Commonwealth of Puerto Rico. Mr. Montanez has a comprehensive grasp of what it takes to stand up Marketplaces and has extensive project management experience. To support these internal resources, the HMA team will also include Senior Advisor Rosemarie Day, who has participated in most of HMA’s Marketplace planning and implementation support projects. Ms. Day, the founding Deputy Director and Chief Operating Officer of the Massachusetts Health Connector, is the President of Day Health Strategies, a consulting firm specializing in the implementation of health reform. Ms. Day has a deep understanding of the people, processes, and technology needed to fully implement an SBM and has extensive experience implementing large-scale health care programs. The project core team is not the complete list of HMA staff with relevant qualifications, and we will draw upon additional HMA staff as needed to serve the imperatives of the project. HMA staff who will support this project on an as-needed basis include: • Dianne Longley, former Director of Health Insurance Initiatives for the Life, Health and Licensing Division at the Texas Department of Insurance who possesses a keen sense of the private market dynamics at play in the implementation of Marketplaces; • Joan Henneberry, MBA, a longtime state government leader who served as Planning Director for Colorado’s SBM prior to joining HMA; and • Wade Miller, the former Chief Information Officer of Georgia’s Department of Community Health; Mr. Miller is currently supporting the state of South Dakota in the IT implementation of the FFM in that state. Specific project roles for this team are described in more detail in the description of HMA’s staffing structure in the Proposed Approach section of this response.
HMA’s Breadth of Experience In addition to the specific Marketplace projects that HMA has successfully completed or is working on today and the detailed implementation experience of our project team members, HMA will bring to AHIM a partner that has a sophisticated understanding of the progress of ACA implementation and of the unique circumstances present in Arkansas. Because of the innovative structure of Arkansas’ Medicaid Private Option waiver and its national importance, HMA has had a dedicated team that has reviewed the waiver in detail and continues to track its implementation as well as other states’ efforts to emulate it. HMA has deep roots in Medicaid policy and longtime experience in the development and implementation of Medicaid program innovations, including Section 1115 demonstration waivers (e.g. the Texas 1115 waiver approved by CMS in December 2011) and various forms of Medicaid premium assistance programs. Many clients have asked HMA to assess the implications of the Private Option waiver, and as a result, HMA will combine an understanding of the waiver with our in-depth understanding of the interaction of Marketplaces and state Medicaid programs to help support the ongoing integration of the Private Option into SBM functions.
Page 6 Proposal to Provide Professional Consulting Services for the Arkansas Health Insurance Marketplace February 18, 2014
It is worth emphasizing the critical nature of IT to the success of AHIM and any Marketplace implementation project. HMA has extensive expertise in information system assessment, architecture development, design and implementation. Members of the project team have worked with states to design and develop eligibility and enrollment systems and to ensure interoperability with health plans, the Federal Marketplace, and the federal data hub. For example, we are currently working on an IT project in which an HMA staff member is serving as a functional manager for an eligibility IT project in Massachusetts. In South Dakota, an HMA team is providing project management services for a state ACA eligibility project, including connecting the system with the FFM. Finally, our team knows Arkansas. Starting a number of years ago, we participated in the evaluation of the Covering Kids and Families initiative by the Robert Wood Johnson Foundation; as part of this project we conducted focus groups and site visits in Arkansas. We have tracked the performance of the state’s Medicaid Primary Care Case Management program and its impact on patient outcomes, costs, and population health. We have analyzed and reported on the Private Option waiver and its pathway to adoption. Familiar with many of Arkansas’ major providers, we have followed recent activity and developments in the public and private health care delivery system. We understand the insurance market dynamics in Arkansas and the interaction of the state’s insurers with the small business community and providers that have important implications for the SBM.
Evidence of Financial Sustainability Health Management Associates, Inc. has a long history of sustained growth and financial stability. Since its establishment in 1985, HMA has grown steadily in size and revenues, with over 135 employees and 15 offices strategically located throughout the country. For the year ended December 31, 2013, HMA had assets exceeding $14.5 million and annual revenue in excess of $45 million. HMA’s success, continued growth, and solvency for almost 30 years are the result of sound financial management utilizing fiscally responsible practices and procedures designed to ensure stability. HMA is able to provide a detailed financial statement upon request. In addition to demonstrating financial stability over the years, HMA has taken steps to ensure that we are able to maintain our independent status by establishing an Employee Stock Ownership Plan (ESOP) effective March 31, 2008. The creation of an ESOP can establish a market for the ownership shares of a closely held company and provide for ownership continuity that will ensure HMA’s independence and avoid the creation of a potential conflict of interest. The following table shows HMA’s growth in staff and revenue over the last four years: TABLE 2: HMA STAFFING AND REVENUES BY FISCAL YEAR # Employees Revenues (at year-end) 2010 85 $21.7 million 2011 96 $31.0 million 2012 128 $39.0 million 2013 135 $45.1 million
Page 7 Proposal to Provide Professional Consulting Services for the Arkansas Health Insurance Marketplace February 18, 2014 PROPOSED APPROACH
Overview and Project Timeline Our approach to the Arkansas SBM project recognizes that the creation of an SBM is a substantial undertaking. The Arkansas Health Connector is successfully operating, and it is essential that the SBM project not interrupt that work. At the same time, we know from reviewing the state’s most recent establishment grant request that AHIM and AID understand that transitioning to an SBM is also a very significant and complex effort. Moreover, the Private Option waiver adds a unique element to AHIM that generates different imperatives in its business requirements and stakeholder engagement. We note that this approach is meant to define the first six months of activity after AHIM selects a professional services consulting firm, even though the SBM project will extend well beyond this six- month period. Nevertheless, we think the six-month timeframe provides a useful checkpoint to assess overall how well-formed the plan is, what resources are missing, and what changes to the approach will be required to ensure that the AHIM is fully operational by July 1, 2015 and prepared to enroll individuals in the Arkansas SBM starting in October 2015 for plan year 2016. We recommend that the six-month engagement (March – August 2014) with HMA have two primary phases as illustrated in Figure 2 (below): FIGURE 2. PROJECT PHASES
Phase 1 Phase 2 Strategic & Operational Assessment Design & Establishment of State-based Marketplace Estimated duration: April - August (and ongoing) Estimated duration: March-April
Phase 1: Strategic and Operational Assessment We propose beginning the SBM project with a short, intensive, and collaborative assessment of the state’s SBM strategy, existing operations, and systems that might be germane to establishing and running an SBM. This important ‘level setting’ phase will help HMA understand the goals of AHIM as a state-based model, create consensus among Arkansas’ leadership, and identify areas that Arkansas currently believes need attention and management. Based on our experience, we recommend a team approach to this phase that includes an assessment of the spectrum of capabilities AHIM could include in its SBM while leveraging certain capabilities in the federal Marketplace (e.g. risk adjustment) to avoid duplication and reduce costs.
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The result of this intensive process will be an SBM vision statement, a high level transition project plan, and the creation of a project structure that includes workgroups or subprojects. We also anticipate that this process will identify how to best ensure stakeholder engagement in the overall project.
Phase 2: Designing and Establishment of State-Based Marketplace Using the approved deliverables from Phase 1, we will begin the process of designing a comprehensive SBM transition and establishment plan. This phase will entail working on the ground with people from AHIM, the Arkansas Insurance Department, the Arkansas Medicaid program, and other private and state stakeholders. We believe that the success of this design phase will ultimately depend on a close alignment between HMA and AHIM, working together to achieve the goals of the project. In this phase, we will create a specific transition plan developed in cooperation with CCIIO to move from a partnership model to an SBM. This transition plan would include establishing how the state will transition records and manage transactions-in-progress from the FFM to the SBM as well as a clear cutover plan that works for both Arkansas and CCIIO. The plan will include, at a minimum, the areas required to ensure compliance with Federal regulations and CCIIO’s eleven “Exchange Areas”. HMA expects that the areas that will need to be covered by the transition plan in one fashion or another will reflect the required Exchange Areas. The important element of planning, however, is prioritizing and organizing those activities. Taking into account the intensive assessment process, HMA can perform the following tasks: • Providing planning and technical assistance for forums or other avenues for stakeholder engagement • Identifying and drafting regulations, policies, and operating procedures that will guide the performance and governance of the SBM • Serving as liaison to state and Federal officials, SBM partners, and vendors to ensure seamless operation and buy-in • Creating a financial sustainability model that will work in Arkansas’ market and governing environment • Identifying information system changes and enhancements to existing enrollment and eligibility systems and other relevant systems • Establishing how the SBM will interface with the federal data hub and, if/as needed, the FFM. • Determining areas of needed expertise and assisting with procurement of resources (e.g. by supporting RFP drafting or contract negotiations) • Identifying functional areas and IT components that may benefit from business process outsourcing (BPO) and IT service outsourcing (ISO) solutions. While this process is taking place, there is an imperative to file an establishment grant application by May 15. We intend to use the process of developing the establishment grant to support the creation of the transition and establishment plan – and we recognize that we must do both activities in parallel. HMA is experienced with the establishment grant process and will be able to ensure that the activities
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necessary to create the grant documents are complementary to the overall project. HMA is also very experienced with the Implementation Advance Planning Document (IAPD) process that CMS uses to extend Medicaid IT funding for major projects; we may recommend that this process be invoked to obtain funding for eligibility and enrollment system changes and interfaces. By the sixth month of the project, we propose to transition to SBM implementation mode. As part of this transition we would work with AHIM and relevant state agencies to define processes for the oversight of implementation activities, stakeholder engagement, BPO and ISO procurement, and information systems design, development, and implementation Throughout the engagement, we will routinely provide in-depth research and analysis on issues related to SBM formation, consistent with our research capabilities across all domains of health care. Additionally, defining the roles and leadership attributes of the AHIM executive team and developing a plan for promptly recruiting and hiring leadership is an important priority in establishing a successful state-based Marketplace and managing the transition. However, HMA is able and willing to provide interim executive leadership in early stages of this engagement, and we will work with Arkansas leadership on an Executive Director recruiting plan.
Project Staffing and Structure The HMA Team will be organized functionally and staffed to ensure we have ready resources available throughout our engagement. Figure 3 is an organizational chart indicating task leads and other HMA resources for each subject area. FIGURE 3: HMA TEAM - ORGANIZATIONAL DIAGRAM
Project Director Tom Dehner
Policy and Regulatory, Stakeholder Business Operations and Information Technology Engagement, and Functions Governance
Task Lead Task Lead Task Lead Barbara Markham Smith Stephanie Chrobak Juan Montanez
Dianne Longley Rosemarie Day Rosemarie Day Joan Henneberry Wade Miller
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The initial strategic assessment, which will include assessing the political and regulatory environment in Arkansas and discerning expectations of the AHIM Board and other relevant staff, will be managed out of the Policy and Regulatory, Stakeholder Engagement, and Governance subject area. Because we believe that IT must be informed by and driven by business imperatives, the initial operational and IT capability assessment will be led jointly by the Operations and Functions and Information Technology task leads. We also recommend that together with AHIM we appoint an executive team with a defined scope and charter to support the management of the project. A description of the Project Executive Team and more detail on what is encompassed in each SBM project subject area is included in Figure 4. FIGURE 4: PROJECT EXECUTIVE TEAM DESCRIPTION
SBM PROJECT EXECUTIVE TEAM Team: Executive Director (interim or permanent), HMA Project Director, AHIM Project Director, HMA Subject Area Leads, AHIM/AID Subject Area Leads Charter: • Strategic planning & vision for state-based Marketplace • Creation of SPM to SBM transition milestones and success measures • Overall accountability, program oversight, decision making and issue resolution
SBM PROJECT SUBJECT AREAS
Policy & Regulatory Marketplace Operations Information Technology (IT) Stakeholder Engagement and Marketplace Functions Governance
Legal authority and Product strategy, plan Establish required IT capabilities governance management and SHOP by Marketplace function
Federal liaison and Marketplace business model IT capabilities: current-state and stakeholder engagement and business operations gap assessment
Establishment Grant Operational capabilities: Establish IT capability acquisition current-state and gap strategy (build vs. buy vs. partner) assessment
Marketplace Blueprint Establish operational Contracts/MOUs capability acquisition strategy (build vs. buy vs. partner)
Contracts/MOUs
HMA recognizes the importance of the Exchange core areas, and we are very familiar with the use of those areas for the purposes of Establishment Grants and the Marketplace Blueprint. In fact, certain core areas are explicitly included in the subject areas described above. Organizing Marketplace planning
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and implementation work, however, will necessarily entail activating much more detailed, ground-level activities designed to operationalize a new enterprise. In addition, as noted throughout this proposal, we anticipate working very quickly with the state to assess the situation at the Arkansas Health Connector and AHIM, and we will be flexible to modify our project structure to suit the needs we identify. That noted, we believe the proposed project structure will prove useful in making sure that we have a team in place that can support all of the needs that arise over the course the project.
STAFF BIOGRAPHICAL INFORMATION As discussed in the preceding section, the core HMA team for this project will be comprised of Tom Dehner, Barbara Markham Smith, Stephanie Chrobak and Juan Montanez. HMA staff we anticipate working on the project include HMA Senior Advisor Rosemarie Day, Dianne Longley, Wade Miller, and Joan Henneberry. Additional staff will be drawn upon as needed. The brief biographical sketches of the named HMA staff members are included below. We are happy to provide detailed resumes upon request.
TOM DEHNER, MANAGING PRINCIPAL Tom Dehner is a managing principal in HMA’s Boston office, providing assistance to states, health plans, providers and foundations in the areas of Medicaid policy and operations, health reform implementation, and strategic planning. Before joining HMA, Tom was the Director of the Commonwealth of Massachusetts Medicaid Program, known as MassHealth, overseeing a health insurance program that covered 1.1 million members, with a $9 billion budget and a workforce of over 800. In this role, Mr. Dehner led implementation and federal approval of the Medicaid-related components of the Massachusetts Health Care Reform law. In addition to his duties as Medicaid Director, Tom served as a member of the Board of the Commonwealth Health Insurance Connector, the public entity charged with facilitating implementation of the Commonwealth’s health care reform effort to make available affordable health insurance to all residents of Massachusetts. Tom was also a member of the Council of the Massachusetts e-Health Institute, a public corporation created to advance the dissemination of health information technology across the Commonwealth.
BARBARA MARKHAM SMITH, JD, PRINCIPAL Barbara Markham Smith, JD, is a principal in the Washington, DC office of Health Management Associates. Prior to joining HMA, she was the founding Director of the CO-OP Program Division at the Center for Consumer Information and Insurance Oversight at the Department of Health and Human Services. Under her leadership, new nonprofit, consumer-governed health insurance companies have become operational in almost half of the country. She previously served as Policy Coordinator for Exchanges and as a Senior Advisor in the Office of Health Reform during the Congressional debate leading to the passage of the Affordable Care Act. In her capacity as a consultant prior to her government service, she worked with Health Management Associates, the Economic and Social Research Institute, and the Institute of Medicine. Ms. Smith is an expert on health insurance coverage and coverage expansion, financing, delivery system reforms, and the impact of health reform on government budgets, institutions, and programs. She is the author of numerous articles and published studies on health reform and the effects of policy changes on government health programs and access
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to care. While at the Institute of Medicine as a senior program officer, she analyzed quality initiatives in federal health programs. While at George Washington University School of Public Health as a Senior Research Scientist, she conducted research and analysis on Medicaid managed care implementation and the effects of the Balanced Budget Act of 1997 on Medicare. During health care reform in 1993-94, she was a senior health policy aide in Congress to Representative Jim McDermott who served on the House Ways and Means Subcommittee on Health. She is a graduate of Harvard College and Boston University Law School studying in a joint curriculum with the Harvard School of Public Health.
STEPHANIE CHROBAK, PRINCIPAL Stephanie Chrobak has more than 20 years of experience in the public and private health care sectors, including 16 years of leadership experience in private health insurance. In her most recent role, Stephanie served as the Director of Program Management for the Massachusetts Health Connector, the model for health insurance exchanges in national health reform. She was responsible for the oversight of two programs that covered 250,000 Massachusetts residents, Commonwealth Care and Commonwealth Choice. At the Health Connector, Stephanie also played a leadership role in strategic and transformation planning for the 2014 Massachusetts Exchange. In this role, she developed an in- depth knowledge of the Affordable Care Act. Her areas of expertise include subsidized eligibility and coverage policy, individual and small group market reforms, business operations, external party negotiations and management, web-based member experience, and outreach and education. Prior to her role at the Health Connector, Stephanie held a number of leadership positions at Tufts Health Plan, a New England health plan with nearly 1 million covered lives. Highlights of her tenure at Tufts Health Plan include business operations, budget development and management, customer service, provider reimbursement and business process re-engineering, and incorporating technology solutions. Stephanie is known for her strong leadership and collaboration skills, strategic visioning, and managing and leading highly complex initiatives. Stephanie earned a Master of Health Services Administration from the University of Michigan and Bachelor of Arts, with honors, from Western Michigan University.
JUAN M. MONTANEZ, MBA, PRINCIPAL Juan has more than twenty years of experience and an extensive knowledge base that encompasses information technology, financial planning, business process optimization, strategic planning, cost- benefit analysis, government procurement and project management. Recently Juan led the multi-disciplinary team that worked with the Puerto Rico Department of Health on the feasibility assessment and planning of a Health Insurance Marketplace for the Territory. Juan has also worked on several Medicaid Management Information System (MMIS) and eligibility and enrollment system projects with government and private sector clients. Additionally, during his time at HMA Juan has led an eligibility system reengineering initiative in the state of California and several health plan IT readiness assessment projects. Finally, Juan has served as HIT/HIE solution architect to several states and provider organizations seeking to establish health home and accountable care organization (ACO) programs. Before joining HMA was a senior consultant at a firm subsequently acquired by Mercer. While at that firm Juan led MMIS, encounter data management system and health information technology initiatives
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in Florida, Georgia, Hawaii, New Mexico, Tennessee and the U.S. Virgin Islands. Juan also provided project management and readiness assessment leadership to numerous managed care system implementations including implementations in the aforementioned states. Juan was also a key player in the design and implementation of Puerto Rico's Government Health Insurance Plan; Juan's role included project plan development, procurement strategy and facilitation of proposal evaluation teams. Juan is also a highly recognized expert in cost-benefit analysis and return-on-investment analysis in the public sector; while at the firm subsequently acquired by Mercer Juan led the cost-benefit/return-on- investment analysis phase of the Minnesota Health Care Connect project which led to reengineered eligibility and enrollment processes for Minnesota's health care programs. Prior to his work as a consultant Juan served as senior advisor to Georgia's Chief Information Officer, Director of Strategic Research and Analysis for Georgia’s Department of Community Health, and Budget Director and IT Manager with a thirteen-hospital system in the Atlanta metropolitan area. Juan holds a Bachelor of Science in Engineering from the Massachusetts Institute of Technology and a Master of Business Administration from the Georgia Institute of Technology.
ROSEMARIE DAY, PRESIDENT, DAY HEALTH STRATEGIES Rosemarie Day is the President of Day Health Strategies, a consulting firm specializing in the implementation of health reform. She served as the first Deputy Director and Chief Operating Officer for the Commonwealth Health Insurance Connector Authority. In this role, she was responsible for developing the operational strategy to implement many of the key pieces of Massachusetts’ landmark health care reform legislation. She joined the Connector as its second hire in July of 2006. Prior to joining the Connector, Ms. Day served as Chief of Staff to the Dean of the John F. Kennedy School of Government at Harvard. Ms. Day has over 16 years of leadership experience in Massachusetts state government. She served as the Chief Operating Officer for the MassHealth program which provides Medicaid coverage to 1 million people in Massachusetts. Prior to that, she served as an Assistant Secretary of Administration and Finance, ran the state’s Child Support Enforcement Program, and was the Budget Director for the Department of Transitional Assistance. Ms. Day holds an AB in Public Policy from Stanford University, and she graduated from Harvard’s Kennedy School in 1992 with a Master of Public Policy.
DIANNE LONGLEY, PRINCIPAL Ms. Longley joined HMA as a principal in January 2011. Prior to joining HMA, Ms. Longley was Director of Health Insurance Initiatives for the Life, Health and Licensing Division at the Texas Department of Insurance. Her primary responsibilities included directing research, data collection and analysis related to health insurance, health technology and health care issues, and providing technical assistance to various legislative committees. She also had responsibility for directing implementation of federal health insurance reform and oversaw Department activities related to implementation of several legislative initiatives designed to improve health care transparency as it relates to reimbursement and health insurer payment issues. From 2001 through 2006, she served as Director of the Texas State Planning Grant Program, a comprehensive five-year study of the uninsured, and continues to coordinate the Department’s efforts to expand health insurance coverage in Texas, including implementation of the recently enacted Healthy Texas Program for small employers. Her professional appointments include
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the National Workgroup for Electronic Data Interchange (WEDI) Board of Directors, Governor’s Health Care Policy Council, East Texas Rural Healthcare Access Program, National Uniform Claim Committee, Texas Health Care Information Council, and the Texas Hospital Data Advisory Committee. She holds a Bachelor of Science from Texas A&M University.
JOAN HENNEBERRY, PRINCIPAL Joan Henneberry joined HMA in January 2012 after serving as the Planning Director for the Health Insurance Exchange in Colorado, where she developed the strategic plan for the establishment of an exchange, staffed the first board of directors, monitored and responded to proposed rules and regulations, and developed four work groups of stakeholders and experts to advise the planning process. From 2007-2011, Joan served on the cabinet of Governor Bill Ritter, Jr. as the executive director of the Department of Health Care Policy and Financing, the state agency responsible for public health insurance programs including Medicaid and CHP+. She was the senior health policy advisor to the Governor, developing and implementing policies and programs that expanded the availability of public health insurance programs for the State of Colorado. Between 1997 and 2004 Joan held several positions at the National Governors Association in Washington, D.C., including Director of Health Policy. Joan serves on several state and national boards and advisory committees and serves on the board of Senior Support Services in Denver. She has a master’s degree in management from Regis University, and completed the Senior Executives in State and Local Government program at the Harvard University, Kennedy School of Government in 2008. Joan was the 2011 recipient of the John Iglehart Award for Leadership in Health Policy from The Colorado Health Foundation.
WADE MILLER, PRINCIPAL Wade Miller is a Principal for HMA in our Atlanta office. Mr. Miller has more than 20 years of experience in the Health and Human Services industry with extensive experience in Medicaid policy, Medicaid systems testing and implementation, managed care and health care claims processing. Having worked for two state Medicaid programs (Arizona and Georgia), he brings direct experience from a Medicaid operations perspective and combines that with his private sector consulting experience to provide customers with information to allow them to make informed decisions and solutions that meet their needs. He is a strong, disciplined leader with experience leading large system development projects, performing quality assurance activities, project management, technical writing assistance, MITA assessments, systems analysis, system testing and independent verification and validation (IV&V) services. Prior to joining Health Management Associates (HMA), Wade was an Executive Consultant with FourThought Group Inc. for the past seven years where he served in various consulting roles including Client Executive, Project Manager, IV&V Lead, Systems Analyst, MITA Assessment Specialist, and CMS Certification Specialist. Additionally, Wade served over five years as the Georgia Department of Community Health (DCH) Chief Information Officer. As DCH CIO, Wade led the departments Information Technology Division which is responsible for providing network and infrastructure support to the entire department. Wade was responsible for the Departments Information Technology Strategic Planning, was a member of the State’s Technology, Standards and Protocol Committee and was responsible for the Fiscal Agent Systems
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development and maintenance efforts. He served as the DCH IT liaison with the CMS Atlanta Regional Office and wrote all Advance Planning Documents to secure federal funding for DCH initiatives. A results-oriented team player, who can effectively manage staff, Wade is adept in understanding and communicating the customer’s needs in order to complete projects timely, efficiently, and meet customer expectations.
REFERENCES
MICHIGAN HEALTH INSURANCE EXCHANGE PLANNING Christopher Priest Health Policy Advisor, Office of Governor Rick Snyder (formerly, MiHealth Exchange Project Director, Office of Licensing and Regulatory Affairs): P.O. Box 30013 c/o Christopher Priest Lansing, Michigan 48909 517-241-4072 office 703-231-3756 mobile 517-335-6863 fax [email protected] Brief Summary of Project: Throughout 2011, and under an extension of the contract through 2012, HMA served as the prime vendor for Health Insurance Exchange planning services for the State of Michigan. HMA and its partners managed a comprehensive stakeholder facilitation process, completed research tasks related to Health Insurance Exchange planning, assessed implications of ACA insurance market changes and Medicaid expansion options, and presented the state with a comprehensive work plan for Health Insurance Exchange implementation. Subsequent to the initial planning contract and report, HMA was engaged to provide additional assistance, including a demographic and insurance market modeling project completed in partnership with Dr. Jonathon Gruber and the actuarial firm Milliman.
STATE OF ILLINOIS DIVISION OF INSURANCE – INSURANCE EXCHANGE NEEDS ASSESSMENT PLANNING AND A TECHNICAL ASSESSMENT OF THE ENROLLMENT VERIFICATION AND ELIGIBILITY SYSTEM DESIGN Colleen Burns Special Counsel for Health Policy, Office of Illinois Governor Pat Quinn 100 W. Randolph 16th Floor Chicago, IL 60601 [email protected] (312) 814-1236 Brief Summary of Project: HMA was awarded a contract to complete a needs assessment to support Illinois Health Insurance Exchange planning activity and to develop an enrollment, verification, and eligibility system for individuals seeking Exchange‐based and Medicaid health coverage. Under the original contract, the HMA team was tasked with: projecting likely costs associated with implementing
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an Exchange in Illinois, including new staff, infrastructure, information technology, and outreach costs; developing a comprehensive summary of necessary changes in state insurance regulation associated with new requirements established by the ACA and creation of a state Health Insurance Exchange; completing an analysis of the likely impact Illinois’ Health Insurance Exchange would have upon other state programs; providing a review of the current eligibility processes and information technology tools; determining federal requirements for eligibility, verification, and enrollment (EVE) identifying options available to the state and developing a plan and budget for EVE. In 2012, this contract was extended to include a detailed Navigator planning project. That project, based on Illinois’ decision to become a State Partnership exchange and further federal guidance on consumer assistance, transformed to include the Navigator program and a state-run “in-person assistance” program to provide consumer assistance. Activities included: a survey of over 20 external stakeholders determined by the state; the development of consumer assistance program options; the identification of funding and grant compensation approaches for consumer assistance; and a set of recommendations for design of a consumer assistance program.
VERMONT JOINT LEGISLATIVE FISCAL OFFICE; INDEPENDENT REVIEW OF EXCHANGE BUDGET Stephen A. Klein Fiscal Officer, Legislative Joint Fiscal Office One Baldwin Street, Drawer 33 Montpelier, Vt. 05633 802-828-5769 office 802-828-2483 fax [email protected] Brief Summary of Project: In April 2013, on behalf of the Vermont Legislative Joint Fiscal Office, HMA provided an independent analysis of estimated state costs for operating a state-based Exchange in Vermont. HMA summarized and analyzed the existing Vermont Health Connect operating budget, utilizing establishment grant information and other data submitted to the legislature, information available from other states planning for state-based exchanges, and HMA’s own knowledge of budget considerations and issues in such states. The evaluation resulted in a presentation of HMA’s findings to the legislative committees dealing with exchange financing issues and to legislative leadership.
TENNESSEE HEALTH INSURANCE EXCHANGE PLANNING AND ESTABLISHMENT Brooks Daverman Strategic Planning and Innovation Group, Division of Health Care Finance & Administration (formerly, the Tennessee Insurance Planning Initiative): 310 Great Circle Road Nashville, TN 37243 615-532-3163 office 615-741-0028 fax [email protected] Brief Summary of Project: In Tennessee, HMA was one of three firms being utilized under a “blanket” or “convenience” contract by the Department of Finance and Administration. Work under the contract
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addressed aspects of the planning and design of an Exchange as the state was contemplating a state- based or partnership Exchange. HMA’s work was wide-ranging and included: • Developing a work plan with the State to develop and submit its Insurance Exchange Establishment grant applications (the first was submitted September 2011; a second one in December 2011, and a third in March 2012). • Writing and editing a comprehensive white paper that examined key Exchange policy questions, explained relevant options and the advantages/disadvantages of each, and summarized the State’s recommendation for implementing a state-based Exchange. • Researching and writing a report on provider network adequacy standards for QHPs (See work sample). • Drafting an approach and contract language for the SHOP Exchange. • Reporting on a detailed examination of options for mitigating non-payment of premiums on the individual Exchange, and recommending QHP contract requirements associated with premium payment. • Conducting an assessment of internet and web-based access across the state of Tennessee. • Designing a program of training and certification for brokers working with the Exchange. • General strategic and implementation planning as the state assessed the opportunity to establish a state-based Exchange.
COST PROPOSAL The rates below are provided by position title or staffing category. These rates as proposed are fully- loaded, i.e. they incorporate allocated indirect costs and – in the case of our onsite rates – they cover costs of travel associated with on-site work in Little Rock. Offsite hourly rate Onsite hourly rate Principal $295 $350 Senior Consultant $250 $305 Consultant $175 $225 Research Assistant $125 N/A
As noted in this proposal, HMA is willing to provide an Interim Executive Director and has experience doing so for health insurers and health delivery systems. We assume that the cost structure for such a position, should it be required, could be different than our base rates and we are happy to discuss this topic when there is more information about the duration and character of the need.
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ARKANSAS HEALTH INSURANCE MARKETPLACE PROFESSIONAL SERVICES PROPOSAL MANATT/LEAVITT RESPONSE
TABLE OF CONTENTS
PROJECT OVERVIEW ...... 2 TECHNICAL PROPOSAL ...... 3 Our Approach ...... 3 Work Stream 1: Strategy and Operations Planning ...... 4 Work Stream 2: Establishment Grant and Blueprint Development ...... 9 Work Stream 3: Communication and Liaison Activities ...... 10 Work Stream 4: Project Management ...... 11 STAFFING & PROJECT TEAM ...... 11 Staffing Plan ...... 11 Project Team Biographies ...... 12 CORPORATE BACKGROUND, QUALIFICATIONS & REFERENCES ...... 15 About Manatt, Leavitt Partners and Oliver Wyman ...... 15 Team Qualifications ...... 16 Strategy and Operational Plan Development ...... 16 Establishment Grant and Blueprint Development ...... 17 Communication and Liaison Activities ...... 17 Project Management ...... 17 References ...... 19 COSTS & CONTRACTING ...... 19 Costs ...... 19 Contracting…………………………………………………………………………………………………………………………………… 20
Redacted - Available for Public Review Organization Contact Info: Primary Contact Info: Manatt Health Patricia Boozang, Managing Director 7 Times Square, 7 Times Square New York, NY 10036 New York, NY 10036 (212) 790-4500 (212) 790-4523 [email protected]
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PROJECT OVERVIEW
. . . a . . .
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Arkansas Health Insurance Marketplace (AHIM) Request for Proposal Manatt/Leavitt Response
Work Stream 1: Strategy and Operations Planning
The following summaries provide a high-level and preliminary assessment of issues that the Team would expect to discuss with the Board as focal points for the Gap Analysis.
