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D. PROJECT ABSTRACT SUMMARY

Title: New Mexico Level Two Health Insurance Exchange Establishment Grant

CFDA #: 93.525 FON #: IE-HBE-12-001

Applicant: New Mexico Health Insurance Exchange (NMHIX)

Address:

6301 Indian School Rd. NE Suite 100 Albuquerque, NM 87110

Congressional Districts Served: NM 1, 2, 3

Contact: Amy Dowd, Chief Executive Officer

Phone: (505) 314-5300 Fax: (505) 998-3814 Email: adowd@nmhix.com

Website: www.BeWellNM.com Category of Funding: Level Two

Project Dates for Project Completion: January 1, 2015 December 31, 2017

Goals for Level Two Establishment Grant Application:

New Mexico is applying for a Level Two Health Insurance Exchange Establishment Grant solely to:

Enhance functionality of technology systems after the initial launch to improve the customer shopping experience, including broker notifications and alerts, ability for consumer to select QHP which offers best coverage for consumer’s prescriptions, and a centralized provider directory technology capability. Cover the additional cost of the recent CMS design changes for enhanced integration with HSD/Medicaid. Please note that this is not rework. Cover the costs to be incurred as a result of pushing the go-live date of the individual exchange to 10/1/2015.

New Mexico is a hybrid Exchange through 2015 with the SHOP operated by the NMHIX and individual exchange operated by the Federally-facilitated Exchange. NMHIX is in the process of developing its own individual platform to be complete for open enrollment beginning October 1, 2015. NMHIX is working with HSD to develop a CMS-compliant eligibility verification process.

This requested funding will allow continued implementation of the NMHIX for the period January 1, 2015 through December 31, 2017. Ongoing maintenance and operations of the SHOP, starting in 2015, and ongoing maintenance and operations of the Individual Exchange, starting in 2016, will not be covered by this grant. Additionally, this grant is requested solely

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for the costs required for IT functionality noted above and will not be used for rework. of $97.9 million in funding is requested for this Level Two grant.

A total

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NEW MEXICO HEALTH INSURANCE EXCHANGE LEVEL TWO GRANT

TABLE OF CONTENTS

  • A. STANDARD FORMS (electronic)

  • B. REQUIRED LETTERS OF SUPPORT

.........................................................................................

1

LETTER FROM GOVERNOR MARTINEZ…………………………………………………………….……… 1

LETTER FROM NEW MEXICO DIVISION OF INSURANCE…………………………………………. 3

LETTER FROM HUMAN SERVICES DEPARTMENT/ MEDICAID

4

  • C. APPLICANT’s APPLICATION COVER LETTER…………………………………………………………

..…………

6

  • D. PROJECT ABSTRACT SUMMARY…………………………………………………………….………………………

7

TABLE OF CONTENTS…………………………………………………………………………………………………………

9

ACRONYMS………………………………………………………………………………………………………………

..……..

11

  • E. PROJECT NARRATIVE………………………………………………………………………………………………………12

    • a. DISCUSSION OF EXISTING EXCHANGE PLANNING AND PROGRESS…………………….……13

      • 1. Background Research…………………………………….…………………………………… ........13

      • 2. Legal Authority and Governance…………………………………………….………………..13

      • 3. Stakeholder Consultation………… ……………………………………

..

..………………………..15

  • 4. Long-term Operational Costs…………………………………………………………….……… ..16

  • 5. Program Integration………………………………………………………… ..……………………….16

  • 6. Business Operations of the Exchange………………………………………………………….17

  • 7. IT Gap Analysis and Exchange IT Systems………………… ...………………………………17

  • 8. Reuse, Sharing, and Collaboration……………………………….…………………………… ..17

  • 9. Organizational Structure…………………………………………….……………………………. 19

  • 10. Program Integrity………………………………………………….…….

..……………………….

24

  • 11. Affordable Care Act Requirements ….…………………….…………………………………. 24

  • 12. SHOP……………………………………………………………………………………………………

..…..

24

  • b. PROPOSAL TO MEET PROGRAM REQUIREMENTS…………………….…………………………… 26

    • 1. Current Exchange Pathway………………………………………………………………………. 26

    • 2. State’s Strategy to Complete the Exchange Activities ……………………………… 26

    • 3. State’s Strategy to Address Early Benchmarks in Section I.4……………………… 45

  • 4. Proposed Solution for IT System ………………………

..……………………………………..

45

  • 5. IT Seven Standards and Conditions……………………………

..…………………………….

51

  • 6. Organizational Structure……………………………………………

..…………………………….

51

  • 7. Coordination with the Federal Government on Exchange Activities………… 51

..

  • 8. Strategies for Reuse, Sharing, Collaboration for NMHIX Activities with the Federal Exchange and Other States…………………………………………………………….51

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9.

Strategies to Ensure Financial Integrity Mechanisms to Prevent Fraud, Waste,

and Abuse and Provide Oversight of Cooperative Agreement Funds and the

Exchange………………………………………………………….……………

..………………………..

51

  • 10. Challenges That May Affect Progress in Work Plan…………………………………… 52

  • 11. SHOP………………………………………………………………………………

..……………………….

52

  • F. WORKPLAN………………………………………………………………………………………

..…………………………

53

  • G. BUDGET AND BUDGET NARRATIVE……………………………………………………………………………… 56

  • H. ADDITIONAL LETTERS OF AGREEMENT AND/OR DESCRIPTION(S) OF PROPOSED/EXISTING

PROJECT ………………………………………………………….…………………………………………………………………60

  • I. DESCRIPTION OF KEY PERSONNEL AND ORG CHART……………………..…………………………………61

  • J. COST ALLOCATION METHODOLOGY…………………………………………………………………………………62

    • K. DOCUMENTATION SUPPORTING ELIGIBILITY OF APPLICANT (LEVEL TWO EXCHANGE

ESTABLISHMENT ONLY) ………………………………………………..…………….………………………………………81

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ACRONYMS

ACA or PPACA

Patient Protection and Affordable Care Act

AHBE

American Health Benefits Exchange

APTC

Advance Premium Tax Credits

CSR

Cost Sharing Reductions

FPL

Federal Poverty Limit

GSA

Governmental Services Agreement

HSD

New Mexico Human Services Department

IAD

New Mexico Indian Affairs Department

IHCIA

Indian Health Care Improvement Act

ISD

Income Support Division

ISD2R

Integrated System Delivery Replacement Project

MAD

New Mexico Medical Assistance Division

MMIS

Medicaid Management Information System

MAGI

Modified Adjusted Gross Income

NAIC

National Association of Insurance Commissioners

NMHIA

New Mexico Health Insurance Alliance

NMHIX

New Mexico Health Insurance Exchange

NMMIP

New Mexico Medical Insurance Pool

OHCR

New Mexico Office of Health Care Reform

OSI

Office of the Superintendent of Insurance

PSC

Professional Services Contract

QHP

Qualified Health Plan

RFP

Request for Proposals

SCI

State Coverage Insurance

SDLC

Software Development Life Cycle

SERFF

System for Electronic Rate and Form Filing

SHOP

Small Business Health Options Plan

SOA

Service Oriented Architecture

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E. PROJECT NARRATIVE INTRODUCTION

The Affordable Care Act (ACA) allows states to develop Health Insurance Exchanges to help

individuals and small businesses purchase health insurance. The New Mexico Health Insurance

Exchange (NMHIX) has been designed to be high quality, cost-efficient, self-sustaining, and

tailored to meet the diverse needs of New Mexicans.

New Mexico faces many challenges in developing and implementing NMHIX, including health

workforce shortages, language and cultural barriers, significant poverty, poor educational

attainment, rural and remote areas, and a majority of its small businesses do not offer health

insurance to employees.

Of New Mexico’s population of two million, Medicaid covers approximately 530,000

individuals, Medicare covers 300,000 and 430,000 are uninsured. Of the uninsured, an

estimated 175,000 may become eligible for Medicaid and up to 211,433 for NMHIX between

2014 and 2020. An estimated 171,557 uninsured individuals will enroll in 2014; approximately

89,000 through Medicaid expansion, and 82,557 in the NMHIX.

The New Mexico Legislature passed the “New Mexico Health Insurance Exchange Act,” during

the 2013 Regular Session, and Governor Susana Martinez signed the Act on March 28, 2013.

New Mexico applied for and, on November 29, 2011, received a Level One Health Insurance

Exchange Establishment Notice of Award of $34.3 million to develop the NMHIX. An additional

grant of $18.6 million was awarded to New Mexico in July 2013. These initial grants were

awarded to the New Mexico Human Services Department (HSD) and have now been

transferred to the NMHIX as required by statute through a Change of Grantee of Record

process.

The NMHIX was also awarded a third Level One grant totaling $69.4 million on 1/22/2014.

NMHIX is requesting a No Cost Extension to increase the duration of this grant to 12/31/2015.

This grant was awarded on 1/22/2014 with an end date of 12/31/2014.

New Mexico is a hybrid Exchange through 2015 with the SHOP operated by the NMHIX and

utilization of the federal platform for individual enrollments. NMHIX is in the process of

developing its own individual platform to be complete for open enrollment beginning October

1, 2015. NMHIX is working with HSD to develop a CMS-compliant eligibility verification

process.

Through this proposal, New Mexico seeks $97.9 million for continued implementation of the

NMHIX for the period January 2015 December 2017. Ongoing maintenance and operations

of the SHOP, starting in 2015, and ongoing maintenance and operations of the Individual

Exchange, starting in 2016, will not be covered by this grant. Additionally, this grant is

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requested solely for the costs required for IT functionality and integration with HSD, will not

be used for rework.

a. Discussion of Existing Exchange Planning and Exchange Establishment Progress

1. Key Findings of Background Research

New Mexico conducted in-depth planning and research activities during the initial Level One

grant planning period. Enrollment projections indicate the following projected take-up for the

NMHIX for both the individual and SHOP markets:

Membership Count Projected at End of Open Enrollment
Membership Count Projected at End of Open Enrollment
3/2016 3/2021 10/2020- 3/2020 10/2019- 3/2019 10/2018- 3/2018 10/2017- 3/2017 10/2016- 10/2015- 3/2015 10/2014- 140,830 134,124
3/2016 3/2021 10/2020- 3/2020 10/2019- 3/2019 10/2018- 3/2018 10/2017- 3/2017 10/2016- 10/2015- 3/2015 10/2014-
3/2016
3/2021
10/2020-
3/2020
10/2019-
3/2019
10/2018-
3/2018
10/2017-
3/2017
10/2016-
10/2015-
3/2015
10/2014-
140,830 134,124 127,737 121,654 76,416 60,564 38,333 Individual SHOP 600 650 700 750 800 850 900
140,830
134,124
127,737
121,654
76,416
60,564
38,333
Individual
SHOP
600
650 700
750
800
850
900
134,974
128,537
122,404
77,116
61,214
38,933
141,730
460,000
681,248
859,562
1,084,548
1,368,423
1,436,844
1,508,686
Total Members
Member Months
3/2016 3/2021 10/2020- 3/2020 10/2019- 3/2019 10/2018- 3/2018 10/2017- 3/2017 10/2016- 10/2015- 3/2015 10/2014- 140,830 134,124
3/2016 3/2021 10/2020- 3/2020 10/2019- 3/2019 10/2018- 3/2018 10/2017- 3/2017 10/2016- 10/2015- 3/2015 10/2014- 140,830 134,124

* 2014 restated down based on actual results through September 2014

2. Legal Authority and Governance

Governance and Exchange Structure--The NMHIX was created by the New Mexico Legislature

in 2013 as a quasi-governmental nonprofit entity to “Provide qualified individuals and qualified

employees with increased access to health insurance in the state and shall be governed by a

board of directors constituted pursuant to the provisions of the New Mexico Health Insurance

Exchange Act (the “Act”). The legal authority for establishment of the Exchange is provided in

the Act, which was submitted as part of the second Level 1 grant application and is on file at

CCIIO. The NMHIX is governed by a 13-member board of directors that was appointed in April

2013; the members have outstanding qualifications and will comply with state and federal

conflict of interest requirements.

