BC ITGapAnalysis

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MINNESOTA HEALTH INSURANCE EXCHANGE (MNHIX)

GAPANALYSIS

Minnesota Health Insurance

Exchange (MNHIX)

3.1.4 Gap Analysis

Date: November 12th, 2012

Version: Final 1.0


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Table of Contents

1. Introduction to the Gap Analysis ...................................................................................................... 61.1 Project Background .......................................................................................................................... 61.2 Scope of Deliverable ........................................................................................................................ 71.3 Approach to Gap Analysis ................................................................................................................ 71.4 COTS Listing .................................................................................................................................... 92. Module 1 - Individual Eligibility and Exemption .............................................................................. 113. Module 2 - Individual Enrollment .................................................................................................... 424. Module 3 - Small Employer Eligibility and Enrollment .................................................................... 485. Module 4 - Health Plan Benefits and Navigator/Broker Certification and Display .......................... 606. Module 5 - Provider Display ........................................................................................................... 717. Module 6 - Fund Aggregation and Payment ................................................................................... 838. Module 7 - Account Administration ................................................................................................ 97

Table of Tables

Table 1 - Gap Analysis Requirements and Standards 7Table 2 - Gap Analysis Standardized Table Format 9Table 3 - MNHIX COTS Modules 10Table 4 - Module 1 - Individual Eligibility and Exemption Gaps 41Table 5 - Module 2 - Individual Enrollment Gaps 47Table 6 - Module 3 - Small Employer Eligibility and Enrollment Gaps 59Table 7 - Module 4 - Health Plan Benefits and Navigator/Broker Certification and Display Gaps 70Table 8 - Module 5 - Provider Display Gaps 82


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Gap Analysis

Date: November 12th, 2012

Submitted By: Benni DeMarco

Benni DeMarco, Project Management Officer, MAXIMUS Date

MNHIX Approver:

Peter Frank, State MNHIX Project Manager Date


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DateDocument

VersionDocument Revision Description Document Author

10/05/2012 v.0 DRAFT Benni DeMarco

11/12/2012 v.1.0 Final Initial Gap Analysis delivery Benni DeMarco


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Acronyms

ACA Federal Patient Protection and Affordable Care Act

BTI Business Transaction Inventory

CCA Child Care Assistance

CHIP Childrens Health Insurance Program

COTS Commercial Off-The-Shelf

HHS Health and Human Services

ID Unique Identifier

MAGI Modified Adjusted Gross Income

MNHIX Minnesota Heath Insurance Exchange

RTM Requirement Traceability Matrix

SERFF System for Electronic Rate and Form Filing

SNAP Supplemental Nutrition Assistance Program

TANF Temporary Assistance for Needy Families


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1. Introduct ion to the Gap Analysis

1.1 Project Background

Under the Federal Patient Protection and Affordable Care Act (ACA) enacted in March of 2010 (PublicLaw 111-148 and 111-152), new mechanisms for comparing and obtaining health care coverage werecreated called Health Benefit Exchanges (Exchange). An Exchange must be operational in each State byJanuary 1, 2014. By January 1, 2013, a State must have taken the necessary steps to have an Exchangeoperational by January 1, 2014 or the U.S. Department of Health and Human Services (HHS) will establish

one on a States behalf.

An Exchange is an organized competitive marketplace to facilitate the comparison, choice, and purchaseof health care coverage for individuals and employees of small businesses. Through an Exchange,individuals and employees will have access to comparable information on costs, benefits, health careproviders, quality, and customer satisfaction for an array of coverage options, and they can use thisinformation to choose and enroll in the health benefit plan that best fits their personal and family needs.Exchanges will also assist eligible individuals and small businesses in receiving premium tax credits andcost-sharing reductions or help individuals enroll in Federal or State health care programs. By engagingconsumers in a one-stop shopping experience with transparent information, Exchanges will makepurchasing health insurance easier and more understandable, put more control and choice in the hands ofindividuals and employees of small businesses, and incent greater market competition.

An Exchange will carry out a number of functions that include:

Ensuring that health insurers and health benefit plans meet certain standards for Exchangeparticipation.

Providing comparative information on costs, benefits, health care providers, quality, and customersatisfaction using a standard format.

Determining individual, employer, and employee eligibility for Exchange participation, exemptionsfrom individual coverage responsibilities, premium tax credits and cost-sharing reductions,Federal and State health care programs, and potentially other social service programs.