Legal Authority & Governance. Act 1500 addresses the three major legal authority and governance requirements for establishing an SBM: state authority to meet federal requirements, which is vested with the Board; a governing body for the SBM which is accomplished through creation of AHIM; and authority to provide long term funding, which is addressed by the power to establish an assessment or user fee to operate the SBM. Act 1500 gives the Board the necessary prerequisites to pursue a Level 2 establishment grant (funding to implement and run an SBM through its first year of operations) by the fall of 2014. The Manatt/Leavitt team will outline the strategic considerations associated with Level 1 and Level 2 establishment funding, including the timelines for AHIM to spend the funds under each of these grant authorities. With this foundationRedacted in place, the Team’s - Availa Gap Analysis will le focus on the federal requirements for public accountability, transparency, and conflict of interest protections. These issues will be more challenging with a non-profit governance model, where public accountability is not “baked in” as it would be with a state agency. We will provide examples from previously-approved SBMs, including non-profit models in Colorado, Hawaii, and New Mexico, to give the Board a range of policy options in each of these areas.
Consumer and Stakeholder Engagement & Support. It is imperative the AHIM meets the needs of all Arkansas residents. To help accomplish this, the Team will work closely with the Board to develop a stakeholder engagement approach that builds on past efforts, including identifying key stakeholders from a variety of
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perspectives such as consumer groups, tribal representatives, employers, healthcare providers, community representatives, insurance carriers, brokers, and government leaders. This approach is designed to elicit a broad range of ideas and expertise in a highly collaborative manner.
The Team proposes to work with the Board to leverage existing stakeholder engagement activities, to the extent appropriate, to establish an AHIM Stakeholder Work Group.1 The Stakeholder Work Group will serve in an advisory role, informing the Board in policymaking decisions and providing a forum for stakeholder input. Their purpose will be to provide specific feedback on any Marketplace areas that warrant detailed discussion such as outreach materials, Call Center options, the Marketplace Website, Navigator Program development, plan management, and the role of agents and brokers.
Based on Gap Analyses and other reviews of State program operations, the Team can assist the Board in identifying the issues to be addressed by this stakeholder group as well as provide necessary materials (e.g., white papers, relevant articles, bulletins, etc.) to inform and aid their decision-making process. The Team proposes to assist the AHIM Board with facilitation of the Stakeholder Work Group meetings as necessary, including meeting schedules, meeting logistics and preparing summary reports.
Eligibility and Enrollment. Eligibility and enrollment (E&E) is the most complex aspect of Marketplace functionality and poses the highest risk to successful Marketplace operations, as evidenced by the troubled operations of the FFM and several SBMs since October. AHIM is uniquely positioned with respect to “E&E” functionality given that the State has several critical building blocks al eady in place for its Private Option, including: (1) an online and paper single streamlined application for insurance affordability programs; (2) the Arkansas eligibility/enrollment framework (EEF) supported by the IBM/Curam eligibility rules engine for Medicaid and Private Option eligibility determinations; (3) the Hewlett Packard (HP) Private Option portal, through which consumers shop among and select qualified health plans (QHPs); and, (4) QHP enrollment functionality administered by Arkansas Division of Medical Services (DMS) that transmits Private Option enrollments to QHP issuers.
Through the Gap Analysis, the Team will evaluate the policy, business requirements and technology underlying each of these existing building blocks against Marketplace E&E requirements and industry best practices, and develop for the Board’s consideration options and recommendations for building robust Marketplace E&E capacity. Such options may include building on and expanding the current IT systems to support QHP and APTC/CSR eligibility determination. As such, the Team will conduct an analysis of current systems and make recommendations as to their reuse for AHIM. Arkansas also has the option to develop a service to process eligibility determinations for the individual responsibility exemption, or, defer to the federal exemption service as most state Marketplaces (with the exception of Access Health CT) have done.
Recognizing the importance of ensuring a “no wrong door” path for all AHIM users, the Gap Analysis will be conducted with an eye to ensuring that consumers are able to successfully enroll in Medicaid, ARKids, the Private Option, or a commercially available health plan, through a seamless, integrated process across these coverage options.Redacted The Gap Analysis will- includeAvailable in-depth interviews for with Public state agencies Review and stakeholders that will directly interface with the AHIM as well as an analysis of E&E operating procedures for other state health programs and how they can be efficiently integrated with the AHIM.
As part of the Gap Analysis, the Team will also evaluate existing notices and eligibility appeals resources supporting the Private Option to determine whether these resources can be leveraged to support AHIM. Manatt subject matter experts (SMEs) have worked extensively with HHS and SBMs to develop model, compliant
1 Discussed further in Work Stream 3
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Marketplace notices and appeals processes, and are ideally positioned to quickly evaluate and provide options and recommendations to the Board with regard to these key aspects of E&E functionality.
Plan Management. Arkansas has a solid foundation for the plan management function through its SPM. The Arkansas Insurance Department (AID) started a Plan Management Advisory Committee (PMAC) in early 2012 and that group has worked with insurers and other stakeholders on many of the key plan management issues, including how to manage issuer certification and rate and form reviews to maximize competition across the State’s seven rating areas. The AID issued more than a dozen bulletins in 2013 that translated policy decisions into an operational plan for the four issuers and 71 individual plans that were approved for the 2014 enrollment season. Manatt worked closely with the AID and DMS on Bulletin 7, which spelled out key details on integrating the Private Option into the AID review process.
Through the Gap Analysis, the Team, in collaboration with our partners at Oliver Wyman, will evaluate the 2014 experience and provide the Board with options for improvement, based in part on analysis of what has worked best in the 14 current SBMs, as well as next steps with the Private Option. Key issues looking ahead are integrating health savings accounts (HSAs) into the Private Option, refining the State’s approach to QHP oversight and complaint resolution, accrediting QHPs and requiring quality reporting, Reviewand expanding outreach to new prospective entrants to the AHIM because of the Private Option and other market-oriented plan management practices. A critical priority underlying all plan management work will be effective translation of policy decisions into simple and streamlined business rules to avoid the IT problems that have plagued the FFM and some SBMs. The Team is well versed in every one of these challenges through work with states and the federal government. Public
Financial Management, Risk Adjustment and Reinsurance. With a transition to an SBM, the Board will need to consider whether to administer risk adjustment or allow HHS tofor continue to do so, and whether to use the HHS risk adjustment model or select an Arkansas-specific approach. While only a single state, Massachusetts, currently administers its own risk adjustment program, Arkansas will want to seriously consider whether administering its own risk adjustment program would be valuable and, if so, whether doing so is realistic for the 2016 benefit year. Because the Arkansas individual market includes Private Option enrollees, the health status and utilization for the Arkansas individual market may be substantially different than it is for other states, resulting in inaccuracies when the HHS riskAvailable adjustment model is applied in Arkansas. The regulatory and technical requirements- for risk adjustment will evolve over the next few years. Several members of the Team, including our Oliver Wyman partners, have been involved in implementing risk adjustment and have deep working knowledge of the HHS-HCC model and the anticipated impact it will have on market strategies around pricing, product design, and provider contracting. Relying on this expertise, actuarial modeling and experience in Arkansas and other states in 2014, the Team will present the Board with an analysis of whether Arkansas should pursue administering risk adjustment for 2016.
Arkansas will also need to determine whether to administer the transitional reinsurance program for 2016, however this decisionRedacted is less complicated. Because 2016 is the last year for this program to operate under the federal rules, it seems unlikely that it will be helpful for Arkansas to build infrastructure to administer this program for a single year, though Arkansas could choose to operate such a program under state law beyond 2016.
Finally, the Board must also decide what role, if any, AHIM will play in processing premium payments for the individual market. If the SBM does process payments for initial or ongoing payments, the Board must establish policies to ensure payments are accounted for and made securely and efficiently.
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Small Business Health Options Program (SHOP). Although Powell and Associates estimates that there are 28,000 small employers (under 50 employees) not offering health insurance in Arkansas, the SPM has not been able to make much progress on SHOP because the FFM has delayed online enrollment, employee choice, and most other aspects of SHOP implementation until 2015. In addition, only one insurer filed QHPs for SHOP in Arkansas and offered only three plans for the 2014 enrollment period. The AID has a contract with the Arkansas Small Business and Technology Development Center for outreach to the small business community that should provide helpful input on how to best reach the full potential of the SHOP, but much more remains to be done.
The consensus among experts on the small business market is that the most promising value-add for SHOP is the extension of employee choice to small employers, who traditionally have not been able to offer more than one or two choices to their employees. ACA regulations require SHOPs to offer at least one employee choice model starting in 2015, under which employees can choose among all plans offered on the SHOP on a single metal level, but the regulations allow SBMs to require broader choice models and many have done so, though progress has been slow in this first year. The Team has worked with several states on employee choice models and could advise the Board on the various approaches states are using to reach the small employer market, where tax credits are more limited than in the individual market and therefore not as significant as an enrollment incentive. Other key Blueprint requirements are premium aggregation, a required service to make employee choice manageable for small employers; compliance with eligibility and enrollment rules for SHOP that accommodate the rolling enrollment and participation requirements unique to this market sector; and electronic reporting to the IRS.
Organization & Human Resources. In a recent report by Manatt on successful SBMs,2 key findings included the importance for Marketplaces to stay nimble in order to respond to shifting circumstances. To that end, the Team will provide recommendations on an organizational model that is unique to Arkansas, while preserving the flexibility and scalability required to adjust to changes and accommodate future contingencies. The Blueprint is straightforward with regard to this area, requiring “an appropriate organizational structure and staffing resources to perform Exchange functions.” This flexible standard recognizes the fact that states are widely divergent in size and political culture.
For human resources, several experts, including the first director of the Massachusetts Connector, have emphasized that the Marketplace is fundamentally an insurance store and should rely heavily on staff who understand marketing and sales of health insurance. The director of the Connecticut Marketplace, one of the most successful to date, subscribes to this view and recently opened two retail stores to go with the state’s online insurance store.
The Team will leverage its current relationships with SBMs and research effective organizational structures and Human Resources models of successful SBMs, and in particular SBMs with a non-profit, non-governmental governance mode We will offer the Board options for organizational structure, desired skill sets, levels of staffing, and other key organization-building issues. We will view these different options through the following guiding principRedactedles: - Available for Public Review . Clearly defined leadership structure comprised of individuals with appropriate skills, capabilities, experience and organizational autonomy to advance the interests of the AHIM; . A short-term and long-term plan for technical and administrative staff in operationalizing AHIM and maintaining fiduciary soundness as AHIM matures; . Compensation and employment parameters that enables AHIM’s competitiveness in Arkansas’ labor market;
2 Report from the States: Early Observations About Five State Marketplaces, available at: http://www.statenetwork.org/wp- content/uploads/2013/12/State-Network-Manatt-Report-from-the-States-Early-Observations-about-Five-State-Marketplaces.pdf
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. Properly sizing marketplace operations critical for providing high service quality while remaining cost- efficient; and, . Strategies to leverage the capabilities of outside entities on a provisional and cost effective basis.
Finance & Accounting. The Team will work closely with the Board to develop a financial plan that ensures that AHIM’s expenses are adequately planned for, accounted for, and funded. The Team will assist in developing financial projections for AHIM expenses, what an appropriate level of user fee would be, and how it should be collected. The Team is mindful of the Arkansas view that the 3.5% federal user fee is too high and that Arkansas should be able to manage the AHIM on a 2.5% user fee States have wide discretion in how they fund SBMs, so the Team will provide options that could be used instead of or as a supplement to user fees. One aspect of this will be to develop a comprehensive and compliant Cost Allocation Plan (CAP) for the activities associated with the planning and operations of the AHIM, such that costs associated with Private Option related enrollees are appropriately accounted for and allocated to Medicaid. The level of complexity of the CAP will ultimately be determined by the breadth and level of integration between AHIM and other state programs.
Technology/IT Systems. Developing an adaptive and agile IT implementation strategy for AHIM will be critical to its successful launch, ongoing operations, and meeting the needs of all Arkansas residents. Indeed the failures and false starts of the FFM and several SBMs have been in large part due to poor technology planning and implementation. The Team proposes to work with the AHIM Board and state personnel and vendors as necessary to develop an AHIM strategic technology and IT systems plan. The objectives of this plan will be to help the Board define its strategy and business priorities with respect to technology development and ensure the AHIM is compliant with the CMS Guidance for Exchange and Medicaid Information Technology Systems and meets the following CMS requirements:
. Technology and system functionality complies w th relevant HHS IT guidance, including the CMS Guidance for Exchange and Medicaid IT Systems; . Has the adequate technology infrastructure and bandwidth required to support all of the Exchange activities; and, . Effectively implements IV&V, quality management, and test procedures for Exchange development activities and demonstrates it has achieved HHS defined essential functionality for each required activity.
To accomplish this, the Team will work with the Board, state personnel and current IT vendors, as necessary, to (1) define the future architecture and create a technical roadmap for AHIM and (2) conduct an IT Gap Analysis to evaluate Arkansas’s legacy IT infrastructure and new technology components supporting the Private Option to identify gaps, mitigation needs, and any inconsistencies with respect to federal requirements and the technical roadmap. The AHIM strategic technology and IT systems compliance plan will include recommendations to address any identifiable gaps or inconsistencies.
Reuse of proven and vetted technologies has the potential to significantly reduce AHIM costs, resources and time to launch.Redacted As such, this plan will -also Available include a comprehensive for analysis Public and recommendations Review of SBM technologies that have been successfully rolled out in other states like Connecticut, Kentucky, Washington, etc.
The Team also proposes using the analysis and recommendations to assist the Board with the development of technology and IT systems business rules and scope of work that could be used for any future AHIM technology implementation procurements, including those related to privacy and security infrastructure needs, discussed below.
Privacy & Security. The security of individually identifiable information is of utmost importance and the Team proposes working with the Board, State personnel and State vendors, as necessary, to develop an AHIM
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strategic privacy and security compliance plan. One of the objectives of this plan will be to assist the Board with meeting the privacy and security requirements outlined in 45 CFR § 155.260(a) - (g), including appropriate safeguards based on HHS IT guidance and protections for Federal information.
The Team proposes to accomplish this by assisting the Board and applicable state personnel with conducting an analysis of the current privacy and security standards in State programs including Medicaid. The Team will use this analysis to identify any potential gaps and develop recommendations to address them.
Oversight & Program Integrity. AHIM will be required to comply with oversight and program integrity requirements articulated in the ACA and implementing HHS and IRS regulations. The Marketplace will be required to submit an annual financial report, an external audit, and frequent operational performance and eligibility determination reports to HHS and Treasury. As a new private, non-profit entity responsible for services affecting nearly all Arkansans, the Marketplace will need to display a high degree of transparency, competency, and program integrity. As a result, AHIM will require a system of internal control, program integrity and reporting capacity that reflects the best practices of public and private markets.
As part of the Gap Analysis, and leveraging the work described under the Financial Management section, the Team will evaluate existing state program integrity and reporting resources, including capacity of Arkansas’s Medicaid program, Employee Benefits Division, and Insurance Department. The Team will identify private market best practices for mitigating fraud, waste and abuse including without limitation: effective ERP/Financial Management systems, planning, forecasting, and budgeting processes, timely account reconciliation, vendor oversight, procurement management, grants management, effect ve internal controls, payment process oversight, and Sarbanes-Oxley-like control environments.
Based on the Gap Analysis and our extensive experience in Marketplace oversight and operational reporting, the Team will develop an operational plan for the Board that focuses on mitigating financial risk, ensuring the integrity of programs it administers, and meeting key federal and state reporting requirements.
Work Stream 2: Establishment Grant and Blueprint Development
With only four dates left to secure Level 1 o Level 2 grants in 2014, and with little likelihood of Congress or HHS extending funding opportunities beyond 2014, the window is narrowing for the State to prepare and submit Exchange Establishment grants Having been awarded five Level 1 grants, Arkansas has already secured approximately $57M in federal funding to stand up and operate an SPM. The last grant award of $3.5M is dedicated to supporting engagement with consumers and stakeholders and research on other states’ SBM implementation to establish an SBM within Arkansas.
Given the magnitude of developing and implementing an SBM, there is no doubt that Arkansas will require significant, additional funding. However, as the first state to transition from an SPM to an SBM, Arkansas has already established key Marketplace The Team has supported functions and stands to benefit from the lessons learned from initial SBM planning and or submission of states and secondRedacted-generation technology - Available solutions. for Public EstablishmentReview Grants or Blueprint Applications in The Board has noted its intent to submit a Level 1 Establishment Grant on Idaho, Missouri, Mississippi, th May 15 and may leverage additional application submission opportunities in New Mexico, North Carolina, August, October and November. The Team has provided a half dozen states Pennsylvania, and provided with hands-on assistance in submitting successful Exchange Establishment training for many other grant applications. The Board’s Establishment Grant application(s) will rely states. heavily on the Gap Analysis set forth in Work Stream 1. Once gaps have been identified, we will work with the Board and AHIM executive staff to develop the AHIM Strategy and Operations
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Plan, targeting achievable design and implementation solutions for SBM operations beginning in 2015. The Strategy and Operations Plan will include a staffing and staffing ramp-up plan and anticipated vendor procurements to be supported through establishment funding. Based on the Gap Analysis and Strategy and Operations Plan, the team will be able to write the Establishment Grant application narrative and move to sizing the budget request, developing the budget justification and providing a detailed work plan by Marketplace activity. We also suggest working with the appropriate State agencies and leadership to secure needed letters of commitment as soon as feasible.
There may be a pathway by which the Board is prepared to submit up to two exchange establishment funding applications by the end of 2014, whether Level 1 and/or a Level 2 applications. A key consideration will be the funding “ask” within each grant, and when it makes sense to leverage the Level 2 three-year performance period versus the Level 1 one-year performance period, with some extensions available on each type of grant.
Arkansas will also be required to submit a Blueprint application for an SBM by June 15, 2015 to begin operations for the 2016 coverage year. The Team has extensive experience in assisting states with their Blueprints, including providing Blueprint training for the 11 states in the Robert Wood Johnson Foundation (RWJ) State Health Reform Assistance Network, and has successfully guided states through the CMS/CCIIOReview establishment review process. With the intricate knowledge and familiarity of Blueprint requirements and establishment reviews, the Team has an in-depth understanding of CCIIO’s expectations and processes, as well as checklist to support pulling documentation together, such that it can expedite the AHIM Blueprint.
Similar to the consultative process employed with the Establishment GPublicrant, the Team will work with the Board on the integral components of the Blueprint. Some components consist of strategic goals, implementation timelines, gap analyses of system competencies, plans to develop new capabilities, and core policy decisions. If requested during this project phase, the Team will work with thefor Board to integrate these components into a Blueprint framework, resulting in a draft Blueprint customized to the Board’s vision, needs, and resources.
Work Stream 3: Communication and Liaison Activities
Arkansas’s move to an SPM and implementation of the Private Option has already required significant collaboration among State agencies and stakeholders. To meet the needs of all Arkansas residents, the transition to an SBM will continue to require collaborationAvailable and communication under a new paradigm as the Board establishes its scope of responsibility -and new issues arise beyond those addressed in SPM planning. As the AHIM Board and executive staff move forward with SBM planning and implementation, the Team will aid in the development of a formal communications hierarchy and framework to support priority setting and decision-making. A well-defined organizational structure and regular communication are critical for AHIM mission attainment. We are aware that the creation of an SBM requires input from a variety of entities involved and suggest convening two work groups: the AHIM Agency Work Group and the AHIM Stakeholder Work Group as highlighted on page two ).
The Team will Redactedwork with the Board to build on existing work group infrastructure, as appropriate, or develop a new work group structure. The Board will determine the policy and issue areas for which it seeks input and/or buy in from its work groups. For example, AHIM may want the Stakeholder Work Group3 to weigh in on employer/employee choice in SHOP, key QHP certification requirements (e.g., network adequacy), and consumer engagement strategies. The Board may want the Agency Work Group, which will be comprised of key agency liaisons, to weigh in on items such as appeals coordination and collaboration, QHP participation requirements and, perhaps most importantly, IT procurement and governance considerations. Given the quick
3 Composition of the MSW is addressed in Work Stream 1 under Stakeholder Engagement
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timeline for decision-making, we suggest standing meetings with each work group to raise and address items as needed. The Team will support work groups through development of agendas, meeting materials, facilitation of meetings, and documenting Team members have worked with meeting notes and recommendations. Arkansas DHS and AID to develop the Private Option, and are adept The Team will also act as liaison with key federal agencies including at understanding the relationships CMS/CCIIO, OIS and IRS. We envision this contact at a number of between agencies in Arkansas. We different levels, and in conjunction with already established have also convened and facilitated communication channels that Arkansas has with CMS and CCIIO, Marketplace stakeholder groups in specifically with Arkansas’s CMS State Exchange Group State Officer and North Carolina, Maryland, CMCS SOTA lead. The Team has well-established relationships at both the Missouri, Virginia and other states. leadership and staff levels within CCIIO, which we can leverage to the benefit of AHIM. We also anticipate working in concordance with the Board to coordinate establishment reviews. In addition to being a direct liaison with CMS/CCIIO and other key federal agencies, we can advise the Board on how best to approach CCIIO as key policy and operations issues that require resolution at the leadership level.
Work Stream 4: Project Management
Immediately after contract execution, we will have a kick-off meeting (in-person or virtual, depending on Board preference) with the Board and its designees. During the kick-off mee ing, the Team and the Board will discuss the strategic goals and principles for the project, review the Team s proposed approach, and address timing and specific, immediate project needs identified by the Board and executive staff.
Informed by the kick-off session, the Team will develop a comprehensive work plan which will be used to manage the project. The work plan will highlight the major project tasks and deliverables, including individual activities and corresponding timelines, to ensure our internal processes and deadlines allow for meeting project requirements and the Board’s needs as they are identified.
The Team proposes weekly calls with the Board or its project management designee(s). The purpose of these calls will be to track progress against the work plan, raise questions and identify any risks to the plan/timeline and corresponding mitigation strategies To bolster communication with the Board and ensure broader transparency, we will craft monthly written progress reports that can be disseminated to a broader audience.
Finally, we note that the Team has worked together extensively. Manatt and Leavitt have a solid working relationship having worked in Arkansas, Mississippi and other states prior to this effort. Manatt and Oliver Wyman worked extensively in North Carolina on a long-standing engagement. Because of these relationships, we already have established communication channels between our teams, and are used to working jointly to craft deliverables and meet deadlines. STAFFING & PROJECTRedacted TEAM - Available for Public Review Staffing Plan
We have assembled a highly qualified team to deliver unparalleled depth and breadth of expertise, experience, and capabilities. Patricia Boozang will lead the project and provide her substantive knowledge of Marketplace functions and infrastructure as well as her knowledge of the Arkansas healthcare market, State agencies, and the Private Option. Joel Ario and Brett Graham will provide strategic direction and substantive expertise. Sharon Woda will serve as Project Manager, combining extensive experience in project management with substantive knowledge of Marketplace development. Figure 2 provides an overview of the proposed team.
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Arkansas Health Insurance Marketplace (AHIM) Request for Proposal Manatt/Leavitt Response
Brett Graham, Partner and Managing Director (Leavitt Partners)/Senior Advisor. Mr. Graham provides strategic advisement and resources to a variety of insurance exchange clients, including: states; national, regional and state national health insurance carriers; payer associations; exchange technology firms; and others. He has significant expertise in the private health insurance practice, specifically leading the operations and sale of a regional administrator of self-funded benefit plans to Meritain Health, now owned by Aetna. Following the transaction, Mr. Graham led the post-merger integration and was a member of Meritain’s strategy team. Before his time at Meritain Health, he worked as Vice President at UnitedHealth Group within the Ingenix business unit. Mr. Graham was previously a Management Consultant with the Boston Consulting Group where he worked with senior business leaders to develop growth strategies for Fortune 100 clients.
Sharon Woda, Director (Manatt)/Project Manager. Ms. Woda advises public sector clients on how to implement new healthcare programs and works with payers and other private sector compan es to understand healthcare reform implications. She has worked Maryland, North Carolina, New York, California, Michigan, Rhode Island and Colorado on various aspects of exchange implementation. Many of these efforts required multi-stakeholder collaboration. Ms. Woda is also an experience project manager, managing multi-million dollar market reform work for a state Department of Insurance where she advised on market reforms and assessed capabilities and requirements for implementing plan management. Ms. Woda also managed several efforts addressing the design and development of Maryland’s Navigator program, advising the Marketplace on considerations for deploying a Navigator model.
Robin Arnold-Williams, Partner (Leavitt Partners)/Exchange and Medicaid Regulatory Guidance. Ms. Arnold- Williams directs Leavitt Partners’ Medicaid and Provider practices. With knowledge gained over a 30-year career in public service, Ms. Arnold-Williams can help AHIM navigate complex interagency regulatory issues and refine operational processes. Ms. Arnold-Williams has over a decade of experience leading large state-level health and human service agencies. In her most recent role, Ms. Arnold-Williams served as Secretary of Washington State’s Department of Social and Health Services (2005-2008, 2011-2013). She was responsible for the administration of Medicaid, aging and disability services, mental health, finance, technology, and regulatory functions.
Deborah Bachrach, Partner (Manatt)/Private Option Integration. Ms. Bachrach has more than 25 years of experience in health policy and financing in both the public and private sectors and an extensive background in Medicaid policy and healthcare reform Ms. Bachrach has served as an advisor to the Center for Health Care Strategies, the Medicaid and CHIP Payment and Access Commission (MACPAC), the Robert Wood Johnson Foundation and the Kaiser Family Foundation as well as state Medicaid agencies, foundations, healthcare providers and other healthcare organizations.Most recently, Ms. Bachrach was the Medicaid Director and Deputy Commissioner of Health for the New York State Department of Health, Office of Health Insurance Programs. Ms. Bachrach is the project director of Manatt’s work on the Arkansas Private Option.
Matt Graham, Project Manager (Leavitt Partners)/Project Management. Mr. Graham has over a decade of project and client management experience, in both the public and private sectors. His primary focus in healthcare is tracking and evaluating the evolving capabilities of exchange technology vendors and the platforms they support. RedactedMr. Graham has also conducted - Available primary research for to ascertain Public and docu Reviewment health plan, employer, and broker sentiment regarding public and private exchanges. Prior to Leavitt Partners, Mr. Graham served as VP of Business Development for Gaiacor Management, a privately held international agricultural management company. In this capacity, he identified, developed and presented new business opportunities to management, investors and foreign government officials.
Michael Kolber, Associate (Manatt)/ACA Regulatory Support. Mr. Kolber is an associate who counsels health systems, managed care plans, technology firms, and other stakeholders on complex regulatory and compliance issues affecting their business. His practice focuses on ACA implementation, Medicare and Medicaid managed
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care and employee benefits issues. Previously, Mr. Kolber was an attorney in the CMS Division in the Office of the General Counsel at HHS He served as lead legal advisor to federal policymakers on central elements of health reform and provided counsel on the formation of Marketplaces and risk adjustment, reinsurance and risk corridor programs. He also advised HHS on defining the essential health benefits package and operating the Pre- Existing Condition Insurance Plan program.
Joseph Ray, Managing Director (Manatt)/Financial Modeling and Analysis. Mr. Ray provides business and technology strategy, planning, process analysis and implementation services to providers, payors, state governments and other healthcare organizations, with an emphasis on health information technology. Mr. Ray has significant experience in project management, financial and data analytics, process redesign, and systems gap analysis with respect to health IT. His experience includes directing statewide, multistakeholder health information exchange planning efforts, developing cost and revenue models, identifying funding streams, and shaping strategies for the long-term viability of state exchanges. He managed a state’s health benefit exchange system design and development process, which included coordinating the state’s IT gate eviews with CCIIO.
Daniel Schuyler, Senior Director (Leavitt Partners)/Exchange Planning and Implementation. Mr. Schuyler combines functional exchange knowledge and expertise with a notable background in IT, to assist state agencies, lawmakers, payers, technology vendors, brokers and others in navigating the technical challenges associated with public health insurance exchanges. Prior to his work with Leavitt Partners, Mr. Schuyler was the Director of Technology for the Utah Health Insurance Exchange. Mr Schuyler was responsible for defining the technical goals and business processes associated with the exchange as well as with the first of its kind statewide defined contribution market. He successfully worked with technology vendors, state agency project directors, and insurance carrier IT managers to optimize development for time, cost, quality and predictability. Mr. Schuyler has extensive software, programming and IT project management experience.
Laura Summers, Director (Leavitt Partners)/Marketplace and Medicaid Policy. Ms. Summers guides state governments in planning and developing Marketplaces, playing a lead role in stakeholder engagement activities as well as in helping states develop and secure Exchange Establishment Grants. Additionally, she played a central role in the team that successfully helped states develop 1115 Medicaid expansion waivers and amendments. As part of this team, Ms. Summers has provided states with detailed assessments of the demographics and health conditions of the expected Medicaid expansion population, developed Medicaid 1115 demonstration proposals that include Private Option like elements, and is currently working with the State of Arkansas to design amendments to its Private Option program. Prior to joining Leavitt Partners, Ms. Summers served as Research Director for Utah Foundation.
Tammy Tomczyk, Actuarial Principal (Oliver Wyman)/Actuarial Support and Marketplace Rules. Ms. Tomczyk has over 20 years of experience assisting health plans, HMOs and State/Federal regulators evaluate risk. Her primary experience includes pricing, reserving, provider contracting, and product development. Over the past few years she has assisted several states and CCIIO prepare for implementation of the ACA. She is the primary architect of Oliver Wyman’s ACA microsimulation model, and with it has assisted several states in making key policy decisionsRedacted based on the modeled - impactAvailable of Federal reforms for on rates. Public Ms. Tomczyk Review has a solid understanding of the ACA rating requirements, and has assisted several health plans and HMOs develop, price and file ACA compliant products. She is also deeply familiar with the HHS-HCC risk adjustment model and has studied the impact that the program will have on various populations and payer types, and the potential market reactions as it relates to benefit design, provider networks, and pricing. She is a Fellow of the Society of Actuaries and a Member of the American Academy of Actuaries.
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Arkansas Health Insurance Marketplace (AHIM) Request for Proposal Manatt/Leavitt Response
Team Qualifications
The Manatt/Leavitt Team offers deep subject matter expertise, a strong understanding of state priorities and decision-making processes, skilled management of complex engagements and a thorough understanding of the Arkansas landscape. The Team has worked together in Arkansas previously. The Team’s qualifications and relevant experience are described below and are organized by Work Stream. See also Table 1 at the end of this section for a list of engagements by capability.
Strategy and Operational Plan Development
Ensuring AHIM can navigate the pathway toward meeting Marketplace requirements and making strategic decisions necessary to transition from an SPM and an SBM will be critical to success. The Manatt/Leavitt Team brings first-hand experience working with state agencies as they prepare to become SBMs. Our team combines this expertise with a deep working knowledge of the Arkansas landscape as a result of our work to develop and implement the Private Option. Our Team has the ability to “hit the ground running” focusing immediately on the Gap Analysis, which sets the stage for identifying critical elements for the Board’s strategy and operational plan.
Manatt and Leavitt both have extensive experience and subject matter expertise regarding all the components of a successful SBM. Manatt has honed its approach through work with (RWJ) and work directly with a number of states. RWJ recently renewed Manatt’s contract for a third year to serve as technical advisor to a select group of 11 states to implement key coverage provisions of the ACA. The 11 states include and Alabama, Colorado, Illinois, Maryland, Michigan, Minnesota, New Mexico, New York, Oregon, Rhode Island, and Virginia. Manatt provides legal and regulatory counsel with respect to eligibility, enrollment and re-certification issues, plan management, Medicaid and other public health insurance programs and insurance market reforms, and provides analyses of statutes and emerging regulations issued by the federal government for significant implications. Manatt also develops templates and frameworks to guide state decision-making and help facilitate implementation activities. Manatt has also worked on separate engagements in Missouri, New York, North Carolina, Virginia to support states in development various components of their SBMs. This includes everything from documenting business rules and ensuring federal and state requirements are met for eligibility and enrollment systems in New York, to working to support Navigator Program planning and design work for Maryland’s SBM.