Composition of the Governing Body and Selection Process-- By statute, the NMHIX Board has

13 voting directors:

The Superintendent of Insurance or his designee.

Six directors appointed by the Governor (including the secretary of HSD, a health

insurance issuer, and a consumer advocate).

Six directors appointed by the Legislature (with three appointed by the president pro

tempore of the senate including one health care provider, and three appointed by the

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speaker of the house of representatives including one health insurance issuer. One of

the directors appointed by the president pro tempore and one of the directors

appointed by the speaker shall be from a list of at least two candidates provided by the

minority leader of the senate and the minority leader of the House of Representatives.

Coordination with HSDthe statute requires the Medical Assistance Division of HSD to

cooperate with the NMHIX to share information and facilitate transitions in enrollment

between the Exchange and Medicaid.

Coordination with OSI The Act charges the Superintendent of Insurance with promulgating

rules necessary to implement and carry out the NMHIX, including rules to establish the criteria

for certification of Qualified Health Plans (“QHPs”) offered on the exchange. NM OSI has the

regulatory responsibility for licensing Qualified Health Plan (QHP) issuers and reviewing and

approving QHP policies. On April 15, 2013, DOI released its submission guidelines for qualified

health plans (QHPs). The Act expressly prohibits the NMHIX from duplicating, impairing,

enhancing, supplanting, infringing upon or replacing the powers, duties, or authority of the

superintendent, including the superintendent’s authority to review and approve premium

rates pursuant to the provisions of the NM Insurance Code. Carriers are required to offer Silver

and Gold levels of coverage, and must offer at least one statewide plan at each metal level for

which the carrier submits a plan. Carriers can offer plans in either the individual Marketplace

or SHOP, and will not be required to offer the same plan in both Marketplaces. Final guidelines

were promulgated in August 2013. Five companies have been certified as QHPs for individual

plans, four companies for SHOP, and two companies for dental coverage. During 2014, one

of those carriers certified for both individual and SHOP left the market, and a new company

entered the individual market. Thus, going into 2015 Open Enrollment, New Mexico has three

plans certified as QHPs for SHOP, and five carriers certified as QHPs for the individual

exchange.

Coordination with Native AmericansCoordination with Native Americansthe Act requires

designation of a Native American liaison to assist the Board in developing and ensuring

implementation of communication and collaboration between the NMHIX and Native

Americans in the state. Currently the Native American Coordinator serves as the Native

American Liaison and is expected to be officially designated as Native American Liaison at the

November Board of Directors meeting.

The Native American liaison will serve as the contact person between the NMHIX and the New

Mexico Native American Nations, Tribes, and Pueblos and will ensure that training is provided

to the staff of the NMHIX to ensure cultural competency, understanding of Indian health laws,

and other Native American issues. The Act also allows permissive language for the

establishment of a Native American Service Center to ensure that the NMHIX is accessible to

all Native Americans, complies with the provisions of the Indian Health Care Improvement Act

and Indian-specific provisions of the ACA, and facilitates meaningful, ongoing consultation with

Native Americans.

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NMHIX has officially convened a Native American Advisory Committee that has officially

developed and implemented a Guiding Principles and Protocols. This document includes

provisions for proper communication with Native American leadership and communities as

well Guidelines for proper Collaboration efforts. The Native American Advisory Committee

convened every month for the first half of 2014 and every other month thereafter.

NMHIX and its partners have also established a Native American Enrollment Counselor

Network statewide. Currently there are sub-agreements with every federally recognized

Native American tribe in New Mexico providing for on-site Enrollment, outreach and education

on each reservation.

Other Governance Strategies

To ensure that the NMHIX has an accountable and transparent governance structure, is staffed

with competent leadership, and is in compliance with requirements of the statute, the NMHIX

Board of Directors:

  • a) Conducts monthly public meetings, adhering to NM Open Public Meetings law.

  • b) Implemented Conflict of Interest Policies (for both board members and NMHIX staff).

  • c) Maintains, posts, and updates an Exchange website with meeting agendas, minutes, and other materials related to Exchange activity and operations.

  • d) Develop a Plan of Operations shortly after the Exchange was established and updated it at the board first anniversary meeting.

  • e) Maintains communication with NM Medicaid/HSD and NM OSI.

3. Stakeholder Consultation

Prior to the creation of the NMHIX, the Human Services Department held public stakeholder

meetings beginning in December 2010 and continuing through December 2012. HSD created

the NMHIX Exchange Advisory Task (ATF), composed of 14 members, and NMHIX Advisory

Work Groups, composed of 12-18 members. The Task Force and Work Groups represented a

variety of perspectives, including consumers, tribal representatives, large and small employers,

self-employed, health care providers, hospitals, insurance carriers, brokers, government

leaders and agencies, underserved populations, and other community representatives. These

members acted in an advisory role to inform and provide recommendations in the following

areas:

Essential Health Benefits

Outreach, Education, Adoption, and Enrollment

Employer Participation

Exchange Market Regulation

Native Americans

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Program Integration

Financial Sustainability

Legislative

Public attendance was encouraged at every meeting, dial-in phone numbers were provided,

and press releases were submitted to newspapers of general circulation and posted on the

HSD website to encourage participation. An email box was created to allow public comments

and acknowledge requests for information through email.

The NMHIX statute requires establishment of the following advisory groups:

  • a) Stakeholders, including health insurance issuers, health care consumers, health care providers, health care practitioners, brokers, qualified employer representatives and advocates for low-income or underserved residents;

  • b) Advisory committee made up of members insured through the NMHIA and the NMMIP to make recommendations to the board regarding the transition of each organization’s insured members into the Exchange; and

  • c) Advisory committee made up of Native Americans, some of whom live on reservations and some of whom do not live on a reservation, to guide the implementation of Native American-specific provisions of PPACA and federal Indian Health Care Improvement Act.

  • d) Public input is solicited at every NMHIX board meeting and additional listening sessions are being held.

  • 4. Long Term Operational Costs

The Act provides that the Board may “generate funding, including charging assessments or

fees, to support its operations in accordance with provisions of the NMHIX solely for the

reasonable administrative costs of the exchange. NMHIX Board of Directors has established a

Finance Committee which is responsible for financial sustainability, budget development and

review of monthly financials. NMHIX recently completed a Financial Sustainability Plan

proposal after having 6 Finance Committee meetings, solicitation of public comment, and a

Public Finance Committee Meeting. NMHIX expects to attain financial self-sustainability in

January 1, 2016 for the Individual Exchange and January 1, 2015 for the SHOP operations. The

recommended revenue source that has been approved by the Finance Committee and will be

presented to the Board of Directors on November 21, 2014 is a broad assessment of all health

insurance carriers in the state. Prior to approval at the December 2014 Board Meeting, the

financial sustainability plan will be posted for 30 days for public comment.

  • 5. Program Integration

Program Integration --The NMHIX will continue to work with all stakeholders to address any

issues that could have an impact on the development and implementation of the NMHIX. The

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NMHIX relies on the HSD ASPEN Medicaid eligibility verification engine and, with HSD, is in the

development phase of the IT system development life cycle.

Memoranda of Understandingthe Act requires HSD and MAD to cooperate with the NMHIX.

A second MOU was also developed with HSD in May 2014 for purposes of providing a

mechanism for moving federal funds received by NMHIX to HSD for costs associated with

design, development, and implementation of an information technology (IT) system that

facilitates eligibility, advance premium tax credit, and cost sharing reduction determinations

through the ASPEN Medicaid System.

A MOU was also developed with New Mexico Office of Superintendent of Insurance (NM OSI)

for purposes of providing a mechanism to support regulatory and quasi-regulatory activities

carried out by NM OSI in support of the NMHIX and New Mexico’s implementation of the

Affordable Care Act with funds received by NMHIX. ACA’s Blue Print activities related to Plan

Management were delegated to NM OSI by the New Mexico statute.

  • 6. Business Operations of the Exchange

Business Operations of the Exchange were described at length in the 3 rd Level One

Establishment Grant Request which was awarded on 1/22/2014 (HBEIE 140193).

  • 7. IT Gap Analysis and Exchange IT Systems

The NMHIX utilizes GetInsured’s Commercial Off-The-Shelf (COTS) product for Marketplace

functions and ASPEN for Medicaid functions. New Mexico has conducted detailed gap analysis

of both the systems against what is required to implement full State Based Marketplace. Based

on the identified gaps design and development work has begun to close those system gaps.

Establishment Reviews by CCIIO/OIS

The following establishment reviews have been conducted by CCIIO to date:

An establishment review was conducted in October 2012. New Mexico received

conditional approval for its State Based Exchange in January 2013.

SHOP Design and Operational Readiness Reviews on September 26, 2013

Project Baseline (Planning) Review of the Individual Marketplace on February 11, 2014

Detailed Design Review of the Individual Marketplace on April 10 11, 2014

Final Design Review of the Individual Marketplace on June 10 11, 2014.

  • 8. Reuse, Sharing, and Collaboration

New Mexico will inform and assist other states through various means, including HHS Learning

Collaborative and User Groups. Beyond reuse and sharing of IT, New Mexico is committed to

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leverage existing infrastructure and re-purpose business functions and processes to maximize

resources and is working with other states to determine how aspects of their systems can be

replicated in New Mexico. This is demonstrated through the partnership with the State of

Idaho in sharing in the cost of certain functionality described within this request.

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  • 9. Organizational Structure, as of 11/12/2014

9. Organizational Structure, as of 11/12/2014 Organizational Chart New Mexico Health Insurance Exchange Board of Directors

Organizational Chart

New Mexico Health Insurance Exchange

 

Board of Directors

   

Chief Executive

Officer

Amy Dowd

 

Executive Assistant

Lisa Garcia

Customer Service Center Director Michael Dineen Customer Support staff/walk in center TBD
Customer Service Center
Director
Michael Dineen
Customer Support
staff/walk in center
TBD
  • Teresa McLane

Shop Support

  • In Recruitment

Shop Support

Advisory Committees

9. Organizational Structure, as of 11/12/2014 Organizational Chart New Mexico Health Insurance Exchange Board of Directors
 

Admin. Assistant

 

Tracy Gwash

 

Information Technology

 

Director Raj Shethia

 
 
 

Technical Analyst

 

Karen Galbreath

 

Business/Technical Analyst

 

In Recruitment

9. Organizational Structure, as of 11/12/2014 Organizational Chart New Mexico Health Insurance Exchange Board of Directors
9. Organizational Structure, as of 11/12/2014 Organizational Chart New Mexico Health Insurance Exchange Board of Directors
Chief Financial Officer Anita Schwing
Chief Financial Officer
Anita Schwing
Sr. Accountant
Sr. Accountant

Genelyn McFarlane

Accountant Kimberly

Llamas

Reconciliation Specialist

TBD

9. Organizational Structure, as of 11/12/2014 Organizational Chart New Mexico Health Insurance Exchange Board of Directors
9. Organizational Structure, as of 11/12/2014 Organizational Chart New Mexico Health Insurance Exchange Board of Directors

Director of Communications

 

and Marketing

 

Linda Wedeen

 

Broker Relations Manager

In Recruitment

   

Scott Atole

 

Native American Coord.

