Successfully Implementing a Federally-Facilitated Exchange

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Introduction
The Affordable Care Act (ACA) directs the Secretary of the Department of Health and
Human Services (HHS) to establish and operate a Federally Facilitated Exchange (FFE) in
any state that does not elect to establish a State-Based Exchange (SBE). As the dead-
line for state submission of a state blueprint and declaration letter approaches, many
states are faced with implementing an FFE by the statutorily required enrollment date of
October 1, 2013.
While an FFE allows states to meet federal timeline mandates, its implementation pro-
vides states with limited options and flexibility. States are challenged to determine what
activities they must undergo to implement an FFE successfully.
State Actions
While there are still many unknowns, there
are a number of steps that states can take
now to better prepare for the FFE. The
Centers for Medicare and Medicaid Ser-
vices (CMS) has repeatedly stated it is
preparing for “Day One” FFE implementa-
tion, meaning that CMS is working toward
critical FFE functionality to be ready by the deadlines. States need to begin prepara-
tions now. The following are some of the activities to consider.
• Create a strategic vision for implementing an FFE: As the first step in the “on ramp,”
states should create a shared, high-level common vision and strategy. States must
understand key dates, deliverables, and activities in their FFE implementation
project schedule. Additionally, states need to understand what resources, including
technical capabilities, are required and where additional staffing and capabilities
are to be obtained.
• Understand the state’s technical environment: Many states have previously com-
pleted IT gap analysis studies as part of the Planning Grant efforts. States implement-
ing an FFE will now need to understand the specific requirements and the necessary
changes to their Medicaid and Children’s Health Insurance Program (CHIP) eligibility
systems that will be required to perform the account transfer function with the FFE.
Each state faces unique challenges with this task. States now need to include activi-
ties related to interfacing with the FFE, processing, and managing of account trans-
fers. These activities may need to be carefully integrated into a state’s eligibility
modernization project.
• Identify state capabilities and resources that can be leveraged: With several key in-
itiatives already in progress, states face resourcing challenges. It is critical for states
to secure partners that can provide the subject-matter expertise, experience, and
capability to help them prepare for implementing an FFE.
• Develop the technical capability needed to interface with the Exchange: Currently,
CMS has identified seven potential interfaces with the state Medicaid/CHIP envi-
ronment. These interfaces will be used to establish the account transfer with Medica-
id/CHIP, then to process notifications, renewals, life-change events, and determina-
tions of eligibility (or ineligibility). States must be prepared to not only implement the


necessary interfaces, but to be able to process case data, update Medicaid/CHIP
case information, receive and link self-attestation documentation from the FFE to in-
dividual Medicaid/CHIP eligibility cases, and potentially be able to track and report
the status of cases for interaction with customer assistance or in response to Federal
reporting requirements.
• Assess Medicaid Expansion impacts: In the wake of the Supreme Court decision in
June 2012, many states are reassessing their Medicaid expansion options and costs.
Federal guidance regarding the ability of an FFE to support state expansion options
has not yet been issued. States need to understand the gaps in FFE flexibility and
capability then accordingly adjust their options or develop internal capabilities to
support these options as guidance becomes available.
• Review plan management, plan certification, and qualification processes and ac-
tivities: The guidance issued in May 2012 stipulates that the FFE’s role and authority
does not extend beyond the Exchange or otherwise affect state laws pertaining to
which health insurance products maybe sold in the individual or small group mar-
kets. States must understand what products are being offered through the FFE and
what flexibility they are given to limit or prevent products that are not certified in
their state from being offered on the FFE. States are still expected to play their tradi-
tional and primary role in the regulation of the market and the products that are be-
ing offered. However, how these processes are to merge with the FFE are still to be
defined and confirmed with each state.
• Review consumer assistance capabilities: The FFE will provide the call center capa-
bilities. The FFE will also provide outreach, education, and limited broker/navigator
assistance for helping individuals enroll on the FFE. States have the option to provide
in-person assistance. This is an area where requirements are still evolving. States
should understand the hand-offs and touch-points between in-person assistance
delivered in walk-in eligibility offices and the FFE.
Develop an On-ramp Strategy
In implementing an FFE, states should be-
gin with the end in mind. HHS has indi-
cated that an FFE is a temporary solution
for states and that states still have to pre-
pare for operating a SBE or State Partner-
ship Exchange (SPE) after 2014. States must
now begin considerations of whether the
SPE or SBE is the right solution for future
years. Each state must understand its op-
tions, opportunities, timelines, and create a
roadmap to implement an FFE — and eventually transition from an FFE to a sustainable,
state-controlled and operated Exchange.
Time is diminishing quickly for states to develop the necessary interfaces and processes
to interact with an FFE. Since deadlines are fixed, CMS will likely decide the schedule,
milestones, deliverables, and test conditions for states. This places the responsibility
clearly on states to analyze and develop process flows, make the necessary software