Leavitt Partners offers an equally rich set of expertise and experiences. Dan Schuyler, a key member of the Leavitt Team, played a pivotal role in designing the Utah Health Insurance Exchange (UHE), one of the first two functioning state health insurance exchanges, prior to joining Leavitt Partners. As UHE’s Director of Technology, Mr. Schuyler was responsible for all aspects of technology implementation, including advising state officials on key policy issues, assisting in drafting enabling legislation, coordinating projects and ensuring adequate administrative and financial control, quality, and procedural efficiencies, and defining technical goals and business processes associated by working closely with technology vendors, state agency project directors, and insurance carrierRedacted IT managers. In Mississippi, - Available Leavitt Partners advisedfor thePublic Mississippi InsuranceReview Department with the research, design, and development of a health insurance exchange. Specifically, Leavitt Partners assessed the feasibility of exchange establishment and issues related to different exchange models among diverse population segments; developed a plan to promote stakeholder involvement; performed an initial demographic analysis of the health insurance market; conducted an initial eligibility and enrollment analysis for the exchange, Medicaid, CHIP, and other state programs; evaluated the potential market to be served by the Medicaid expansion and the establishment of subsidized coverage through the exchange; and analyzed existing health plans and benefits. Leavitt conducted similar work with Pennsylvania’s Insurance Department and the New Mexico Department of Human Services.
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Establishment Grant and Blueprint Development
As Establishment Grant opportunities narrow, it is critical that the Board take advantage of access to federal funding. Manatt and Leavitt have hands-on experience in six states supporting the planning, development and/or submission of Establishment Grant applications and Blueprints. The Team has also successfully guided states through the CMS/CCIIO gate establishment review process. For example:
. Establishment Grant Applications: Manatt supported Establishment Grant applications in Alabama, Missouri and Virginia – preparing Missouri’s Level 1 application through which the state was awarded $21 million. Leavitt Partners drafted Level 1 Establishment Grant applications for Pennsylvania and Mississippi. Leavitt Partners also assisted New Mexico with the preparation of their Level 1 Establishment Grant, including preparing and reviewing reports for gate reviews and status calls required by the HHS Enterprise Life Cycle Framework. . Blueprint: Leavitt Partners assisted Mississippi, New Mexico and Idaho with the development of their respective Blueprints. Manatt directly supported Blueprint development in M ssouri and North Carolina and provided Blueprint training for the 11 RWJ states.
Communication and Liaison Activities
The Team understands that state policy making is by definition a collaborative process, typically requiring the participation of or consultation with a wide range of internal and external stakeholders. The Team will leverage its understanding of Arkansas’ existing infrastructure to support outreach and communication activities, and brings experience managing large, multi-stakeholder engagements which successfully leveraged inter-agency coordination and stakeholder engagement to support Board decision-making and gain buy-in for key decisions.
For example, Manatt worked with seven Missouri state agencies under a contract with the Missouri Foundation for Health to manage Marketplace planning and establishment across multiple years, conducting quantitative and qualitative analyses, coordinating activities through workgroups, engaging stakeholders and producing final deliverables for submission to HHS. Manatt has also assisted multiple states – including Arkansas, California, Maryland, Missouri, New York, North Carolina, and Washington – in convening stakeholders, addressing major policy questions, and developing consensus-based recommendations while ensuring compliance with state and federal requirements. This work has included interdivisional strategy sessions; cross-agency work groups; intergovernmental consultations with legislative and/or local government; technical advisory groups with representatives of industry, business and consumers; and community meeting “road shows” across the state. Manatt’s rich experience of our team members reflects decades of working with public sector groups including states, foundations, community organizations and other stakeholders.
Leavitt Partners offers complementary expertise and experience. As part of its work with the Mississippi Insurance Depa tment, Leavitt Partners organized a targeted educative healthcare symposium, assisting staff members to develop presentations and communication materials. In Pennsylvania, Leavitt Partners developed a plan with the StateRedacted Insurance Department - Available to promote partnership for and Public stakeholder involvement Review in Marketplace planning and design.
Project Management
The transition to an SBM requires sophisticated project management across state and federal agencies and stakeholders. Manatt and Leavitt Partners have composed a highly qualified team to deliver unparalleled depth and breadth experience, and project management capabilities. Manatt’s highly coordinated and organized team excels at managing complex, multi-dimensional projects that require a wide breadth of subject matter and in- depth management expertise. In particular, Manatt is nationally recognized for managing large scale state
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REDACTED--AVAILABLE FOR PUBLIC REVIEW Proposal for Professional Consultant Services for the Arkansas Health Insurance Marketplace
Submitted by Mehri & Skalet, PLLC, by Jay Angoff 1250 Connecticut Ave., NW. Washington, D.C. 20036 P: 202-822-5100 F: 202-822-4997 http://www.findjustice.com
1
Preliminary Statement
The Board of Directors of the Arkansas Health Insurance Marketplace is in the midst of doing something great. It is seeking to enable Arkansas to become the first state that initially opted for a federally-run marketplace to now establish its own marketplace. It is also seeking to enable Arkansas to become the first state to privatize its Medicaid program along the lines of classic managed competition rules with its Private Option for Medicaid. Should the Board succeed in attaining these goals, the Arkansas experience will have far-reaching consequences for health reform throughout the nation. Arkansas will have made clear the advantages for a state in operating its own Exchange rather than ceding its authority to do so to the federal government; and Arkansas will have made clear that managed competition not only can work, but can work and attract the support of both political parties.
Perhaps most important for Arkansas, however, what the Board is now doing holds the promise of improving the health status of Arkansans. It is a truism that when people have health coverage they get better health care. By substantially increasing the number of Arkansans with health coverage, and by increasing their ability to have access to the same providers regardless of income, the Board may well improve the average health status of Arkansas citizens.
The most closely analogous experiment to what Arkansas is in the midst of today may be Missouri's experience with its version of the Private Option in the mid-1990's. This proposal draws heavily on the experience of the proposal’s team leader in implementing the Missouri Private Option, as well as his experience in implementing the Affordable Care Act as the Director of the Office of Consumer Information and Insurance Oversight (OCIIO).
To assist the Board in establishing an Arkansas marketplace and in implementing the Arkansas Private Option would be both an exciting opportunity and a privilege.
2
I. Company profile and contact information
The firm submitting this proposal is Mehri & Skalet, PLLC, 1250 Connecticut Avenue, NW., Washington, DC 20036, phone 202-822-5100. The primary contact for this proposal is Jay Angoff, at the same address and phone number. The firm has been in business since 2001. It is primarily a plaintiff’s class action firm, but also represents individuals, corporations and non- profit organizations in non-class action matters. It has particular expertise in consumer protection law, civil rights law, wage and hour law, antitrust, and health care and insurance law. Its continued growth--at a time when many primarily plaintiffs’ firms are retrenching--is evidence of its financial stability. Major cases it has successfully resolved are discussed at the firm’s website, www.findjustice.com.
II. Vendor Qualifications and Prior Experience
A. Provision of consulting services to at least one state that implemented a health insurance marketplace
In 1994 Missouri established a health insurance marketplace, known as the Missouri Consolidated Health Care Plan, or MCHCP. Jay Angoff, the primary contact and team leader for this proposal, served as Vice-Chair of the marketplace Board as well as Insurance Director of Missouri. The Board, which was granted broad discretion under the statute establishing the MCHCP, ran it according to classic managed competition rules: it standardized the benefit package, established a competitive bidding process, and subsidized each state worker to the extent of the low bidder's bid. As a result, health care costs for state workers, and for state taxpayers, fell dramatically. The trade-off for lower rates was some restriction on choice of provider: the old system was a modified traditional indemnity system, whereas the carriers selling through the Exchange were generally either HMO's or PPO's. While there were occasional complaints about such restrictions, in general the new system was well-accepted, and it resulted in the state saving tens of $millions a year. Exhibit A sets forth the bids submitted by each carrier in each region of Missouri in each year from 1994--when the new system began phasing in--and 2000, as well as the number of enrollees each carrier received each year. The cost to the state in 1993, the last year of the old indemnity system, was $224 per member per month. As the bids set forth in the attached charts show, even six years later, in 2000, the cost to the state was still less than that amount. Notably, the standardized benefit package adopted by the Missouri marketplace was for coverage substantially more generous than the Gold coverage currently offered through the Exchanges.
After Governor Mel Carnahan died in a plane crash in October 2000 and Administrations changed, and for a whole host of reasons, the Missouri marketplace fell apart. But for six years it worked exactly the way managed competition is supposed to work.
Somewhat similar to the Missouri marketplace were the separate marketplaces New Jersey established in 1992 for the individual and small group markets. As Special Assistant to the Governor Jay Angoff helped draft the statute authorizing both marketplaces and then helped
3 implement them. As originally authorized five standard benefit packages were sold through the individual Exchange, and standard benefit packages were also sold through the small group Exchange. Due to a subsidy program that was in effect in the first few years of the individual Exchange, enrollment initially grew substantially, but began declining when the subsidies were eliminated in 1996. The small group Exchange, which has always been unsubsidized, grew substantially for more than a decade but then began to decline.
The issues considered in connection with both the Missouri and New Jersey marketplaces--and both the judgments and misjudgments Missouri and New Jersey made--may have relevance for both AHIM in general and the Medicaid Private Option in particular. Those issues include
* How to set and calculate the subsidy; * How to structure the bidding process; * Whether and how to regionalize; * Whether and how to create exceptions for residents of border counties; * The extent of standardization; * The extent to which the Board should intervene in disputes between carriers and providers, or carriers and enrollees.
In addition, as Director of OCIIO Mr. Angoff oversaw the provision of consulting services to all 14 states that implemented a health insurance marketplace. Further, while serving as Senior Advisor to the Secretary in 2011 and in 2012 as Director of HHS Region VII-- Missouri, Kansas, Iowa and Nebraska--he advised legislators and other government officials in several states regarding implementation of their health insurance marketplaces. Some of those states, including New Mexico, Colorado, and Rhode Island, established state Exchanges, while others--including Wyoming, Missouri, and Nebraska--did not.
The team providing services under this proposal also includes three additional individuals who have provided services to states that implemented a health insurance marketplace. Those individuals, who were formerly with OCIIO and are now at the Georgetown University Health Policy Institute, are former Indiana Insurance Commissioner Sally McCarty, who led the rate review unit at OCIIO; Kevin Lucia, who held high level positions in both the Oversight and Consumer Services units of OCIIO and, as an executive board member, participated in the development of the DC Health Link, the marketplace for the District of Columbia; and David Cusano who assisted with the drafting of the rate review proposed regulation and provided implementation guidance to states at OCIIO and served as an attorney with Coventry Health Care, Inc., where he was chief legal counsel to seven health plans and lead attorney on health reform implementation.
As Senior Research Fellows at Georgetown, Ms. McCarty, Mr. Lucia and Mr. Cusano have provided technical assistance, policy/strategy support, and consulting services to several state exchanges. Their representative engagements include (i) assisting the Maryland Health Benefit Exchange with drafting its carrier agreement, (ii) developing an interagency Memorandum of Understanding for Connect for Health Colorado, and (iii) developing a Qualified Health Plan (QHP) checklist (available to all states) and providing training on its use to
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Cover Oregon and to issuers preparing to offer products on the New Mexico partnership exchange.
B. Program management experience with at least one state implementing a state-based or state partnership marketplace
As Vice-chair of the Missouri marketplace board Jay Angoff managed the process of getting the Missouri marketplace off the ground--a process which may well be similar to the process the Board is going through now.
In addition, the management of OCIIO required dealing with many issues that may be similar to those the Board is dealing with today, and with respect to which the OCIIO experience may be instructive. For example:
* OCIIO was a start-up organization. The analogy of building the plane and flying it at the same time may be overused, but it’s apt. OCIIO met all deadlines--both statutory and non-statutory--and grew from one employee to approximately 300 in less than a year. (After the 2010 election OCIIO was merged into and became a Center within the much larger CMS, where it had access to CMS funding it did not have as an independent unit.) AHIM is also a start-up organization, and will also need to meet aggressive deadlines and staff up quickly.
* Even before OCIIO was officially constituted, IT vendors and other vendors and consultants inundated us with proposals. The AHIM Board may well be experiencing the same phenomenon today.
* OCIIO constantly responded to inquiries from, and attempted to assuage, members of Congress from both parties. The Board may well have had an continue to have similar experiences with Arkansas legislators.
* OCIIO dealt constantly with the press. Although the coverage of the rollout of the federal Exchange was unrelentingly, and deservedly, negative, press coverage of ACA implementation during the first year was fairly upbeat. Coverage of the proposed Arkansas Private Option has also been very upbeat, and can continue to be upbeat.
C. Strategic analysis and decision making support provided to at least one state implementing a state-based or state partnership marketplace
As OCIIO Director throughout 2010, Jay Angoff oversaw the unit that provided strategic analysis and decision-making support to all states. In addition, Ms. McCarty, Mr. Lucia and Mr. Cusana have provided such analysis and decision-making support, both at OCIIO and now with Georgetown, as described in section IIA.
The fundamental decision Exchanges had to make was whether to establish and operate their own Exchange or allow the federal government to do so. HHS has always had a strong
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preference that states operate their own Exchanges; despite (or perhaps in some cases because of ) that preference more than two-thirds of the states opted to have the federal government run their Exchanges in 2014, either alone or in conjunction with the state (although the so-called “partnership” Exchange is still, statutorily, a federal Exchange). Several arguments support the conclusion that it is in the state’s best interest to operate its own Exchange. First, a state operating its own Exchange is eligible for unlimited grant funding from HHS. Second, state officials are likely to have a deeper knowledge of their health insurance markets than do federal officials. Third, state government is easier to navigate than the federal government--rules can be promulgated and decisions made more quickly, there is less bureaucracy, hiring is easier, and processes are less formal. Fourth, and most obviously, a state that operates its own Exchange controls its own Exchange, including the dissemination of information regarding the Exchange and enrollment in the Exchange. A state that cedes its authority to operate an Exchange to the federal government, on the other hand, does not have such control. Nevertheless, the large majority of states rejected HHS urgings to establish their own Exchange. Arkansas has apparently made the decision to establish its own Exchange. We would anticipate explaining to interested parties, to the extent requested by the Board, the implications of the state vs. federal Exchange decision.
D. An understanding of the Arkansas Private Option
As noted in section IIA, what Missouri went through in 1994-95 with its health plan for state workers is similar in concept to what Arkansas is going through now with its Private Option for Medicaid: in both cases, the state is privatizing coverage that has traditionally been provided by the government. The MCHCP Board divided the state into eight regions and in 1994 bid out the business in the two most populous regions, in 1995 in five more, and in 1996 all eight. As Exhibit A indicates, the low bids in 1996 for substantially the same benefit package which had cost the state $224, ranged from $184.58 in Northwest Missouri to $120.00 in Central Missouri, with restricted but adequate networks. In addition, the Board required the insurers to guarantee that they would stay in for five years and could raise their rates by, at most, medical CPI plus 3.5% each year. To be sure, the Arkansas Medicaid Private Option must accommodate Medicaid-related federal government mandates that the Missouri marketplace did not need to accommodate. We would anticipate assisting AHIM to structure the program, to the extent possible, so that it results in effective price competition among the private carriers participating in the program, notwithstanding the fact that the beneficiary does not pay the premium. We believe that the Private Option holds promise for both improving quality and, contrary to the conventional wisdom but consistent with the Missouri experience, reducing the cost of the Medicaid program.
E. Knowledge of the Arkansas health care environment
There are substantial differences between the Missouri and Arkansas health insurance markets, and the Missouri and Arkansas hospital markets, and in the demographics of the states. Nevertheless, there are also commonalities between the Missouri and Arkansas health systems. First, both the Missouri and Arkansas Medicaid programs are among the least generous in the
6 nation. (When Missouri established the MCHCP the Board considered trying to merge the MCHCP with the Medicaid program--which among other things would have increased the state's buying power--but it was simply too big a change, both practically and politically, to get done in too short a time.) Second, in both Missouri and Arkansas there is a huge difference between the health care markets in the major urban areas, where there are a sufficient number of hospitals for classic managed competition rules to work, and in the rural areas, which do not lend themselves to managed competition. Nevertheless, when the Missouri marketplace enabled private insurers to for the first time sell to state employees in the sparsely populated regions of the state, those carriers developed networks there, and were able to provide an attractive product at a lower price than the state had been able to provide the same coverage for. Some of those networks, including those centered in Springfield, Joplin, West Plains and Poplar Bluff, also served northern Arkansas.
The concerns raised when the Missouri marketplace Board structured the marketplace by dividing Missouri into regions may also have particular relevance for AHIM.
III. General approach to executing the anticipated responsibilities
Option 1
Jay Angoff would provide a substantial portion of the services described in this proposal personally. Analysis and research under his direction would be provided by Ingrid Babri, a young lawyer who has been working full-time with Mr. Angoff for the last year on Exchange- and other ACA-related issues, including Navigator legislation and litigation. Mr. Angoff would also be staffed, in particular for the preparation and of the Exchange grant proposals, by Logan Meltzer and Tatiana Reyes Jove, paralegals at Mehri & Skalet.
Ms. McCarty, Mr. Lucia and Mr. Cusano would also provide a substantial portion of the services described in this proposal, based on their experience both at OCIIO and at Georgetown, and drawing on their analysis of emerging trends, best practices, and implementation challenges.
Other lawyers at Mehri & Skalet will participate in this project to the extent there expertise is called for. For example, we anticipate drawing on Mehri & Skalet partner Steve Skalet's business background in ensuring that AHIM meets the requirements of all eleven CCIIO-defined Exchange areas and with respect to terms of contracts with vendors. In addition, in connection with both meeting those requirements and analyzing issues raised by the role played by Arkansas Blue Cross, we would rely on the expertise of Craig Briskin, the antitrust lawyer in the firm.
Finally, to the extent an actuary's services are needed for this project Mehri & Skalet anticipates contracting with Allan Schwartz, the principal of AIS Associates of Freehold, NJ.
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Option 2
Same as Option 1, except that Mr. Angoff would provide the services of an interim Executive Director for a period of up to four months. During this period Mr. Angoff would anticipate being on-site in Little Rock, or elsewhere in Arkansas, for at least three days each week.
IV. How the Offeror plans to fulfill the scope of work, as outlined on pages 1-2 of the RFP, to provide or assist the AHIM Board and/or the Executive Director with the following activities:
A. Strategic analysis, planning and assistance with decision making on key areas involved with the implementation of state-based marketplaces.
In advising the Board and/or the Executive Director on such decision making, we anticipate that key areas will include:
1. Whether the marketplace will be a clearinghouse or an active purchaser. HHS has opted for the clearinghouse model for 2014, while issuing guidance stating that it may revisit this issue in the future. The Missouri marketplace, on the other hand, was an active purchaser: it standardized the benefit package, and it established a pure competitive bidding process based on the submission of pure community rates. Notably, no plan was excluded from the Exchange based on its bid, but because the state paid the amount of the low bidder’s bid for each state employee, plans bidding very high were unlikely to attract many enrollees, and the low-bidder had an enormous advantage, since employees could get that plan for free.
We would anticipate assisting the Board in considering the relative merits of maximizing consumer choice through the clearinghouse model vs. maximizing the bargaining power of the marketplace through the active purchaser model.
2. Whether network adequacy standards should be general or prescriptive. On the one hand, in order to drive down price an insurer cannot accept any willing provider into its network, nor can it pay each provider their optimum rate. On the other hand, consumers must have practical access to providers--and having to drive an unreasonable distance or wait an unreasonable length of time to see a provider is not practical access. The Missouri marketplace implemented distance- and availability-related network adequacy standards, while to date HHS has promulgated only the most general of guidelines, although recent statements by the Secretary indicate that that may change. In any event, we would anticipate helping the Board work through the inherent tension between the goal of driving down health care costs and the goal of maximizing choice of provider. In that regard we would make use of the findings in a recent health policy brief co-authored by Sally McCarty, entitled “ACA Implications for State Network Adequacy Standards,” available at http://www.statenetwork.org/wp- content/uploads/2014/02/State-Network-Georgetown-ACA-Implications-for-State-Network- Adequacy-Standards.pdf.
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3. The selection of an IT vendor. IT vendors to CMS have had an incentive to over-promise in order to get the business, and to worry about performance later. We would anticipate helping the Board to maximize the likelihood that an IT vendor will deliver what it has promised, by the time it has promised, by advising on negotiating strategy and contract terms, among other things. We also anticipate assisting AHIM in weighing the relative merits of building, purchasing or leasing various IT components.
Notably, OCIIO established three new websites during the first 90 days following the enactment of the ACA--the original healthcare.gov website (which provided price estimates, as well as additional insurance and health information, rather than binding quotes); a website for those qualifying for the Early Retiree Reinsurance Program (a subsidy program for employers and other sponsors of group coverage who provided coverage for their workers who retired before age 65); and the website for the PreExisting Condition Insurance Plan, the federally operated high-risk pool (which approximately half the states opted into). All three websites went live on time, and they worked. While an Exchange website is much more complicated than any of these websites, certain aspects of our experience may be relevant to AHIM. We would anticipate assisting AHIM in considering all IT-related options.
We also note that government procurement regulations can have the effect of increasing the cost of an IT project, delaying it and, perversely, weakening the government's hand in dealing with the contractor. (The federal government's procurement rules--the Federal Acquisition Regulation, or FAR--have been so counter-productive that they have come to the attention of the President, who has emphasized the damage they have done and the necessity for streamlining them.) The government benefits if such rules can be waived or avoided. We were very pleased to see that Arkansas has done just that.
4. Maximizing the effectiveness and efficiency of available HHS grant funding. The ACA confers authority on the Secretary to make Exchange grants to states through the end of 2014. Unlike with almost all other grant programs, Congress established no limit on the amount that can be granted. Arkansas should not, of course, be profligate. But if AHIM can make a compelling case that it needs funding to accomplish a goal that HHS also wishes to see advanced, it should be able to obtain that funding. We anticipate assisting AHIM in doing so.
Finally, we note the recent policy brief co-authored by Kevin Lucia, entitled “Implementing the Affordable Care Act: Key Design Decisions for State-Based Exchanges,” available at http://www.commonwealthfund.org/Publications/Fund-Reports/2013/Jul/Design- Decisions-for-Exchanges.aspx, which we expect will also have relevance to AHIM.
B. Analysis and research in various areas.
All lawyers working on this project have significant experience doing both legal and non- legal analysis and research. The firm's analysis and research skills have resulted in several landmark legal victories, many of which are discussed at the firm's website, www.findjustice.com. Based on their experience, M & S personnel also have extensive libraries that may well be helpful to the Board.
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In addition, Ms. McCarty, Mr. Lucia and Mr. Cusano continue to conduct analysis and research regarding state-based marketplaces and the implementation of the new insurance market reforms throughout the nation.
C. Assistance with the development of rules, regulations, policy and operational procedures governing the state-based marketplace.
As Director of OCIIO Jay Angoff oversaw the drafting of both the original HHS rule governing state-based marketplaces, and the so-called Patient's Bill of Rights, which carriers both on and off the Exchange must comply with. Those rules include the prohibition on annual and lifetime limits, rescissions, and pre-existing condition exclusion clauses, as well as the minimum Medical Loss Ratio regulation. Ms. McCarty, Mr. Lucia and Mr. Cusano were also involved in developing rules and policy at HHS, and Ms. McCarty led the development of the rate review rule. In addition, Mr. Angoff was involved in the process of developing subregulatory guidance--Qs and As--that explained the Department's policy on issues that are not expressly resolved by regulation. HHS has made, and continues to make, major policy decisions through the subregulatory guidance process rather than through regulation. We would anticipate assisting AHIM in drafting regulations and statements of policy and procedures, and also in participating in the HHS rulemaking and subregulatory guidance process, should that become necessary.
D. Function as a liaison between the AHIM and Federal and State agencies' representatives, health insurance marketplace partners, and vendors.
We would anticipate functioning as such a liaison based on the experience of Mr. Angoff. Ms. McCarty, Mr. Lucia and Mr. Cusano at OCIIO, and based on the experience of Mr. Angoff and Ms. McCarty as state insurance commissioners. OCIIO cooperated with many different components of HHS, jointly wrote regulations with two other federal agencies--Treasury and Labor--and also worked with OMB, the National Economic Council and White House staff. AHIM will be impacted by many of these same federal components.
Mr. Angoff is also familiar with the Arkansas Insurance Department, both from his years at the Missouri Department and his having dealt with the Department while in private practice. He is also familiar with Arkansas's major health insurer, Arkansas Blue Cross Blue Shield, having worked with and analyzed non-profit Blue Cross plans, as well as publicly-held Wellpoint, for the last 20 years. In Arkansas, as in virtually all states, the Blue Cross plan has traditionally dominated the individual market. That dominance can have either a pro- competitive or anti-competitive effect on the Arkansas Exchange, and on the health insurance market as a whole, depending on what the Exchange does to manage it.
Notably, many of the original OCIIO staff are still at HHS, including the current Director of CCIIO, who was one of OCIIO’s first hires, as were several of his senior staff. Mr. Angoff also worked with the HHS Medicaid director, including during the incipiency of the
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marketplaces, and would anticipate continuing to do so in connection with the Arkansas Medicaid Private Option.
At OCIIO Mr. Angoff, Ms. McCarty, Mr. Lucia and Mr. Cusano dealt constantly with the Department's marketplace partners, most notably the insurers. While the Administration and the industry did not always agree about the details of implementation, the Administration recognized that it needed the industry, and the industry recognized that it needed the Administration. The same dynamic should apply with respect to AHIM and the industry.
E. Preparation and submission of the May 15, 2014 Level I Exchange grant, Blueprint requirements, and possibly the Level II Exchange grant.
Mr. Angoff oversaw the drafting of the Level I and Level II Exchange grant FOAs as OCIIO Director, and is also familiar with the Blueprint requirements based on his review while serving as Senior Advisor to the Secretary and an HHS Regional Director. We would anticipate preparing and submitting these documents based on both having overseen their drafting and/or participated in their review, and having analyzed both successful and unsuccessful grant proposals.
F. Assistance in meeting the requirements of the eleven "Exchange Areas" defined by CCIIO.
Mr. Angoff oversaw the drafting of the initial rule defining and describing these eleven areas as OCIIO Director. We would anticipate working with AHIM to ensure that AHIM meets all these requirements. Importantly, HHS has encouraged and assisted states to meet these requirements rather than opt for the federal government to run their marketplace in the past, and can reasonably be expected to do the same in the future.
G. Other responsibilities as assigned.
We would be happy to take on whatever additional responsibilities for which we are qualified that the Board wishes to assign.
IV. Biographies
Jay Angoff, Partner Mehri and Skalet
The director of this project for Mehri & Skalet will be former Missouri Insurance Commissioner and U.S. Department of Health and Human Services official Jay Angoff. Mr. Angoff returned to Mehri & Skalet after three years with the U.S. Department of Health and Human Services. The only person to have served as the lead federal health insurance regulator,
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the Director of an HHS Region, and a state Insurance Commissioner, he is one of the nation’s leading insurance experts.
In March 2010, Mr. Angoff was appointed by HHS Secretary Kathleen Sebelius as the first Director of the HHS Office of Consumer Information and Insurance Oversight. In that capacity, Mr. Angoff was responsible for the Patient’s Bill of Rights, for implementing the Medical Loss Ratio rule, and implementing the Exchanges. In addition, Mr. Angoff served at HHS as the Senior Advisor to the Secretary and as Regional Director of HHS Region VII, headquartered in Kansas City.
Before serving at HHS Mr. Angoff was in private practice, first in Jefferson City, MO and most recently in Washington, DC with Mehri & Skalet, PLLC where he served as lead counsel in several successful class actions, including, Landers v. Inter-insurance Exchange of the Automobile Club (Los Angeles County, Cal., $24 million settlement), Clutts v. Allstate (Madison County, Ill., $6 million settlement), and Foundation for Taxpayer and Consumer Rights v. GEICO (Los Angeles County, Cal., settlement valued at up to $12 million). He has also represented individuals before state insurance departments, and has consulted for and advised governmental entities, consumer groups, the plaintiff’s bar, and other interest groups.
Mr. Angoff is also an expert on non-profit to for-profit conversions. As Missouri Insurance Commissioner he won a five-year legal battle with Blue Cross of Missouri, after which Blue Cross agreed to fund a new healthcare foundation, now one of the nation’s largest. In private practice, Mr. Angoff has been retained by various state Insurance Departments faced with proposed Blue Cross transactions and has analyzed and opined on the reasonableness of the Blues’ executive compensation. He has also been an expert on charitable trusts, fiduciary duties, antitrust implications and other issues relevant to conversions and other insurance transactions.
Mr. Angoff has advocated for managed competition and successfully implemented systemic reforms. As Missouri Insurance Commissioner and a Director of the Missouri state health plan, Mr. Angoff required insurers to submit competitive bids for a single standardized benefit package. As a result, rates fell by up to 45%.
Prior to serving in Missouri, Mr. Angoff was Deputy Insurance Commissioner of New Jersey and Special Assistant for Health Insurance Policy to New Jersey Governor Jim Florio. In those positions, he played a major role in drafting and implementing New Jersey’s individual and small group community rating law.
Mr. Angoff began his career as an antitrust lawyer with the Federal Trade Commission. He has written for The New York Times, The Washington Post, and The Wall Street Journal, among other publications. He is a member of the District of Columbia, Missouri, New Jersey, and U.S. Supreme Court bars, and is a graduate of Oberlin College and Vanderbilt Law School.
Steve Skalet, Partner Mehri & Skalet Steven A. Skalet is a principal and managing partner in the firm of Mehri & Skalet, PLLC. Mr. Skalet has over 35 years of litigation and transactional experience in real estate, consumer fraud, bank fraud and class action litigation.