TBD

Native American Liaison

Human Resources Manager Michelle Brooks
Human Resources
Manager
Michelle Brooks
Compliance Officer Yolanda Miles
Compliance Officer
Yolanda Miles

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Key Personnel

Amy Dowd Chief Executive Officer, NMHIX, August 2014. Amy Dowd started her career in

healthcare working for a regional BlueCross BlueShield health plan in operations where she held

leadership positions in membership and billing, enterprise program management office, and

vendor relations. She was also a national practice health care consultant at Ernst & Young LLP,

advising several of the largest national health insurance carriers on Affordable Care Act strategy,

implementation, and compliance. Amy has over 20 years of experience leading large-scale

technology and operational improvement projects across the private, public, and non-profit

sectors. Amy has a Bachelor of Science degree, and holds Project Management Professional

certification.

Amy started working on the Idaho Health Insurance Exchange, now known as Your Health Idaho,

in 2010 leading efforts to define options for implementing an exchange in Idaho. Since May of

2013, she has served as Executive Director of Your Health Idaho, which achieved the second

highest exchange enrollment per capita in the nation within four months of launch. Amy recently

joined the New Mexico Health Insurance Exchange (NMHIX) as the newly appointed Chief

Executive Officer (CEO). She is currently working with the NMHIX Board, staff and key stakeholders

to continue NMHIX on a path to success.

Anita SchwingChief Financial Officer, NMHIX, September 2013. Ms. Schwing brings over 20 years

of financial management experience, including ten years in New Mexico managed care. She

previously worked four years as Chief Financial Officer at Coventry Health Care’s Medicaid

Managed Care Organization, in St. Louis, MO. Prior to that, she was Chief Financial Officer at

Molina Healthcare of New Mexico (four years), Controller at Cimarron Health Plan (4 years), and

Director of Finance at Lovelace Health Plan (two years). She also worked seven years for CIGNA

Corporation, in Philadelphia, PA. Ms. Schwing has served on the Board of the New Mexico Medical

Insurance Pool, as well as the Board of the New Mexico Health Insurance Alliance. She is a

Certified Public Accountant, and has a Master of Business Administration degree from Temple

University, Philadelphia, PA.

Raj Shethia Director of Information Technology, NMHIX, November 2013. Mr. Shethia came to

the NMHIX after working at Lovelace Health Plan for seven years in various IT roles, including over

two years as the Technical Lead, Chief Architect and Subject Matter Expert on the Health Insurance

Exchange/Marketplace implementation for the health plan’s integration with the Federal and New

Mexico Health Insurance Marketplace. He also served as Lovelace’s representative on NMHIX’s

Information Technology and Integrated Services RFP evaluation team, providing the opportune

introduction to full participation as an employee. Mr. Shethia has a Master of Science in Software

Engineering from the University of Houston, and a Bachelor of Engineering in Computer Science

from the University of Mumbai. In addition, he holds a Master’s Certificate in Project Management

from the University of New Mexico as well as a Certificate in Supervisor Academy from Central

New Mexico Community College.

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Linda Wedeen Director, Communications and Outreach, NMHIX, October 2014. Ms. Wedeen has

been in the Strategic Marketing and Communications for more than 30 years. Her areas of

expertise include: Executive Communications, Strategic Planning, Brand Awareness and

Development, Community Connections Lobbying, and Program and Vendor Management. Ms.

Wedeen recently joined the New Mexico Health Exchange as Director, Communications and

Outreach to lead a strategic team of vendors and staff to ensure success during the November

2015 Open Enrollment period and into the future.

Previously Ms. Wedeen worked with a number of corporations and private entities including the

New Mexico Cancer Center Foundation, Hewlett Packard, First Community Bank, and AT&T. Ms.

Wedeen has also owned her own consulting firm focusing on Strategic Planning and Evaluation.

Additionally, Linda has an extensive community network through her association with many local,

state and national organizations.

Yolanda Miles Compliance Officer, NMHIX, June 2014. Ms. Miles brings 25 years of experience in

the health insurance industry. She held the positions of Director of Enrollment & Eligibility and

Director of Project Management prior to joining NMHIX. Ms. Miles is exceptionally knowledgeable

about all operational, IT, and compliance aspects of Commercial, Medicare Advantage, and

Medicaid lines of business. She has worked with governmental and regulatory agencies for several

years to ensure program compliancy based on product and line of business. Ms. Miles is certified

as a Project Management Master and was awarded the Circle of Excellence award in her previous

positions. She attended University of New Mexico and New Mexico State University.

Michael Dineen Customer Service Director, NMHIX, October 2013. Mr. Dineen will oversee call

center and customer support operations as well as SHOP operations. He has more than 15 years

of call center experience, specializing in technology and healthcare. Prior to joining NMHIX, Dineen

worked with America Online, T-Mobile and Lovelace Health Plan. He has a strong focus on the

customer experience and customer service.

Michelle BrooksHuman Resources Manager, NMHIX, January 2014. Ms. Brooks brings over ten

years of Human Resources Management experience to the NMHIX. She is experienced in

recruitment, policy and procedure development and compliance, compensation and benefits,

team building, supervision and leadership, employee relations, and workers comp. Ms. Brooks

has a Bachelor of Science in Business Management with a concentration in Human Resources from

the University of Phoenix. She is an active member of the Human Resource Management

Association (HRMA) and the Society of Human Resources Management (SHRM).

Scott AtoleNative American Coordinator, NMHIX, September 2013. Mr. Atole is an enrolled

member of the Jicarilla Apache Nation, is responsible for facilitating communication and

collaborative efforts with Native American communities and leadership in New Mexico to address

health care coverage and health insurance issues. Mr. Atole has earned a Bachelor’s of Science in

Education & Community Health at the University of New Mexico and is currently completing a

Masters of Public Administration/Health Policy and Administration. Mr. Atole has twenty years of

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experience in working at multiple levels with diverse populations to identify and engage a variety

of health education and prevention initiatives, research, curriculum development and health

program administration. Professional experience includes UNM-MPH & MPA Research,

Albuquerque Area Indian Health Board Program Manager, Health Educator/Prevention Specialist

and IHS Community Health Program(s). In addition to previous appointments to the American

Cancer Society’s Advisory Group, the New Mexico State Tobacco Advisory Committee, and the NM

Statewide Strategic Planning Committee and Native American Workgroup. Mr. Atole also serves

as the Jicarilla Apache delegate to the New Mexico Department of Health’s American Indian Health

Advisory Committee.

Karen Galbreath--Technical Analyst, NMHIX, February 2014. Mrs. Galbreath is primarily focused on

providing ongoing analysis, maintenance, and technical and functional support for application

systems throughout the organization. She brings over 15 years of experience in the healthcare

industry, including 2 years at Lovelace Health plan, and 6 years at UNM Health Science Center.

She has a Master’s Degree in Information Systems.

Genelyn McFarlane--Senior Accountant, NMHIX, September 2014. Ms. McFarlane has over 14

years of experience in Finance, Accounting and Retail Management. Prior to joining NMHIX, she

was the Accounting Supervisor for Pueblo De Cochiti. Managing over 30 Federal and State Grants,

Ms. McFarlane has an extensive knowledge in budgeting, analysis, auditing, payroll, accounting,

federal and state grants. In addition, she was the Finance Manager for Foothill Community Health

Center in San Jose, CA. She has experience in private, public and non-profit organizations. Ms.

McFarlane earned her Bachelor degree in Accounting from San Jose State University.

Kimberly LlamasAccountant, NMHIX, December 2013. Ms. Llamas brings over 15 years of

experience in accounting, including 9 years with Delta Dental of New Mexico. Since coming to

NMHIX, she has participated in the development of reconciliation processes for the premiums

billed on the SHOP marketplace. In this role, she will work with the carriers in the 820/834

reconciliation processes for both SHOP and Individual Marketplaces. She is also responsible for

accounts payable, vendor contract tracking and encumbrance reconciliation, and fixed assets.

Ms. Llamas has a Bachelor’s Degree in Business Accounting from the University of Phoenix.

Lisa Garcia Executive Assistant, NMHIX, August 2013. Ms. Garcia has served in this position since

August 1, 2013. Prior employment was at the New Mexico Institute of Mining and Technology as

the Executive Assistant to the Vice President for Research and Economic Development where she

was responsible for the management of the Division and the research entities within the Division

for over 16 years. Prior to that she was the Office Manager for the Center on Aging within the

Population Research Institute at Pennsylvania State University for four years. She brings extensive

knowledge of planning, management and customer service to her position at the Exchange. Ms.

Garcia earned an Associate of Science from New Mexico Institute of Mining and Technology in

2007.

Page 22 of 121

Tracy Gwash--Administrative Assistant, NMHIX, January 2014. Since coming the NMHIX, Ms.

Gwash has received her Healthcare Guide Certification and Presumptive Eligibility Determiner

Certificate. Prior to coming to the Exchange, Mrs. Gwash was Office Manager/Assistant to the

Director at New Mexico Press for over 13 years. She brings extensive knowledge of planning,

management and customer service to her current position. Mrs. Gwash earned her Medical

Receptionist Certificate from Franklin Medical College. Mrs. Gwash also earned a Medical billing

and Coding Degree from the University of New Mexico.

Key Board Members:

James R. Damron, M.D., FACR, NMHIX Board Chair - Dr. Damron is an attending radiologist at UNM,

Health Science Center, School of Medicine and teaches in the specialty of Clinical Mammography,

overseeing radiology residents and providing lectures to medical students on state and federal

health policy issues. Prior to UNM, he was President of Santa Fe Radiology, P.C., providing

diagnostic radiology imaging services in Santa Fe for 30 years before he retired. Dr. Damron

received his Medical Degree from Indiana University School of Medicine, his radiology training at

the University of Kentucky Medical Center and completed a Nuclear Medicine Fellowship at the

University of New Mexico. He is Board Certified by the American Board of Radiology and the

American Board of Nuclear Medicine. He is a Fellow in the American College of Radiology. Dr.

Damron has been associated with numerous state and national professional organizations and

boards and is the author of several peer-reviewed articles.

He has received several national awards, such as the Capitol Dome award and the Physician’s

Award for Outstanding Service from ACS, the 2006 Physician of the Year award from the National

Republican Congressional Committee and the NRCC 2007 Congressional Order of Merit. He also

serves on the NM Coalition for Literacy Board, the St. Vincent Hospital Foundation Board and has

served on other numerous community boards, state committees and task forces. Dr. Damron was

the Republican Nominee for Governor in 2006 and a candidate for Lt. Governor in 2010.

Jason Sandel, NMHIX Vice-Chair- is a native of Farmington, New Mexico and was elected to the

Farmington City Council in March of 2006. Jason Sandel is the Executive Vice-President of Aztec

Well Servicing and its subsidiaries in Aztec, New Mexico. He is the 3rd generation of the Sandel

family to dedicate himself to the company and the community. Jason attended the University of

New Mexico where he received a B.A. in Political Science and served as a Senior Leadership Analyst

for the New Mexico State Senate. Along with his appointment to the Board of the New Mexico

Health Insurance Exchange, Jason serves as the Vice-Chairman of the New Mexico Medical

Insurance Pool, immediate past President of the Four Corners Safety Council, member of the New

Mexico Oil and Gas Executive Committee, former member of the Statewide Economic

Development Commission, and was honored with the Paul Harris award by the San Juan Rotary

Club.