and operational changes, and to perform testing and certification activities for state
systems that interact with the FFE.
States implementing an FFE need to begin preparations immediately or face the diffi-
cult task of implementing numerous system changes in a limited timeframe. States must
be ready for open enrollment by October 1, 2013 — less than one year. The May 2012
General Guidance on Federally-facilitated Exchanges, published by HHS, reveals many
specific activities to coordinate with states. However, much of the detail has not been
specified. The guidance discusses at a high level the project schedule, state develop-
ment specifications, and testing and certification be process for interfacing state Medi-
caid/CHIP systems with an FFE. It should be noted that the process has not been fully
communicated by HHS, meaning that this key area for state involvement is still evolving.
The majority of system changes need to occur in the Medicaid/CHIP eligibility systems.
CMS has acknowledged that this is the primary interface between an FFE and the state
and where the individual account transfer process will occur. States are responsible for
developing not only the interfaces to an FFE, but also developing the capabilities within
their eligibility system to process transactions and exchange case level information with
an FFE, preferably in a real-time environment.
As an additional challenge, many states are in the process of modernizing their eligibili-
ty systems. Interfacing with an FFE may not be part of the scope for these eligibility
modernization projects and will need to be managed in addition to the current eligibili-
ty system implementation effort. States should consider modifying their advanced plan-
ning documents (APD) to incorporate needed changes to the eligibility system. If a
state has not yet initiated a modernization APD, the state may benefit financially by le-
veraging the cost allocation special rules to help finance the eligibility modernization
effort.
With about 35 states expected to use an FFE, securing additional resources with the sub-
ject-matter expertise to assist states in the preparation, implementation, testing, and
certification effort is critical. Federal guidance delays also limit the time that states have
to find resources that understand the program requirements. Cognosante provides ex-
perts in system assessment, planning, quality assurance, and implementation who are
prepared to help states immediately. Cognosante documents the unique perspective,
challenges, and technical capabilities of the state. To develop this understanding,
Cognosante conducts validation sessions with state subject-matter experts and vision-
ing sessions with state leaders utilizing the CMS Seven Conditions and Standards as a
discussion guide. Cognosante focuses on:
• Creating high-level vision and strategy for the implementation of an FFE
• Understanding state technology capabilities and resources
• Planning for Medicaid expansion
• Scheduling, testing, and certification
The outcome of this assessment provides a comprehensive as-is understanding of state
capabilities and a blueprint for the to-be vision of the Exchange solution for 2015 and
beyond. The resulting gap analysis provides insight to the unique capabilities, needs,
and situation of the state.



Cognosante provides the strategic planning and analysis, knowledge of Medica-
id/CHIP, Exchange subject-matter expertise, and experience with Exchange interface
development that states need to succeed in implementing an FFE. Leveraging our vast
experience in Medicaid Information Technology Architecture (MITA) state self-
assessments, we assist states in the development of the to-be vision and as-is current
condition and gap analysis. Once the assessment and gap analysis are completed,
Cognosante works with states to identify strategic choices. Cognosante identifies and
provides states with a range of solution options, including developing a roadmap, for
transitioning from an FFE to an SPE or SBE solution.
Key Areas of State Engagement
The scope of integration points between
state systems and an FFE has not yet been
fully defined. States should plan for the de-
sign and delivery of a mix of policies, sys-
tem enhancements and external interfaces that will touch on the following key areas:
Medicaid and CHIP Eligibility and Enrollment
States need to determine the changes re-
quired of eligibility systems to process,
track, and report on account transfer ac-
tivities from an FFE. State Medicaid/CHIP
systems and the FFE will need to determine
in near real time whether the individual is enrolled by Medicaid/CHIP or a Qualified
Health Plan (QHP). States will need to be prepared to process X12 transactions to verify
eligibility and process enrollment. Integration points between an FFE and Medica-
id/CHIP include the following.
• Each state must decide whether the FFE will assess or determine eligibility for the
state’s Medicaid and CHIP programs. If the FFE determines eligibility for these pro-
grams, the FFE decision is final and the state must accept the FFE determination. If
the state decides the FFE will only assess eligibility, the FFE will verify the information
contained on the application, and transfer the account/case to Medicaid/CHIP for
assessment. After the account is transferred, the state is required to utilize the infor-
mation from the applicant’s FFE application to determine eligibility and may not fur-
ther verify the information contained therein or request additional information from
the applicant. In either case, the FFE must electronically transfer and the state must
receive the eligible or potentially eligible individual’s account.
• The FFE will need to determine at the time of application whether the applicant is
currently enrolled in Medicaid/CHIP.
• States will need to provide the FFE with relevant information from the state such as
information regarding the state’s applicable MAGI-based income standards for
Medicaid/CHIP.
• AN FFE will use certain state-based data sources such as the State Wage Information
Collection Agency and the unemployment benefits agency to support assessments
or determinations of Medicaid/CHIP eligibility, and to determine eligibility for Ad-
vance Premium Tax Credit (APTC) or Cost Sharing Reductions (CSR).