Facilitating real time eligibility determination and enrollment using a uniform format


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comparable information on costs, benefits, health care providers, quality, and customer satisfaction for an

array of coverage options, and they can use this information to choose and enroll in the health benefit planthat best fits their personal and family needs. Exchanges will also assist eligible individuals and smallbusinesses to receive premium tax credits and cost-sharing reductions or help individuals enroll in Federalor State health care programs.

By engaging Minnesotans in a one-stop shopping experience with transparent information, the Exchangewill make purchasing health insurance easier and more understandable. It will put more control and choicein the hands of individuals and employees of small businesses, and will foster greater market competition.

1.2 Scope of Deliverable

The table below lists the requirements for this deliverable as defined in the Contract.

Deliverable Requirements and Standards

Document ID Description

Contract

Main

Definitions

Gap Analysis means the identification of any differences between the current situation or environment and thefuture state that is necessary for completion of the Solution and the identification of tasks required to becompleted for that end Solution.

Contract

Main

Section 3.5

3.5 Analysis/Definition Duties, Contractor shall, in accordance with Exhibit A and Exhibit B and subject to Stateapproval:

a) Develop and submit to the State requirements documents for the Solution; including functional,technical and integration requirements. Contractors requirements document shall be subject toStates approval in accordance with Section 25;

b) Conduct business requirements sessions for requirements for the Solution. Businessrequirements sessions shall be based upon the requirements contained within Exhibit A andExhibit B.

c) Document business requirements findings, conduct Gap Analysis, prepare high level process flow

documents, develop test use cases, and deliver Gap Analysis to State.Table 1 - Gap Analysis Requirements and Standards

1.3 Approach to Gap Analysis


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Figure 1 - Gap Analysis Deliverable Process

Based on this approach which is illustrated in Figure 1 MAXIMUS will deliver the first version of the Gap


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Gap Analysis Column Definitions

Column Description

Gap ID A unique identifier assigned to each line item in the Gap Analysis.

RequirementText

The text of the requirement a shown in the source document. The source of the requirement may be theContract, Exhibits A or B, or the Requirements Traceability Matrix (RTM).

RequirementSource

Provides a reference to the source for the requirement. The source of the requirement may be the Contract,Exhibits A or B, or the Requirements Traceability Matrix (RTM).

RequirementType

Provides the classification of the type of requirement (e.g. business or technical).

RequirementSource ID

Provides a reference to the ID of the requirement in the Requirement Source. The Requirement Source willhave its own identifier for the requirement. The source of the requirement may be the Contract, Exhibits A orB, or the Requirements Traceability Matrix(RTM)

Module ID A numeric reference to the Module number as described in the contract, when applicable.

BusinessTransaction

A reference to the business transaction identifier as shown in BTI, when applicable.

Process Model A reference to the business process model, when applicable.

COTS Indicator Indicates whether the requirement is satisfied by the base COTS product or not. Values in this column areeither Yes or No. A Yes value indicates that the requirement is satisfied by the COTS product Out-Of-The-Box (OOTB). A No value indicates that a gap exists between the COTS functionality OOTB and therequired solution. Filling a gap may only require configuration of the COTS product, or may require customdevelopment to modify the product or create the necessary system integration components.

Gap Solution If the COTS Indicator is No, a description of solution necessary to fill the gap. The solution may requireconfiguration or modification to one or more COTS products, or may require custom development.

Table 2 - Gap Analysis Standardized Table Format


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Module Vendor Software Version

Gatherin

IBM Cram Verification

IBM Cram Business Intelligence

and Analytics

IBM Cram Citizen Portal

IBM Cram Health Care Bundle

Individual Enrollment Connecture Connecture StateAdvantage

Individual/AHBE: Shopping;

Individual/AHBE: Initial Enrollment;

Individual/AHBE: Renewals/Re-enrollment.

Small Employer Eligibilityand Enrollment

Connecture SHOP-Shopping (Employer andEmployee)

SHOP-Enrollment (Employer andEmployee)

SHOP-Employer Maintenance

SHOP-Employee Maintenance

SHOP-Employer Renewal.