Page 23 of 121

John G. Franchini, Superintendent of InsuranceMr. Franchini is a native New Mexican and

graduate of Creighton University, with 35 years of experience in the insurance industry. He joined

Consolidated Agency, his father’s independent insurance agency, purchased it ten years later and

expanded it to four locations employing 82 people and servicing nearly 15,000 customers. He

served on the New Mexico Workers’ Compensation Assigned Risk Pool Board of Governors, the

Patient Compensation Administration Board of Directors, and was elected president of the

Independent Insurance Agents of New Mexico. In 1998, Poe & Brown, a national insurance broker,

purchased the business. He was named vice president. His responsibilities included new business

production, development of specialized insurance programs, and agency acquisitions. He joined

New Mexico Mutual in 2002 and later named Vice President of Government and Industry Affairs.

He is a member of the Leadership New Mexico Class of 2007, former board member of the Rocky

Mountain Insurance Information Association, and past president of the NM Insurance Association.

  • 10. Program Integrity

The NMHIX hired a Compliance Office in June 2014 to focus on program, system, and financial

controls within the operating system and business processes of the Exchange. Additionally, the

NMHIX was subject to its first A-133 and financial statement audit in September 2014, with a

favorable audit opinion. Financial and internal controls have been developed to ensure that the

NMHIX can account for grant funds in accordance with CMS expectations. The NMHIX will

continue adhere to HHS financial monitoring activities for the Level Two Establishment Grant.

NMHIX successfully completed a business assessment by CMS in July 2013.

  • 11. Affordable Care Act Requirements

Health Insurance Market Reforms--The Department of Health and Human Services (HHS)

determined that New Mexico had an effective rate review program as of August, 2011.

  • 12. SHOP

Summary of State’s Small Group Market--New Mexico’s current small group market has

approximately 60,500 covered lives with $277 million in earned premiums. Market shares are as

follows:

Carrier

Members (2011)

Market Share

Earned Premium (2011)

Market

Share

Blue Cross Blue Shield of NM

19,566

32.4%

$100,722,000

36.4%

Lovelace Health Plan

16,355

27.1%

$ 68,451,360

24.7%

Presbyterian Health Plan

17,821

29.5%

$ 74,432,580

26.9%

United Health Care

6,693

11.1%

$ 33,202,618

12.0%

Total

60,435

100%

$276,858,558

100%

Page 24 of 121

Research/Reports on Small Group Market Issues/SHOP Operations and Stakeholder Consultation on

SHOP--An Employer Participation work group held extensive meetings to work on various SHOP

issues and provide recommendations. Issues reviewed included participation requirements,

definition of “small business”, adverse selection issues, defined contribution, premium

aggregation, and plan selection.

The NMHIX utilized the information from the stakeholders in designing the NMHIX SHOP program

with the following features:

Minimum 50 percent participation requirement (except for a “golden enrollment period”

in November and December 2013 when there will be no participation requirement).

Minimum employer contribution of 50 percent.

Employers select a “metal” level and a reference plan as a cost parameter and then

employees may select plans from within that metal level.

Page 25 of 121

b. PROPOSAL TO MEET PROGRAM REQUIREMENTS

  • 1. Current Exchange Pathway

On December 14, 2012 New Mexico submitted its Blueprint application to HHS to operate a

State-Based Exchange and the Blueprint was conditionally approved on December 31, 2012

and additional conditional approval was received in July 2013. The State of New Mexico has

elected to operate a hybrid health insurance marketplace where initially the State will operate

its own SHOP marketplace and utilize the Federally Facilitated Marketplace (FFM) for the

Individual marketplace. Starting October 1, 2013 NMHIX has begun the process of developing

a state-based individual marketplace with the aim to Go-Live for 2016 Open Enrollment. Once

New Mexico is live with core marketplace functionality in 2015 New Mexico will continue to

add capabilities to support our goal to increase enrollment and enhance self-sustainability.

  • 2. State’s Strategy to Complete the Exchange Activities

The chart below shows the status of the NMHIX activities as a State-Based Exchange:

EXCHANGE ACTIVITIES

STATUS

Legal Authority and

New Mexico has enabling legislation creating the NMHIX to operate the

Governance

Exchange and SHOP SB221.

To ensure the NMHIX has an accountable and transparent governance

structure, is staffed with competent leadership and is in compliance with

applicable conflict of interest provisions, the NMHIX Board of Directors

conducts monthly public meetings, adheres to open public meeting laws,

developed a Plan of Operations, and implemented a Conflict of Interest

Policy, Procurement Policy, and Communication Policy.

Consumer and Stakeholder

Advisory groups will be continued through the NMHIX throughout the

Engagement and Support

development and implementation of the NMHIX to ensure stakeholder

engagement and support. A comprehensive outreach and education plan

has been developed that ensures culturally and linguistically appropriate

materials and ensures access to information and enrollment for individuals

with disabilities. A website has been developed in English and Spanish. A

Health Care Guide program with associated training requirements and

broker roles has been developed.

Eligibility and Enrollment

NMHIX has implemented its SHOP eligibility and enrollment system.

NMHIX is coordinating with HSD on eligibility and enrollment which will

be documented through regular meetings between the NMHIX and

HSD staff. NMHIX plans to have the capacity to accept and process

applications for the individual market by October 1, 2015. NMHIX is

working with HSD to develop appropriate exchange interfaces.

GetInsured is developing a system for NMHIX enrollment with capacity

for notices, verifications, privacy and security protections, storing and

processing documents, determine eligibility for enrollment in QHPs, to

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process QHP selections and terminations, and comply with required

reporting to HHS. See more in the section below as this grant request

focuses on this blueprint core area.

Plan Management

NM’s enabling legislation delegated to the Office of the Superintendent

of Insurance (OSI) the authority to certify and oversee QHPs and is

coordinating with the NMHIX. The NMHIX has a plan management

system to support the collection of QHP issuer and plan data and

facilitate the certification and renewal process and integrate with other

Exchange business areas.

Risk Adjustment and

New Mexico plans to use the federal service for risk adjustment and

Reinsurance

reinsurance.

SHOP

The NMHIX SHOP system allows for the enrollment and billing of

employer groups and employees, online invoice payment capability as

well as premium aggregation and remittance to insurance carriers. It

also has required electronic reporting functionality.

 

Organization and Human

The NMHIX has hired core staff and continues to hire additional staff

Resources

for performance of NMHIX activities.

Finance and Accounting

The NMHIX is developing a long-term operational cost, budget and

management plan through its Finance Committee. A Financial

Sustainability Plan Proposal is scheduled to be presented at the

November 21, 2014 Board of Directors Meeting for approval and

adoption. NMHIX is exploring functionality and options in the

technology solution that will ensure financial sustainability beyond

2015-2016, by enhancing consumer facing functionality.

 

Technology

The NMHIX has contracted with Get Insured to ensure adequate

technology infrastructure and bandwidth, and to achieve essential

functionality for all NMHIX activities.

Privacy and Security

The NMHIX’s IT solution ensures required privacy and security within

the technology solutions.

Oversight,

Monitoring,

The NMHIX is complying with all oversight, monitoring, and reporting

and Reporting

requirements.

Contracting, Outsourcing,

NMHIX has contracted with Get

Insured

and

PCG for ongoing

and Agreements

development of the Exchange; Xerox for the Call Center and SES for

IV&V functions.

Page 27 of 121

Consumer and Stakeholder Engagement

The NMHIX is implementing a process for a formal Advisory Committee to obtain consumer

and stakeholder input and engagement as required by statute. Each of the NMHIX outreach

and enrollment partners are being asked to provide a representative to serve on the initial

Advisory Committee for one year. The Advisory Committee meets quarterly to provide input

and feedback to the NMHIX with the first meeting held December 2013. The meetings have

been held in various locations around the state to allow broad geographic input during public

comment portions of the meetings. The Committee is being structured to allow representation

from various stakeholders including consumers, business groups, providers, brokers, QHPs,

enrollment partners, and others. The NMHIX will continue to enhance the stakeholder

engagement process as the NMHIX is implemented.

Outreach, Education, and Enrollment Program

The comprehensive outreach and education program that began in 2013 will continue to be

implemented throughout the state in 2014 for 2015 open enrollment. An assessment of the

effectiveness of the initial outreach and education activities will be conducted after the first

90 days of open enrollment to refine and expand outreach, education, and marketing activities

as necessary. Ongoing activities will include the following components:

Outreach and education with ACI, New Mexico Association of Counties, Albuquerque

Hispano Chamber of Commerce, New Mexico Green Chamber of Commerce, UNM and

NMSU and the higher education system, and additional contracts for hard-to-reach

populations.

Additional outreach will be conducted based on a comprehensive assessment of initial

strategies. In January 2014, NMHIX will review all strategies and results and make

modifications and expansion of activities as necessary to increase enrollment. It is

anticipated that significant recalibration of messaging and additional media and

strategies will be necessary due to the federal technology delays.

Implementation of a series of focus groups in spring 2014 to assess reasons why people

may have not signed up for coverage and exploration of alternative strategies to

generate enrollment.

Continued implementation of significant “in-reach” for existing patients of clinics and

hospitals, as well as outreach. Over 60,000 postcards will be mailed in early November

to reach as many patients as possible. Additional postcard strategies are being

developed for use at events with signature authorizations by consumers to allow a

Health Care Guide to call them back to provide information and help them sign up for

coverage.

Development of additional strategies with diverse partners, such as Rotary, Kiwanis,

schools, trade associations (restaurants, retail, credit unions, banks, realtors, utilities,

homebuilders, etc.)

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Ongoing marketing and media activities in partnership with BVK and local marketing

partners, including TV, radio, print, billboards, and social media. In January 2014,

NMHIX reviewed all marketing and media strategies and results and made

modifications to increase enrollment. The campaign was refreshed to run again in

late summer 2014 for the second open enrollment period. Weekly press

releases and public relations.

Enrollment activities will continue through contracts with NMPCA, NAPPR, and other

enrollment entities. The enrollment network and capacity will be assessed on an

ongoing basis and additional enrollment sites added as necessary. Performance goals

with enrollment metrics will be established for each county in the state and monitored

and additional resources will be targeted to counties not meeting enrollment goals.

Group training sessions will also be implemented to accommodate enrollment demand

in the shortened timeframe due to the federal technology issues.

Targeted Native American assistance programs will also continue to be implemented

to serve New Mexico’s Native American population in partnership with NAPPR and the

Navajo Nation.

To support the second open enrollment period, NAPPR opened a Walk-In Center in

Albuquerque on a pilot basis, which may be taken state-wide if found to be effective,

to provide specialized technical assistance and support to New Mexico’s Native

population. This Walk-In Center will also serve the non-Native population as well, with

enrollment guides from NMPCA

NMHIX will use a variety of methods to assess enrollment and outreach strategies, including

consumer surveys that will be completed after each interaction with a Health Care Guide,

reviews of decreased number of uncompensated care patients at clinics, hospitals, and with

County Indigent Funds, social media feedback, media metrics, and feedback solicited by all

outreach partners. NMHIX will monitor enrollments bi-weekly through reports from NMPCA,

NAPPR, and UNMHSC and with monthly reports from CCIIO.

Eligibility and EnrollmentNMHIX is building an ACA compliant marketplace IT system that

supports an online single-streamlined application process to provide consumers with access

to Insurance Affordability Programs and an online tool to shop and enroll in commercial

insurance. The Customer Service Center shall also support a mail room function in the event

that a consumer prefers to complete a paper application. The mail room will mail the

applications to individuals as well as employees who request a paper application to enroll in a

small employer and/or individual benefit plan. The mail room will also receive completed paper

applications. The New User Open Enrollment exhibit below shows high level design flow of our

planned integrated eligibility and verification system.