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Mr. Skalet enjoyed a varied litigation practice before state and federal courts throughout his career. From 1995 until the formation of M&S, Mr. Skalet practiced with Kass & Skalet, PLLC, a well-known real estate, litigation, complex business and consumer protection firm. Prior to that, he and another lawyer formed a practice that focused on real estate and litigation, including consumer class actions under the Truth-in-Lending and Equal Credit Opportunity acts. That firm grew to approximately 23 lawyers in 3 jurisdictions and, when it split up in 1995, was known as Kass, Skalet, Segan, Spevack & Van Grack, PLLC. In 2001, Mr. Skalet and Cyrus Mehri started the firm of Mehri & Skalet, PLLC, concentrating in complex litigation and class actions. Since its inception, Mr. Skalet has been lead counsel or co-lead counsel in successful class action cases against Dell, Inc., Mercury Marine, Hewlett Packard, Sony, Ford, Verizon, Mitsubishi, Morgan Stanley, and many other companies. Mr. Skalet has been an advisor to the Federal Reserve Board on credit and banking matters. He has served on the Montgomery County Advisory Committee reviewing the wholesale simplification of the Montgomery County Code. He also served on the District of Columbia Bar Committee responsible for drafting form commercial leases and the Montgomery County Board of Realtors committee responsible for drafting residential real estate contracts. Mr. Skalet graduated from the University Of Pennsylvania School Of Law in 1971 and the University of Rochester in 1968. Craig Briskin, Partner, Mehri & Skalet Craig Briskin joined the Washington, D.C. office of Mehri & Skalet, PLLC in 2007. Mr. Briskin focuses his practice primarily on class actions related to consumer and mortgage fraud. He serves as co-lead counsel for the class in In re MagSafe Adapter Litigation, representing consumers who allege that their Apple MagSafe laptop adapters prematurely fray, break, spark, and cease functioning. The court granted final approval of a settlement in February 2012. He also serves as co-counsel for the class in Sonoda v. Amerisave, concerning alleged deceptive sales practices by a leading online mortgage broker. The court granted final approval to a $3.1 million settlement in February 2013. Mr. Briskin is co-counsel with AARP in an action against the U.S. Department of Housing and Urban Development, concerning their alleged failure to protect seniors in the reverse mortgage program. Shortly after plaintiffs filed a preliminary injunction motion, HUD rescinded the guidance Plaintiffs challenged, with the result that spouses and family members can retain their family homes by paying 95% of the home’s current appraised value. Plaintiffs continue to litigate to enforce the protection from displacement for borrowers’ spouses. Mr. Briskin is co-counsel with AARP in a proposed class action against Wells Fargo and Fannie Mae regarding their alleged refusal to allow spouses and heirs of reverse mortgage borrowers to purchase their family homes for 95% of the home’s current appraised value, pursuant to federal statute and the mortgage contract. Mr. Briskin is counsel for plaintiffs in Mackmin v. Visa, alleging an agreement to assess supracompetitive access fees to ATM customers. He also serves as co-counsel with Center for Science in the Public Interest in Hensley-McClean v. Safeway, concerning Safeway’s alleged
13 failure to notify customers of Class I food recalls. Mr. Briskin was class counsel in a case alleging a brake defect in the Ford Focus, which was successfully settled in 2008. Mr. Briskin holds a law degree from Harvard Law School and an A.B. cum laude in Psychology from Harvard College. Kevin Lucia, Senior Research Fellow and Project Director, Center on Health Insurance Reforms, Georgetown University Kevin Lucia is a Senior Research Fellow and Project Director at the Center on Health Insurance Reforms (CHIR) at Georgetown University’s Health Policy Institute. He co-founded CHIR in 2011 and now directs policy research and analysis of federal and state laws and programs related to private health insurance and the implementation of the Affordable Care Act. He provides expertise and prepares resources to inform regulators, policymakers and other stakeholder groups on issues related to access, affordability and adequacy of private health insurance. His research is supported by government, private foundations and organizations representing consumers and patients. He serves as a Board Member and Chair of the Insurance Market Committee of the Health Benefit Exchange Authority for the District of Columbia.
Prior to co-founding CHIR, Mr. Lucia led the State Compliance Division within the Office of Oversight, Center for Consumer Information and Insurance Oversight (CCIIO), Centers for Medicare and Medicaid Services.
Mr. Lucia holds his J.D. from The George Washington University Law School and an M.H.P. from Northeastern University.
Sally McCarty, Senior Research Fellow and Project Director, Center on Health Insurance Reforms, Georgetown University
Sally McCarty is an experienced state and federal regulator, and national consumer advocacy expert. She joined the Center on Health Insurance Reform (CHIR) faculty at the Georgetown University Health Policy Institute as a Senior Fellow in June, 2012. Until May of 2012, McCarty was the Director of Rate Review in the Oversight Division at CMS' Center for Consumer Information and Insurance Oversight (CCIIO). She began her work at CCIIO in August of 2010. McCarty directed CCIIO's Rate Review Program from the writing of the regulation that defines the program through its implementation and first eight months of operation
Prior to joining CCIIO, McCarty served as a consumer advocate for the National Hemophilia Foundation (NHF). In that position she provided advocacy and educational services related to health insurance coverage to hemophilia groups throughout the country. McCarty represented NHF for three years as a funded consumer representative in the National Association of Insurance Commissioners' (NAIC) Consumer Liaison Program and served on the Consumer Liaison Board of Trustees for two of those years.
McCarty served nearly 10 years as a state insurance regulator with the Indiana Department of Insurance, including two years as the Deputy Commissioner for Health Issues and nine months as Chief Deputy Commissioner before then Governor Frank O'Bannon appointed
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her to be the state's Insurance Commissioner in July of 1997. She held that position for seven years.
During her tenure as Indiana's Insurance Commissioner, McCarty served on the NAIC Executive Committee for six years and also held positions as vice-chair of the Consumer Liaison Committee, chair of the Special Committee for Health Insurance, and chair of the Consumer Liaison Board of Trustees. As Insurance Commissioner, she filled statutory roles as an Indiana Children's Health Advisory Board member and as a member of the Indiana Comprehensive Health Insurance Association (state high risk pool) Board of Directors.
McCarty holds a Master of Arts degree in Adult and Community Education from Ball State University, Muncie, Indiana, and a Bachelor of Arts degree with a double major in Journalism and Sociology from Indiana University, Bloomington, Indiana. She was a School of Journalism Hazeltine Scholar, a program that awards one member of each graduating class a grant to fund travel and study in a foreign country.
David Cusano , Senior Research Fellow, Center on Health Insurance Reforms, Georgetown University David L. Cusano joined the Center on Health Insurance Reform faculty at the Georgetown University Health Policy Institute as a Senior Research Fellow in July of 2013. Prior to joining Georgetown, Mr. Cusano was an attorney with Coventry Health Care, Inc., and served as chief legal counsel to seven health plans operating in sixteen States on all matters related to their commercial, Medicare, and Medicaid business, and to Coventry corporate senior management on implementation of the ACA.
Mr. Cusano also served as a health insurance specialist to the Office of Oversight, within the Center for Consumer Information and Insurance Oversight, under the Centers for Medicare & Medicaid Services. In this role, he assisted States with interpreting and implementing the requirements under the ACA, and assisted with the drafting and publication of the federal rate review proposed regulation.
Mr. Cusano began his legal career as an associate at both Mintz Levin and Foley Hoag in Boston, MA. Prior to attending law school, Mr. Cusano practiced as a registered nurse, in both clinical and administrative capacities, at Beth Israel Deaconess Medical Center in Boston, MA.
Mr. Cusano holds a B.S. in Nursing from the University of Connecticut and a J.D. from Northeastern University School of Law.
Ingrid Babri, Associate Mehri & Skalet Ingrid Babri joined Mehri & Skalet in March of 2012 as an associate. Ms. Babri’s work has focused on the Affordable Care Act, insurance law, and public-interest advocacy. Ms. Babri works with consumer groups across the country to develop litigation and policy strategies related to ACA implementation. She previously worked for the Columbus, OH City Attorney on civil litigation and public policy matters.
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Ms. Babri holds a J.D. from the Ohio State University and a B.A. in International Relations magna cum laude from the Ohio State University.
Paralegal biographies not included.
V. Three relevant references
1. Mike Wolff, former Chair of the Missouri Consolidated Health Care Plan, now Dean, St. Louis University Law School, 100 N. Tucker Blvd, St. Louis, MO 63101. [email protected], (314) 977-2774.
2. Howard Koh, Assistant Secretary for Health, HHS, [email protected]. 3. Jesse Laslovich, General Counsel, Office of the Montana Commissioner of Securities and Insurance, 840 Helena Ave., Helena, MT 59601. [email protected], (406) 444-2040.
VI. Costs
Staff Hourly Rates
Jay Angoff, Partner Mehri& Skalet $ 500.00/hour Steve Skalet, Parnter Mehri & Skalet $ 500.00/hour Craig Briskin, Partner Mehri & Skalet $425.00/hour Sally McCarty, Senior Research Fellow/Project Director, Georgetown $300.00/hour University,Center on Health Inusrance Reforms Kevin Lucia,Senior Research Fellow/Project Director, Georgetown $300.00/hour University,Center on Health Inusrance Reforms David Cusano, Senior Research Fellow, Georgetown University,Center on $300.00/hour Health Inusrance Reforms Ingrid Babri, Associate Mehri & Skalet $200.00/hour Logan Meltzer, Paralegal Mehri & Skalet $130.00/hour Tatiana Reyes, Paralegal Mehri & Skalet $130.00/hour
Costs would also include reasonable travel expenses.
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ARKANSAS HEALTH INSURANCE MARKETPLACE Proposal Response
Arkansas Health Insurance Marketplace (AHIM) Request for Proposals (RFP) for Professional Consultant Services Response Due: 5:00 p.m., Central time, February 18, 2014
Tyler Covey, Partner Optimity Advisors [email protected] 770 L Street, Suite 950 Sacramento, CA 95814 Phone: (202) 769-7504 Fax: (202) 540-9223
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TABLE OF CONTENTS
Cover Letter ...... 3 Contact Information ...... 4 Company Profile ...... 4 Optimity’s Three Steps to Client Performance ...... 5 Optimity’s Experience, Tools, and Consultants ...... 5 ACA Experience from Multiple Perspectives ...... 5 Comprehensive Guidance to Improve Government’s Delivery of Service ...... 6 Health Care Exchange Qualifications ...... 7 Private and Public Sector Expertise ...... 7 Health Care Reform and Information Marketplace Qualifications ...... 8 Approach ...... 11 Introduction ...... 11 Scope of Work ...... 11 Project Understanding ...... 11 Optimity’s Tools and Techniques ...... 12 Project Work Plan ...... 14 Schedule of Work ...... 14 Capacity Development and Deliverables ...... 15 Staff Biographies ...... 16 Additional Staff and Work Stream Structures ...... 16 Proposed Executive Director ...... 16 Team Member Profiles ...... 17 References ...... 19 Costs ...... 20 Hourly Rates ...... 20 Additional Expenses ...... 20
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COVER LETTER
William Watson Arkansas Center for Health Improvement 1401 Capitol Avenue Suite 300, Victory Building Little Rock, AR 72201
RE: Arkansas Health Insurance Marketplace, RFP for Professional Consultant Services
On behalf of Optimity Advisors, LLC, (Optimity) we are pleased to submit our proposal in response to the Arkansas Health Insurance Marketplace (AHIM) RFP for Professional Consultant Services. We believe our firm is uniquely qualified to carry out this work on behalf of AHIM. Optimity and our proposed team have successfully assisted several states in their efforts to implement a state-based health insurance marketplace, including the states of California, Nevada, Georgia, Pennsylvania, Nebraska, South Dakota, Wyoming, Hawaii, and Mississippi.
Our exceptionally qualified management team is adept at meeting the requirements of applicable state and federal laws and requirements, and has detailed knowledge of the Affordable Care Act (ACA). We assist our clients in maintaining compliance and developing capability by using high-quality deliverables and a proven project management methodology that encourages decision-making and enhances stakeholder engagement. Our project management methodology reduces project risk, improves quality and timeliness of deliverables, and increases project-wide productivity.
Optimity is attuned to Arkansas’ rapidly evolving health insurance market, health care delivery system trends, and state and national legislative and political dynamics. We especially understand that the Medicaid private option waiver legislation will heavily influence how Arkansas implements the insurance marketplace and serve its citizens, especially the state’s poor citizens. We look forward to engaging with all stakeholders involved to bring the marketplace to fruition and serve the State of Arkansas.
Sincerely,
Tyler Covey, Partner (202) 769-7504 [email protected]
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CONTACT INFORMATION
Optimity’s corporate address is:
1600 K Street NW, Suite 202 Washington, DC 20006 Phone: (202) 540-9222 Fax: (202) 540-9223
The point of contact for this proposal is:
Tyler Covey, Partner [email protected] 770 L Street, Suite 950 Sacramento, CA 95814 Phone: (202) 769-7504 Fax: (202) 540-9223
COMPANY PROFILE
A HISTORY OF GROWTH AND SUCCESS
Optimity has more than 200 professional staff with three major office locations and a number of satellite offices throughout the United States. Optimity’s clients include a number of states, counties, cities, more than 25 insurance firms, a number of pharmacy firms, and major clients in the financial services, media, and entertainment industries. Founded in 2009, we serve as an operational advisory firm combining deep industry expertise and integrated solutions to assist companies in enhancing stakeholder value, improving operations, and addressing performance- and risk-related challenges.
FINANCIAL STABILITY
Optimity Advisors, LLC, is a privately held firm. As such, we do not make our financials public nor provide financial information to any reporting agency. We do, however, make a definitive statement that we have the financial ability to successfully perform all of the work presented in this proposal. The partner assigned to this project, Mr. Tyler Covey, can provide additional financial information upon request.
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OPTIMITY’S THREE STEPS TO CLIENT PERFORMANCE We help clients:
• INFORM organizations with knowledge and expertise in identifying and managing barriers to success, optimizing current operations and identifying new efficiency, growth and diversification opportunities.
• TRANSFORM organizations, processes and technologies through practical innovation, creating customer value and competitive advantage.
• OUTPERFORM the industry through bottom-line impact created through strategic and operational excellence.
OPTIMITY’S STRUCTURED AND RESPONSIVE PROJECT MANAGEMENT
We know how to balance the art and science of project management – where to add rigor and structure, and where to allow for a reasonable level of ambiguity and uncertainty. When organizations are a start-up phase, and as policy is being developed, it is permissible and beneficial to allow policies and processes to evolve and then formalize. We will use our standard project management tools that include: project plan, risk register, phase and deliverable checklists, and change control procedures.
OPTIMITY’S EXPERIENCE, TOOLS, AND CONSULTANTS Optimity is an operational health care consulting firm intimately involved in all aspects of state and local government planning, transformation, and service delivery required to meet Affordable Care Act (ACA) mandates. Optimity has numerous areas of healthcare expertise, allowing us to provide comprehensive and outcomes-focused client solutions. Our recent ACA experience has provided us hundreds of tools and techniques for Exchange implementation, allowing our consulting staff to hit the ground running and provide efficient, cost-effective quality advice, guidance, and supporting deliverables. We have consulting teams around the country, and maintain a cadre of health policy, technology, and evaluation experts who can be available as needed. We are confident that our team can leverage their experience and our proprietary tools to get it right the first time and deliver best-in-class service for AHIM.
ACA EXPERIENCE FROM MULTIPLE PERSPECTIVES Optimity has experience in all facets of healthcare consulting including the ACA. Our firm and teams have recent and directly applicable experience that includes numerous State Health Exchanges and carriers and cooperatives working to implement ACA reforms.
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DEEP ACA UNDERSTANDING
Optimity has been at the forefront of engaging public, private, and stakeholder groups in the years leading up to healthcare reform and after the ACA passed into law. Staff at our Washington, D.C. office were, and remain, part of the policy dialogue. Optimity sees its role as not only improving and transforming organizations, but also connecting stakeholders and brokering arrangements among them. The ACA’s success will be determined mainly by stakeholder ability to communicate, cooperate, and consolidate resources. Optimity has continuously facilitated that process and knows where the points of agreement and potential friction exist among the various parties.
COMPREHENSIVE GUIDANCE TO IMPROVE GOVERNMENT’S DELIVERY OF SERVICE We approach each consulting engagement with the end goal in mind. Our recent experience confirms that implementing and delivering quality Exchange services requires healthcare organizations to take a broader view of all assets, resources, and operations. Operational parameters are not always defined by the ACA, and, in those instances, we apply best practices or note assumptions. Organizations can identify and leverage resources and assets by taking a broader view of the ACA implementation landscape as we note in Figure 1.
Figure 1 – Optimity’s Broad View of Exchange Capability
Resources Assets Parameters
Private Partners Strategy Federal Legislation
Governance & Policy Public Partners State Legislation
Staff
Providers Provider Market Procedures & Processes
Funding Technology Customer Sentiment
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HEALTH CARE EXCHANGE QUALIFICATIONS
Below we summarize our expertise and provide a selection of the Exchange projects we have undertaken. We would welcome the opportunity to discuss our experience and can provide example project deliverables upon request.
PRIVATE AND PUBLIC SECTOR EXPERTISE For Exchanges to function effectively and efficiently, the AHIM has to develop its own system, but, beyond this, must engage commercial payers and providers to develop a sense of community and opportunity that will provide the public with a range of viable insurance options. Optimity Advisors is one of the few firms in this sector that has significant experience in the public and private sectors that can assist AHIM develop internally and develop a high-level of interest in the commercial sector. We have listed our primary service offerings below to demonstrate the breadth of our public and private sector experience.
EXCHANGE ADVISORY SERVICES: STATES
We have a portfolio of proven services to help state governments plan, implement, and operate effective, efficient state-based and partnership Exchanges, and both Medicaid and Medicare programs: • Strategy planning and project management • System and operational assessments • Business operations and systems design and implementation • Budgeting and financial planning • Vendor assessment, sourcing, and management • Technical advisory and architecture • Performance and operational audits • Call center implementation and service strategies • Market analysis and consumer adoption strategies
EXCHANGE ADVISORY SERVICES: PAYERS AND PROVIDERS
We have a portfolio of custom-tailored services to help commercial payers navigate an evolving regulatory and market landscape: • Exchange strategy and operational readiness assessment • Qualified health plan submission management oversight • Product portfolio design and roll-out • IT architecture: strategy and design • Vendor evaluation, procurement, and management • Call center implementation and service strategies • Market analysis and consumer adoption strategies
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HEALTH CARE REFORM AND INFORMATION MARKETPLACE QUALIFICATIONS On the pages that follow we list a selection of our relevant qualifications.
CLIENT: STATE OF NEBRASKA DEPARTMENT OF INSURANCE ENGAGEMENT: PLANNING AND DESIGN OF THE HEALTH BENEFIT EXCHANGE
Optimity provided consulting services for the Nebraska Department of Insurance’s Exchange Planning Division as it executed the planning and operational design for its Health Insurance Exchange under a Federal Level I Establishment Grant. Optimity provided federal and state policy-level expertise and policy analysis to assist the department in developing internal policies and procedures that aligned with regulatory mandates. Optimity also assisted with project management, inter-agency workgroup facilitation, requirements definition, and the creation of a request-for-proposal (RFP) to procure an Exchange IT vendor. In this capacity, Optimity also monitored and tracked changes to federal regulations and guidance, monitored progress of other states’ Exchange implementations, and assisted with the CMS gate review process. Through timely and accurate policy advice, the Department was able to better align and structure its policies to meet mandates, restructure some business processes and develop new processes in other cases, and include major elements and mandated requirements into the RFP—which allowed more thoughtful and thorough responses from vendors.
CLIENT: STATE OF SOUTH DAKOTA HEALTH BENEFITS EXCHANGE ENGAGEMENT: FEASIBILITY STUDY AND OPTION DEVELOPMENT
The Optimity Team worked with the State of South Dakota with its Exchange Planning Grant to conduct a feasibility study of the options for developing the systems, organization and staffing models for a web portal Healthcare Exchange. We worked with the State to define Exchange features and business and technology requirements based on federal legislation and guidance and state business needs, existing information technology assets, and resources that could be leveraged from other stakeholders. We summarized the key elements of each option, including business (policy, personnel, governance, and change) and technology requirements. We undertook scenario analysis and planning, and worked with state managers and executives to review and rate each option in light of internal and external parameters. After the State selected the preferred option, we worked with state staff to develop a planning and implementation framework that included detailed tasks, timelines, and an evaluation framework.
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CLIENT: WASHINGTON HEALTH BENEFIT EXCHANGE ENGAGEMENT: CONSULTING SERVICES
Optimity Advisors was selected from a wide range of consultants by the Washington Health Benefit Exchange to provide on-call consulting services in the areas of:
• Advisory services on federal and state legislation • Strategic and operational planning • Partnership and coalition building • Development, assessment, and evaluation services
CLIENT: COMMONWEALTH OF PENNSYLVANIA AND PENNSYLVANIA EXCHANGE ENGAGEMENT: TECHNOLOGY ASSESSMENT
Optimity worked with the Governor’s Office of Health Care Reform to conduct a technology options assessment for its planned State Health Benefits Exchange implementation. Our team performed a comparison of the draft Commonwealth Exchange capabilities statement to federal requirements, guidance from national organizations, and reviewed other state approaches. To complete the assessment, we extensively reviewed systems documentation, analyzed potential gaps among current systems, anticipated business requirements, and identified capabilities of other states’ and commercial payers’ benefit Exchanges.
A major component of this review was to identify stakeholders, research their business, technical, and user requirements and then conduct in-depth stakeholder interviews. Throughout this process, Optimity staff engaged key staff in Commonwealth departments and external users such as providers and insurers. The outreach also involved gathering information on the utility of Pennsylvania’s current online application and enrollment system for its health and human services program, COMPASS.
CLIENT: FREELANCERS UNION ENGAGEMENT: HEALTH COOPERATIVE IMPLEMENTATIONS – NEW JERSEY, NEW YORK, AND OREGON
Optimity led the development and build-out of healthcare back office and operational functions for three health care cooperatives as part of the Freelancer's Union project with the Centers for Medicare and Medicaid Services cooperative insurance project. This work included vendor management of enrollment, billing, claims, medical management, network management, and PBM services; plan design support activities; program management development and support; and management/monitoring of Exchanges requirements across three unique jurisdictions.
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CLIENT: STATE OF GEORGIA, GOVERNOR’S OFFICE ON HEALTHCARE REFORM/GEORGIA DEPARTMENT OF COMMUNITY HEALTH ENGAGEMENT: REDESIGN FAMILIES MEDICAID MANAGED CARE PROGRAM
Optimity worked with staff from the Governor’s Office and the Community Health Department to review the major issues associated with the program, assess program design, and assess managed care vendor procurement, selection, and contracting. Optimity developed assessment criteria that identified best practices, efficiencies, effective outcomes, and a list of criteria that identified how the ACA would impact the program. Optimity led the current state assessment and the development of a comprehensive evaluation report. We gathered relevant documents related to the current performance of the Care Management Organizations currently contracted to serve Medicaid including utilization, cost data, HEDIS measures, physician access, and qualitative assessment. Optimity also managed the portion of the report related to commercial best practices, leveraging experience with managed care nationwide to assess the operations of current care management organizations; areas to target for improvement were prioritized and recommended.
CLIENT: BLUE CROSS BLUE SHIELD OF IDAHO ENGAGEMENT: ACA PREPARATION
Optimity worked with Blue Cross of Idaho (BCI) to plan, review, and support its implementation of health care reform and preparation for participation in the state’s Health Benefits Exchange. The Optimity team undertook a review of the BCI strategic product development plan and worked with senior staff, managers, and line staff to review the impact of the state Exchange on BCI assets and resources. Optimity assisted with reviewing and developing operational requirements, determining how BCI could best prepare for the change by developing sectorial action plans.
Optimity also benchmarked BCI operations against those of health plans undergoing a similar transformation to meet the challenges of the ACA. This provided Optimity with a rich dataset of performance measures, best practices, and barriers to implementation that we continue to leverage with our current clients as they too prepare to meet ACA mandates.
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APPROACH
INTRODUCTION In the section that follows, we outline our understanding of AHIM’s needs, our approach and assets, and a high-level work plan. While we outline the highlights of our approach and schedule, our projects are planned with flexibility in mind and can be altered to best meet client needs and re-focus on key activities as the project progresses. Our tools and practices are structured to get it right the first time and we have an impeccable track record of success as evidenced by our excellent references.
SCOPE OF WORK In line with the scope of work specified in the RFP, Optimity proposes both RFP options listed below:
• Provide the services of an interim Executive Director (RFP Option 1). We propose that Mr. Tom Pelegrin, an Optimity Partner, will act as the interim Executive Director. • Provide advisory and consulting services to the AHIM (RFP Option 2). We outline our advisory services project in the next section, which would be led by Mr. Tyler Covey, an Optimity Partner. We anticipate that Mr. Covey would manage our various work streams, and manage a total staff of between four and eight, depending upon the level of work required.
PROJECT UNDERSTANDING Approximately 570,000 people in Arkansas need some form of affordable health insurance. To meet the federal individual mandate, many of the uninsured have had to search for insurance without help or by connecting to the federal health insurance Exchange through the Arkansas Health Connector. Though the state partnership health insurance marketplace has helped many Arkansans find quality healthcare, to more fully serve its citizens the State decided to implement its own state-based Exchange, beginning with passing the Act 1500 of 2013, and then opting for the Medicaid private option waiver for its citizens. Act 1500 establishes the Arkansas Health Insurance Marketplace as a private, nonprofit health insurance marketplace. Beginning October 1, 2015, a state-based health insurance marketplace will begin open enrollment and coverage will be available on January 1, 2016. Legislation for the Medicaid private option waiver is ongoing.
To help the AHIM establish the state-based marketplace so that it complies with Arkansas Act 1500, the Medicaid private option waiver, and the federal Affordable Care Act (ACA) laws, Arkansas needs a professional services firm that has implemented
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Exchanges, has a healthy knowledge of the Arkansas health care environment, including the private option waiver program, and can provide strategic analysis and decision- making support. Optimity understands the State also needs an executive director that will be responsible for designing, implementing, and operating the state-based health insurance marketplace. The executive director will also guide the integration of the Medicaid expansion population into the broader private health insurance market.
We understand the AHIM Board and/or Executive Director will need help with several activities: • Strategic analysis, planning and assistance with decision-making on implementation of state-based marketplaces • Analysis and research in various areas • Assistance with the development of rules, regulations, policy and operational procedures governing the state-based marketplace • Function as a liaison between the AHIM and Federal and State agencies’ representatives, health insurance marketplace partners, and vendors • Preparation and submission of the May 15, 2014, Level I Exchange grant, Blueprint requirements, and possibly a Level II Exchange grant. • Assistance in meeting the requirements of the 11 “Exchange Areas” defined by the Center for Consumer Information and Insurance Oversight (CCIIO): o Legal Authority and Governance o Consumer and Stakeholder Engagement and Support o Eligibility and Enrollment o Plan Management o Financial Management, Risk Adjustment and Reinsurance o Small Business Health Options Program (SHOP) o Organization and Human Resources o Finance and Accounting o Technology/IT Systems o Privacy and Security o Oversight and Program Integrity
OPTIMITY’S TOOLS AND TECHNIQUES Optimity is well versed in working with public and private sector clients undertaking large-scale and complex program implementations. We have a range of tools and techniques that we apply to structure activities and tasks to accelerate progress. For this project we will leverage our tested assets and apply our recent experience through:
Applying Lessons Learned. As thought leaders in both public and private sector healthcare markets, our staff review proposed and finalized legislation, track state and federal Exchange
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implementation across a number of states, and review lessons learned through studying public documents and through our network of subject matter experts. Moreover, many of our staff have firsthand experience working with state and the federal Exchange, and have a good understanding of which models, approaches, policies, procedures, and technologies were successful. We will apply this body of knowledge and the lessons learned to the implementation tasks faced by AHIM.
Focusing on Quality Throughout. The AHIM’s schedule is short, and there is limited time for re- work, so guidance and formal deliverables need to be right the first time. Optimity’s business processes and project management processes have quality management built into them, rather than being undertaken informally just before deliverables are due. One example of this is our use of supporting work papers that demonstrate our planning, list assumptions, identify relevant data and research, and show managerial oversight. Additionally the staff allocated to this project, have long track records of delivering quality deliverables to clients.
Engaging the AHIM Board. Many of the deliverables that we produce will become AHIM policy, or far-reaching operating procedures or protocols that affect many stakeholders. In this start- up phase, we believe that it is imperative to plan for at least monthly board submissions that provide draft deliverables for discussion and review and final documents for board approval. We will help AHIM to develop a board decision-making calendar—to time needed decisions with needed operational implementation timeframes. This approach ensures that policy is not developed by staff in a vacuum, and is not burdensome for board members, as they will have sufficient time to review and comment on key policy and procedure decisions.
Sustainability and Transition. One of the reasons that Optimity has been successful in program implementation is that we focus on the desired end-state from the outset and develop organizational and operational structures that are self-sustaining and scalable. We know that AHIM has to function as its own entity in the future, so we pay close attention to developing sustainable structures and processes that can be further developed by clients. An example of this is the way that we develop transparent knowledge bases that allow ongoing client review, and which we hand to the client during end of project transition.
Extensive Market Experience. Optimity has provided its clients with policy and design decisions related to many different facets of insurance market and Exchange establishment, including the following: • Merger of individual and small group markets • Establishing benchmark plans for essential health benefits • Exchange governing and operational models • Premium aggregation and disbursement models • User fee models and operational budgets
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• Employer choice vs. employee choice in SHOP • Stakeholder outreach, communication, and education • Risk adjustment and reinsurance management approach
PROJECT WORK PLAN As part of our project initiation, we would develop a detailed project plan that lists major implementation tasks and sub-tasks, and schedule those around milestones and key decisions and deliverables. Many of the activities cited in the AHIM’s RFP are interrelated and will be conducted concurrently, but the key to success for implementing the 11 Exchange areas is detailed strategic planning and coordination with state laws, rules, practices, and stakeholders. The relationship and duration of these activities is shown in the outline schedule in the next section.
SCHEDULE OF WORK Based on our understanding of the State’s scope of work and schedule, we have developed an initial six-phase project plan through September 2014, illustrated in a simplified Gantt form below. Should the contract be extended, we can work with the State to modify the schedule. We have designed the plan so that there is overlap between individual phases and concurrent work opportunities are maximized in order to meet the State’s defined timelines.
Figure 2 – Work Schedule Overview
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CAPACITY DEVELOPMENT AND DELIVERABLES Optimity has a great deal of experience assisting Exchanges and healthcare organizations plan for and undertake start-ups and major transitions. To ensure that the organization can fulfill its mission and meet its mandates, we structure deliverables in the areas as shown in the table in Figure 3.
Figure 3 – Deliverables Structured to Develop Capacity
Area Descriptions and Examples Program and Project Program charter, master project plan, etc. Management Internal policy and Strategic plans and operational frameworks, procedure for example 12 month operational plan External policy and Focused plans and Service Level Agreements (SLA) procedure for example plan management policy and SLA Staffing Organization plan for AHIM, including structure, communication, accountability, and job descriptions Vendor management Contributions to Requests for Proposal (RFP), SLA, project plans, performance management plans Technology and Support Technology master plans, call center plans, accounting policy and procedures, etc.
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STAFF BIOGRAPHIES
Optimity has handpicked a team of policy, process, and technical experts geared to meet the AHIM’s key service areas, as shown in Figure 4 below. For each key service area, we identify the team leader, contributing team members, and identify where our subject matter experts will contribute. Our West Coast Region Director, Tyler Covey, will be the engagement director for all work streams, and will coordinate and oversee all implementation activities. Additionally, we provide staff that can function as an executive team and ably support our interim Executive Director.
Figure 4 - Optimity's Team Skills Align with AHIM's Implementation Needs
Optimity Project Team Tom Tyler Ken Doris Kristina Robert Fred Key Service Area Pelegrin Covey Barrette Stein Park Moss Pilot 1. Strategic analysis and planning
assistance " " ! " 2. Analysis and research " " ! " " " 3. Assistance with rules, regulations, policy " " ! " " " " 4. Liaison between state and federal agencies ! " " " " " "
5. Grant preparation " ! " " 6. Eleven Exchange areas " ! " " " " Notes: ! denotes service area leader " denotes service area advisor
ADDITIONAL STAFF AND WORK STREAM STRUCTURES For each of the staff named in the table above, they will have access to a number of other supporting staff including: managers, senior associates, and associates. The typical work stream structure is a partner or senior manager who then has a team of between two and ten support staff to undertake the necessary work tasks. Optimity work stream teams are loosely coupled so that team members can be shared across specialty areas such as a policy or data analytics, or staff can be shared or temporarily allocated during high workload periods.
PROPOSED EXECUTIVE DIRECTOR Thomas Pelegrin, Proposed Interim Executive Director. Tom is a Partner with Optimity Advisors who has more than 20 years of experience in the healthcare payer and insurance technology industries. He works with the leading health insurance and payer organizations for claims processing, enrollment, premium billing and reporting technologies. Mr. Pelegrin has
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extensive experience with insurance Exchanges and was formerly the Vice President of Enterprise and Government Programs with Benefitfocus where he led the company’s healthcare payer operations and government programs. While at Benefitfocus, Mr. Pelegrin’s team bid and won the Maryland Healthcare Commission’s (MHCC) VIRTUAL COMPARE contract, which served to provide the State of Maryland’s small businesses with an information Exchange for health insurance availability and broker assistance. Mr. Pelegrin also worked with leading health insurance payer organizations to establish portal technologies for enrollment and electronic billing and payment solutions to serve both group and consumer markets.