• States will need to electronically acknowledge the receipt of an account trans-
ferred from the FFE to Medicaid/CHIP.
• Individuals who apply for Medicaid/CHIP through the state’s eligibility determination
process, and who are determined not eligible by Medicaid/CHIP, must be electron-
ically transferred to the FFE for enrollment in a QHP and potential enrollment in an in-
surance affordability program. The FFE will then be responsible for determining if an
individual is eligible and enroll the individual appropriately.
• Eligibility appeals are subject to future regulation, but it is likely some level of coordi-
nation and state specific communication will be necessary.
In the May 2012 guidance, HHS indicated that it will continue to work with states to en-
sure coordination with state eligibility processes. Both the FFE and Medicaid/CHIP eligi-
bility rules outline mutual responsibilities and call for a memorandum of understanding
to specifically identify roles, responsibilities and timelines. Data-sharing agreements and
standards for information exchange will be particularly critical. HHS has promised further
guidance and toolsets to delineate tasks, schedules, and specifications for develop-
ment and testing of FFE and Medicaid/CHIP interactions.
Lacking more specific guidance or specifications from HHS on account transferring re-
quirements, states cannot complete their requirements analysis and all resulting system
changes at this time. Many questions remain for states that HHS has yet to address. For
example:
• For states that already have other HHS programs integrated into a universal applica-
tion such as SNAP/TANF, what questions will an FFE application support for these in-
dividuals? What pre-screening questions will the application contain for a state’s
MAGI exempt population? Will an FFE be able to accommodate the rules and op-
tions for a state’s Medicaid Expansion population?
• How will an FFE application and account transfer process ensure “no wrong door”?
How will states synchronize their application process with that of an FFE if states may
no longer ask additional questions as stipulated under the current guidelines? How
will information be conveyed to the Medicaid/CHIP program in the account transfer
process? What specific account information data will be passed to Medicaid/CHIP
from an FFE? How will documents used for self-attestation of income and residency
be passed to the Medicaid/CHIP case management system?
Despite these many questions, states must begin activities now, understanding some
requirements will change. To do otherwise jeopardizes state readiness.
Cognosante provides the understanding of Medicaid/CHIP eligibility and case man-
agement necessary to help implement the needed changes for account transfer and
for Modified Adjusted Gross Income (MAGI) processing. We will ensure that the neces-
sary application data is gathered, verified, and processed to either assess or determine
eligibility during the interface process with an FFE. Cognosante is leading the effort to
validate requirements, design, and construct the external interfaces for the Oregon Ex-
change. With our understanding of interface development, Medicaid eligibility policy,
MAGI rules, and experience with both SBEs and the FFE development, Cognosante is
qualified and positioned to help states successfully implement an FFE.