Health Benefit Plan andNavigator-BrokerCertification and Display

Connecture Health Plan Management (Plan

and Rate Maintenance)

Provider Display Connecture Provider Facilities/Directory andSearch

Fund Aggregation EngagePoint Bill Generation

Bill Aggregation

Bill Presentment


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2. Module 1 - Individual Eligibili ty and Exemption

The Individual Eligibility and Exemption Module includes MNHIX functions which determine and process eligibility for an individual before that

individual is allowed to purchase health insurance coverage through the MNHIX.

Module 1 must be able to interface with other MNHIX Modules and determine eligibility for Medicaid, Childrens Health Insurance Program (CHIP),other state programs, premium tax credits, cost-sharing reductions and potentially a Basic Health Plan. The Contractors Solution shall bedesigned, developed and implemented to support future scaling to include future eligibility determination and transfer of data for additional healthcare programs and human services programs including, but not limited to Temporary Assistance for Needy families (TANF), Cash Assistance,Supplemental Nutrition Assistance Program (SNAP), Child Care Assistance (CCA) and Child Support.

Module 1- Individual Eligibility and Exemption

ID Requirement Text Source Source ID Mod Business

Transaction

Process

Model

COTS

Ind.

Gap Solution Req Type

1 Provide information on health programs andscreen eligibility of programs without log-inor account creation.

Exhibit A ExA III(a) 1 19: ProcessApplications

IND370 Yes The framework forsatisfying this requirementcomes OOTB. Will needlist of program specificrules and detailedscreening information fromState in order to producerules diagrams in theCuram Rules Editor.

Functional


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Transaction

Process

Model

COTS

Ind.


2 The Contractors Solution will provide theability to perform Pre-Screening through theuse of the Contractors standard calculatorfunctionality for individuals to determineMNHIX participation, potential eligibility forInsurance Affordability Programs: advancepayments of the premium tax credit, cost-sharing reductions, MAGI Medicaid, CHIP,and State-established Insurance

Affordability Programs related initiatives(e.g., Basic Health Program or additionalpremium incentives as defined in the ACA),and potential exemptions from theindividual mandate, by displaying andcapturing an individuals responses to a

limited set of questions without-requiring anindividual to log-in.

Exhibit A ExA III(a)(1) 8:PerformEligibility IND370IND480

IND490

IND500

Yes An anonymous pre-screening calculator isprovided OOTB in the HCRsolution. Specific languagedisplayed to users in theresults is configurable.

Functional

3 The Contractors Solution shall ask thefollowing three questions in supportscreening: (1) Are you over 65? (2) Are youdisabled? and (3) Are you blind?

Exhibit A ExA III(a)(2) 1 19: ProcessApplications

IND380 Yes The framework existsOOTB. Will need a list ofprogram specific rules anddetailed screeninginformation from the Statein order to produce rulesdiagrams in the CuramRules Editor.

Functional

4 The Contractors Solution shall provideScreening functionality to Users per allstate and federal requirements to efficientlyand accurately determine potential eligibility

for programs.

Exhibit A ExA III(a)(3) 1 8:PerformEligibility

IND380 No The framework existsOOTB. Will need a list ofprogram specific rules anddetailed screening

information from the Statein order to produce rulesdiagrams in the CuramRules Editor.

Functional

5 The Contractors Solution shall allowAssisters to enter the answers to the threescreening questions on behalf of anindividual.

Exhibit A ExA III(a)(4) 1 8:PerformEligibility

IND380 Yes An anonymous pre-screening calculator isprovided OOTB in the HCRsolution.

Functional


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Transaction

Process

Model

COTS

Ind.


6 The Contractors Solution will displayresults of Pre-Screening and Screening toan individual and display State providedinformation on how to apply. Regardless ofresults, individuals may apply for fulleligibility determination through existingState provided channels.

Exhibit A ExA III(a)(5) 1 8:PerformEligibility IND380IND480

IND490

IND500

No Specific language related tothe Pre-Screening andScreening results isconfigurable. Theapplication processedthrough the Exchange orother existing statechannels are not controlledby these results.

Functional

7 The Contractors Solution shall allowindividuals to create an account to saveinformation entered during the screeningprocess, and later continue the Screeningprocess using the saved data.

Exhibit A ExA III(a)(6) 1 2: ManageAuthentication;5: IdentityMatching

IND380 Yes User account creation willbe done in collaborationwith Module 7. The abilityto save and continue duringthe application process isOOTB.