TEAM MEMBER PROFILES Tyler Covey, CPA, CMA, CFM, Engagement Manager and Implementation and Financial Lead. Tyler is a Partner who has managed and conducted more than 120 consulting and audit engagements over his 19-year career. Tyler’s extensive health care experience includes projects to assist the states of California, Nevada, Washington, Idaho, Florida, Oklahoma, Wyoming, Mississippi, Hawaii, and Vermont with conducting operational assessments and implementing provisions of the Affordable Care Act. He could fulfill the role of interim Chief Financial Officer (CFO). He oversaw the start-up of the Silver State Health Insurance Exchange for a year and a half, including the development of a detailed implementation plan, board decision calendar, Level I and II grants, RFPs for eligibility and enrollment systems, draft staffing and financial model, consumer assistance and appeals study and plan, audit protocols report, essential health benefits study, procurement strategies, strategic planning overview document, program integrity report, IT gap analysis, IAPDs, program integration plan, public disclosures report, and web-based broker study. He also provided some work for exchanges in Wyoming, Hawaii, and Mississippi and is a former CFO for a high-growth, start-up healthcare staffing company.
Kenneth Barrette, Operations and Market Lead. Kenneth is a results-oriented executive with more than 15 years of experience in healthcare and financial services operations and technology and could fulfill the role of interim Chief Operations Officer (COO). Kenneth is the firm's lead advisor on health insurance Exchanges, integrated care operations and technology planning (i.e., accountable care organizations), and operations and technology performance and efficiency assessments. Kenneth has led business and technology planning, design, implementation, and ongoing management support for multiple health insurance Exchanges and accountable care organizations. He prepared technology recommendations for developing health benefits Exchanges in states such as Nebraska and South Dakota. He facilitated board- level reform planning with a Medicare-contracted quality improvement organization for Wyoming, which included planning and strategy support to provider boards, community partners, and health stakeholders on how to prepare for accountable care, insurance reform, and consumer engagement. In addition to this great work, he is also a frequent speaker and contributing author on the commercial and public implications of technology on PPACA health
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insurance Exchange planning and implementation related to Exchange and integrated health operations and technology strategy. Doris Stein, PMP, Policy and Business Lead. Doris has more than 20 years’ healthcare consulting and industry experience with functional expertise in program management, strategic visioning, business process reengineering, system migrations, process improvement, and team facilitation She also received a Lean Six Sigma certification through Villanova University. Doris is providing program management to a national health plan to implement a Medicaid program in two states, which includes developing business requirements, policies and procedures, workflows, and staffing plans, identifying and coordinating cross-dependencies, and supporting the readiness review to meet the State contract requirements. Kristina Park, Strategy and Analysis Lead. Kristina has more than 20 years’ consulting experience working across all areas of healthcare, including strategy, operations, and technology. She has worked with commercial payers, state agencies, providers, and recently set up Consumer Oriented and Operated Plans (CO-OPs) in several states. Her work focuses on driving solutions to support legislative mandates and regulatory changes. She works across all functional areas of a health plan to address Exchange impacts on product/plan strategy and design, operational readiness, network strategy and management approaches, and member experience programs. Robert Moss, Technology Lead. Robert is an experienced strategy and technology leader whose expertise bridges the business, policy, and technical realms. He is an expert in the design, implementation, and operation of online insurance Exchanges as mandated by the ACA. Robert has worked with numerous state governments as they plan and implement their state-based Exchanges under federal establishment grants. As a two time Chief Technology Officer (CTO), we are confident that he could fulfill this role during the AHIM transition. Additionally has also worked with commercial carriers and co-ops as they transform their operations to support the ACA mandates.
Fred Pilot, Federal/State Liaison Lead. Fred Pilot has a broad and deep grasp of health care regulation and reform gained over more than two decades in both the private and public sectors. While serving on the initial staff of the California Health Benefit Exchange (Covered California), the nation’s first state health benefit exchange formed under the ACA, Pilot reviewed and researched laws and regulations to help guide Exchange policymaking, drafted elements of the Exchange’s blueprint application for federal state-based exchange certification and tracked and analyzed proposed federal regulations and state legislation affecting the Exchange. Since early 2010, Pilot has authored an authoritative and widely read blog, www.healthinsurancecrisis.net, which covers challenges facing the private health insurance market, the implementation of the ACA and the state health benefit exchange marketplace.
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REFERENCES
We believe the following references will strongly highlight Optimity Advisors’ ability to support the AHIM with expertise, perspectives, and tools developed from our extensive work at the state, local, and commercial levels related to ACA.
REFERENCE ONE: STATE OF NEBRASKA DEPARTMENT OF INSURANCE
Martin Swanson, Health Policy Council 941 O Street, Suite 400 Lincoln, NE 68508 Office: (402) 471-4648 [email protected]
REFERENCE TWO: HEALTH REPUBLIC INSURANCE COMPANY - OREGON
Dawn Bonder, Chief Executive Officer 4000 Kruse Way Place, Suite 2-300 Lake Oswego, OR 97035 [email protected]
REFERENCE THREE: BLUE CROSS OF IDAHO
David Jeppesen, Senior Vice President 300 E. Pine Ave. Meridian, ID 83642 Phone: (208) 331-7513 [email protected]
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COSTS
Below we list our hourly rates and anticipated expenses. We would be willing to provide a six- month (or longer) total project cost after clarifying the scope of work and level of effort that the AHIM desires.
HOURLY RATES The table below in Figure 5 lists the hourly rate for staff members not inclusive of travel.
Figure 5 – Position Titles and Associated Hourly Rates
Title/Position Hourly Rate
Partner $275 to $325 Senior Manager $225 to $265 Manager $195 to $215 Senior Associate $150 to $175 Associate $125 to $140
ADDITIONAL EXPENSES In addition to the hourly consulting rates listed in Figure 5, we anticipate that the majority of staff would be onsite frequently—resulting in some travel related expenses. Typically travel expenses range between 10 and 15 percent of total costs.
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State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services
February 18, 2014 5:00 PM
William Watson Arkansas Center for Health Improvement 1401 Capitol Avenue Suite 300, Victory Building Little Rock, AR 72201
148 State Street, Tenth Floor, Boston, Massachusetts 02109 Tel. (617) 426-2026, Fax. (617) 426-4632 www.publicconsultinggroup.com
Public Consulting Group, Inc. is an Affirmative Action/Equal Opportunity Employer. February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services
Contents II. Executive Summary ...... 3
II. Firm Overview ...... 5
III. Qualifications ...... 5
IV. General Approach to the Scope of Work ...... 10
V. Team Biographies ...... 14
VI. References ...... 19
VII. Cost Proposal ...... 19
Public Consulting Group, Inc. Page 2
February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services
II. Executive Summary
Public Consulting Group, Inc. (PCG) is pleased to present this proposal in response the Request for Proposals (RFP) released by the Arkansas Health Insurance Marketplace (AHIM) on January 31, 2014. We hope that what we have written over these twenty pages is sufficient to earn us an invitation to Little Rock for onsite presentations by selected finalist(s) on February 26, 2014. We would embrace an opportunity to have a conversation with AHIM Board members about how, in our view, PCG is so uniquely well-positioned to help Arkansas establish a state-based marketplace.
PCG has built its proposal around three key themes:
First, PCG is the most qualified firm to execute the RFP’s scope of work and support AHIM over the next 6 months (and possibly up to 24 months). Nearly 50% of the country – 24 states and the territory of Guam – have turned to PCG at some point over the last four years for assistance in some way with the implementation of the Affordable Care Act. Ten of those states are state-based, and supported state-based, marketplace states. Perhaps most importantly, PCG is currently providing services very similar to those in this RFP to both Idaho and New Mexico, two states currently traveling the path upon which Arkansas is preparing to embark.
Next, PCG will have very little, if any, learning curve. We understand this scope of work well because we have executed it multiple times over the last four years. We have become highly skilled at researching, synthesizing, and presenting Marketplace information in ways that executives find useful and actionable. We are equally adept at executing the day-to-day tasks and activities that are required over the course of months to stand up a Marketplace. And we do all this while routinely lifting our heads above the tree line to provide our clients with insight to drive policy and set a course. We think you will find our writing about how Arkansas can lead the “Second Generation” of Marketplaces illustrative of the thought leadership PCG can provide while simultaneously tending to the day-to-day blocking and tackling any project of this sort requires.
There are more specific and practical reasons as well for why PCG can hit the ground running in Arkansas. PCG has been working with the Arkansas Insurance Department since 2012 on the Marketplace‟s existing Plan Management function. We are pleased to offer the AID as one of our three references. Moreover, PCG has a pre-existing relationship with the state Medicaid Agency which provides us with strong background on the healthcare environment in the state.
Finally, PCG is proposing some of the most qualified and experienced Marketplace resources that exist in the marketplace today. Our proposed Project Manager (and de facto Executive Director if AHIM goes in that direction temporarily) is one of the country‟s most knowledgeable and passionate Marketplace consultants. We look forward to introducing him to you at the onsite presentation if we are selected to attend. The proposal provides extensive (within the confines of the 20 page limit overall) background information about all our staff. We are pleased that all four key core staff has previously worked on the Marketplace at AID. In addition, two staff has substantial Arkansas ties – one currently lives in Arkansas and the other was born and raised in Mountain Home.
Our Marketplace work has covered the gamut. We have worked under all possible Marketplace models, we have helped states forge connections between their Marketplaces, their Medicaid programs, their Insurance Departments, and their State Innovation Model initiatives. We understand the Private Option and have the Medicaid program expertise that successful Private Option adoption requires. We have brought together stakeholders and, in the process, we have been exposed first hand to the perspectives of
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services
II. Firm Overview
Name, address, phone of the company
Public Consulting Group, Inc., 148 State Street, Boston, Massachusetts 02109 Telephone: (617) 426-2026
Name, address, phone of primary contact for the proposal
Michael Hurley, 148 State Street, Boston, Massachusetts 02109 E-mail: [email protected] Phone: (617) 717-1031 . Brief company profile including number of years in business
Public Consulting Group, Inc. (PCG) has been in business over 25 years. We are a professional services management consulting firm, founded in 1986, that has dedicated itself almost exclusively to public sector health, human services, education and other state, county and municipal government clients. PCG has grown from a single individual sitting at his kitchen table to a firm of over 1,400 employees, located in 44 offices across the United States, Canada, and the European Union.
PCG is organized into five practice areas each of which has a proven track record of achieving results for clients. They are Health, Human Services, Education, Technology Consulting, and Public Partnerships. This bid is being submitted by the Health Practice Area.
PCG Health helps state and municipal health agencies to respond optimally to reform initiatives, restructure service delivery systems to best respond to regulatory change, maximize program revenue, and achieve regulatory compliance. The Practice Area uses industry best practices to help organizations deliver quality services with constrained resources, offering expertise in revenue cycle management, payer support services, and health care reform to name a few specialties.
Service offerings include those provided from our earliest years – cost allocation planning, revenue maximization, rate setting, and cost settlement – to those that developed over time with the evolving needs of our clients – health care expense management, cost containment services, and operations outsourcing. Most recently, PCG has established a strong leadership position among states in providing planning and implementation services as each state charts its own individual course for implementing the Affordable Care Act (ACA). PCG won its first ACA professional services consulting contract with Nevada in June 2010, and today roughly 50% of the country has used or is using PCG‟s expertise in Federally Facilitated Marketplaces, Partnership Marketplaces, or State-Based Marketplaces.
PCG does ACA and marketplace work in a cross section of states. This includes Arkansas border states (Tennessee, Mississippi, and Texas), the first fully functioning state-based marketplace (Massachusetts), the nation‟s largest marketplace (California), a state soon to follow Arkansas‟ lead in adopting the Private Option (New Hampshire), and, finally, the two states whose experience seems most relevant to Arkansas (Idaho and New Mexico). And we can always arrange a fact-finding mission to another client – Hawaii. More information about PCG‟s superior track record in assisting states follows next in Section III: Qualifications.
III. Qualifications
Qualifications and Prior Experience: Program management experience with, and strategic analysis and
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services decision making support provided to, at least one state implementing a state-based or state partnership marketplace. (Page 3 of RFP)
Public Consulting Group, Inc. has helped ten states implement either a state-based or state partnership marketplaces, as well as thirteen other states implement a federally facilitated marketplace (see Figure – 1 below). A total of 24 states and the territory of Guam, or nearly 50% of the country, have turned to PCG at some point over the last four years, to assist them, in one way or another, with the Affordable Care Act (ACA). We are prepared to put that hard-earned experience and record of accomplishment to work for the State of Arkansas.
Figure 1 – PCG’s Prior Experience
In all of these states, whether “state” or “federal”, PCG supplied insightful strategic analysis and effective decision-making support. In the early months after passage of the ACA, the analysis and support focused on “planning” which Marketplace model a state should pursue. As political leaders conducted vigorous debates on which marketplace model to pursue, PCG provided information, data, and analysis to support the dialogue. In Tennessee, for example, PCG devised potential timelines and project plans, conducted a gap analysis of information technology infrastructure, and devised a cost allocation plan aimed at optimizing federal financial participation. In n Wyoming, PCG provided policy analysis, market assessments, and financial planning services. Across all our clients at the time, PCG„s strategic analysis and decision making support took the form of analyzing ACA legislation and regulations, studying policy, developing options, and making factually-supported recommendations, all in an effort to help each state choose its own path wisely. While Arkansas has already expressed a commitment to a state-based
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services marketplace, the experience PCG gathered during these early months following passage of ACA will still be tremendously useful to AHIM.
As 2010-11 turned to 2012-13, and states were committing to either using the federal marketplace or creating some version of a state-based model, existing and new clients continued to turn to PCG for assistance, now for “implementation” strategic analysis and decision making support. States had decided on their marketplace model but needed to better understand how to prepare, and then execute, an implementation strategy and plan. In Delaware, for example, PCG provided strategic guidance, project management, and issue and risk management services. We became the “one-stop shop” for all system and policy issues. We developed and executed detailed plans, processes, and procedures to manage and control the life cycle of all marketplace activities. In Nevada, PCG undertook requirements definition, conducted feasibility studies, and authored documents requesting federal funds and requisite approvals. We also conducted stakeholder and vendor forums. We know that the Arkansas Insurance Department (AID) has already successfully executed an implementation strategy for Plan Management, for example, and PCG was pleased to be an active participant. But this RFP confirms that AHIM understands there is much more to do. Thus, we believe you would benefit greatly from the experience PCG gained during its multiple ACA implementations.
But where AHIM will benefit most from selecting PCG is our At this writing, Idaho ranks program management experience, expertise, knowledge, and second in the nation for per- understanding of how to stand up a state-based marketplace. Only two states have travelled down the path that Arkansas is anticipating. capita successful enrollments. And PCG is the exclusive provider of professional consultant PCG helped to design Idaho’s services to both of them. It is our current work in New Mexico and enrollment strategies which Idaho that we think is most relevant to your needs and where we remain the key to achieving clearly demonstrate our unrivaled capabilities in overall marketplace sustainability. program management, as requested by this RFP.
Today PCG provides consulting services across all eleven Exchange Areas1 for the two states, Idaho and New Mexico, whose experience is most relevant to Arkansas. No one else can say this. Figure 2 – PCG‟s Idaho and New Mexico Responsibilities, found at the end of this section, summarizes a range of services, tasks, and deliverables PCG is providing for both states. These activities are representative of precisely the type of assistance AHIM will require as it assumes its proper role pursuant to Act 1500.
AHIM will benefit from obtaining the services of a firm like PCG that can apply, to your advantage, all the (hard) lessons learned these last 3+ years. Whether it is receiving last minute CMS guidance resulting in compressed timelines, coordination of state agencies with competing priorities, or technology vendors that overpromise and under deliver – PCG has seen and dealt with it all.
Qualifications and Prior Experience: Knowledge of the Arkansas health care environment (Page 3 of RFP)
PCG has significant knowledge of the Arkansas health care environment. This knowledge not only includes current marketplace work for the AID activities, but also longer standing work for the state Medicaid agency within the Department of Human Services. In addition, PCG has worked with the
1 as defined by the Center for Consumer Information and Insurance Oversight (CCIIO), the governing federal entity AHIM will soon be dealing with on a weekly basis,
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services
Division of Children and Family Services and local school districts which, while not necessarily directly related to health, supports our assertion that we know Arkansas better than most national firms.
Today PCG works with AID to assist with the design, development, and implementation of a process to certify the qualified health plans (QHPs) participating in the Arkansas federal partnership marketplace. The scope of work addresses certification, decertification, and recertification of QHPs, as well as ongoing oversight and monitoring for compliance. Consistent with this RFP‟s emphasis on program management, strategic analysis, and decision making support, PCG has provided issue briefs, attended and presented at the Plan Management Advisory Committee and Federal Partnership Steering Committee meetings, and developed recommendations for plan selection and quality improvement processes. In addition, PCG developed multiple business processes supporting minimum essential benefits, quality ratings, other rating systems (e.g., financial), quality of care, and consumer and small business education.
PCG‟s work with the Medicaid Agency dates back to July 1, 2012. In 2012, PCG facilitated a national training seminar held in Little Rock to train senior state finance professionals on the intricacies of Medicaid financing which several Arkansas staff attended. PCG is currently contracted to implement a pricing strategy for handling certain claims that are eligible for Medicaid and Medicare reimbursement. The strategy focuses on paying providers a fair reimbursement for the services they provide while maximizing federal payments in place of state dollars. PCG has also evaluated the reimbursement schedule for services provided under the state‟s behavioral health system, comparing them to other states and making recommendations for possible revisions. All of PCG‟s work at Medicaid required a detailed understanding of rules, regulations, policies, reimbursement, and financing. Such deep Medicaid program knowledge is essential to understanding the nuances that the Private Option waiver program will present. No other firm in the country combines Medicaid and marketplace knowledge as well as PCG.
PCG‟s knowledge of Arkansas is not limited to simply the health care environment. PCG has also worked with the Division of Children and Family Services to examine the agency‟s cost allocation plan (CAP) to ensure its methodologies are compliant and fully utilize federal financing mechanisms, thus lowering the burden on the state budget. Finally, PCG works in 125 local school districts across Arkansas, including Paragould, Monticello, Searcy, Mena, and North Little Rock, providing the technology needed to support assessments of students in grades 3-11 in literacy, mathematics, or science. Our point is that this RFP did not bring PCG to Little Rock, in fact the Affordable Care Act did not bring PCG to Little Rock. We have been here for a few years now.
Qualifications and Prior Experience: An understanding of the so-called “Private Option” waiver program recently pursued and obtained by the State of Arkansas (Page 3 of RFP)
PCG has been one of Arkansas‟ key partners in successfully implementing the Private Option. Private Option enrollees access their health care through certain of the Qualified Health Plans (QHPs) offered in the State Partnership Marketplace. Since PCG was hired to be the Arkansas Plan Management consultant in 2012, we assisted the Insurance Department in assuring that QHP features complied with all aspects of the approved Private Option waiver.
PCG‟s deep experience and understanding working with state Medicaid programs make us the ideal vendor to bridge the legal, regulatory and business requirements of the Arkansas Insurance Department (AID), the Arkansas Department of Human Services (DHS) and federal agencies to make the Private Option successful. The proposed Project Manager for this engagement is Rich Albertoni, who administered five Medicaid 1115 waivers during his years working for the Wisconsin Department of Health Services. PCG understands the private option is intended to demonstrate improved continuity of
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services coverage. We are better prepared than any other vendor to assure alignment of specific elements such as network adequacy, benefit alignment and enrollment mechanisms.
Evidence of financial stability (Page 6 of RFP)
PCG has been profitable in each of its 28 years of operation including the most recent FY2013. In fact, PCG has achieved double digit growth in all but two of its fiscal years. In FY 2013 the firm‟s revenue was approximately $244 Million. PCG has projected revenue of $288 Million in FY 2014. PCG‟s profitable growth, coupled with its conservative balance sheet and available credit facilities, provide more than adequate resources to carry out the obligations of the firm and to support its continued planned growth, including this engagement, if we are fortunate enough to be chosen.
Figure 2 – PCG’s Idaho and New Mexico Responsibilities Idaho Health Insurance Exchange New Mexico Health Insurance Exchange Your Health Idaho YHI Professional Services PMO of NMHIX Provide oversight and recommendations for all Established a Program Management Office areas of IHIE Facilitate NMHIX – Department of Insurance (OSI) Draft and maintain multiple Project Plans collaboration and act as a liaison between the two Deliver presentations to the Board, topics Facilitate Medicaid (HSD) and NMHIX relations including: Provide Consultant Services and SME for core HIX o YHI Actions functional areas such as E&E, SHOP, Financial o Grant Budget Management, Technology, Plan Management, o Outreach and Education Consumer Assistance, Notices, Reporting, and Web o Procurement Process Portal. Manage Grant Writing Process: Assist with development of Sustainability Plans of the o Wrote Level 1 Grant as well as related HIX budget items Assist with Grant writing o Wrote second grant while Level 1 Grant Participate and helping prepare for CCIIO gate was already in process reviews o Created tracking document for managing Participate and help prepare for Marketplace Board two concurrent Level 1 grants meetings o Worked with CCIIO managing grant Regularly present at: approval process from start to finish o Board Meeting Participate in weekly CCIIO calls o Legislative Hearings Develop the RFP Vision document for both o CMS / CCIIO Review Meetings Technology RFP and Customer Service Center Provide oversight of QHP Certification Process RFP including status updates and check-ins on Carriers and Lead Technology Procurement from start to the vendor system finish: Host weekly Carrier meetings o Wrote Technology Vendor RFP Provide oversight and management of the IT Vendor o Answered Technology Vendor Questions to stand up the SHOP system (Oct 2013) for RFP Provide oversight and management of the IT vendor to o Conducted RFP Evaluation stand up the full SBE (Oct 2014) o Orchestrated Vendor Demonstrations for Develop the SHOP Operations and Procedures Manual Technology RFP Perform and led UAT efforts for the SHOP system o Provided recommendation for vendor implementation selection Assist in writing the Independent Verification Write Independent Verification & Validation &Validation, Audit, and Call Center RFP RFP Develop a training program for their Health Care Write Customer Service Center RFP Guides (Navigators, In-Person Assistors)
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services
IV. General Approach to the Scope of Work
General approach to executing the anticipated responsibilities, including staffing for each of the 1. Offeror provides services to the AHIM Executive Director 2. Offeror provides the services of an interim Executive Director in addition to Option 1 Page 6 of the RFP)
In Section 2: Firm Overview and Section 3: Qualifications, we made our case that Public Consulting Group Inc. (PCG), as a firm, is (more than) well-qualified to provide the professional consultant services necessary for the establishment of a State-based Health Insurance Marketplace. In Section V: Team Biographies, we make the case that the PCG Team, as individuals, is (more than) well-qualified to execute the tasks and activities anticipated by Act 1500 and this RFP. In this section, PCG shares how its Team will approach the work.
In the pages that follow, we address three components that taken together provide AHIM with a clear window into PCG‟s approach. These include:
the eleven CCIIO Marketplace Areas; resources, including a temporary Executive Director role, and, visioning.
Marketplace Areas
Our suggested approach here mirrors the approach we outlined in our January 10, 2014 correspondence to the Board. If selected as your professional services consultant, we would undertake two tasks in parallel. First, PCG would immediately convert the generic work plan provided on January 10 into an AHIM- specific work plan. This proposed Work Plan would be organized by the eleven Marketplace Areas but have no “due dates” initially; it would simply be the most exhaustive inventory possible of all the tasks required to stand up a state-based marketplace, customized to the Arkansas environment. Its purpose would be to provide AHIM an accurate, informative, and understandable view of “how big is the bread box” when it comes to establishing a state-based Marketplace. This objective of this exercise would be to provide invaluable grounding to AHIM for what is to come, which would in turn empower the Board as it redirects its energy and focus to setting policy and providing direction to an Executive Director.
The second task, executed in parallel with the first, is developing a Project Plan. The PCG Project Plan is markedly different from the PCG Work Plan though it will also draw from it. The Project Plan is action-oriented, tactical, and targeted. It would set forth a rolling 30-60-90 day plan for moving forward with energy and direction. It would address all those tasks and activities that are keeping Board members awake at night. It would be a blueprint for getting done all the things the Board knows needs to get done (and many things members have not yet thought about), complete with action steps, due dates and responsible PCG staff. We can already anticipate some of its components – it would commit to paper a plan to: 1) address the next AHIM grant application, 2) establish a budget and spending plan for the grant monies recently received, 3) craft new or amended Memorandums of Understanding, 4) establish AHIM‟s own interface and protocols with CCIIO, and, 5) perform an impact analysis of the recent vote by the Legislature to defund consumer assistance activities.
PCG is confident that it can produce both a Work Plan and a Project Plan shortly after hitting the ground because 1) we have deep knowledge of what is needed to establish a state-based marketplace in general, 2) we are very familiar with your local circumstances based on our existing work at AID and our
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services attendance at Board meetings, and, 3) we are skilled at researching, synthesizing, and presenting information in ways that executives find useful and actionable. At this stage of the Board‟s existence particularly, it needs a consultant who is adept at providing the big picture, and subsequent snapshots, in easy to digest pieces, effectively communicating what issues, pros/cons, and what needs to be done. The Board does not need PowerPoint‟s and primers as much as it needs analysis and action items.
Resources
“Day 1 Team” PCG is proposing a staffing plan that provides AHIM with 1) dedicated resources, 2) access to additional subject matter experts as needs arise, and 3) an ability to manage its consulting budget.
PCG‟s staffing plan calls for a “Day 1 Team” comprised of six individuals. Four staff will be core members with the other two playing specialized roles. PCG will also make available, but only on “just- in-time, as-needed” basis, more than a dozen additional resources, pulling from PCG‟s significant ACA knowledge store whenever AHIM can benefit from it. Stated differently, you will see and utilize Messrs. Albertoni, Curatola, and O‟Donnell, along with Ms. Odom, starting Day 1 for as long and as intensively as needed. Mr. Jones, who is managing our Idaho project, will also be available, particularly during the first three months of the engagement. Mr. Huse, consistent with his responsibilities described in Section V: Team Biographies will be on-site in his managerial role 1-2 times a month.
We are reluctant to quantify exact percentages of time for the “Day 1 Team” without first allowing the Board to articulate how it wishes to manage its consulting resources. PCG can commit to as much or as little time as desired by the Board. PCG certainly believes that a significant amount of time and effort will be required over the initial six month period to support standing up a state-based marketplace, but we do not want to be presumptuous. We can discuss this issue further at the Oral Presentation or during contract negotiations. Be assured, though, PCG is committed to providing its resources to the fullest extent needed by the Board.
Section V: Team Biographies provides detailed information about each of the six members of the “Day 1 Team”, including marketplace work experience.
Just-in-Time, As-Needed Resources Our marketplace experience over the last four years taught us that the type and intensity of the work can vary, even on a month to month basis. We learned very early not only how important it was to establish a core team of staff dedicated to the project throughout, but also how necessary it was to have access to additional staff on an as-needed basis, as their expertise was required. This strategy ensured the client would not be paying for “make work” and also assured the client there would always be sufficient and familiar resources available throughout. PCG has mastered this management model for our marketplace clients. Work is executed efficiently and effectively, and clients maintain greater control over their consulting dollars.
Organizational Chart The organizational chart on the next page reflects our overall staffing plan.
Executive Director Position PCG is aware of the Board‟s current search for an Executive Director. We fully agree that the Board needs its own full-time senior manager employee to take Board direction, execute the Director‟s job description, and manage the resources provided by the consulting firm you hire. If circumstances
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services require, however, PCG is prepared to modify the role of its Project Manager, Mr. Albertoni, to assume any Executive Director responsibilities the Board wishes to assign on a temporary basis.
Visioning
PCG‟s approach is not simply a work plan, a project plan, and staff ready to execute tasks and activities. PCG also brings to its marketplace engagements thought leadership to share with our clients. Certainly we plan the work and work the plan; but we also lift our heads up above the tree line on a regular basis to provide our client with insight, as well as action. Looking out from today, with 2016-17 closer to the effective date of this contract than March 2010 when the Affordable Care Act was passed, the design of a fully functioning and successful state-based marketplace, consistent with the goals and objectives of the state‟s political leadership, must understand the unique position Arkansas finds itself with respect to the calendar. Our point is not that you are somehow behind; our point is you are starting under different circumstances with potentially greater advantages.
The truth is starting the process of building a state-based health insurance marketplace in 2014 will bear little resemblance to the way the same effort played out during the past four years. Both the policy and technical landscapes have changed considerably. Only a vendor, like PCG, that has worked the past 1,000 days, through development of both policy and technical requirements nationwide and worked within all of the marketplace models that evolved, can help Arkansas optimize the tremendous advantages it has in commencing its journey now. Truly, the last can be first, if done in a thoughtful way.
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services
Arkansas is uniquely positioned to not repeat the challenges the “first generation” of state-based marketplaces experienced. One of the smartest decisions Arkansas can make is to distinguish itself right away as blazing the trail of a “Second Generation” state-based marketplace. Opportunities may exist in which Arkansas need not be encumbered by every last federal rule and where Arkansas can benefit from the knowledge of successful and failed blueprints of the past. Paying attention to these guideposts, in the end, could make the Arkansas Marketplace more effective and financially efficient. We believe we can help you better than anyone explore these possibilities.
But to achieve these goals, Arkansas‟ choice of a full-service consultant with both policy and operations management expertise may be the most critical decision it makes. Arkansas needs a policy and operations consultant, such as PCG, that has had the most complete range of exposure to marketplace models and has worked just as deeply in crafting marketplaces that meet state health policy objectives as they have in defining IT system business requirements. The marketplace really is much more than a website. It is a fundamental component of what will drive a state‟s health care economy and quality of care in the years ahead. Its success requires consulting resources who thoroughly understand both the policy and technical framework.
Consider: Beginning January 1, 2017, under Section 1332 of the Affordable Care Act, states may request waivers of any of the Health Insurance Marketplace provisions that are authorized under Title I. This may include waiver of rules governing the type of health insurance products to which subsidies may apply, employer eligibility to participate in the Small Business Health Options (SHOP) program, the acceptable actuarial value of metal level plans, fundamental requirements about who is eligible to gain coverage in the marketplace, even the individual mandate itself.
Similar to Medicaid 1115 waivers, ACA Section 1332 waivers will be approved by CMS to demonstrate that innovative state approaches to coverage may be successful in covering as many people with benefits that are just as comprehensive and at equal or lesser cost. Should Arkansas decide on a state-based marketplace launch of 1/1/17, it could embark on becoming the first state in the country to develop one with a fundamentally different set of policy parameters and according to ideas and principles that are much more suited to state-specific needs.
CMS already envisions 1332 waivers to be part of Arkansas‟ future. In approving Arkansas‟ “private option” Medicaid waiver, CMS imposed an end date of December 31, 2016, and in guidance released to all states, indicated “private option” Medicaid would sunset at this time in consideration of ways that may be converted to Section 1332 waivers. Even if Arkansas does not elect to pursue a 1332 waiver immediately, the current policy environment is “so not 2012.” Arkansas will launch a state-based marketplace at a time when individual mandate penalties have reached their highest levels. Carriers will have 2-3 years of experience in the market, and their products will be maturing and adjusting to consumer needs. Employers will have already made a series of initial decisions about how to interact with the new law, and, like other stakeholders, they will be able to offer marketplace input that is well-informed and specific. Consumer preferences will have been documented and evaluated.