Page 29 of 121

New Mexico is developing an Integrated Eligibly and Verification System based on principles laid out in

New Mexico is developing an Integrated Eligibly and Verification System based on principles

laid out in Guidance for Exchange and Medicaid Information Technology (IT) Systems version 2.0.

New Mexico has developed a single streamlined application (based on CMS SSAp guidelines)

and a Single Rules Engine that can be used by consumers who apply for either QHP on the

individual marketplace and for insurance affordability programs.

Upon entry into New Mexico’s integrated shared portal, enrollees will be asked if they wish to

complete an insurance affordability assessment (anonymous shopping). If an enrollee decides

they do not want to pursue financial application path, he or she will be asked to provide

information on a shorter version of single streamlined application and guided thru process to

Page 30 of 121

enrollee in QHP. New Mexico will send a web services query a Shared Data Services HUB for

verification of enrollee’s information as required in 45 CFR part 155.

For enrollees who wish to pursue financial application path, NMHIX will seamlessly transition

to insurance affordability single streamlined application that will collect the required data from

enrollees and family members. New Mexico will send a web services query a Shared Data

Services HUB for verification of enrollee’s information as required in 45 CFR part 155.

The system has capacity to assist consumers with disabilities or with limited English proficiency

that comply with all applicable federal policies and laws, through the following features:

User friendly, plain English, web portal with mouse-over help feature

508-compliant web portal for the visually impaired

Text Telephone (TTY) services for the hearing impaired

Third-party language translation services for individuals with limited English proficiency

Applications and supporting materials, notices, and correspondence in multiple

languages upon request.

New Mexico will develop a system that is able to generate and send correspondence in

electronic formats, print correspondence onto standardized paper, and provide services for

sending notices, which includes folding, postage, and delivering correspondence.

Additionally New Mexico IT System will be able to accept and process updates, and responses

to redeterminations from applicants and enrollees (see figure below that shows high level

design flow).

Page 31 of 121

Page 32 of 121

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Call CenterThe New Mexico initial Call Center (currently primarily a referring call center) will

be expanded to accommodate all Call Center activities once the Individual Marketplace is

implemented in October 2015. It will be capable of assisting New Mexicans with questions

related to open enrollment, eligibility, plan selection, complaints, and all NMHIX activities.

NMHIX will issue a RFP for a comprehensive call center for its State Based Exchange for both

individual and SHOP full functionality.

Plan Management

The Superintendent of Insurance has authority over all health insurance plans sold in New

Mexico. OSI is responsible for plan management functions, including QHP certification, of the

NMHIX solution. OSI and the NMHIX have developed a standard QHP contract whereby issuers

certify that they will comply with all applicable state and federal laws, regulations, and

guidelines. In the event of an adverse event or adverse finding from a periodic assessment that

may affect a QHP’s certification status, OSI coordinates support to resolve the issue. OSI will

notify NMHIX to remove the QHP from sale upon finding cause to decertify a QHP. OSI is

responsible for the management of the consumer complaint process for QHPs, including

complaints referred from the call center, and will coordinate among internal units as needed

to resolve consumer complaints or identify potential compliance issues. SERFF will be used to

record all QHP administrative data. The QHP service area must cover a minimum geographical

area that is at least an entire county or group of counties, unless the NMHIX determines that

serving a smaller geographic area is necessary, nondiscriminatory, and in the best interest of

the qualified individuals and employers. The QHP service area must be established without

regard to racial, ethnic, language, health-status related factors, or other factors that exclude

specific high utilizing, high cost, or medically-underserved populations. OSI ensures that the

QHP has made its provider directory available for online publication (or has provided the

source of online publication) and has indicated providers who are no longer accepting new

patients according to PPACA § 156.230(b). Rating areas are a consideration in the QHP review

process. A third party actuary assists the state in defining rating areas for QHPs.

OSI ensures QHP compliance with market reform rules in accordance with all applicable

regulations and guidance. New Mexico currently has a small number of carriers and a total of

56 plans offered on the NMHIX. OSI provides all QHP certification for the NMHIX. New Mexico

has a new CO-OP plan, New Mexico Health Connections, which is offering plans on the NMHIX.

DOI will provide recommendations to CMS on whether the CO-OP plan meets NMHIX

standards for a QHP to assist CMS in its decision to deem CO-OP as certified to participate

according to 42 CFR 156.520 (e).

OSI is responsible for oversight of the licensure, solvency, and market conduct of issuers who

submit QHPs to be offered on the NMHIX. Market conduct exams will be conducted every 3

years and compliance issues will be addressed. QHPs may be decertified or withdrawn in the

course of ongoing or periodic monitoring or as the result of an adverse event reported to OSI.

If there is a voluntary company/issuer withdrawal from the state, the company must give the

state 180 days’ notice. For QHP individual plan withdrawal, OSI sends notification to the

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consumers. For SHOP plan withdrawal, OSI will coordinate with the NMHIX to send

notifications to the employers.

Risk Adjustment and Reinsurance

New Mexico is utilizing the federal system for risk adjustment and reinsurance.

SHOP

NMHIX has implemented the SHOP program and will continue to refine operations. The SHOP

is fully compliant with regulatory requirements of 45 CFE Sec. 155, Subpart H. The NMHIX

SHOP is performing premium aggregation. IRS reporting capabilities are in progress and are

expected to be functional in time for 2014 reporting.

Organization and Human Resources

NMHIX has hired key staff, including a Chief Executive Officer, Chief Financial Officer, IT

Director, Compliance Officer, Native American Coordinator, Customer Service Director,

Director of Marketing and Outreach as well as support staff.

Finance and Accounting

NMHIX hired a CFO in September 2013. The NMHIX purchased a fund accounting system to

provide the necessary control and reporting capabilities required for the grant. The NMHIX

has been through two budget seasons, an A-133 and financial statement audit, and has

received approval from the NMHIX Finance Committee to take their Financial Sustainability

Plan Proposal to the Board of Directors for approval. Financial policies and procedures have

been developed to provide the financial control structure desired for grant management and

reporting.

Technology

The State of New Mexico has elected to operate a hybrid health insurance marketplace where

initially the State will operate its own SHOP marketplace and utilize the Federally Facilitated

Marketplace (FFM) for the Individual marketplace. Starting October 1, 2013 NMHIX has begun

the process of developing a state-based individual marketplace with the aim to Go-Live for

2016 Open Enrollment.

Once New Mexico is live with core marketplace functionality in 2015 New Mexico will continue

to add capabilities to support our goal to increase enrollment and enhance self-sustainability.

General theme for types of enhancement work that will be undertaken in 2016 and 2017 are:

Catalyze enrollment through active and increasing participation of brokers

Broaden distribution opportunities maximally through a range of enrollment options

Page 34 of 121

Enhance ease of use by users, particularly for New Mexico specific user communities

NMHIX has retained the services of GetInsured (GI) to implement both the SHOP marketplace

and the Individual marketplace. NMHIX produced a set of functional requirements for the

SHOP and Individual marketplace systems that were incorporated into the Request for

Proposals (RFP) to which GI responded. NMHIX has retained the services of Public Consulting

Group (PCG) to assist with various aspects of implementing the SHOP and Individual

marketplaces, including a Project Management Office (PMO). In addition NMHIX has

contracted with Software Engineering Services (SES) as an Independent Verification and

Validation to oversee the design, development, and implementation of the marketplace

functions.

Among the functions of the PMO and IV&V are to work with GI to ensure that:

o

Standard industry Systems Development Life Cycle (SDLC) protocols are followed,

including iterative and incremental development methodologies.

o

Requirement specifications, analysis, design, code, and testing are developed and

carried out in accordance with CMS/CCIIO requirements and generally accepted

professional practice.

o

The design takes advantage of a Web Services Architecture and Service Oriented

Architecture approach for design and development.

o

The services description/definition, services interfaces, policies and business rules

are published as required and the solution provides role-based access to underlying

data.

o

The solution adheres to standards published by the Office of the National

Coordinator (ONC) and the National Institute of Standards and Technology (NIST).

o The GI system is interoperable and integrated with State Medicaid/ Children’s

Health Insurance Program (CHIP) programs and is able to interface with HHS and

other data sources in order to verify and acquire data as needed.

o

The GI system achieves any required interoperability with other health and human

services programs for purposes of coordinating eligibility determinations, referrals,

verification or other functions.

Systems Design

New Mexico’s IT Solution will be created to insure more New Mexicans while fostering

competitiveness, encouraging efficiency, and creating sound individual and small employer

private health insurance choices. Qualified individuals and small employers will be able to

shop, compare, and choose a Qualified Health Plan (QHP) as well as apply for other insurance

affordability programs. The IT System will:

1.

Create

an

integrated

Health

Insurance

Exchange

that

provides

the

following

functionalities:

 
  • a. Integrated Individual Eligibility & Enrollment

  • b. SHOP Eligibility & Enrollment

Page 35 of 121

  • c. Determination of Eligibility for Individual Federal Subsidy of Insurance Premium, Advanced Premium Tax Credit (APTC), Cost Sharing Reduction (CSR) as well integrate with HSD system for other Insurance affordability programs

  • d. Carrier and Plan Certification and Recertification

  • e. Monitor Carrier and Plan Certification Compliance

  • f. Display Carrier Ratings by Price and Quality (Star Rating)

  • g. Maintain Operational Data

  • h. Process Change in Plan Enrollment Availability

  • i. Premium Processing/Payment Aggregation

  • j. Issuer Payment Transfers

  • k. Web Portals architecture for Call Center CSRs, Navigators, Tribal Assistance, Marketing/Outreach Personnel, Agents and Brokers

  • l. Receive, Process and Retain Client Correspondence

  • m. Management of Exchange Operations

  • n. Identity and account management

  • o. Federal, State and Management Reporting

  • p. Interface with Shared Data Hub

  • 2. Meet as prudently as possible the critical deadlines associated with Health Care Reform requirements set forth in the PPACA and New Mexico related regulations.

  • 3. Provide integrated screening, choice, coordination, eligibility and enrollment; aligning systems to support health plan selection; and aggregating payments.

  • 4. Implement a modern technology that meets New Mexico’s business needs, is flexible to changing requirements, and is easily maintainable.

The high level major factors that have influenced the technical design of the proposed system

are:

ACA Section 1561 standards

MITA 3.0 framework and guidelines

Security, privacy and operational standards required by HIPAA, HITECH, NIST, FIPS and

IRS standards

Providing a first class customer experience.

Maintaining cross-program integration so that consumers continue to enjoy a breadth

of on-line support

Being able to offer on-line, real-time eligibility determination and enrollment

capabilities

Providing seamless integration of systems to provide efficient and effective service

delivery

Relevant Standards

The relevant standards that will be followed by NMHIX and its supporting solutions are:

ACA Section 1561 standards for enrollment

ACA Section 1104 operating rules for each HIPAA transaction

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National Information Exchange Model (NIEM) common language

MITA 3.0 standards for reusable components and modularity

Service Oriented Architecture (SOA) standards

HIPAA (5010 compliant)

HITECH

NIST

FIPS

Federal security standards for cloud computing environments

(http://www.gsa.gov/portal/category/102371)

NIST standards for Disaster recovery and Continuance of Operations Program (COOP)

(http://csrc.nist.gov/publications/nistpubs/800-34-rev1/sp800-34-rev1_errata-

Nov11-2010.pdf)

ADA Section 508 and W3C standards for disability support

Limited English Proficiency (LEP) standards

Design Goals for New Mexico Solution:

Design principles for New Mexico solution are in line with Guidance for Exchange and Medicaid

Information Technology (IT) Systems version 2.0.