Functional

8 Provide for collection of information onindividuals to create an account in theMNHIX and guide Users throughappropriate options (7)

Exhibit A ExA III(b) 1 2: ManageAuthentication;5: IdentityMatching;13: ProcessIndividualChanges;6: Perform DataVerification

No User account creation willbe done in collaborationwith Module 7.

Functional

9 The Contractors Solution shall determine ifa User does not already have an existingaccount within the MNHIX. (7)

Exhibit A ExA III(b)(1) 1 2: ManageAuthentication;5: IdentityMatching

No User account creation willbe done in collaborationwith Module 7.

Functional

10 The Contractors Solution shall allow aUser to recover User account log-ininformation, with this requirement providedvia a link to the Identity ManagementSoftware. (7)

Exhibit A ExAIII(b)(1)(A)

1 2: ManageAuthentication

Yes User account creation willbe done in collaborationwith Module 7.

Functional


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Transaction

Process

Model

COTS

Ind.


11 The Contractors Solution shall allow Usersto update data about themselves and othermembers of the Users household perprogram rules and in support of change incircumstance processing associated withModule 1. (7)

Exhibit A ExAIII(b)(1)(B) 1 13: ProcessIndividualChanges


Functional

12 The Contractors Solution shall create anew User account if the User is notregistered within the MNHIX. The creationof the new user account will be triggeredfrom Module 1 but stored in, and managedby the Identity Management System (7)

Exhibit A ExA III(b)(2) 1 2: ManageAuthentication


Functional

13 The Contractors Solution will be able toauthenticate the identity of Users

electronically.

Exhibit A ExAIII(b)(2)(A)

1 2: ManageAuthentication

Yes User account creation willbe done in collaboration

with Module 7.

Functional

14 The Contractors Solution will requestinformation such as Social Security Number(SSN) and date of birth (DOB) to allowfor authentication of data by external meansby

Exhibit A ExAIII(b)(2)(A)(i)

1 2: ManageAuthentication;5: IdentityMatching

Yes The Curam HCR solutionprovides OOTBfunctionality to requestdemographic data that willbe used to verify applicationdata.

Functional

15 Gathering information from external datasources such as the Department of MotorVehicles, credit reporting agencies andother public data sources.

Exhibit A ExA3(b)(2)(A)(i)(1)

1 6: Perform DataVerification

Yes The HCR product willintegrate with the Module 7solution to retrieveverification data fromexternal sources.

Functional

16 Requesting the User to answer knowledge-

based questions based on data gatheredfrom the called routine to facilitateauthentication of identity.

Exhibit A ExA

III(b)(2)(A)(i)(2)

1 2: Manage

Authentication;5: IdentityMatching

No Need to define the

knowledge based answersand integrate with Module 7solution.

Functional

17 Comparing Users answers to theknowledge based identification questionswith data gathered from available sources.

Exhibit A ExAIII(b)(2)(A)(i)(3)

1 2: ManageAuthentication;5: IdentityMatching

No Need to define theknowledge based answersand integrate with Module 7solution.

Functional


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Transaction

Process

Model

COTS

Ind.


18 The Contractors Solution shall allowAssisters to manually record that they haveauthenticated the identity of the Userthrough non-electronic verificationmechanisms. Assisters will use thestandard contractor solution interface tomeet this requirement.

Exhibit A ExAIII(b)(2)(B) 1 Yes Assisters will use OOTBevidence verificationfeatures to meet thisrequirement.

Functional

19 Accept, locate, match and verify dataneeded to determine eligibility for Insurance

Affordability Programs and relatedexemptions from Users and associatedUsers.

Exhibit A ExA III(c) 1 19: ProcessApplications;6: Perform DataVerification;23: PerformEligibilityReevaluation

IND390IND400

IND480

IND490

IND500

No Portions of this high-levelrequirement are coveredOOTB and configurablefunctionality. Additionalportions will need to be builtto integrate with the ESB.

Functional

20 The Contractors Solution shall display toUsers with information provided by theState associated with privacy practices,rights, and responsibilities in accordancewith federal and state requirements.

Exhibit A ExA III(c)(1) 1 19: ProcessApplications

IND400 No The online applicat ionprovides standard languagerelated to rights andresponsibilities which canbe configured to meet statespecific requirements.