The technical landscape will also be vastly different. CMS has taken a strong interest in system capacity reuse funded by Establishment grant dollars. States like Colorado have begun marketing their marketplace IT platform to other states in the hopes of lowering the per member cost of sustaining long term maintenance budgets. Clearly, IT system business mapping will not be starting from scratch and implementation “lessons learned” from other states will provide a roadmap for successful development.
Let us be clear. PCG understands that our first requirement and first responsibility to AHIM is to provide the expertise and resources necessary to plan and execute the Work Plan and Project Plan proposed earlier
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services in this section. Our second requirement and responsibility is to ensure we can carry out the scope of work defined in the RFP. Our third requirement and responsibility is to “support the efforts of AHIM in establishing a state-based marketplace consistent with the goals, objectives, and requirements of Act 1500 of 2013….” It is with this third requirement and responsibility in mind that we offer our observations about a vision going forward, one that with the proper partner, Arkansas will have the capacity to fully explore.
V. Team Biographies
Biographies of the staff that would be executing the scope of work anticipated under this contract. (Page 6 of the RFP)
Individual Overview
Richard Albertoni – Project Manager/Executive Director (temporary) Mr. Albertoni comes to his role in Arkansas with a significant head start, as he is deeply familiar with current circumstances in Arkansas already. He has been working in the state on the federally facilitated marketplace since 2012. His scope has been specific to certification of Marketplace plans, but as you will read, his capabilities extend far beyond that. Nevertheless, in his current role, he has developed intimate knowledge of the current state and desired future state of a Marketplace in Arkansas.
Nationally, Mr. Albertoni provides policy and operational consulting to both state Health and Insurance Departments, employing that role to help states better understand how the Marketplace can support broader health policy goals and objectives. He has also managed scopes of work that addressed how the Marketplace is linked to the state Medicaid program, an important skill set for a state pursuing the Private Option. He has led efforts to identify critical timelines for Marketplace policy and operational planning, which is a critical component of an Executive Director‟s job description.
In addition to working in Arkansas, Mr. Albertoni has consulted and provided leadership to Delaware, New Hampshire, and Nevada on a broad range of Marketplace topics and models. In Delaware, his work includes project managing the design, delivery and implementation of all Partnership functions while efforts in New Hampshire focus on both Consumer Assistance and Plan Management. In Kentucky and Minnesota, Mr. Albertoni provided subject matter expertise on managed care value and compliance, as those states considered how health care delivery systems impact their oversight of health plans.
Mr. Albertoni joined PCG as an Associate Manger after holding several leadership roles in state government with Wisconsin Medicaid. In his most recent role before leaving state service, as the state‟s Medicaid eligibility director, his accomplishments included overseeing the successful enrollment of 270,000 members into newly procured managed care plans, authoring an eligibility Maintenance of Effort (MOE) 1115 waiver that was approved by the federal government and helping the State anticipate program changes resulting from ACA provisions, skills transferable to his proposed role in Arkansas.
Christian Jones Mr. Jones will serve as a Technical Advisor on this project, working closely with Mr. Albertoni. Mr. Jones has worked on a number of PCG‟s Marketplace engagements as you will learn, but his senior leadership role for the State of Idaho‟s Marketplace (YourHealthIdaho) will provide tremendous value to Arkansas.
Mr. Jones is responsible for the planning and the establishment of Idaho‟s Health Insurance Marketplace, defined as a “supported state-based marketplace” by CCIIO. Mr. Jones‟ work as the project manager puts
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services him at the forefront of all eleven of CCIIO‟s Marketplace Areas, which form the roadmap for the successful implementation of a state-based marketplace in Arkansas. In Idaho he works shoulder-to- shoulder with that state‟s Executive Director. Idaho employs a Board of Directors like Arkansas and Mr. Jones‟ work brings him into frequent contact with the Board members.
Among his responsibilities to date in Idaho have been advising YourHealthIdaho staff and executing activities related to Legal Authority and Governance, Consumer and Stakeholder Engagement and Support, Eligibility and Enrollment, Finance and Accounting, and Technology/IT Systems. Achievements include writing Idaho‟s second Level 1 grant, creating a budget that combined two concurrent Level 1 grants, managing the technology solution procurement process, managing the Marketplace‟s relationship with the state‟s Medicaid agency, overseeing the writing of requests for proposals for an IV&V (Independent Verification and Validation) vendor and a customer service center vendor, and overseeing PCG‟s consumer assistance work for the state.
Mr. Jones has also served as the Project Manager for PCG's engagement with the Wyoming Health Insurance Marketplace, touching on all aspects of Marketplace planning and implementation activities. Mr. Jones helped the state‟s Steering Committee understand all aspects of a Marketplace, including providing a cost model for the Marketplace's operations, detailing various governance models, analyzing risk pool mergers, and considering potential ways to finance a Marketplace. For the Hawaii Health Connector, Christian was PCG‟s lead for SHOP development and design. This included working directly with the client to provide technical and policy advice and also with the client‟s other contractors to work through requirements, process flows, and design of the SHOP.
Mr. Jones also has experience with marketplace legislation in a number of states, including Colorado, Massachusetts, Oregon, Mississippi, and Washington.
Ashley Odom Ashley Odom is one of three key staff Mr. Albertoni will rely on in supporting the Board and eventually the Executive Director as well. A native of Mountain Home, Arkansas (where her parents still reside) and soon relocating to the Atlanta area for family reasons, she too has been working with the Arkansas Insurance Department since 2012 as part of PCG‟s scope of work for Plan Management. Ms. Odom‟s work in Plan Management has been recognized by CCIIO for its high quality.
Ms. Odom has supported AID on the Qualified Health Plan (QHP) policy development side as well as behind-the-scenes business process and compliance activities. Ms. Odom has authored policy briefs and has coordinated with the Department and stakeholders to develop policy solutions. She conducted plan management business process and gap analyses and authored the plan management blueprint (named by CCIIO as a model for other states); additionally, she was a key contributor to the successful compliance review and approval of plans submitted to the Department for certification in 2013 (PCG took only one month to complete this task). She is in tune with developments in Arkansas‟ Private Option program, and incorporated Private Option considerations into all policy analysis and QHP certification processes.
Ms. Odom has also worked with Delaware and New Hampshire insurance departments, supporting similar business process and policy analysis and authoring standard operating procedures. Ashley developed a familiarity with the Medicaid program through work at PCG prior to marketplaces when she was focused on Medicaid Fraud, Waste, and Abuse (FWS) projects, waiver programs and daily operations such as billing and claim data management.
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services
Fortunato (Tony) A. Curatola, PMP Tony Curatola is one of three key staff Mr. Albertoni will rely on in supporting the Board and eventually the Executive Director as well. Mr. Curatola is a certified PMP (Project Management Professional), a key attribute in managing the scope of responsibilities before AHIM in the coming months. Mr. Curatola has more than 17 years in project management and 14 years in Medicaid. His extensive project management experience comes in both the private and public sectors including: State Government, Healthcare Insurance, Property and Casualty Insurance, and Banking. A core competency of Mr. Curatola is Information Systems.
While at PCG, Mr. Curatola has worked on a number of state projects in support of the ACA, including Arkansas as well. He was part of the PCG Team that assisted the Arkansas Insurance Department with the development of its Plan Management Business Operations and Process Manual. He also created templates for the Memorandums of Understanding (MOU) that define the division of responsibilities as well as a number of inter-agency agreements for use with other state agencies that may perform specific functions on behalf of the existing Marketplace.
Mr. Curatola assisted the Hawaii Health Connector in the design, development and implementation of systems and processes in support of the Plan Management functions for Hawaii‟s state based health marketplace. He served as PCG‟s PMO (Project Management Office) advisor to the Hawaii Health Connector own internal PMO. He is also the project manager for the systems development of the Hawaii Navigator registration and certification system.
While working for the State of Delaware, Department of Health and Social Services, Mr. Curatola was responsible for creating an Implementation Advanced Planning Document Update (IAPD-U) for the Delaware Eligibility Modernization Project. The IAPD-U documents the MMIS changes needed to support the ACA with respect to the eligibility modernization project. Additionally, Mr. Curatola worked with the Delaware Department of Insurance to create Standard Operating Procedures (SOP) in support of the plan management functions for the Health Insurance Marketplace.
Prior to joining PCG, Mr. Curatola worked for EDS as an implementation project manager for the Wisconsin‟s MMIS replacement project as well as a number of other enhancements over a 14 year period.
David O’Donnell David O‟Donnell is one of three key staff Mr. Albertoni will rely on in supporting the Board and eventually the Executive Director as well. He too is an experienced Project Manager with extensive, hands-on experience with Health Insurance Marketplaces, state Medicaid programs, business process redesign, and IT systems analysis. Mr. O‟Donnell has supported planning efforts for Arkansas, Delaware, Hawaii, Idaho, Rhode Island, and Wyoming, as those states assessed implementation options for their Marketplaces and determined how to transform their eligibility technology environments in accordance with the ACA.
For his clients, Mr. O‟Donnell has performed a range of critical tasks to support their Marketplace planning and implementation efforts including technical assessments, gap analyses, strategic consulting on Marketplace IT system acquisitions, business process mapping, business and technical requirements identification and documentation, technical and functional system design, and technical project management.
In Hawaii, for example, Mr. O‟Donnell has played a pivotal role is helping establish the Hawaii Health Connector. Some of the duties performed on this project include performing technical project management over Marketplace implementation, prepare and updating blueprint documentation, tracking
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services the project status, risks, and issues, as well as preparing escalation memos and independent project analysis for senior leadership.
In Rhode Island, Mr. O‟Donnell has worked with program subject matter experts to identify functional requirements for the technologies needed to support the Marketplace, the underlying state eligibility system, and the Medicaid claims processing system to ensure all conform to ACA and other CMS- mandated requirements. He has assisted in the development of procurement documentation and has also assisted in performing project financial management, including developing financial change control processes, invoice tracking and disposition, cost allocation tracking and management, and the development and update of federal budget requests to support project activities.
Prior to joining PCG, Mr. O‟Donnell was a Senior Project Manager for the Commonwealth of Massachusetts‟s Medicaid Program where he managed numerous critical Medicaid operations and programmatic projects including the Commonwealth‟s efforts to comply with the National Provider Identifier standard, improving its provider enrollment and credentialing processes and technical solutions, and its eligibility business processes through the implementation of an Electronic Document Management system.
Sean Huse Mr. Huse is responsible for all PCG projects dealing with Marketplaces, the Affordable Care Act, and any other aspect of Health Care Reform. Moreover, Mr. Huse has been with PCG for over 15 years and is a member of the firm‟s leadership team.
As the Engagement Manager, he coordinates PCG‟s Health Marketplace activities across all projects, ensuring that lessons learned in one engagement can be transferred to others seamlessly. He maintains relationships with eleven state Marketplace CEOs/Executive Directors/Administrators. This rolodex will come in quite handy as AHIM seeks to build on the experiences of those that have come before you. Mr. Huse will assist Mr. Albertoni with resource management, contracting, invoicing, and other administrative matters. He will work with the entire project team to identify opportunities and risks that present from CCIIO, CMS, peer states, and other organizations internal or external to the Arkansas market.
Team Perspective
This “Day 1” Team, comprised of four core members (Messrs. Albertoni, Curatola, and O‟Donnell and Ms. Odom), a Technical Advisor (Mr. Jones) and an Engagement Manager (Mr. Huse) is as strong a team of Marketplace professionals as you will find anywhere in the country. They are well-prepared and are ready to assist the Board and (eventually) the Executive Director in implementing Act 1500. As described elsewhere in this proposal, their plan and approach is to focus on what needs to get done in those eleven CCIIO-mandated Marketplace Areas to ensure a successful transition to a State-Based Marketplace. The table below summarizes each member‟s capabilities based on their experience working on the Affordable Care Act. If AHIM chooses PCG as its consultant, you will be securing a core group of people that are very well-qualified, bring both a depth and breadth of experience with them, and who have worked together on multiple projects.
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services
Just-in-Time, As Needed Recourses (Bench)
Over the past several years of working in the Health Insurance Marketplace realm, PCG has acquired and developed numerous experts with a wealth of knowledge in each of the eleven Marketplace areas. The table below provides AHIM insight into the breadth and depth of resources that PCG can make available to you over the life of the engagement, as AHIM evolves from “planning” to “implementation.” Our strategy as your professional services consultant is to make these resources available to the project “just- in-time, when needed.” So staff with expertise in Marketplace technology won‟t be deployed, and AHIM will not be billed, until that stage of the project is reached. Until a subject matter expert on “The Bench” can make a significant and material contribution to a need, task, or deliverable, s/he will not be deployed. The ability of PCG to make highly qualified individuals available in the numbers and with the expertise is a differentiator between our firm and others who may submit bids. Choosing PCG ensures that, unlike the experience of www.healthcare.gov., AHIM will never be caught short of resources and knowledge as the project evolves over the course of 6, 12, and even 24 months.
The selected Marketplace Area Expertise is numbered according to the following key:
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services
VI. References
Provide three relevant references
Public Consulting Group, Inc. is pleased to provide the following relevant references pursuant to the requirement found on page 6 of the RFP. Information about PCG‟s role working with these clients is found in Section III: Qualifications.
Idaho Health Insurance Exchange Name Title Contact Phone Email Rick Moran Project Director 208-890-1128 (m) [email protected]
New Mexico Health Insurance Exchange Name Title Contact Phone Email Mike Nunez Executive Director 505-350-2936 (m) [email protected]
Arkansas Insurance Department Name Title Contact Phone Email Insurance Deputy Cindy Crone 501-683-3634 [email protected] Commissioner
VII. Cost Proposal
Position titles and associated hourly rates, and other anticipated expenses, including indirect costs. (Page 6 of the RFP)
Pursuant to instructions found on page 6 of the RFP, Public Consulting Group Inc. (PCG) provides the following information regarding cost. Figure 1 - Staff Rates lists PCG position titles and rates. PCG rates are usually set annually and accurately reflect, we believe, current market conditions. You will likely find our rates highly competitive with like-sized and like-minded consulting firms, lower than larger global consulting firms, and slightly higher than firms whose core consulting competency is in technology. If at any time you do not believe that PCG‟s effort, production, value-add, and overall contribution does not justify our monthly invoice, you should contact the Engagement Manager immediately.
Please note the following as well: Budget Certainty – To ensure that AHIM maintains full control over its budget and PCG remains responsive over time to any budget constraints AHIM may encounter, PCG proposes that the rate card be utilized in conjunction with a task order approach. As needs and
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February 18, 2014 State of Arkansas Arkansas Health Insurance Marketplace (AHIM) Professional Consultant Services
assignments are identified by AHIM, PCG will provide AHIM with estimates of staff “input” (positions, duration, and intensity) required to execute the assignment or deliverable. This approach provides AHIM with an active role in allocating resources which drive your costs and allows AHIM to weigh in on what level of staff is assigned to what deliverable. Hourly Rates – These rates include all direct, indirect, and overhead cost with the exception of travel. Travel – Travel will be charged in addition to the rates quoted below. Travel includes airfare, car rental, hotels, taxis, and parking. PCG will utilize the GSA Per Diem rates for Little Rock for meals and incidentals. To provide AHIM with some measure of cost certainty, PCG is proposing AHIM adopt a management practice currently used by our Idaho HIX client. PCG will project a two week “travel forecast” bi-monthly, naming specific staff proposed for upcoming travel to Little Rock and detailing the reason for the on-site visit. AHIM can thus maintain active oversight of this variable cost by modifying projected travel plans if AHIM thinks appropriate. Applicability – Pursuant to the requirement found on page 5 of the RFP, PCG attests that the rates quoted are applicable for one full year from the effective date of this proposal.
Figure 1- Staff Rates
Position Hourly Rate Manager $ 285.00 Associate Manager $ 270.00 Senior Consultant $ 250.00 Consultant $ 200.00 Business Analyst $ 155.00
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Wakely Consulting Group
Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services Wakely Consulting Group February 18, 2014
One Constitution Center * Suite 300 * Boston, MA * 02129 Wakely Consulting Group, Inc.
Introduction
Primary Contact: Diana Galatian Email: [email protected] Phone: (918)403-9312
Company Profile:
Name of Organization: Wakely Consulting Group, Inc. Address: One Constitution Plaza, Suite 300, Boston, MA 02129 Telephone Number: (617) 939-2006 Principal Officers: Patrick Holland, Managing Director & Jon Kingsdale, Managing Director
Description of Organization
Founded over 30 years ago, Wakely is a mid-sized consulting firm that specializes in health care advisory and actuarial services, working directly with government and commercial health insurance carriers on public and private program offerings. Wakely has considerable experience in carrying out complex projects, yet its size and structure allow it to be both more nimble and responsive than larger, national firms. Its corporate headquarters are in Clearwater, Florida, with additional offices in Denver, Louisville, Minneapolis, and Boston. For the past three years the Boston office has led a number of projects relating to the establishment of health care exchanges.
Wakely is a leader in public and private healthcare reform initiatives, led by nationally-recognized health care reform professionals. Our clients include eleven states that participate in the “State Network1,” organized and funded by the Robert Wood Johnson Foundation, plus twelve states that have contracted on their own for Wakely’s services. (With some overlap between the two groups, Wakely has provided exchange-related technical assistance to eighteen states.) Our clients also include health plans including Medicaid Managed Care Organizations (“MMCOs”), hospitals, and other private firms seeking strategic advice on health reform.
Wakely’s expertise in exchange design, operation and implementation started with our hands-on involvement in establishing Massachusetts’ Commonwealth Health Insurance Connector Authority (“Health Connector”). Our Boston office includes five nationally-recognized health care reform professionals who helped design, build, and operate the Health Connector. In addition, Wakely actuaries in our Denver office continue to work with the Health Connector.
1 The State Health Reform Assistance Network (“State Network”) is a program dedicated to providing technical assistance to states in order to maximize coverage expansion under the Affordable Care Act (“ACA”). Through its work with the State Network, Wakely has provided actuarial services and strategic business assistance and support to selected states (Alabama, Colorado, Illinois, Maryland, Michigan, Minnesota, New Mexico, New York, Oregon, Rhode Island and Virginia) since 2011, working with newly formed health insurance exchanges, Medicaid agencies, insurance departments and other state agencies to effectively implement ACA’s coverage expansions.
Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services 2 Wakely Consulting Group, Inc.
Qualifications & Experience
Wakely is uniquely qualified to provide the professional services sought by Arkansas. Wakely has experience with other state-based marketplaces (“SBMs”) performing each request listed in the scope of work. Wakely professionals also have experience working in states that have negotiated unique federal waivers, and would be comfortable participating in more detailed discussions regarding the so-called “Private Option” in the State of Arkansas. We recognize the importance of a close relationship with the Board of Directors for the Arkansas Health Insurance Marketplace (“AHIM”), collaboration with other Arkansas state agencies, and consultation with stakeholders to ensure that the organizational plan being developed is in line with overall goals and priorities of the State. We believe that our depth of experience in operating and consulting SBMs is unmatched.
Our client base includes governments, employers, care providers, and commercial health insurance carriers on both public and private programs. Our professional staff has grown significantly over the past four years, as have gross revenues—from just over $7 million in 2010 to over $35 million in 2013.
As part of this growth, Wakely has assembled a broad, experienced team of consultants specializing in health reform under the ACA to deliver strategic and technical advice, conduct research and data analysis, perform actuarial and financial modeling, and provide project management services. Jon Kingsdale and Patrick Holland, both managing partners in the Boston office, and Diana Galatian, Senior Consultant, will serve as the project leads for Arkansas and will ensure that the entire project team provides the appropriate level of analytic and support services to AHIM. Jon and Patrick have consulted to eighteen states and to the Center for Consumer Information and Insurance Oversight (“CCIIO”) on developing SBMs and the federal exchange.
Individual Qualifications
Patrick Holland, with over 25 years of experience in the health care industry, brings a broad background, including accounting, finance, strategy, and analytics, with direct leadership experience at several health insurance and provider organizations. Prior to starting Wakely’s Boston office, Patrick was the Chief Financial Officer of the Health Connector. Since leaving the Health Connector, Patrick has led Wakely’s consulting engagements in Oregon, Washington, Missouri, Wisconsin, Maryland, Rhode Island, and Colorado, and has advised another half-dozen states in developing exchanges.
Jon Kingsdale, PhD, has run a Washington, D.C.-based health policy consulting group and has over 25 years of experience at two health plans. Jon also served as the Health Connector’s founding Executive Director for four years. Since leaving the Health Connector in 2010, Jon has led Wakely’s consulting engagements in California, Illinois, New York, the District of Columbia, New Mexico, Vermont, and Connecticut, and has advised a half-dozen other states on developing their insurance exchanges.
Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services 3 Wakely Consulting Group, Inc.
Diana Galatian, CPA, joined Wakely in 2012 and has provided advisory services ranging from organizational development and financial management to development of internal controls, contract analysis, grant management, and system design guidance to Rhode Island, Maryland, the District of Columbia, and Washington State, has provided support for State Network projects, and has provided project management services to Vermont. Though currently based out of Boston, Diana will be relocating to Oklahoma in March 2014. This move will allow her to provide more regular on-site support for Wakely clients located in the mid-west and southern mid-west.
A number of other key individuals from Wakely will lead or support the efforts outlined in our proposal.
Kerry Connolly helped build the Health Connector as one of its first employees, and since joining Wakely in 2011 has coordinated Wakely’s support for Rhode Island’s Level II Establishment grant application, developed numerous work plans for state projects, and contributed to various exchange analyses, including resource assessments and business plans, for several states. Julia Lerche, FSA, MAAA, MSPH, joined Wakely from the North Carolina Department of Insurance (“NCDOI”) where she was responsible for implementation of market reform enforcement, rate review enhancements, and planning for the Health Benefit Exchange (under state-based, partnership, and federally-facilitated models). During her time at NCDOI, Julia managed the procurement and use of two Level I exchange grants and two rate review grants. She was also chair of the State Rate Review Subgroup, a National Association of Insurance Commissioners’ forum for state regulators to discuss the impact of health care reform on health insurance rate review. Julia was also actively involved in providing feedback to CCIIO on rate review and plan management approaches. James Woolman joined Wakely in May 2011, having previously held responsible financial analytic positions at the Massachusetts Division of Health Care Finance and Policy, the Health Connector, and Tufts Health Plan. At Wakely, he has worked on exchange self- sustainability models, business plans, and various other exchange planning analyses for Washington, Missouri, Rhode Island, and Maryland. Kathie Mazza is a licensed broker with some 25 years of experience in sales and marketing, product development project management, and member service and account management for several health plans. Since joining Wakely in March 2011, Kathie has led analytic projects on exchange development and broker and navigator management for CCIIO, Illinois, Missouri, Vermont, Rhode Island, and New York. Jason Aurori joined the Wakely team in 2012 with a background in private equity. Jason specializes in the predictive analysis, modeling, and regulatory research. During his time with Wakely, Jason has provided budgetary and other financial modeling services along with assistance in system implementations and testing.
In addition to this core team of professionals, Wakely will pull in other staff as needed and will rely heavily on its managerial and actuarial professionals to provide a variety of analytical modeling and production of decision support tools, including recommendations on the ability of the exchange to
Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services 4 Wakely Consulting Group, Inc. influence cost reduction initiatives, enrollment statistic projections and analyses, review of current rate submission and rate review processes, and statistical support for grant submissions. Organizational Experience
Among the many qualifications that make Wakely an ideal choice to support AHIM is our proven track record in providing strategic analysis and decision-making support for numerous SBMs and state partnerships. Our analysis and decision-making support have been applied at all phases and levels of business operations; however, we believe our most relevant experience for AHIM will be in the area of business planning. The following are some examples of the business planning tasks performed by Wakely for states such as Missouri, Oregon, Washington, New York, Illinois, Maryland, Rhode Island, Vermont, and New Mexico:
Board Retreats & Goal Setting: As the former CEO of the Health Connector, Jon Kingsdale has four years of experience staffing and supporting an exchange board of directors, and has in a consulting role facilitated priority-setting sessions of the boards of both the Washington and New Mexico exchanges. Most recently, he guided New Mexico’s board of directors through a two-day retreat in which the board succeeded (after eight months in existence) in formalizing an agreement on its priorities for 2014, 2015, and on the essence of a vision for 2016 and beyond. Financial Sustainability, Plan Management, and Systems Integration: Patrick Holland has performed and led a number of SBM projects ranging from budget modeling, sustainability projects, development of business specifications for key system platforms, especially premium billing, and devising and executing Qualified Health Plan (“QHP”) strategies and procurements. Financial Management: As auditor for both the Health Connector and Commonwealth of Massachusetts, Diana Galatian has first-hand experience with the full range of relevant financial management issues. She brings a wealth of knowledge in designing internal control structures, as well as federal grants management and contract management. Exchange Staffing: As part of its five-year financial modeling for a half-dozen other state exchanges, Wakely has developed recommendations on how to cost-effectively sequence hiring consultants and staff, has provided job descriptions and organization charts for higher-level staff, and has developed staffing budgets, year-by-year, through 2015 and beyond. SHOP Exchange: Wakely has worked on SHOP design issues for Missouri, Illinois, New York, Vermont, and Rhode Island, through competitively bid state contracts and through its work with the State Network. Our research in Rhode Island, Vermont, Illinois, and New York included focus groups with small employers and employees of small firms, plus interviews with employers, employees, brokers, and general agents to test different models for a SHOP exchange. The focus of this research was on ways for the SHOP exchange to add value for employers and employees, as well as on the appetite among agents and employers to work with SBMs. Health Insurance Market Reform: Wakely has performed comprehensive analyses of health insurance market reforms, the impacts on pricing levels, pricing methods, and the “three Rs” of risk adjustment for Oregon, Illinois, Vermont, and Rhode Island, and has or is performing analyses of aspects of market reform and risk adjustment in New York, Maryland, Colorado, and Wisconsin. Exchange Evaluation: Wakely has created a data and evaluation plan for the Rhode Island and Vermont exchanges, including reform goals and selected indicators appropriate for Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services 5 Wakely Consulting Group, Inc.
assessing progress toward these goals. Wakely also assessed which of these indicators were available from existing data sources, including how up-to-date the baseline data was and whether the data could be used to provide state-level estimates. For recommended indicators that are not currently being collected, Wakely described strategies that could be used to obtain this data. Program Integrity: Wakely completed projects on the prevention of fraud, waste, and abuse for the Maryland, Washington, and Missouri exchanges, and designed Blueprint documentation for program integrity in Rhode Island. Broker and Navigator: Wakely has worked closely with several states on both broker and navigator outreach programs. We conducted a comprehensive analysis of the broker community for the New York exchange and did similar assessments in state-based exchanges in Vermont and Rhode Island, as well as Illinois, a partnership state. One of Wakely’s senior consultants is a licensed broker with more than 20 years of experience in commercial health plan sales, marketing, and client services. Our work with navigator outreach is equally extensive and includes assistance developing the navigator programs in Washington, Rhode Island, and Vermont. Wakely also assisted with the development of business system requirements for both brokers and navigators in several state-based exchanges.
These are just a few examples of the assistance that Wakely has provided to its many exchange clients. In addition, Wakely staff have authored or otherwise contributed various papers and thought leadership on objectives for SBMs, operating models and rating methods for the SHOP, organizing customer contact centers, financial self-sustainability, options to help the “unbanked” make premium payments, and risk adjustment, among other relevant topics.
Not only do Wakely professionals have an in-depth understanding of federal regulations, but our extensive and wide-ranging experience with other states gives us a thorough understanding of potential state regulatory responsibilities and the potential tensions between state and federal perspectives. Our professionals have provided policy, procedure, and regulatory advice and guidance in California, Missouri, Maryland, Rhode Island, Washington, Vermont, and the District of Columbia. We recognize that each state has different needs and objectives, and we believe that policy and operational plans should be crafted with a mind towards local needs as well as federal requirements.
Wakely also appreciates the need for communication with all stakeholders involved in the exchange development process. To that end, we have served as a functional liaison between exchange organizations and other state agencies, issuers, consumers, vendors, and the federal government. Rhode Island provides a prime example of this experience. There we have assisted the state by facilitating conversations and cooperation with groups such as carriers and vendors. Similarly, in the District of Columbia Wakely has served as facilitators and subject matter experts to four separate advisory groups on how the exchange and issuers should coordinate premium billing, defining essential health benefits, designing employee choice in SHOP, and coordinating broker and navigator activities that were organized by the exchange to generate stakeholder input on key board decisions.
In addition, Wakely has worked with six states on Level I and/or Level II Establishment grant applications, providing project management, drafting, and budget development expertise. Wakely wrote the project narrative, budget, budget narrative, work plan, and other components for Vermont, Washington, and Rhode Island’s successful Level II applications—and in the case of Rhode
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Island, multiple Level I applications. We also assisted Missouri, Connecticut, and the District of Columbia with their successful grant submissions. In our experience, drafting a successful grant application is a months-long process involving close coordination with state staff. In the absence of staff for Arkansas’ exchange, we would propose working closely with a committee of directors.
A key component to all grant and Blueprint documents developed by Wakely is a focus on ensuring that the requirements of the eleven “Exchange Areas” are highlighted and addressed within those documents, while customizing the organizational design to the individual needs of each state. Wakely’s entire team is well versed in each core exchange area, as designated by the federal government. This gives us the ability to work with any organization and find ways to plan strategically for compliance with federal guidance while building a highly individualized state- based operation.
Beyond our exchange work, Wakely has worked with a half dozen private health plans, most of them MMCOs, to prepare operationally to participate on exchanges, to negotiate provider contracts, and to make commercial product filings for the first time. This experience brings an important private-sector perspective to our work with states. Indeed, the decades of experience that Jon Kingsdale and Patrick Holland brought to the Health Connector when they joined in 2006 was all in the private sector, working for a half-dozen different health plans and large provider systems.
General Approach
General Approach Option 1
Project Plan Option 1: Assumes Executive Director has been hired
Wakely will begin this project by sitting down with the AHIM board and Executive Director to gain a full understanding of the strategic decisions that have been made or need to be made, and to establish a map of the applicable stakeholders specific to the state of Arkansas.
Once stakeholders have been fully identified, Wakely will work with AHIM to design a communication strategy specific to the respective stakeholder groups and will assist in initiating communications with those groups. Wakely will stress the need for efficient working groups given the project timeline and will provide services to help facilitate productive meetings.
Simultaneously, Wakely will begin to thoroughly analyze any existing data and available market information to determine where additional data collections must be performed and establish a list of recommended surveys and strategic analytics. Based on our preliminary understanding of the Arkansas market, some surveys and analytics might include:
A review of plan availability and cost to determine competitiveness in each market and identify ways to increase competition; A review of network offerings (tiering, consolidating, etc.) and quality improvement initiatives, the impacts on cost, and the role the exchange can have to influence cost reduction initiatives;
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A market survey to determine awareness of financial assistance through the exchange among target populations; A review of the current rate submissions to help determine what role the exchange should play in encouraging more issuers, and reviewing rates; A survey of current enrollees to determine positive/negative aspects of current (federal) exchange interface, levels of understanding (or confusion) about comparing and selecting QHPs, etc., in order to design an Arkansas exchange that works better for consumers; and A review of potential uses of All Payers Claim Database (“APCD”) information to support rate review and policy decisions.
Utilizing the results of the aforementioned strategic analysis and stakeholder feedback, Wakely will provide decision-making support to AHIM for overall exchange strategies, as well as provide options/recommendations for exchange Blueprint documentation.