The following are the design goals and its supporting solutions:

System design that is consistent with section 1561 guidelines

System design to achieve first class consumer experience

System and interface design to achieve real-time and seamless integration with Federal

and State systems (web services)

Design that will allow maximum reusability for other states

System design to achieve real-time and seamless integration with relevant state portals

System design that is consistent with HIPAA (5010), NIST, HITECH, FIPS and IRS

guidelines and standards

System design that accommodates the accessibility guidelines by ADA section 508 and

W3C

Application of MITA 3.0 standards as appropriate

System design that accommodates the Limited English Proficiency (LEP) guidelines

Agile Development based methodology

Active and ongoing participation of the stakeholders and Subject Matter Experts

(SMEs) throughout the design and development phases

Working prototype based development approach (AGILE Development)

Clear integration and maintenance expectations expressed in RFP for vendors to

understand and comply with

Service Oriented Architecture (SOA) that is consistent with MITA

Services managed on an Enterprise Service Bus (ESB)

Rules engine that follow the 1561 Standards and is a loosely coupled service that can

support re-use

System architecture based on open standards

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Reusable services and system components

Flexible architecture that can easily incorporate change and new features

Highly available and highly scalable architecture

Robust disaster recovery

High Level Architecture

NMHIX solution is based on a service-oriented architecture (SOA) that defines common

business and technical services that are loosely coupled and can be modified relatively easily

to accommodate changing business and regulatory needs. This architecture is consistent with

CMS guidelines that define the key business processes, functional groupings and underlying

services. The GetInsured exchange architecture is developed as a modular system consisting

of open source components and libraries wherever appropriate. Business rules and process

workflows are built as separate components that support and enable the core engine of the

exchange to be extended and configured with ease. GetInsured’s SOA-based architecture is

scalable and provides a degree of customization without the need to make costly and complex

changes.

• Reusable services and system components • Flexible architecture that can easily incorporate change and new

GetInsured exchange architecture is consistent with the CMS Technical Reference Architecture

(TRA), the Medicaid Information Technology Architecture (MITA) and the Exchange Reference

Architecture. Business process and technical services are exposed using standard, defined

interfaces. These services interoperate based on a formal definition that is independent of the

underlying platform and programming language. The interface definition hides the

implementation of the language-specific service. Key to these services is their loosely coupled

nature i.e., the service interface is independent of the implementation.

Page 38 of 121

Web service interoperability protocols provide seamless and automatic connections from one

software application to another (Financial Management, Plan Management, Plan Selection,

etc.).

Web Service Definition Language (WSDL), Universal Description, Discovery and Integration

(UDDI) and Simple Object Access Protocol (SOAP) are the fundamental pieces of the SOA

infrastructure. WSDL is used to describe the service; UDDI, to register and look up the services;

and SOAP, as a transport layer to send messages between service consumer and service

provider.

SOAP, WSDL, and UDDI protocols define a self-describing way to discover and call a method in

a software applicationregardless of location or platform. Data is converted into XML request

and response documents and moved between software modules using HTTP or message based

protocols.

Business services are maintained in the exchange by a registry that acts as a directory listing.

Applications can look up the services in the registry, get the WSDL for the service that has the

description, and invoke the service using SOAP. Universal Description, Definition, and

Integration (UDDI) are the standard used for service registry. Business Services are published

to a public or private UDDI web services registry. The web services registry is used by exchange

software modules to discover and interact with each other.

Application Architecture

The goal of this project is to produce a user-friendly, web-based system which supports

principles of the Medicaid Information Technology Architecture (MITA) and open standards

wherever possible. The use of an enterprise architecture shall allow the separate, standalone

systems to communicate using exposed, shared services through a common architecture. SOA,

coupled with open standards-based-software components, will have a prominent role in the

implementation of the enterprise architecture required by the NMHIX. The NMHIX SOA will be

used to facilitate functional re-use and data sharing among loosely coupled services and

business objects. Services will be loosely coupled to reduce system dependencies and self-

contained pieces of business functionality deployed as discrete pieces of code and/or data

structures that can be reused.

The NMHIX, GetInsured, solution foundation is Service-Oriented Architecture (SOA) with a

design pattern that is based on loosely-coupled software components providing application

functionality as services to other software components. These software components can be

upgraded on a regular basis to avoid obsolescence without affecting the rest of the system.

The GetInsured solution uses modern web technologies such as Representational State

Transfer (REST), predominate web API design tool, and Web Services. Additionally the software

solution is based on the latest software design frameworks. The components and libraries

comprising these frameworks are kept current with the latest features.

Page 39 of 121

Security and Privacy Architecture Security services will provide the safeguards to protect the Exchange from threats

Security and Privacy Architecture

Security services will provide the safeguards to protect the Exchange from threats that could

lead to the loss of confidentiality of data, the loss of data integrity, the unavailability of data

or services and/or any unauthorized use of Exchange resources.

Accounting of Disclosures Report

The following diagram depicts how accounting of disclosure reports can be tracked and

provided to an individual.

Page 40 of 121

Figure 30: Accounting of Disclosures Report

View / Access Exchange Operations MS Exchange Reporting Information (PHI) Protected Health Data Store Engine ess

View / Access

Exchange Operations

MS Exchange Reporting Information (PHI) Protected Health Data Store Engine
MS Exchange
Reporting
Information (PHI)
Protected Health
Data Store
Engine
MS Exchange Reporting Information (PHI) Protected Health Data Store Engine ess Accounting of Disclosures Report

ess

Accounting of

Disclosures

Report

View / Access
View / Access
View / Acc
View / Acc

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule

requires “covered entities and business associates to account for disclosures of

protected health information to carry out treatment, payment, and health care

operations if such disclosures are through an electronic health record. Pursuant to

both the HITECH Act and its more general authority under HIPAA, the Department

proposes to expand the accounting provision to provide individuals with the right to

receive an access report indicating who has accessed electronic protected health

information in a designated record set.”

Whenever NMHIX administrative staff view or access PHI (Personal Health

Information), the action is captured by and stored as part of the audit logging

functionality. The data is stored and reports are provided when requested by

individuals, in accordance with the requirement.

PHI/PII in Transit

The following diagram depicts how GetInsured secures all health information (PHI or

PPI Personal Identifiable Information) in transit, rendering it unusable, unreadable,

or indecipherable to unauthorized individuals. This is done in accordance with the

Page 41 of 121

technology and methodology specified by the Secretary of the Federal Department

of Health and Human Services in the guidance issued under section 13402(h)(2) of

the American Recovery and Reinvestment Act of 2009 (P.L. 111-5), or any update to

that guidance.

Figure 31: PHI / PII in Transit

Data
Data
Data Information (PHI) Protected Health Transmissions Web Services SSL Encryption Information (PHI) Protected Health MS Exchange
Information (PHI) Protected Health Transmissions Web Services SSL Encryption Information (PHI) Protected Health MS Exchange SFTP**
Information (PHI) Protected Health Transmissions Web Services SSL Encryption Information (PHI) Protected Health MS Exchange SFTP**
Information (PHI) Protected Health
Information (PHI)
Protected Health

Transmissions

Web Services

SSL Encryption

Information (PHI)

Protected Health

MS Exchange

Information (PHI) Protected Health Transmissions Web Services SSL Encryption Information (PHI) Protected Health MS Exchange SFTP**
Information (PHI) Protected Health Transmissions Web Services SSL Encryption Information (PHI) Protected Health MS Exchange SFTP**
Information (PHI) Protected Health Transmissions Web Services SSL Encryption Information (PHI) Protected Health MS Exchange SFTP**
SFTP**
SFTP**
Data Information (PHI) Protected Health Transmissions Web Services SSL Encryption Information (PHI) Protected Health MS Exchange

** Secure File Transfer Protocol

(SFTP) or other secure transmission

method for data transfers.

Encryption Method

Data Field

Data Information (PHI) Protected Health Transmissions Web Services SSL Encryption Information (PHI) Protected Health MS Exchange
Data Storage Encryption Information (PHI) Protected Health
Data Storage
Encryption
Information (PHI)
Protected Health
  • GetInsured’s solution will provide the ability for web service providers and service consumers to interact, and will implement security for transport and messaging via web services.

o

The Solution will utilize SSL as an encryption method to help ensure

data confidentiality prior to data transmission via web services.

  • Within the solution, PHI will not be transmitted via email.

Physical Security

GetInsured’s solution will maintain strict physical access controls to safeguard all

areas where sensitive data could be accessed. This includes, but is not limited to the

following physical safeguards:

  • All doors to the hosted data center facility will be locked and monitored via a card-based Access Entry System (AES).

Page 42 of 121

o

Access to sensitive areas within the office space (i.e., the server

room) will be gained using role-based security with the AES.

o

The AES will have independent battery backup sufficient to keep

the office secure in the event of power failure until such time as

normal power is resumed or the backup generator cycles on.

  • All doors and common areas (i.e., break room, conference rooms, the call-center floor, etc.) will be monitored via IP security cameras.

o

The security camera system will record 100% of activity 24x7 and

retain 2 weeks of recordings on disk.

  • All exterior doors will be connected to an alarm system.

o

This alarm system will be remotely managed and will allow for

one-touch emergency calling to the Police, Fire, and Ambulance.

  • The call center will have a small server room located such that all walls are interior to the office space and extend through the plenum for fire- safety reasons.

  • The server room will contain all security-related management equipment, and access will be granted solely to IT services and upper management staff.

Monitoring (including Intrusion Detection)

Intrusion detection will monitor access to the Exchange resources maintain logs and

issue alerts related to unauthorized access. Unauthorized access also includes the

prevention and monitoring for malware and/or malicious software within the

confines of Exchange computer systems. This live protection of the Exchange servers

shall be centrally managed and provide for at least:

  • Audit data regarding threats and attacks including false positives;

  • Continual updates to the protection/detection mechanisms and algorithms to ensure proper detection and response;

  • Procedures and methods to isolate and neutralize an active threat in order to protect Exchange resources.

The Alert Logic Threat Management™ system monitors the GetInsured solution

as hosted in the Rackspace Environment. The system is used to detect external

and internal threats. When it detects an incident, Alert

Logic's ActiveWatch service provides expert guidance from its Security

Operations Center (SOC), staffed round the clock by Alert Logic security analysts.

Integrated vulnerability scanning helps identify possible points of entry and

correct them, and assists with meeting regulatory compliance requirements.

Page 43 of 121

The figure below visually depicts the Alert Logic’s threat management system.

Figure 25: Alert Logic Threat Management System

The figure below visually depicts the Alert Logic’s threat management system. Figure 25: Alert Logic Threat

The Alert Logic Log Manager™ automatically aggregates, normalizes, and stores log data

from GetInsured’s environment. It also features log searches, forensic analysis, and

report creation through real-time or scheduled analysis.

LogReview, a service enhancement to Log Manager, provides daily event log monitoring

and review by a team of Alert Logic security professionals.

Figure 32: Alert Logic Log Manager

The figure below visually depicts the Alert Logic’s threat management system. Figure 25: Alert Logic Threat

The Alert Logic suite provides a rich set of tools for analysis and system log monitoring.

Page 44 of 121

Contracting, Outsourcing, and Agreements

NMHIX has contracted with GetInsured and PCG for ongoing development of the Exchange. In

2014, NMHIX contracted with Software Engineering Systems (SES) for the independent

verification and validation (IV&V) efforts. NMHIX has contracted with Xerox for the Call Center

and with NMPCA and NAPPR for enrollment functions. Additional local partners and

consultants are being utilized for implementation of the outreach and education plan.

  • 3. State’s Strategy to Address Early Benchmarks in Section I.4

Please see the New Mexico Blueprint document for information on early benchmarks.