Consumer Assistance and Customer Service
CMS will provide a call center for an FFE. However, state Medicaid/CHIP agencies, the
Department of Insurance and the FFE will need to share information and coordinate ac-
tivities and protocols closely to help consumers resolve issues and ensure handoffs be-
tween entities go as smoothly as possible. Questions states should consider are:
• Should the Medicaid/CHIP call center have access to consumer information in an
FFE and will the FFE call center have access to information in Medicaid/CHIP? How is
this best accomplished? What interfaces may be necessary?
• What training must a state Medicaid/CHIP call center staff have to support ques-
tions about the Exchange and QHPs? What will be the process for warm hand-offs of
callers to/from an FFE call center?
• How will an FFE appeals process coordinate with state Medicaid/CHIP agencies?
States may choose to provide in-person consumer assistance in the SPE model. States
are awaiting further guidance from HHS on what functions they would be required to
perform.
Cognosante built and implemented an ISO-certified call center operation for CMS that
services the nation’s providers. This same call center is used on behalf of the Missouri
Medicaid Program to perform member eligibility determination, enrollment, and cus-
tomer service for the Missouri Rx Senior Pharmacy Assistance Program (SPAP) program.
We understand the importance of the seamless integration of the various levels of con-
sumer assistance — both technically and from a process and training perspective. Our
team will guide your state through the decisions you need to make to prepare you for
an FFE.
Plan Management
In the FFE model, the FFE’s role and authority are limited to the certification and man-
agement of participating QHPs. Federal authority does not extend beyond the FFE or
affect otherwise applicable state law governing which health insurance products may
be sold in the individual and small group markets. HHS has declared that it intends to
work with states to preserve the transitional responsibilities of state insurance depart-
ments and seeks to harmonize policies with existing state programs and laws wherever
possible.
States may use grant funding available under section 1311 of ACA for the develop-
ment, refinement, and testing of plan management functions under an SPE. To ensure
operational efficiency, the state will have the choice to conduct all plan management
and/or consumer assistance activities in this model. With regard to plan management,
the state would operate all plan management functions including analysis and reviews
necessary to support QHP certification, collection and transmission of data to an FFE
and management of certified QHPs.
Under the SPE, HHS will enter into agreements with state partners to establish roles and
responsibilities and outline specific workflows, deliverables, review standards, and time-
frames. In addition to possible integration with SERFF, states may elect to use the Feder-
al plan management system to carry out plan management activities, or may deter-
mine that using a specially configured COTS plan management solution is a better op-



tion. Many questions surround what options are available, what functionality will be
provided, and on what timeframe they will be released. In addition, sample agree-
ments have not yet been shared with states who are contemplating assuming plan
management activities, making it difficult for states to determine whether they want to
take on the plan management role, and if so to what level.
Questions states need to consider include:
• How much will operational control of state insurance markets (and competition in
those markets) change under the FFE model? Will a limited offering of plans under an
FFE meet the needs of state citizens?
• Are there state benefit mandates that are above and beyond the minimum Essen-
tial Health Benefits? If so, how does that impact plan management and connectivi-
ty to the FFE?
• To what level will the state and the state’s carriers need to understand the new
process to ensure participation and available plans on the Exchange for Plan Year
One and beyond?
• What functionality will the state and state’s carriers need to best manage their plan
offerings available on the FFE?
• What are the regulatory and policy issues that need to be addressed and for what
participants? What memoranda of understanding need to be in place and to
whom should they be targeted?
• What IT assets/interfaces need to be developed by the Department of Insurance to
engage with an FFE?
• To what level can — and should — plan management be aligned with the existing
regulatory processes for each state? How can this alignment be handled once for
both FFE and potential future SBE preparation to maximize the effort’s impact?
Why Cognosante?
Cognosante is uniquely positioned to assist states in planning and executing implement-
ing an FFE. Since the ACA’s passage, Cognosante has assisted states in the planning
and establishment of state exchanges. Cognosante has assisted states in the develop-
ment of the Early Innovator, Planning and Establishment Grant submissions, as well as
conducting and leading visioning sessions to assist stakeholders in key elements of es-
tablishing an Exchange. More recently, Cognosante led efforts to create the Exchange
blueprint for the Utah Health Exchange and is currently assisting the Oregon Health Au-
thority in requirements validation, design, and construction of external interfaces for the
Oregon Exchange and the DHS Modernization projects.
Cognosante is part of the team developing the FFE system. Cognosante support in-
cludes: providing system design leadership and functional subject-matter expertise for
the areas of eligibility, enrollment, and plan management; contributing to system de-
velopment efforts for the eligibility and enrollment, plan management, and financial
management components; executing quality verification plans to ensure functional
and technical compliance of the system with CMS-established requirements; and plan-



ning and facilitating state-focused communication efforts related to the implementa-
tion of an FFE for specific states.
Cognosante personnel participate in sprints to develop iterative versions of plan man-
agement and eligibility and enrollment modules. We have provided elaboration of the
detailed functional architecture blueprint for the overall system, leveraging subject-
matter expertise in MITA and spearheading the development of an exchange-specific
corollary, the Exchange Information Technology Architecture (EITA).



Successfully Implementing a Federally-Facilitated Exchange

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