Another area of immediate focus will be the development of exchange Blueprint information, where our knowledge base will be leveraged to move through this process as efficiently as possible. Although we will utilize the core exchange areas as defined by CCIIO and best practices from both private and public organizations as a general backbone for the Blueprint, we will also rely heavily on the stakeholder feedback and the Board’s views to ensure that the overall design is customized to meet the Arkansas’ specific needs.
Efficiency is critical during this entire project. Our experience with major Level I and Level II grant submissions has allowed us to develop a general timeline for production that will be utilized to ensure that proper review and attention is given to the grant development process. With efficiency in mind, an assessment will be made of previous Level I grant awards to Arkansas to determine where synergies or areas for potential collaboration may exist with groups such as the Arkansas Division of Insurance. Additionally, this review will enable us to design a grant application free of duplicative requests.
Wakely’s approach to the creation of AHIM’s grant application will include a detailed project plan outlining the composition and editing process for each component of the application. We recommend that the Board assign a small oversight group to this project in order to assist Wakely with the collection of state-specific data and information needed to complete the application. Wakely will report to this group weekly on the application’s progress including activities completed, key activities pending, outstanding issues, and an updated project plan. The first product of this project will be a draft work plan. This work plan will drive the creation of the narrative and budget.
Wakely will work closely with AHIM, state staff, and outside personnel to create the remaining deliverables that support the application. This scope includes coordinating the IT budget and narrative with the staff and/or vendors overseeing IT projects, but presumes that any IT technical components of the grant application will be primarily developed by a separate party. If the Arkansas is in need of an IT Gap Analysis, Wakely has partner IT vendors and can discuss providing this expertise to the state. Wakely will assume responsibility for all other components of the grant (cover letter, project abstract, project narrative, budget, budget narrative, work plan, organization chart/staff descriptions), and the final product. Depending on what is included as part of the grant application, Wakely may need to track resources and timelines across multiple programs and agencies. For some staff, the exchange planning work happens in addition to their normal workload, so we will be judicious with the amount of time requested from state personnel.
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As with other start-up organizations, the development of policies, procedures, and internal controls is key in establishing a sold operational and financial base on which the exchange will grow. Wakely will work with AHIM to craft policies and procedures that will support the organization’s strategic goals while also aligning with federal and state regulations. We will incorporate any required state policies into this documentation process and will also look to work with state agencies in a collaborative manner to determine if best practices could be leveraged by the exchange. Wakely will provide assistance and thought leadership in developing documentation for the following business areas:
Staffing – including, development of organizational charts and job descriptions. Budgeting – including development of long term operational budgets, templates for grant budget tracking, and budget template for contract management. Operational Policy and Procedures Documents – each operational component of the exchange, including: o Purchasing o Human Resources o Outreach and Education/Consumer Support o Financial Management and Accounting Internal Control Plans – including specific controls to address risk of fraud, waste, and abuse.
In addition to the more traditional business planning documents described above, the exchange will need to develop a number of rules, regulations, and policies in accordance with federal guidance. For example, some key exchange design decisions that Wakely can support Arkansas in making are:
Determining whether Arkansas or CMS will provide of reinsurance; Determining whether Arkansas or CMS will calculate risk adjustment annually; Creating policies for eligibility and enrollment such as cut-off for enrollment payments; Determining how to structure “bids” for QHP certification and whether to specify plan designs; Selecting of Premium allocation methods and type of employee plan choice in SHOP; and Broker contracting, compensation, and oversight, as well as Navigator selection, contracting, compensation and management.
The policy and procedures documentation highlighted above touches on a variety of the required “exchange areas” as defined by CCIIO. For these required areas, Wakely will provide enhanced analysis and decision support as dictated by the needs of AHIM. In general, our approach to each exchange area will be as follows:
Legal Authority and Governance
Wakely will work with staff to support AHIM’s Board of Directors, by helping the Board clarify roles, expectations, and norms for monitoring the performance of the exchange. Board support should include strategies to develop (1) a robust understanding of exchange issues; (2) norms of decision-making for the exchange and the Board’s role therein; (3) management tools for keeping the Board well informed and helping it grapple with strategic decisions; and (4) oversight processes for developing annual priorities and measuring progress in executing them.
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Developing an effective working structure with the Board can be facilitated by engaging Board members around a set of explicit decisions about how the exchange should operate and relate to the wider state government. It is equally important to develop norms of behavior in public meetings. Basic decisions such as where to meet, how frequently and for how long, and who engages the press after controversial meetings can have real effects on the process.
Tools for building trust will include identifying the range of process issues explicitly and briefing individual board members as appropriate to help prepare them for meetings. We will also help develop a plan for Board training in the areas that they feel most in need.
Consumer and Stakeholder Engagement and Support
We believe that effectively communicating the benefits and availability of the exchange to Arkansas residents requires both a deep knowledge of the issues and an understanding of Arkansas itself. As such, we will assist AHIM in identifying a vendor with Arkansas-specific knowledge and capabilities to assist in the development of a communications campaign aimed at building awareness and motivating target segments of the market to enroll. Wakely will work closely with both the vendor and management to impart program-specific knowledge to the development process and to ensure that the overall strategy is in line with the core principles and needs of the exchange.
Eligibility and Enrollment
Eligibility and enrollment is a key component of exchange operations, and Wakely will provide a full range of decision-making support in this area. The advice we will provide is enhanced by our extensive industry experience and our exposure to wide variety of eligibility and enrollment systems. It is our experience that choosing an appropriate system implementer and developing a strong working relationship with that vendor is paramount to the success of the overall process. We will work with AHIM and provide support throughout the vendor selection process, and will provide a business perspective to the technical build discussion. We will support the process by attending design meetings, providing process flow charts and other organizational development tools, and by serving as an expert advisor when working with other vendors to develop system design documents.
Agent & Navigator Relationship Development
Wakely will develop a request for information that the AHIM can use to identify the capabilities of navigators and in-person assisters, and will help AHIM organize an Agent & Navigator Advisory Council to use in testing outreach and enrollment approaches, and soliciting input. Wakely will identify key issues and options for soliciting, training, and contracting with navigators, in-person assisters, and agents. Wakely will help AHIM develop, or contract for the development of, broker and navigator training & certification programs. Wakely will work with AHIM’s outreach and marketing staff to develop a robust sales and marketing program, including sharing “best practices” from other SBMs, evaluating agents and navigators, developing relationships and joint efforts with issuers’ sales and marketing departments, and protocols for transferring subsidy-eligible individual enrollees to AHIM.
Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services 10 Wakely Consulting Group, Inc.
Plan Management
Under the ACA, an exchange is required to consider certain criteria regarding the issuer of a QHP as well as regarding the QHP benefit plan itself when making determinations related to QHP certification. Health and Human Services (“HHS”) has provided minimum criteria that states will need to review during the certification process. Beyond these minimum criteria, states have the ability to include additional criteria that they deem to be in the “best interest of qualified individuals and qualified businesses.” Wakely will provide AHIM with an in-depth analysis outlining state and federal requirements and criteria for QHP certification. This will provide the baseline information upon which the state will establish its own detailed QHP criteria. A few examples of the work Wakely will support in relation to the QHP process are:
1. We will work collaboratively with the Arkansas Insurance Department and other relevant state agencies to review relevant documents and policies to assess existing state capacity and activity related to rate review, licensure, and other oversight activities. We will use this information to develop a recommended certification process that leverages and complements existing processes to maximize efficiency and coordination while minimizing market confusion. 2. We will assist with identifying specific goals the state hopes to achieve through the certification process. 3. At the request of the state, we will interview key stakeholders to identify priorities, concerns, and issues with direct relevance to the QHP certification process, including a discussion of both content and regulatory process issues. 4. Based upon our analysis of state and federal policy, assessment of existing processes, and information gathering from state officials and carriers, we will develop recommendations related to QHP criteria, as well as a process structure that will most effectively and efficiently meet state goals. 5. Draft model contract instrument to memorialize state goals, meet state and federal standards, and address other issues, concerns, and priorities identified during our review.
Financial Management, Finance and Accounting, Risk Adjustment and Reinsurance
Under Section 1313 of the ACA, an exchange is required to keep an accurate accounting of all activities, receipts, and expenditures, and to submit annually to the Secretary of HHS a report of such accounting. The exchange is also subject to annual audits and oversight from the Secretary of HHS, in coordination with the Inspector General of HHS, the Government Accountability Office (“GAO”) oversight, the Comptroller General, and state officials.
To meet these financial management responsibilities, Arkansas’ exchange will need to develop a strong system of internal controls along with the necessary financial staff, cash management infrastructure, and accounting and reporting capabilities. Aside from federal requirements, the exchange, as a start-up organization, will seek to build credibility and trust with the public as well as its business partners. The quickest way to lose credibility and public trust is to fail to develop a strong system of internal control, there by resulting in errors and tarnishing the image of the exchange. To guard against this potential, the exchange will need to ensure in its business operations planning that resources are identified and allocated for this often overlooked financial and operational process.
Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services 11 Wakely Consulting Group, Inc.
Wakely has broad significant experience in developing financial policies and reporting systems in a variety of private and public settings, including state-based health benefit exchanges. For this task, Wakely will help AHIM focus on developing the necessary resources required to adequately manage the organization’s finances, including developing recommendations related to staffing and timing for hiring, key external vendors needed to manage the finances of the exchange, and the core financial infrastructure elements and external interfaces that will need to be established to operationalize the organization. Specific areas of focus will include:
The type of accounting and financial reporting systems appropriate to the exchange model under consideration, including expected cost of implementation and reporting structure; Premium billing systems, including lockbox functions; Policies and procedures in the areas of financial reporting, accounts payable/receivable, and premium write-off; Organizational integration required to track and reconcile payments and collections, particularly related to premium collections; Vendor, carrier, and systems interface and reporting relationships; and Control and management of exchange data and financial information.
In compiling recommendations for AHIM regarding the development of fiscal controls and audit protocols, we will rely upon current best practices for both public and private organizations. While there are multiple definitions for what constitutes financial control, the most commonly used framework comes from the Committee of Sponsoring Organizations of the Treadway Commission (“COSO”). COSO defines internal control as having five components: Control Environment, Risk Assessment, Control Activities, Information and Communication Systems, and Monitoring. Because maintaining a system of control is an ongoing effort, we will also propose a system of ongoing processes related to maintenance and verification, as well as assistance with planning for and engaging external auditors.
Risk Adjustment and Reinsurance
Arkansas, like other states, faces several important policy decisions when considering whether to implement reinsurance and risk adjustment strategies, and, if so, how to design those programs. Wakely’s policy and actuarial expertise, including the area of risk adjustment, makes it particularly well suited to support AHIM and Arkansas decision-making in this arena.
The following tasks are key examples of services we could provide related to reinsurance:
• Educate AHIM regarding options with reinsurance. • Work with stakeholders to define a process and timeline for developing a state reinsurance program as required under the ACA, including key decision points and milestones. • Define information needed and develop a plan to obtain this information. Specify the data needed and develop a plan to operate the reinsurance program in accordance with federal guidelines, utilizing data from the all payers claims database. • Work in partnership with the health plan(s) affected by the reinsurance program to develop the policies and procedures for the program. • Conduct needed analyses and draft methodology, policies and procedures for operating the reinsurance program (in the individual market) in accordance with federal requirements.
Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services 12 Wakely Consulting Group, Inc.
Many of the issues discussed in relation to reinsurance also pertain to risk adjustment. Additional considerations for risk adjustment include:
Pros/cons of federal versus state administered risk adjustment program; If state administered, what state agency will administer the program; If state run risk adjustment, which risk adjustment tool to use; If state run risk adjustment, what premium rates to use, rating factors, etc.; If state run risk adjustment, data collection schedule and other stakeholder interaction; and Specifics of the risk adjustment audit programs.
The full list of design questions is very long, but the items above are some of the most critical. Throughout the assessment and decision-making process we will bring information and experiences from other states. We believe that a major benefit to AHIM’s delayed exchange implementation is the opportunity to learn from the experiences of other states and from Arkansas carriers’ experiences with the current federal system.
Small Business Health Options Program (SHOP)
The development of a SHOP exchange poses unique challenges for states. While the individual exchange has a clear value proposition for its individual clients—access to substantial tax credits not available in the commercial market and ease of comparison shopping and enrolling in a matter of minutes—the value of the SHOP exchange to small employers is less clear. Therefore, AHIM should think strategically about what value the SHOP exchange could add for employers and agents.
Wakely will bring its first-hand knowledge of SHOP exchanges, leveraging work the firm has performed in numerous other states and lessons learned working with CCIIO on SHOP design. For example, through Wakely’s work in other states it has become clear on SHOP design that close attention must be paid to building into the IT specifications appropriate mechanisms for screening employees for the affordability of employer sponsored insurance (“ESI”). An automated, “easy” way to screen enrollees for ESI affordability should be built into the SHOP business processes, as this screening will likely save money for both employers and lower-wage employees. As such, it represents a “value-add” for the SHOP exchange. This is but one example of what Wakely will want to discuss with AHIM and then (as appropriate) build into business design planning for SHOP.
Working closely with AHIM and with Arkansas employers and employees, Wakely will also identify priorities for AHIM’s SHOP exchange and develop corresponding exchange models. Wakely will organize design meetings with insurers, employers, and employees. If given a choice, it is the employer and his/her agent—not the employee—who chooses SHOP versus another buying channel, so design meetings with agents and employers are a priority for developing a SHOP model that will “sell.”
To help inform decision-making around the SHOP exchange, Wakely will provide an assessment of the budget and operational impacts of carrying out a minimal set of functions versus an expanded set. This will include a high-level assessment of the minimum required business processes as well as the business processes associated with optional features or services that the state may wish to offer. We will provide cost estimates, leveraging work from other states where possible, to maximize the efficiency of our work. We will also document the operational procedures needed for the SHOP, including required elements as well as “nice-to-have” features.
Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services 13 Wakely Consulting Group, Inc.
Organization and Human Resources
Wakely consultants have developed job descriptions, organization charts and/or staffing plans, and human resource manuals for insurance exchanges in several other states. Wakely will work closely with AHIM’s leadership to build a staffing plan that comports with a financial model of self- sufficiency, including personnel expense for each of the next five years. We believe that the importance of maintaining fiscal accountability and operating the exchange in a business-like model cannot be overstated. Ensuring that operations are designed in a consumer friendly yet streamlined business way will be highly beneficial to the long term viability of the organization.
Wakely often recommends building and training staff through a phased plan that relies more heavily on external expertise initially, while bringing many of those functions in-house as that becomes more efficient and the exchange moves toward self-sufficiency. Using outside professional assistance in the pre-operational years is more cost-effective and quicker than hiring, and it allows the exchange access to the highest caliber assistance through competitive bidding. Experts can help the exchange set up internal systems, train in-house personnel hired to operate and maintain such systems, and provide permanent employees with informed consultation. Staffing needs will evolve over time, and cross-staff training in AHIM will be important. Wakely will work closely with the relevant agencies to develop appropriate training and cross-training protocols and programs that serve multiple agencies and client needs.
Technology/IT Systems and Privacy and Security
Selection of a technology vendor will be among the most important decisions that AHIM management will make. As has been observed in many other states and with the federal exchange, the quality of business and operational policies and procedures will have no impact if technology components are not correctly designed and operational when needed. Wakely will provide decision support to AHIM during the initial selection of a technology vendor and will assist AHIM as a technical advisor on business requirements during the system design process. (These advisory tasks do not include managing the IT and other vendors.)
One of the most significant and public facing components to vendor selection and eventual system design is the technology vendor’s ability to design a system with appropriate levels of security and data protection. The nature of the information collected and transmitted by an exchange is highly personal and confidential, and the ability of the exchange to build trust with consumers will be cemented by the organization’s ability to protect the data with which it has been entrusted. We will provide AHIM with high-level decision support from a business perspective when dealing with technology vendors and security experts.
Oversight and Program Integrity
As previously discussed, Wakely believes that to build credibility for the organization and its mission, AHIM must have a strong commitment to governance, oversight, and general program integrity.
Wakely will provide decision and documentation support in these areas both during the development of the exchange Blueprint and as the exchange begins to implement policies and procedures previously developed. Chief among the ongoing responsibilities of AHIM management
Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services 14 Wakely Consulting Group, Inc. will be vendor oversight, and Wakely can provide the training and tools necessary for effective vendor and contract management.
Conclusion
We understand that as AHIM begins to more fully develop its vision for a SBM, the needs of the organization will change. Our past experience and organizational design allows us to be highly responsive to those changing needs. The general approach described above assumes that the AHIM Board will have identified a permanent executive director by the time our work is scheduled to begin, and, as such, we will be working hand-in-hand with this individual in all elements of this engagement. In the event a permanent executive director is not identified in time for the start of work, we will be capable of providing the AHIM Board with some temporary executive director services. The option to provide those additional services is shown as Option 2 in this proposal.
We are committed to working in a collaborative way with all stakeholders in the exchange building process and will be prepared to assist AHIM in its dealings with the many other groups who must be involved in the development of an exchange organization. We believe that the ideal exchange design is the one that best matches the needs of the constituents which it serves.
Primary Project Staffing Option 1:
Jon Kingsdale Patrick Holland Project Director Project Director
Wakely Diana Galatian Actuarial and Project Lead Special Project Support
Kerry Connolly Julia Lerche Senior Consultant Senior Consultant
Jason Aurori Analyst
Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services 15 Wakely Consulting Group, Inc.
General Approach Option 2
Project Plan Option 2 In the event that AHIM has not hired an executive director at the time our agreement for provision of professional consultation is signed, Wakely would also be able to provide the following interim director services in addition to the work described in Option 1:
We will provide a full time, dedicated employee to service the needs of AHIM. We will plan to spend two to three days per week on site in Little Rock working directly with AHIM board members and representatives from other state agencies to ensure progress on organizational design and development continues during the search for a permanent executive director. We will prepare and present information to keep the board informed of all critical exchange design decisions. We will provide instruction and guidance to AHIM staff when needed. We will provide general support and guidance to the board throughout their search of a permanent executive director.
In filling this role of temporary executive director, we would propose a three-pronged approach to staffing:
1. Diana Galatian, as project lead, would provide the majority of the needed day-to-day on-site support and would be a dedicated resource to AHIM. She is experienced at managing large projects with decentralized staffing and is skilled at working collaboratively with many components of state government. Her background of working with both governmental and non-governmental start-up organizations has been highly valuable in developing exchange operations. 2. Jon Kingsdale, the former Executive Director of the Health Connector, will provide direct support to the board when needed and will review and provide guidance in the overall project management by working closely with Diana. 3. Patrick Holland, former CFO of the Health Connector, will also provide direct support to the board when needed and will be utilized for additional guidance and oversight throughout the project.
Wakely is uniquely qualified to provide these services as it is able to offer access to both the former executive director and the former CFO of the country’s first exchange organization. This access to Jon and Patrick complements Wakely’s ability to provide a full-time dedicated resource that has spent the last seven years assessing and providing guidance to both governmental and non- governmental start-up organizations.
Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services 16 Wakely Consulting Group, Inc.
Primary Project Staffing Option 2:
Jon Kingsdale Project Director Providing Support for Executive Director Services Diana Galatian Project Lead Providing On-site Executive Director Patrick Holland Services Project Director Providing Support for Executive Director Services
Providing Additional Support for Temporary Executive Director
Kerry Connolly Julia Lerche Wakely Senior Senior Actuarial and Consultant Consultant Special Project Support Jason Aurori Analyst
Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services 17 Wakely Consulting Group, Inc.
Primary Staff Biographies
Jon Kingsdale, Ph.D., is Managing Director and co-founder of the Boston office of Wakely Consulting Group. Jon has worked over the past three decades on developing a broad range of innovations in health care financing. As a senior vice president at Tufts Health Plan, he developed new products, provider networks, and provider reimbursement arrangements for commercial, Medicaid, and Medicare populations. More recently, Jon founded the Health Connector. As the Executive Director for the first four years of reform, he led key initiatives to make health insurance universally available and to reform health care financing in Massachusetts. Most recently, Jon has consulted for state exchanges, CMS, foundations, provider entities, and health plans on implementation of the ACA generally, and American Health Benefit Exchanges in particular, including the evaluation of exchanges.
Patrick Holland, with over 25 years of experience in the health care industry, brings a broad background, including accounting, finance, strategy and analytics, with direct leadership experience at several health insurance and provider organizations. Prior to starting the Boston office of Wakely Consulting Group, Patrick was the Chief Financial Officer of the Health Connector. At the Health Connector, Patrick was primarily responsible for the development of the financial operations, enrollment projections, integrity and reconciliation, and the analytical support, planning, and implementation of carrier procurements for the exchange. Since leaving the Health Connector, Patrick has led Wakely’s consulting engagements in Maryland, Rhode Island, Vermont, Oregon, Washington, Missouri, Wisconsin, and New York, and has advised another half-dozen states in developing exchanges. Patrick has also been working extensively with national and regional health insurance carriers, MMCOs, provider organizations, and Accountable Care Organizations on diverse projects including business strategy, risk share modeling, network development and contracting, and innovative payment methodologies.
Diana Galatian is a Senior Consultant working in the Boston office of Wakely Consulting Group. From 2006 to September 2012, Diana served as a senior external audit manager for the Commonwealth of Massachusetts, the Health Connector, several independent managed care organizations, and numerous cities and towns. She has worked with her clients through the implementation Massachusetts’ historic health reform legislation and, more recently, payment reform legislation. As the senior manager for these clients, Diana was responsible for identification of risks that are specific to the government, insurance, and exchange entities and the communication of internal control observations and recommendations. Her perspective is unique in that she has worked with clients on all sides of the health care and payment reform market and has extensive experience with start-ups and other rapidly transitioning organizations.
Respectfully submitted,
Jon Kingsdale Managing Director Wakely Consulting Group
Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services 18 Wakely Consulting Group, Inc.
References
Christine Ferguson, State of Rhode Island Director HealthSource RI State House Room 124 82 Smith Street Providence, RI 02903 [email protected] 401-222-5192
Dwight Fine, State of Missouri ACA Coordinator Missouri Health Net Broadway State Office Building 221 West High St, 2nd Floor Jefferson City, MO 65101 [email protected] 573-526-3288
J.R. Damron, M.D. Chairman, Board of Directors New Mexico Health Insurance Exchange [email protected] (505) 470-7000
Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services 19 Cost
Option 1 Task 1 Task 2 Task 3 Task 4 Task 5 Task 6 Task 7 Total before Travel Travel Grand Total
Liasion Between AHIM Develop Rules, Regs, Meeting Requirments of Other As Assigned StrategicAnalysis Analysis&Research and Federal &State Grant Development Policy & Oper Procedures 11 CCIIO Exchange Areas (Special Projects) Agencies
Title Staff Name Hourly Rate Hours Dollars Hours Dollars Hours Dollars Hours Dollars Hours Dollars Hours Dollars Hours Dollars Hours Dollars # of Trips Dollars Dollars Managing Director Patrick Holland 382.00$ 25 9,550$ 30 11,460$ 30 11,460$ 0 -$ 40 15,280$ 100 38,200$ 0 -$ 225 85,950$ -$ 85,950$ Managing Director Jon Kingsdale 382.00$ 100 38,200$ 30 11,460$ 30 11,460$ 0 -$ 0 -$ 100 38,200$ 25 9,550$ 285 108,870$ -$ 108,870$ SeniorConsultant Kathie Mazza 246.00$ 0 -$ 50 12,300$ 0 -$ 0 -$ 0 -$ 200 49,200$ 75 18,450$ 325 79,950$ -$ 79,950$ SeniorConsultant James Woolman 246.00$ 0 -$ 0 -$ 50 12,300$ 0 -$ 0 -$ 90 22,140$ 75 18,450$ 215 52,890$ -$ 52,890$ SeniorConsultant Diana Galatian 246.00$ 50 12,300$ 75 18,450$ 50 12,300$ 100 24,600$ 100 24,600$ 300 73,800$ 0 -$ 675 166,050$ -$ 166,050$ SeniorConsultant Steven McStay 246.00$ 0 -$ 0 -$ 0 -$ 0 -$ 0 -$ 90 22,140$ 0 -$ 90 22,140$ -$ 22,140$ Consultant KerryConnolly 191.00$ 50 9,550$ 100 19,100$ 100 19,100$ 0 -$ 200 38,200$ 175 33,425$ 100 19,100$ 725 138,475$ -$ 138,475$ Analyst JasonAurori 164.00$ 0 -$ 75 12,300$ 0 -$ 0 -$ 150 24,600$ 100 16,400$ 0 -$ 325 53,300$ -$ 53,300$ SeniorActuary Julia Lerche 340.00$ 0 -$ 0 -$ 0 -$ 0 -$ 0 -$ 100 34,000$ 0 -$ 100 34,000$ -$ 34,000$ DirectorActuary TBD 375.00$ 0 -$ 0 -$ 0 -$ 0 -$ -$ 25 9,375$ 0 -$ 25 9,375$ -$ 9,375$ 251.17$ 225 69,600$ 360 85,070$ 260 66,620$ 100 24,600$ 490 102,680$ 1,280 336,880$ 275 65,550$ 2,990 751,000$ 20 58,000$ 809,000$
Option 2 Task 1 Task 2 Task 3 Task 4 Task 5 Task 6 Task 7 Total before Travel Travel Grand Total Liasion Between AHIM Develop Rules, Regs, Meeting Requirments of Other As Assigned StrategicAnalysis Analysis&Research and Federal &State Grant Development Policy & Oper Procedures 11 CCIIO Exchange Areas (Special Projects) Agencies Title Staff Name Hourly Rate Hours Dollars Hours Dollars Hours Dollars Hours Dollars Hours Dollars Hours Dollars Hours Dollars Hours Dollars # of Trips Dollars Dollars Managing Director Patrick Holland 382.00$ 25 9,550$ 30 11,460$ 30 11,460$ 0 -$ 40 15,280$ 150 57,300$ 0 -$ 275 105,050$ -$ 105,050$ Managing Director Jon Kingsdale 382.00$ 125 47,750$ 30 11,460$ 30 11,460$ 0 -$ 0 -$ 200 76,400$ 25 9,550$ 410 156,620$ -$ 156,620$ SeniorConsultant Kathie Mazza 246.00$ 0 -$ 150 36,900$ 0 -$ 0 -$ 0 -$ 200 49,200$ 50 12,300$ 400 98,400$ -$ 98,400$ SeniorConsultant James Woolman 246.00$ 0 -$ 0 -$ 50 12,300$ 0 -$ 0 -$ 90 22,140$ 75 18,450$ 215 52,890$ -$ 52,890$ SeniorConsultant Diana Galatian 246.00$ 200 49,200$ 75 18,450$ 50 12,300$ 200 49,200$ 100 24,600$ 300 73,800$ 0 -$ 925 227,550$ -$ 227,550$ SeniorConsultant Steven McStay 246.00$ 0 -$ 0 -$ 0 -$ 0 -$ 0 -$ 90 22,140$ 0 -$ 90 22,140$ -$ 22,140$ Consultant KerryConnolly 191.00$ 50 9,550$ 150 28,650$ 100 19,100$ 100 19,100$ 200 38,200$ 200 38,200$ 100 19,100$ 900 171,900$ -$ 171,900$ Analyst JasonAurori 164.00$ 0 -$ 75 12,300$ 0 -$ 0 -$ 150 24,600$ 100 16,400$ 0 -$ 325 53,300$ -$ 53,300$ SeniorActuary Julia Lerche 340.00$ 0 -$ 0 -$ 0 -$ 0 -$ 0 -$ 100 34,000$ 0 -$ 100 34,000$ -$ 34,000$ DirectorActuary TBD 375.00$ 0 -$ 0 -$ 0 -$ 0 -$ -$ 25 9,375$ 0 -$ 25 9,375$ -$ 9,375$ 254.09$ 400 116,050$ 510 119,220$ 260 66,620$ 300 68,300$ 490 102,680$ 1,455 398,955$ 250 59,400$ 3,665 931,225$ 24 69,600$ 1,000,825$
Travel Assumptions per Trip: Airfare (RT) 600$ Hotel (2-night stay avg.) 600$ Ground Transport 150$ Meals ($50/day) 100$ Total/Trip 1,450$ #ofpeople/Trip-Avg. 2 Total Cost/Trip 2,900$
Arkansas Health Insurance Marketplace Proposal for Professional Consultant Services 20 REDACTED--AVAILABLE FOR PUBLIC REVIEW Proposal for Professional Consultant Services for the Arkansas Health Insurance Marketplace
Submitted by Mehri & Skalet, PLLC, by Jay Angoff 1250 Connecticut Ave., NW. Washington, D.C. 20036 P: 202-822-5100 F: 202-822-4997 http://www.findjustice.com
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Preliminary Statement
The Board of Directors of the Arkansas Health Insurance Marketplace is in the midst of doing something great. It is seeking to enable Arkansas to become the first state that initially opted for a federally-run marketplace to now establish its own marketplace. It is also seeking to enable Arkansas to become the first state to privatize its Medicaid program along the lines of classic managed competition rules with its Private Option for Medicaid. Should the Board succeed in attaining these goals, the Arkansas experience will have far-reaching consequences for health reform throughout the nation. Arkansas will have made clear the advantages for a state in operating its own Exchange rather than ceding its authority to do so to the federal government; and Arkansas will have made clear that managed competition not only can work, but can work and attract the support of both political parties.
Perhaps most important for Arkansas, however, what the Board is now doing holds the promise of improving the health status of Arkansans. It is a truism that when people have health coverage they get better health care. By substantially increasing the number of Arkansans with health coverage, and by increasing their ability to have access to the same providers regardless of income, the Board may well improve the average health status of Arkansas citizens.
The most closely analogous experiment to what Arkansas is in the midst of today may be Missouri's experience with its version of the Private Option in the mid-1990's. This proposal draws heavily on the experience of the proposal’s team leader in implementing the Missouri Private Option, as well as his experience in implementing the Affordable Care Act as the Director of the Office of Consumer Information and Insurance Oversight (OCIIO).
To assist the Board in establishing an Arkansas marketplace and in implementing the Arkansas Private Option would be both an exciting opportunity and a privilege.
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I. Company profile and contact information
The firm submitting this proposal is Mehri & Skalet, PLLC, 1250 Connecticut Avenue, NW., Washington, DC 20036, phone 202-822-5100. The primary contact for this proposal is Jay Angoff, at the same address and phone number. The firm has been in business since 2001. It is primarily a plaintiff’s class action firm, but also represents individuals, corporations and non- profit organizations in non-class action matters. It has particular expertise in consumer protection law, civil rights law, wage and hour law, antitrust, and health care and insurance law. Its continued growth--at a time when many primarily plaintiffs’ firms are retrenching--is evidence of its financial stability. Major cases it has successfully resolved are discussed at the firm’s website, www.findjustice.com.
II. Vendor Qualifications and Prior Experience
A. Provision of consulting services to at least one state that implemented a health insurance marketplace
In 1994 Missouri established a health insurance marketplace, known as the Missouri Consolidated Health Care Plan, or MCHCP. Jay Angoff, the primary contact and team leader for this proposal, served as Vice-Chair of the marketplace Board as well as Insurance Director of Missouri. The Board, which was granted broad discretion under the statute establishing the MCHCP, ran it according to classic managed competition rules: it standardized the benefit package, established a competitive bidding process, and subsidized each state worker to the extent of the low bidder's bid. As a result, health care costs for state workers, and for state taxpayers, fell dramatically. The trade-off for lower rates was some restriction on choice of provider: the old system was a modified traditional indemnity system, whereas the carriers selling through the Exchange were generally either HMO's or PPO's. While there were occasional complaints about such restrictions, in general the new system was well-accepted, and it resulted in the state saving tens of $millions a year. Exhibit A sets forth the bids submitted by each carrier in each region of Missouri in each year from 1994--when the new system began phasing in--and 2000, as well as the number of enrollees each carrier received each year. The cost to the state in 1993, the last year of the old indemnity system, was $224 per member per month. As the bids set forth in the attached charts show, even six years later, in 2000, the cost to the state was still less than that amount. Notably, the standardized benefit package adopted by the Missouri marketplace was for coverage substantially more generous than the Gold coverage currently offered through the Exchanges.