  • 4. Proposed Solution for Exchange IT Systems

The NMHIX SHOP Exchange is fully functional. The individual exchange functions will be

implemented in 2015. The NMHIX will have the following functionalities:

  • a. Individual Eligibility & Enrollment

  • b. Individual Responsibility Exemption

  • c. Small Business Health Options Plan (SHOP) Eligibility & Enrollment

  • d. Verify Eligibility for Individual Federal Subsidy of Insurance Premium

  • e. Data Exchanges/Interfaces

  • f. Carrier and Plan Certification and Recertification

  • g. Monitor Carrier and Plan Certification Compliance

  • h. Establish Issuer and Plan Renewal and Recertification

  • i. Review Rate Increase Justifications

  • j. Display Carrier Ratings by Price and Quality

  • k. Maintain Operational Data

  • l. Process Change in Plan Enrollment Availability

  • m. Advanced Payments in Premium Tax Credit and Cost Sharing Reduction

  • n. Premium Processing/Payment Aggregation

  • o. Data Collection

  • p. Risk Adjustment and reinsurance (to be provided through federal services)

  • q. Issuer Payment Transfers

  • r. Call Center Module

  • s. Navigator Module

  • t. Broker Module

  • u. Client Correspondences

  • v. Management of Exchange Operations

  • w. Federal and Management Reporting

  • x. Interface with Federal Data Hub

  • y. Interface with Medicaid (Aspen)

  • z. Interface with NAIC SERFF

Page 45 of 121

An intuitive web portal (including mobile device access) through which New Mexico residents

can access subsidized and unsubsidized health insurance including: Individual enrollment and

plan selection and SHOP portal supporting plan selection and enrollment for small employers

and their employees in qualified SHOP health plans.

Back office functions include:

Interface with the integrated eligibility and verification engine

Use system components to provide for monthly “window” for American

Indians/Alaska Natives (AI/AN) to enroll in Plans

Determine tax credit and subsidy credits for enrollees

Use system components to facilitate enrollments into qualified health plans

Use system components to certify and manage insurance issuer, health plan and

provider data

Provide financial management components (such as: billing, receivables, general and

subsidiary ledgers, premium aggregation, reporting, reconciliation, reduced cost-

sharing for AI/AN individuals enrolling in QHP)

Allocate cost for system utilization between NMHIX and Medicaid

Have reporting and business analytics capability

Provide identity and account management

Have document/content management

Provide notification services

New Mexico is developing an Integrated Eligibly and Verification System based on principles

laid out in Guidance for Exchange and Medicaid Information Technology (IT) Systems version

2.0. New Mexico has developed a single streamlined application (based on CMS SSAp

guidelines) and a Single Rules Engine that can be used by consumers who apply for either QHP

on the individual marketplace and for insurance affordability programs.

Upon entry into New Mexico’s integrated shared portal, enrollees will be asked if they wish to

complete an insurance affordability assessment (anonymous shopping). If an enrollee decides

they do not want to pursue financial application path, he or she will be asked to provide

information on a shorter version of single streamlined application and guided thru process to

enrollee in QHP. New Mexico will send a web services query a Shared Data Services HUB for

verification of enrollee’s information as required in 45 CFR part 155.

For enrollees who wish to pursue financial application path, NMHIX will seamlessly transition

to insurance affordability single streamlined application that will collect the required data from

enrollees and family members. New Mexico will send a web services query a Shared Data

Services HUB for verification of enrollee’s information as required in 45 CFR part 155.

The business and functional requirements for processing and screening applications,

determining eligibility, renewing eligibility, and handling appeals includes the following core

processes:

Prepare Initial Individual Application

Page 46 of 121

Verify Individual Citizenship, Status as a National or Lawful Presence

Determine Individual Exchange

Verify Individual Incarceration Status

Renew Individual Eligibility and

Appeal Individual Eligibility

Verify whether an Individual is a Native American (NA/IA)

Verify Individual Residency in Exchange Service

Verify Eligibility for Other Public Minimum Essential Coverage

Verify Income

Qualify Individual for Enrollment Period

Communicate Eligibility Determination and Coordinate Enrollment

Determine Individual Exemption Eligibility

Renew Individual Exemption Eligibility

Change Reporting

Access to Referral

The New Mexico’s Individual Enrollment processes will coordinate seamlessly with its

Individual Eligibility processes. For QHP selections, the NMHIX system will be responsible for

creating enrollment transactions and providing them directly to insurance issuers or allowing

the individual to complete enrollment directly through the insurance issuers’ websites. The

IT System will track all health plan enrollments for individuals who have applied for coverage

through the Marketplace. It will also be responsible for reporting enrollment, as required by

CMS, to the Federal Data Services Hub.

The NMHIX Plan Management function consists of the following core elements:

Establish Issuer and Plan Initial Certification and Agreement

Monitor Issuer and Plan Certification

Establish Issuer and Plan Renewal and Recertification

Maintain Operational Data

Process Change in Plan Enrollment

Review Rate Increase Justifications

NMHIX intends to leverage the SERFF system from the NAIC for the following functions:

Marketing Standards

Accreditation and Quality

Notice of Intent

Reporting Requirements

QHP and state mandate standards

Submission at Plan Level

Indication of Metal Level

Verification of Metal Level

Quality measures

Benefit Package

Page 47 of 121

Cost Sharing and Limits

Rating Tables

Final Determination

Issuer and QHP Status

Renewal and Certification

Decertification of Issuer

Decertification of Plan

SHOP Plan Changes

Individual Plan Changes

Once New Mexico is live with core marketplace functionality in 2015 New Mexico will continue

to add capabilities to support our goal to increase enrollment and enhance self-sustainability.

General theme for types of enhancement work that will be undertaken in 2016 and 2017

include:

Catalyze enrollment through active and increasing participation of brokers;

Broaden distribution opportunities maximally through a range of enrollment options;

Enhance ease of use by users, particularly for New Mexico specific user communities.

New Mexico is looking to implement following enhancements:

Centralized Provider Directory

Prescription Search

Provider Network Stats - Narrow Networks

Provider Maps

Ability to purchase adult dental without QHP

Personalized Plan Scores

Anonymous Shopping for Employers

Automated Reminders

Direct Enrollment Module (EVaaS)

Operational User Alerts -- Part I for Brokers and CSRs (Customer Life-cycle

Management)

Operational User Alerts -- Part II for NMHIX administration

Batch Enrollment Engine from SHOP to Individual Exchange

Consumer Assistance Toolset: PDF proposal creators, notifications to designated CC

of any change to consumer record, scenario analysis for each family.

Advanced Layered, In-context Help

Native mobile apps for iOs and Android for Employees (iPhone, iPad)

Capability to make differing enrollment choices per family member

Scenario and Prospect Management Workbench for Brokers

PDF Proposal Creator, Rapid employer engagement tool

Brokers and CSRs: Advanced Reporting & Analytics (optional feature with Scenario and

Prospect Management Workbench)

Broker Agency Module

Advanced Enrollment Counselor Search

Page 48 of 121

Enrollment Entity Setup Process Enhancements

Enrollment Counselor certification and learning management integration

Enrollment Counselor self-ticket creation and management

Operational User Alerts -- Part III for Brokers (Customer Life-cycle Management)

Enrollment Counselor recertification or renewal automation

Agent License monitoring and action system

Advanced access to Enrollment Counselor functions to the Enrollment Entity

Agent employer relationship lifecycle - multiple notifications

Page 49 of 121

Figure: Timeline to implement enhancements to New Mexico’s IT System

NMHIX Timelines Roadmap to Launch Centralized Provider Directory Technology Capability Ability to purchase adult dental without
NMHIX Timelines
Roadmap to Launch
Centralized Provider Directory Technology Capability
Ability to purchase adult dental without QHP
Addition of GPS Tile-view
Prescription Search
Provider Network Stats - Narrow Networks
Provider Maps
Automated Reminders
Personalized Plan Scores
Anonymous Shopping for Employers Phase 1
Notfication for employer that the agent has declined the broker
designation
CAP Enhancements and Policy Search
Direct Enrollment Module (EVaaS)
Agency Module - Individual
Operational User Alerts -- Part 1 for Brokers and CSRs
Layered, In-context Help
Consumer Assistance Toolset
Scenario & Prospect Management Workbench for Brokers
PDF Proposal Creator, Rapid employer engagemnet tool
Notfication for employer that the agent has declined the broker
designation
Batch Enrollment Engine from SHOP to Individual Exchange
Operational User Alerts -- Part II for NMHIX administration
Ancillary product infrastructure
Native mobile apps for iOs and Android for Employees (iPhone, iPad)
Ancillary Products -- Life, Vision, Critical Illness
Anonymous Shopping for Employers Phase 2: Infrastructure; new
workflows; data transfer
Brokers and CSRs: Advanced Reporting & Analytics
Capability to make differing enrollment choices per family member
Off-Exchange Plans
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Apr-16
May-16
Jun-16
Jul-16
Aug-16
Sep-16
Oct-16
Nov-16
Dec-16
Jan-17
Feb-17
Mar-17
Apr-17
May-17
Jun-17
Jul-17
Aug-17
Sep-17
Oct-17
Nov-17
Dec-17

Page 50 of 121

5.

IT Seven Standards and Conditions

Please see the New Mexico Blueprint document for information on Exchange IT systems.

  • 6. Organizational Structure

The NMHIX organizational chart is shown on page 16. NMHIX has implemented an MOU with

HSD and an MOU with OSI to delineate the roles and responsibilities.

  • 7. Coordination with the Federal Government on Exchange Activities

New Mexico will coordinate with the federal government

implementation activities.

on all its development and

  • 8. Strategies for Reuse, Sharing, Collaboration for NMHIX Activities with the Federal Exchange

and Other States

As outlined in agreements with HHS, all Exchange systems and system components financed

with federal funds are non-proprietary, utilize open architecture standards, and permit re-use

by other states and jurisdictions. New Mexico will inform and assist other states through

various means, including HHS Learning Collaborative and User Groups. Beyond reuse and

sharing of IT, New Mexico is committed to leverage existing infrastructure and re-purpose

business functions and processes to maximize resources and is working with other states to

determine how aspects of their systems can be replicated in New Mexico. Specifically,

Marketplace IT solution is being used by Idaho and Mississippi State Based Marketplace. New

Mexico has collaborated with these SBMs and is in process of forming a formal users group.

As we look at self-sustainability, New Mexico will continue to collaborate with Idaho and

Mississippi SBMs to continue to enhance Marketplace IT solution on a join cost basis via its

Marketplace technology vendor GetInsured.

  • 9. Strategies to Ensure Financial Integrity Mechanisms to Prevent Fraud, Waste, and Abuse and

Provide Oversight of Cooperative Agreement Funds and the Exchange

New Mexico has administrative policies and statutory and regulatory provisions to ensure

appropriate financial management of grant funds. Grant funds are administered following

comprehensive written procedures and procedures approved by the NMHIX Finance

Committee. This includes internal controls and oversight to make sure the system disburses,

tracks, and accounts for grant disbursements. New Mexico will ensure NMHIX program

operations and management integrity, and that federal cooperative agreement dollars are

expended as budgeted in its cooperative agreements and contracts.

Page 51 of 121

10. Challenges That May Affect Progress in Work Plan

New Mexico is monitoring key indicators on a daily basis through its PMO. Weekly project

meetings are conducted to review progress towards meeting identified milestones. Issues are

Risk are escalated as appropriate to New Mexico Leadership.

11. SHOP

Market Challenges—Over 85 percent of New Mexico’s small businesses have fewer than 50

employees and many have never purchased health insurance.