After Governor Mel Carnahan died in a plane crash in October 2000 and Administrations changed, and for a whole host of reasons, the Missouri marketplace fell apart. But for six years it worked exactly the way managed competition is supposed to work.
Somewhat similar to the Missouri marketplace were the separate marketplaces New Jersey established in 1992 for the individual and small group markets. As Special Assistant to the Governor Jay Angoff helped draft the statute authorizing both marketplaces and then helped
3 implement them. As originally authorized five standard benefit packages were sold through the individual Exchange, and standard benefit packages were also sold through the small group Exchange. Due to a subsidy program that was in effect in the first few years of the individual Exchange, enrollment initially grew substantially, but began declining when the subsidies were eliminated in 1996. The small group Exchange, which has always been unsubsidized, grew substantially for more than a decade but then began to decline.
The issues considered in connection with both the Missouri and New Jersey marketplaces--and both the judgments and misjudgments Missouri and New Jersey made--may have relevance for both AHIM in general and the Medicaid Private Option in particular. Those issues include
* How to set and calculate the subsidy; * How to structure the bidding process; * Whether and how to regionalize; * Whether and how to create exceptions for residents of border counties; * The extent of standardization; * The extent to which the Board should intervene in disputes between carriers and providers, or carriers and enrollees.
In addition, as Director of OCIIO Mr. Angoff oversaw the provision of consulting services to all 14 states that implemented a health insurance marketplace. Further, while serving as Senior Advisor to the Secretary in 2011 and in 2012 as Director of HHS Region VII-- Missouri, Kansas, Iowa and Nebraska--he advised legislators and other government officials in several states regarding implementation of their health insurance marketplaces. Some of those states, including New Mexico, Colorado, and Rhode Island, established state Exchanges, while others--including Wyoming, Missouri, and Nebraska--did not.
The team providing services under this proposal also includes three additional individuals who have provided services to states that implemented a health insurance marketplace. Those individuals, who were formerly with OCIIO and are now at the Georgetown University Health Policy Institute, are former Indiana Insurance Commissioner Sally McCarty, who led the rate review unit at OCIIO; Kevin Lucia, who held high level positions in both the Oversight and Consumer Services units of OCIIO and, as an executive board member, participated in the development of the DC Health Link, the marketplace for the District of Columbia; and David Cusano who assisted with the drafting of the rate review proposed regulation and provided implementation guidance to states at OCIIO and served as an attorney with Coventry Health Care, Inc., where he was chief legal counsel to seven health plans and lead attorney on health reform implementation.
As Senior Research Fellows at Georgetown, Ms. McCarty, Mr. Lucia and Mr. Cusano have provided technical assistance, policy/strategy support, and consulting services to several state exchanges. Their representative engagements include (i) assisting the Maryland Health Benefit Exchange with drafting its carrier agreement, (ii) developing an interagency Memorandum of Understanding for Connect for Health Colorado, and (iii) developing a Qualified Health Plan (QHP) checklist (available to all states) and providing training on its use to
4
Cover Oregon and to issuers preparing to offer products on the New Mexico partnership exchange.
B. Program management experience with at least one state implementing a state-based or state partnership marketplace
As Vice-chair of the Missouri marketplace board Jay Angoff managed the process of getting the Missouri marketplace off the ground--a process which may well be similar to the process the Board is going through now.
In addition, the management of OCIIO required dealing with many issues that may be similar to those the Board is dealing with today, and with respect to which the OCIIO experience may be instructive. For example:
* OCIIO was a start-up organization. The analogy of building the plane and flying it at the same time may be overused, but it’s apt. OCIIO met all deadlines--both statutory and non-statutory--and grew from one employee to approximately 300 in less than a year. (After the 2010 election OCIIO was merged into and became a Center within the much larger CMS, where it had access to CMS funding it did not have as an independent unit.) AHIM is also a start-up organization, and will also need to meet aggressive deadlines and staff up quickly.
* Even before OCIIO was officially constituted, IT vendors and other vendors and consultants inundated us with proposals. The AHIM Board may well be experiencing the same phenomenon today.
* OCIIO constantly responded to inquiries from, and attempted to assuage, members of Congress from both parties. The Board may well have had an continue to have similar experiences with Arkansas legislators.
* OCIIO dealt constantly with the press. Although the coverage of the rollout of the federal Exchange was unrelentingly, and deservedly, negative, press coverage of ACA implementation during the first year was fairly upbeat. Coverage of the proposed Arkansas Private Option has also been very upbeat, and can continue to be upbeat.
C. Strategic analysis and decision making support provided to at least one state implementing a state-based or state partnership marketplace
As OCIIO Director throughout 2010, Jay Angoff oversaw the unit that provided strategic analysis and decision-making support to all states. In addition, Ms. McCarty, Mr. Lucia and Mr. Cusana have provided such analysis and decision-making support, both at OCIIO and now with Georgetown, as described in section IIA.
The fundamental decision Exchanges had to make was whether to establish and operate their own Exchange or allow the federal government to do so. HHS has always had a strong
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preference that states operate their own Exchanges; despite (or perhaps in some cases because of ) that preference more than two-thirds of the states opted to have the federal government run their Exchanges in 2014, either alone or in conjunction with the state (although the so-called “partnership” Exchange is still, statutorily, a federal Exchange). Several arguments support the conclusion that it is in the state’s best interest to operate its own Exchange. First, a state operating its own Exchange is eligible for unlimited grant funding from HHS. Second, state officials are likely to have a deeper knowledge of their health insurance markets than do federal officials. Third, state government is easier to navigate than the federal government--rules can be promulgated and decisions made more quickly, there is less bureaucracy, hiring is easier, and processes are less formal. Fourth, and most obviously, a state that operates its own Exchange controls its own Exchange, including the dissemination of information regarding the Exchange and enrollment in the Exchange. A state that cedes its authority to operate an Exchange to the federal government, on the other hand, does not have such control. Nevertheless, the large majority of states rejected HHS urgings to establish their own Exchange. Arkansas has apparently made the decision to establish its own Exchange. We would anticipate explaining to interested parties, to the extent requested by the Board, the implications of the state vs. federal Exchange decision.
D. An understanding of the Arkansas Private Option
As noted in section IIA, what Missouri went through in 1994-95 with its health plan for state workers is similar in concept to what Arkansas is going through now with its Private Option for Medicaid: in both cases, the state is privatizing coverage that has traditionally been provided by the government. The MCHCP Board divided the state into eight regions and in 1994 bid out the business in the two most populous regions, in 1995 in five more, and in 1996 all eight. As Exhibit A indicates, the low bids in 1996 for substantially the same benefit package which had cost the state $224, ranged from $184.58 in Northwest Missouri to $120.00 in Central Missouri, with restricted but adequate networks. In addition, the Board required the insurers to guarantee that they would stay in for five years and could raise their rates by, at most, medical CPI plus 3.5% each year. To be sure, the Arkansas Medicaid Private Option must accommodate Medicaid-related federal government mandates that the Missouri marketplace did not need to accommodate. We would anticipate assisting AHIM to structure the program, to the extent possible, so that it results in effective price competition among the private carriers participating in the program, notwithstanding the fact that the beneficiary does not pay the premium. We believe that the Private Option holds promise for both improving quality and, contrary to the conventional wisdom but consistent with the Missouri experience, reducing the cost of the Medicaid program.
E. Knowledge of the Arkansas health care environment
There are substantial differences between the Missouri and Arkansas health insurance markets, and the Missouri and Arkansas hospital markets, and in the demographics of the states. Nevertheless, there are also commonalities between the Missouri and Arkansas health systems. First, both the Missouri and Arkansas Medicaid programs are among the least generous in the
6 nation. (When Missouri established the MCHCP the Board considered trying to merge the MCHCP with the Medicaid program--which among other things would have increased the state's buying power--but it was simply too big a change, both practically and politically, to get done in too short a time.) Second, in both Missouri and Arkansas there is a huge difference between the health care markets in the major urban areas, where there are a sufficient number of hospitals for classic managed competition rules to work, and in the rural areas, which do not lend themselves to managed competition. Nevertheless, when the Missouri marketplace enabled private insurers to for the first time sell to state employees in the sparsely populated regions of the state, those carriers developed networks there, and were able to provide an attractive product at a lower price than the state had been able to provide the same coverage for. Some of those networks, including those centered in Springfield, Joplin, West Plains and Poplar Bluff, also served northern Arkansas.
The concerns raised when the Missouri marketplace Board structured the marketplace by dividing Missouri into regions may also have particular relevance for AHIM.
III. General approach to executing the anticipated responsibilities
Option 1
Jay Angoff would provide a substantial portion of the services described in this proposal personally. Analysis and research under his direction would be provided by Ingrid Babri, a young lawyer who has been working full-time with Mr. Angoff for the last year on Exchange- and other ACA-related issues, including Navigator legislation and litigation. Mr. Angoff would also be staffed, in particular for the preparation and of the Exchange grant proposals, by Logan Meltzer and Tatiana Reyes Jove, paralegals at Mehri & Skalet.
Ms. McCarty, Mr. Lucia and Mr. Cusano would also provide a substantial portion of the services described in this proposal, based on their experience both at OCIIO and at Georgetown, and drawing on their analysis of emerging trends, best practices, and implementation challenges.
Other lawyers at Mehri & Skalet will participate in this project to the extent there expertise is called for. For example, we anticipate drawing on Mehri & Skalet partner Steve Skalet's business background in ensuring that AHIM meets the requirements of all eleven CCIIO-defined Exchange areas and with respect to terms of contracts with vendors. In addition, in connection with both meeting those requirements and analyzing issues raised by the role played by Arkansas Blue Cross, we would rely on the expertise of Craig Briskin, the antitrust lawyer in the firm.
Finally, to the extent an actuary's services are needed for this project Mehri & Skalet anticipates contracting with Allan Schwartz, the principal of AIS Associates of Freehold, NJ.
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Option 2
Same as Option 1, except that Mr. Angoff would provide the services of an interim Executive Director for a period of up to four months. During this period Mr. Angoff would anticipate being on-site in Little Rock, or elsewhere in Arkansas, for at least three days each week.
IV. How the Offeror plans to fulfill the scope of work, as outlined on pages 1-2 of the RFP, to provide or assist the AHIM Board and/or the Executive Director with the following activities:
A. Strategic analysis, planning and assistance with decision making on key areas involved with the implementation of state-based marketplaces.
In advising the Board and/or the Executive Director on such decision making, we anticipate that key areas will include:
1. Whether the marketplace will be a clearinghouse or an active purchaser. HHS has opted for the clearinghouse model for 2014, while issuing guidance stating that it may revisit this issue in the future. The Missouri marketplace, on the other hand, was an active purchaser: it standardized the benefit package, and it established a pure competitive bidding process based on the submission of pure community rates. Notably, no plan was excluded from the Exchange based on its bid, but because the state paid the amount of the low bidder’s bid for each state employee, plans bidding very high were unlikely to attract many enrollees, and the low-bidder had an enormous advantage, since employees could get that plan for free.
We would anticipate assisting the Board in considering the relative merits of maximizing consumer choice through the clearinghouse model vs. maximizing the bargaining power of the marketplace through the active purchaser model.
2. Whether network adequacy standards should be general or prescriptive. On the one hand, in order to drive down price an insurer cannot accept any willing provider into its network, nor can it pay each provider their optimum rate. On the other hand, consumers must have practical access to providers--and having to drive an unreasonable distance or wait an unreasonable length of time to see a provider is not practical access. The Missouri marketplace implemented distance- and availability-related network adequacy standards, while to date HHS has promulgated only the most general of guidelines, although recent statements by the Secretary indicate that that may change. In any event, we would anticipate helping the Board work through the inherent tension between the goal of driving down health care costs and the goal of maximizing choice of provider. In that regard we would make use of the findings in a recent health policy brief co-authored by Sally McCarty, entitled “ACA Implications for State Network Adequacy Standards,” available at http://www.statenetwork.org/wp- content/uploads/2014/02/State-Network-Georgetown-ACA-Implications-for-State-Network- Adequacy-Standards.pdf.
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3. The selection of an IT vendor. IT vendors to CMS have had an incentive to over-promise in order to get the business, and to worry about performance later. We would anticipate helping the Board to maximize the likelihood that an IT vendor will deliver what it has promised, by the time it has promised, by advising on negotiating strategy and contract terms, among other things. We also anticipate assisting AHIM in weighing the relative merits of building, purchasing or leasing various IT components.
Notably, OCIIO established three new websites during the first 90 days following the enactment of the ACA--the original healthcare.gov website (which provided price estimates, as well as additional insurance and health information, rather than binding quotes); a website for those qualifying for the Early Retiree Reinsurance Program (a subsidy program for employers and other sponsors of group coverage who provided coverage for their workers who retired before age 65); and the website for the PreExisting Condition Insurance Plan, the federally operated high-risk pool (which approximately half the states opted into). All three websites went live on time, and they worked. While an Exchange website is much more complicated than any of these websites, certain aspects of our experience may be relevant to AHIM. We would anticipate assisting AHIM in considering all IT-related options.
We also note that government procurement regulations can have the effect of increasing the cost of an IT project, delaying it and, perversely, weakening the government's hand in dealing with the contractor. (The federal government's procurement rules--the Federal Acquisition Regulation, or FAR--have been so counter-productive that they have come to the attention of the President, who has emphasized the damage they have done and the necessity for streamlining them.) The government benefits if such rules can be waived or avoided. We were very pleased to see that Arkansas has done just that.
4. Maximizing the effectiveness and efficiency of available HHS grant funding. The ACA confers authority on the Secretary to make Exchange grants to states through the end of 2014. Unlike with almost all other grant programs, Congress established no limit on the amount that can be granted. Arkansas should not, of course, be profligate. But if AHIM can make a compelling case that it needs funding to accomplish a goal that HHS also wishes to see advanced, it should be able to obtain that funding. We anticipate assisting AHIM in doing so.
Finally, we note the recent policy brief co-authored by Kevin Lucia, entitled “Implementing the Affordable Care Act: Key Design Decisions for State-Based Exchanges,” available at http://www.commonwealthfund.org/Publications/Fund-Reports/2013/Jul/Design- Decisions-for-Exchanges.aspx, which we expect will also have relevance to AHIM.
B. Analysis and research in various areas.
All lawyers working on this project have significant experience doing both legal and non- legal analysis and research. The firm's analysis and research skills have resulted in several landmark legal victories, many of which are discussed at the firm's website, www.findjustice.com. Based on their experience, M & S personnel also have extensive libraries that may well be helpful to the Board.
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In addition, Ms. McCarty, Mr. Lucia and Mr. Cusano continue to conduct analysis and research regarding state-based marketplaces and the implementation of the new insurance market reforms throughout the nation.
C. Assistance with the development of rules, regulations, policy and operational procedures governing the state-based marketplace.
As Director of OCIIO Jay Angoff oversaw the drafting of both the original HHS rule governing state-based marketplaces, and the so-called Patient's Bill of Rights, which carriers both on and off the Exchange must comply with. Those rules include the prohibition on annual and lifetime limits, rescissions, and pre-existing condition exclusion clauses, as well as the minimum Medical Loss Ratio regulation. Ms. McCarty, Mr. Lucia and Mr. Cusano were also involved in developing rules and policy at HHS, and Ms. McCarty led the development of the rate review rule. In addition, Mr. Angoff was involved in the process of developing subregulatory guidance--Qs and As--that explained the Department's policy on issues that are not expressly resolved by regulation. HHS has made, and continues to make, major policy decisions through the subregulatory guidance process rather than through regulation. We would anticipate assisting AHIM in drafting regulations and statements of policy and procedures, and also in participating in the HHS rulemaking and subregulatory guidance process, should that become necessary.
D. Function as a liaison between the AHIM and Federal and State agencies' representatives, health insurance marketplace partners, and vendors.
We would anticipate functioning as such a liaison based on the experience of Mr. Angoff. Ms. McCarty, Mr. Lucia and Mr. Cusano at OCIIO, and based on the experience of Mr. Angoff and Ms. McCarty as state insurance commissioners. OCIIO cooperated with many different components of HHS, jointly wrote regulations with two other federal agencies--Treasury and Labor--and also worked with OMB, the National Economic Council and White House staff. AHIM will be impacted by many of these same federal components.
Mr. Angoff is also familiar with the Arkansas Insurance Department, both from his years at the Missouri Department and his having dealt with the Department while in private practice. He is also familiar with Arkansas's major health insurer, Arkansas Blue Cross Blue Shield, having worked with and analyzed non-profit Blue Cross plans, as well as publicly-held Wellpoint, for the last 20 years. In Arkansas, as in virtually all states, the Blue Cross plan has traditionally dominated the individual market. That dominance can have either a pro- competitive or anti-competitive effect on the Arkansas Exchange, and on the health insurance market as a whole, depending on what the Exchange does to manage it.
Notably, many of the original OCIIO staff are still at HHS, including the current Director of CCIIO, who was one of OCIIO’s first hires, as were several of his senior staff. Mr. Angoff also worked with the HHS Medicaid director, including during the incipiency of the
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marketplaces, and would anticipate continuing to do so in connection with the Arkansas Medicaid Private Option.
At OCIIO Mr. Angoff, Ms. McCarty, Mr. Lucia and Mr. Cusano dealt constantly with the Department's marketplace partners, most notably the insurers. While the Administration and the industry did not always agree about the details of implementation, the Administration recognized that it needed the industry, and the industry recognized that it needed the Administration. The same dynamic should apply with respect to AHIM and the industry.
E. Preparation and submission of the May 15, 2014 Level I Exchange grant, Blueprint requirements, and possibly the Level II Exchange grant.
Mr. Angoff oversaw the drafting of the Level I and Level II Exchange grant FOAs as OCIIO Director, and is also familiar with the Blueprint requirements based on his review while serving as Senior Advisor to the Secretary and an HHS Regional Director. We would anticipate preparing and submitting these documents based on both having overseen their drafting and/or participated in their review, and having analyzed both successful and unsuccessful grant proposals.
F. Assistance in meeting the requirements of the eleven "Exchange Areas" defined by CCIIO.
Mr. Angoff oversaw the drafting of the initial rule defining and describing these eleven areas as OCIIO Director. We would anticipate working with AHIM to ensure that AHIM meets all these requirements. Importantly, HHS has encouraged and assisted states to meet these requirements rather than opt for the federal government to run their marketplace in the past, and can reasonably be expected to do the same in the future.
G. Other responsibilities as assigned.
We would be happy to take on whatever additional responsibilities for which we are qualified that the Board wishes to assign.
IV. Biographies
Jay Angoff, Partner Mehri and Skalet
The director of this project for Mehri & Skalet will be former Missouri Insurance Commissioner and U.S. Department of Health and Human Services official Jay Angoff. Mr. Angoff returned to Mehri & Skalet after three years with the U.S. Department of Health and Human Services. The only person to have served as the lead federal health insurance regulator,
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the Director of an HHS Region, and a state Insurance Commissioner, he is one of the nation’s leading insurance experts.
In March 2010, Mr. Angoff was appointed by HHS Secretary Kathleen Sebelius as the first Director of the HHS Office of Consumer Information and Insurance Oversight. In that capacity, Mr. Angoff was responsible for the Patient’s Bill of Rights, for implementing the Medical Loss Ratio rule, and implementing the Exchanges. In addition, Mr. Angoff served at HHS as the Senior Advisor to the Secretary and as Regional Director of HHS Region VII, headquartered in Kansas City.
Before serving at HHS Mr. Angoff was in private practice, first in Jefferson City, MO and most recently in Washington, DC with Mehri & Skalet, PLLC where he served as lead counsel in several successful class actions, including, Landers v. Inter-insurance Exchange of the Automobile Club (Los Angeles County, Cal., $24 million settlement), Clutts v. Allstate (Madison County, Ill., $6 million settlement), and Foundation for Taxpayer and Consumer Rights v. GEICO (Los Angeles County, Cal., settlement valued at up to $12 million). He has also represented individuals before state insurance departments, and has consulted for and advised governmental entities, consumer groups, the plaintiff’s bar, and other interest groups.
Mr. Angoff is also an expert on non-profit to for-profit conversions. As Missouri Insurance Commissioner he won a five-year legal battle with Blue Cross of Missouri, after which Blue Cross agreed to fund a new healthcare foundation, now one of the nation’s largest. In private practice, Mr. Angoff has been retained by various state Insurance Departments faced with proposed Blue Cross transactions and has analyzed and opined on the reasonableness of the Blues’ executive compensation. He has also been an expert on charitable trusts, fiduciary duties, antitrust implications and other issues relevant to conversions and other insurance transactions.
Mr. Angoff has advocated for managed competition and successfully implemented systemic reforms. As Missouri Insurance Commissioner and a Director of the Missouri state health plan, Mr. Angoff required insurers to submit competitive bids for a single standardized benefit package. As a result, rates fell by up to 45%.
Prior to serving in Missouri, Mr. Angoff was Deputy Insurance Commissioner of New Jersey and Special Assistant for Health Insurance Policy to New Jersey Governor Jim Florio. In those positions, he played a major role in drafting and implementing New Jersey’s individual and small group community rating law.
Mr. Angoff began his career as an antitrust lawyer with the Federal Trade Commission. He has written for The New York Times, The Washington Post, and The Wall Street Journal, among other publications. He is a member of the District of Columbia, Missouri, New Jersey, and U.S. Supreme Court bars, and is a graduate of Oberlin College and Vanderbilt Law School.
Steve Skalet, Partner Mehri & Skalet Steven A. Skalet is a principal and managing partner in the firm of Mehri & Skalet, PLLC. Mr. Skalet has over 35 years of litigation and transactional experience in real estate, consumer fraud, bank fraud and class action litigation.
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Mr. Skalet enjoyed a varied litigation practice before state and federal courts throughout his career. From 1995 until the formation of M&S, Mr. Skalet practiced with Kass & Skalet, PLLC, a well-known real estate, litigation, complex business and consumer protection firm. Prior to that, he and another lawyer formed a practice that focused on real estate and litigation, including consumer class actions under the Truth-in-Lending and Equal Credit Opportunity acts. That firm grew to approximately 23 lawyers in 3 jurisdictions and, when it split up in 1995, was known as Kass, Skalet, Segan, Spevack & Van Grack, PLLC. In 2001, Mr. Skalet and Cyrus Mehri started the firm of Mehri & Skalet, PLLC, concentrating in complex litigation and class actions. Since its inception, Mr. Skalet has been lead counsel or co-lead counsel in successful class action cases against Dell, Inc., Mercury Marine, Hewlett Packard, Sony, Ford, Verizon, Mitsubishi, Morgan Stanley, and many other companies. Mr. Skalet has been an advisor to the Federal Reserve Board on credit and banking matters. He has served on the Montgomery County Advisory Committee reviewing the wholesale simplification of the Montgomery County Code. He also served on the District of Columbia Bar Committee responsible for drafting form commercial leases and the Montgomery County Board of Realtors committee responsible for drafting residential real estate contracts. Mr. Skalet graduated from the University Of Pennsylvania School Of Law in 1971 and the University of Rochester in 1968. Craig Briskin, Partner, Mehri & Skalet Craig Briskin joined the Washington, D.C. office of Mehri & Skalet, PLLC in 2007. Mr. Briskin focuses his practice primarily on class actions related to consumer and mortgage fraud. He serves as co-lead counsel for the class in In re MagSafe Adapter Litigation, representing consumers who allege that their Apple MagSafe laptop adapters prematurely fray, break, spark, and cease functioning. The court granted final approval of a settlement in February 2012. He also serves as co-counsel for the class in Sonoda v. Amerisave, concerning alleged deceptive sales practices by a leading online mortgage broker. The court granted final approval to a $3.1 million settlement in February 2013. Mr. Briskin is co-counsel with AARP in an action against the U.S. Department of Housing and Urban Development, concerning their alleged failure to protect seniors in the reverse mortgage program. Shortly after plaintiffs filed a preliminary injunction motion, HUD rescinded the guidance Plaintiffs challenged, with the result that spouses and family members can retain their family homes by paying 95% of the home’s current appraised value. Plaintiffs continue to litigate to enforce the protection from displacement for borrowers’ spouses. Mr. Briskin is co-counsel with AARP in a proposed class action against Wells Fargo and Fannie Mae regarding their alleged refusal to allow spouses and heirs of reverse mortgage borrowers to purchase their family homes for 95% of the home’s current appraised value, pursuant to federal statute and the mortgage contract. Mr. Briskin is counsel for plaintiffs in Mackmin v. Visa, alleging an agreement to assess supracompetitive access fees to ATM customers. He also serves as co-counsel with Center for Science in the Public Interest in Hensley-McClean v. Safeway, concerning Safeway’s alleged
13 failure to notify customers of Class I food recalls. Mr. Briskin was class counsel in a case alleging a brake defect in the Ford Focus, which was successfully settled in 2008. Mr. Briskin holds a law degree from Harvard Law School and an A.B. cum laude in Psychology from Harvard College. Kevin Lucia, Senior Research Fellow and Project Director, Center on Health Insurance Reforms, Georgetown University Kevin Lucia is a Senior Research Fellow and Project Director at the Center on Health Insurance Reforms (CHIR) at Georgetown University’s Health Policy Institute. He co-founded CHIR in 2011 and now directs policy research and analysis of federal and state laws and programs related to private health insurance and the implementation of the Affordable Care Act. He provides expertise and prepares resources to inform regulators, policymakers and other stakeholder groups on issues related to access, affordability and adequacy of private health insurance. His research is supported by government, private foundations and organizations representing consumers and patients. He serves as a Board Member and Chair of the Insurance Market Committee of the Health Benefit Exchange Authority for the District of Columbia.
Prior to co-founding CHIR, Mr. Lucia led the State Compliance Division within the Office of Oversight, Center for Consumer Information and Insurance Oversight (CCIIO), Centers for Medicare and Medicaid Services.
Mr. Lucia holds his J.D. from The George Washington University Law School and an M.H.P. from Northeastern University.
Sally McCarty, Senior Research Fellow and Project Director, Center on Health Insurance Reforms, Georgetown University
Sally McCarty is an experienced state and federal regulator, and national consumer advocacy expert. She joined the Center on Health Insurance Reform (CHIR) faculty at the Georgetown University Health Policy Institute as a Senior Fellow in June, 2012. Until May of 2012, McCarty was the Director of Rate Review in the Oversight Division at CMS' Center for Consumer Information and Insurance Oversight (CCIIO). She began her work at CCIIO in August of 2010. McCarty directed CCIIO's Rate Review Program from the writing of the regulation that defines the program through its implementation and first eight months of operation
Prior to joining CCIIO, McCarty served as a consumer advocate for the National Hemophilia Foundation (NHF). In that position she provided advocacy and educational services related to health insurance coverage to hemophilia groups throughout the country. McCarty represented NHF for three years as a funded consumer representative in the National Association of Insurance Commissioners' (NAIC) Consumer Liaison Program and served on the Consumer Liaison Board of Trustees for two of those years.
McCarty served nearly 10 years as a state insurance regulator with the Indiana Department of Insurance, including two years as the Deputy Commissioner for Health Issues and nine months as Chief Deputy Commissioner before then Governor Frank O'Bannon appointed
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her to be the state's Insurance Commissioner in July of 1997. She held that position for seven years.
During her tenure as Indiana's Insurance Commissioner, McCarty served on the NAIC Executive Committee for six years and also held positions as vice-chair of the Consumer Liaison Committee, chair of the Special Committee for Health Insurance, and chair of the Consumer Liaison Board of Trustees. As Insurance Commissioner, she filled statutory roles as an Indiana Children's Health Advisory Board member and as a member of the Indiana Comprehensive Health Insurance Association (state high risk pool) Board of Directors.
McCarty holds a Master of Arts degree in Adult and Community Education from Ball State University, Muncie, Indiana, and a Bachelor of Arts degree with a double major in Journalism and Sociology from Indiana University, Bloomington, Indiana. She was a School of Journalism Hazeltine Scholar, a program that awards one member of each graduating class a grant to fund travel and study in a foreign country.
David Cusano , Senior Research Fellow, Center on Health Insurance Reforms, Georgetown University David L. Cusano joined the Center on Health Insurance Reform faculty at the Georgetown University Health Policy Institute as a Senior Research Fellow in July of 2013. Prior to joining Georgetown, Mr. Cusano was an attorney with Coventry Health Care, Inc., and served as chief legal counsel to seven health plans operating in sixteen States on all matters related to their commercial, Medicare, and Medicaid business, and to Coventry corporate senior management on implementation of the ACA.
Mr. Cusano also served as a health insurance specialist to the Office of Oversight, within the Center for Consumer Information and Insurance Oversight, under the Centers for Medicare & Medicaid Services. In this role, he assisted States with interpreting and implementing the requirements under the ACA, and assisted with the drafting and publication of the federal rate review proposed regulation.
Mr. Cusano began his legal career as an associate at both Mintz Levin and Foley Hoag in Boston, MA. Prior to attending law school, Mr. Cusano practiced as a registered nurse, in both clinical and administrative capacities, at Beth Israel Deaconess Medical Center in Boston, MA.
Mr. Cusano holds a B.S. in Nursing from the University of Connecticut and a J.D. from Northeastern University School of Law.
Ingrid Babri, Associate Mehri & Skalet Ingrid Babri joined Mehri & Skalet in March of 2012 as an associate. Ms. Babri’s work has focused on the Affordable Care Act, insurance law, and public-interest advocacy. Ms. Babri works with consumer groups across the country to develop litigation and policy strategies related to ACA implementation. She previously worked for the Columbus, OH City Attorney on civil litigation and public policy matters.
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Ms. Babri holds a J.D. from the Ohio State University and a B.A. in International Relations magna cum laude from the Ohio State University.
Paralegal biographies not included.
V. Three relevant references
1. Mike Wolff, former Chair of the Missouri Consolidated Health Care Plan, now Dean, St. Louis University Law School, 100 N. Tucker Blvd, St. Louis, MO 63101. [email protected], (314) 977-2774.
2. Howard Koh, Assistant Secretary for Health, HHS, [email protected]. 3. Jesse Laslovich, General Counsel, Office of the Montana Commissioner of Securities and Insurance, 840 Helena Ave., Helena, MT 59601. [email protected], (406) 444-2040.
VI. Costs
Staff Hourly Rates
Jay Angoff, Partner Mehri& Skalet $ 500.00/hour Steve Skalet, Parnter Mehri & Skalet $ 500.00/hour Craig Briskin, Partner Mehri & Skalet $425.00/hour Sally McCarty, Senior Research Fellow/Project Director, Georgetown $300.00/hour University,Center on Health Inusrance Reforms Kevin Lucia,Senior Research Fellow/Project Director, Georgetown $300.00/hour University,Center on Health Inusrance Reforms David Cusano, Senior Research Fellow, Georgetown University,Center on $300.00/hour Health Inusrance Reforms Ingrid Babri, Associate Mehri & Skalet $200.00/hour Logan Meltzer, Paralegal Mehri & Skalet $130.00/hour Tatiana Reyes, Paralegal Mehri & Skalet $130.00/hour
Costs would also include reasonable travel expenses.
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