Strategic SHOP Plan--NMHIX has successfully implemented its SHOP program. Three major

insurers in New Mexico have been certified as SHOP QHPs.

Page 52 of 121

F. Work Plan

NMHIX has retained the services of GetInsured (GI) to implement both the SHOP marketplace

and the Individual marketplace. NMHIX produced a set of functional requirements for the

SHOP and Individual marketplace systems that were incorporated into the Request for

Proposals (RFP) to which GI responded. NMHIX has retained the services of Public Consulting

Group (PCG) to assist with various aspects of implementing the SHOP and Individual

marketplaces, including a Project Management Office (PMO). In addition NMHIX has

contracted with Software Engineering Services (SES) as an Independent Verification and

Validation to oversee the design, development, and implementation of the marketplace

functions.

Among the functions of the PMO and IV&V are to work with GI to ensure that:

o

Standard industry Systems Development Life Cycle (SDLC) protocols are followed,

including iterative and incremental development methodologies.

o

Requirement specifications, analysis, design, code, and testing are developed and

carried out in accordance with CMS/CCIIO requirements and generally accepted

professional practice.

o

The design takes advantage of a Web Services Architecture and Service Oriented

Architecture approach for design and development.

o

The services description/definition, services interfaces, policies and business rules

are published as required and the solution provides role-based access to underlying

data.

o

The solution adheres to standards published by the Office of the National

Coordinator (ONC) and the National Institute of Standards and Technology (NIST).

o The GI system is interoperable and integrated with State Medicaid/ Children’s

Health Insurance Program (CHIP) programs and is able to interface with HHS and

other data sources in order to verify and acquire data as needed.

o

The GI system achieves any required interoperability with other health and human

services programs for purposes of coordinating eligibility determinations, referrals,

verification or other functions.

Page 53 of 121

NMHIX 2014-2015 Individual Re-Baselined Milestone Plan v1.0

 

Start

Task Name

Tue 2/11/14

Fri 10/3/14

Phase II Individual and SHOP Enhancements

Mon 6/24/13

Fri 1/15/16

On Going PMO Services

Mon 6/24/13

Fri 1/15/16

OSI QHP Review dates

Sat 3/1/14

Sun 8/31/14

CMS/CCIIO/IRS - Reviews

Tue 2/11/14

Wed 8/19/15

Planning Review Meeting

Tue 4/1/14

Wed 8/19/15

Design Review Meeting

Wed 4/9/14

Thu 4/10/14

Final Design Review Meeting

Tue 6/10/14

Wed 6/11/14

Operation Readiness Review

Mon 8/3/15

Tue 8/4/15

Internal Readiness Review

Mon 8/10/15

Wed 8/12/15

Mail Room Operations

Mon 8/24/15

Thu 9/3/15

NMHIX Requested Production Based Testing

Fri 9/4/15

Thu 9/3/15

Business Area Development

Mon 2/3/14

Thu 10/15/15

Identify NMHIX owner for each Functional area

Tue 4/1/14

Fri 5/2/14

Review and signoff of JAD documents

Thu 3/27/14

Fri 11/14/14

IRS Visit

Tue 4/1/14

Mon 1/12/15

  • 2.0 Consumer and Stakeholder Engagement and Support

Fri 1/23/15

Wed 3/12/14

Thu 10/15/15

  • 3.0 Eligibility and Enrollment

Tue 2/4/14

Thu 10/1/15

  • 8.0 Finance

Tue 4/1/14

Fri 11/28/14

  • 10.0 Privacy & Security

Wed 8/26/15

  • 11.0 Oversight, Monitoring, & Reporting

Mon 2/3/14

Mon 4/20/15

  • 12.0 Policies and Procedures Documentation

Fri 7/25/14

Wed 1/28/15

Phase II - Technical

Mon 12/16/13

Fri 1/1/16

Requirements and Design Validation

Tue 1/14/14

Thu 2/19/15

External Dependencies

Tue 1/28/14

Thu 2/12/15

Interfaces/Integration Planning

Mon 2/17/14

Wed 5/6/15

Infrastructure

Mon 1/27/14

Fri 8/14/15

Interfaces - Connectivity

Wed 1/29/14

Thu 10/1/15

CP3 Demo for CMS

Fri 7/11/14

Fri 7/11/14

OIG Audit

Check point 2 (Account Creation, SSA data verification rule engine and HUB interface)

Mon 8/17/15

Tue 2/11/14

Mon 5/26/14

Release 0 & 1 (Plan Mgt, Agents, Entities/Assisters) and Release 1 (Pre-screener, Anon.Shop. & Acc. Creation)

Mon 12/23/13

Wed 11/19/14

NMHIX SHOP

Mon 9/1/14

Fri 1/1/16

Release 2 (Public Launch - Open Enrollment)

Mon 12/16/13

Mon 11/2/15

  • 2014 Cycle

Mon 12/16/13

Deploy Release 2 to production environment at the same time as R0 & R1 (Option 1 - based on an October OE)

Mon 2/3/14

Fri 6/13/14

Check point 3 (Plan Selection, Financial Management, Eligibility)

Mon 2/3/14

Fri 7/11/14

Check point 4 (Carrier Interfaces, Individual Portal)

Mon 4/7/14

Wed 11/26/14

Check point 5 (Admin Portal, Reporting)

Mon 12/16/13

Wed 9/10/14

COTS Deferred Items 2.1 & 2.2

Mon 6/30/14

Thu 5/8/14

Fri 9/25/15

2015 Enhancements [Place Holder]

Mon 3/9/15

Fri 3/13/15

INITIAL MEC interface QA (MMIS/Xerox)

Thu 5/8/14

Fri 11/7/14

SIT Verification interface formal test (FDSH) - CMS Hub Testing

Wed 5/14/14

Tue 7/15/14

Product Assessment

Mon 10/20/14

Thu 2/12/15

  • 2015 Cycle

Sun 10/12/14

Mon 11/2/15

Review Content (SSAp Only)

Mon 9/29/14

Fri 3/6/15

External Dependency: CMS Verification Flow Changes (Assessing risk to CMS new changes and possible rework)

Mon 2/9/15

Fri 8/14/15

Validate Sprint Schedule

Tue 12/30/14

Tue 12/30/14

New Mexico Specific Components

Mon 10/6/14

Fri 9/4/15

Fri 10/2/15

Tue 1/13/15

Fri 3/13/15

Develop Training plan

Mon 4/6/15

Fri 5/1/15

Develop System Integration testing (SIT) Test Cases

Thu 5/8/14

Mon 11/2/15

Performance and Stress Test

Mon 8/3/15

Develop Test Plan (UAT / SIT)

UAT prep - R2, Deferred, CR items

Mon 2/2/15

Finish

UAT - R2, Deferred, CR items

Sat 12/27/14

Fri 6/12/15

Stakeholder Assessment (GI will maintain a testing server enviornment)

Mon 5/11/15

Fri 6/26/15

Training [ R0, R1 and R2 training]

Mon 6/1/15

Wed 8/5/15

FFM Renewals & Data Migration [Place Holder]

Mon 8/24/15

Mon 10/19/15

Fri 1/15/16

Wed 7/1/15

Deploy Release 2 to pre-production environment [Place Holder]

Wed 3/25/15

Wed 4/1/15

Client Review before public launch

Mon 8/10/15

Fri 8/14/15

DELIVERABLE: Provide Final Release 0 and 1 Notes to client

Mon 8/17/15

Fri 8/21/15

Client approval to deploy R0 & R1 to production

Project Closure

Tue 8/25/15

Deploy Releases 0 and 1 to production

Wed 8/26/15

Thu 10/1/15

Release 0 and Release 1 - public launch

Fri 9/4/15

Fri 9/4/15

DELIVERABLE: Provide Final Release 2 Notes to client

Mon 8/31/15

Mon 8/31/15

Stabilization Period / Launch

Mon 9/14/15

Fri 9/25/15

Mon 10/19/15

Mon 1/5/15

Mon 2/2/15

External Dependency: Additional HSD data needs [place holder]

Plan validation by carriers [MOVE to 2015]

Mon 7/6/15

Wed 9/2/15

Release 2 - PUBLIC LAUNCH

Fri 10/2/15

Fri 10/2/15

Release 2 Transition to production

Mon 10/5/15

Fri 10/16/15

Operational Normalization

Fri 4/4/14

Fri 12/11/15

Release XX - to be determined

Fri 8/28/15

Fri 1/8/16

Deferred 2.3 - 2015 Renewals [Place holder]

Wed 7/1/15

Tue 10/13/15

Deferred 2.3 - CMS / IRS reports (H36 – monthly / H41 – yearly)

Mon 11/2/15

Fri 1/8/16

Deferred 2.3 - Test CMS / IRS reports (H36 – monthly / H41 – yearly)

Mon 11/2/15

Fri 1/8/16

Page 54 of 121

Timeline to implement enhancements to New Mexico’s IT System

NMHIX Timelines Roadmap to Launch Centralized Provider Directory Technology Capability Ability to purchase adult dental without
NMHIX Timelines
Roadmap to Launch
Centralized Provider Directory Technology Capability
Ability to purchase adult dental without QHP
Addition of GPS Tile-view
Prescription Search
Provider Network Stats - Narrow Networks
Provider Maps
Automated Reminders
Personalized Plan Scores
Anonymous Shopping for Employers Phase 1
Notfication for employer that the agent has declined the broker
designation
CAP Enhancements and Policy Search
Direct Enrollment Module (EVaaS)
Agency Module - Individual
Operational User Alerts -- Part 1 for Brokers and CSRs
Layered, In-context Help
Consumer Assistance Toolset
Scenario & Prospect Management Workbench for Brokers
PDF Proposal Creator, Rapid employer engagemnet tool
Notfication for employer that the agent has declined the broker
designation
Batch Enrollment Engine from SHOP to Individual Exchange
Operational User Alerts -- Part II for NMHIX administration
Ancillary product infrastructure
Native mobile apps for iOs and Android for Employees (iPhone, iPad)
Ancillary Products -- Life, Vision, Critical Illness
Anonymous Shopping for Employers Phase 2: Infrastructure; new
workflows; data transfer
Brokers and CSRs: Advanced Reporting & Analytics
Capability to make differing enrollment choices per family member
Off-Exchange Plans
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Apr-16
May-16
Jun-16
Jul-16
Aug-16
Sep-16
Oct-16
Nov-16
Dec-16
Jan-17
Feb-17
Mar-17
Apr-17
May-17
Jun-17
Jul-17
Aug-17
Sep-17
Oct-17
Nov-17
Dec-17

Page 55 of 121

G. BUDGET AND BUDGET NARRATIVE

$

97,975,535

Total Direct Costs

j

-

$

f

Travel

-

$

g

Construction

-

$

-

e

$

-

  • d Equipment

$

-

  • c Total Personnel Costs

$

-

Supplies

b

$

Fringe Benefits

Salaries

a

h

$

97,975,535

  • i Contractual

$

-

Other

New Mexico requests $97.9 million in federal funding for a Level Two Establishment grant for

the period January 1, 2015 through December 31, 2017.

New Mexico received $34.3 million for an initial Level One grant in November 2011. This grant

is in the process of being closed.

New Mexico also received $18.6 million as an additional (2 nd ) Level One grant in July 2013.

This grant is still open and has a balance of $4.0 million remaining. A No Cost Extension was

requested in September 2014, which increased the duration to 10/14/2015.

New Mexico received $69.4 million for the 3 rd Level One grant, awarded January 22, 2014. A

No Cost Extension is being requested to December 31, 2015. Approximately 80% of this grant

is encumbered by contracts.

Budget detail is provided for each expenditure