Functional

21 The Contractors Solution will provide theUser the ability to indicate their acceptanceor refusal of these terms, and theconsequences of not accepting, for non-SHOP healthcare programs. If a user doesnot accept the terms it will stop the process.

Exhibit A ExAIII(c)(1)(A)

1 19: ProcessApplications

IND400 Yes The online applicationfeature contains a methodto allow a user to indicateauthorization to usepersonal information forverification purposes.

Functional

22 The Contractors Solution will collect therequired data necessary to determineeligibility for Insurance AffordabilityPrograms based on State providedrequirements.

Exhibit A ExA III(c)(2) 1 IND400 No The online applicationprovided OOTB asksquestions based on federalrequirements. Additionalquestions can beconfigured based on staterequirements.

Functional


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Transaction

Process

Model

COTS

Ind.


23 The Contractors Solution will determine,based on State provided requirements,which data elements require verification.The acceptable mechanisms for verificationare electronic, self-attestation, or paper.

Exhibit A ExAIII(c)(2)(A) 1 6: Perform DataVerification No Evidence Verification isprovided OOTB but willneed to be configured forstate specific needs.

Functional

24 The Contractors Solution will attempt toelectronically verify data elements requiringverification and tolerance for the transactionutilizing standard methodologies thatinclude error handling if data elements arenot properly returned.

Exhibit A ExAIII(c)(2)(B)


No The HCR product willintegrate with the Module 7solution to retrieveverification data fromexternal sources.

Additional requirementsrelated to data accuracytolerance will be configuredwith the HCR product tomeet state needs.

Functional

25 The Contractors Solution will attempt toverify relevant data with state sources andthe Federal data services hub.

Exhibit A ExAIII(c)(2)(C)

1 23: PerformEligibilityReevaluation;6: Perform DataVerification


Functional

26 The Contractors Solution will attempt toelectronically gather information fromexternal sources.

Exhibit A ExAIII(c)(2)(D)


IND400 No The HCR product willintegrate with the Module 7solution to retrieveverification data fromexternal sources.

Functional

27 The Contractors Solution shall provideUsers the ability to view and attest to self-specific data collected from externalsources.

Exhibit A ExAIII(c)(2)(D)(i)


IND400 Yes The online applicationprovides the ability to attestto the accuracy ofexternally obtained data.

Functional

28 The Contractors Solution will electronicallyverify information.

Exhibit A ExAIII(c)(2)(E)

1 23: PerformEligibilityReevaluation;6: Perform DataVerification


Functional


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Transaction

Process

Model

COTS

Ind.


29 The Contractors Solution will entail Usershaving the ability to refute the accuracy ofexternal data sources and submit additionalinformation.

Exhibit A ExAIII(c)(2)(E)(i) 1 6: Perform DataVerification Yes The online applicationprovides the option forusers to indicate thatexternal data is incorrectand provide accurateinformation.

Functional

30 The Contractors Solution shall allowAssisters to manually verify information ifnecessary. Assisters will use the standardcontractor solution interface to meet thisrequirement.

Exhibit A ExAIII(c)(2)(E)(ii)


Yes Assisters will use OOTBevidence verificationfeatures to meet thisrequirement.

Functional

31 The Contractors Solution will use datareceived from an external source.

Exhibit A ExA3(c)(2)(F)


No Integration with Module 7 isnecessary to provideaccess to external data.

Once information isrecorded as evidence it willbe used by eligibility andcase maintenancefunctions OOTB.

Functional

32 The Contractors Solution will providefunctionality to support the implementationof the reasonable compatibility and self-attestation verification policy andprocedures.

Exhibit A ExAIII(c)(2)(G)


No The HCR product will beconfigured to meet thestate requirementssurrounding attestation andreasonable compatibility.

Functional

33 The Contractors Solution will supportuploading of documents into an ElectronicDocument Management System (EDMS)with accurate indexing or tracking. TheEDMS, its provision, installation,configuration, integration and allimplementation work, including workassociated with indexing and tracking, isthe responsibility of the State.

Exhibit A ExAIII(c)(2)(H)

1 No Need to develop EDMSintegration.

Functional


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Transaction

Process

Model

COTS

Ind.


34 The Contractors Solution shall ensureUsers have the ability to query the StateEDMS system for and view verificationdocuments that have been loaded into thesystem.

Exhibit A ExAIII(c)(2)(H)(i) 1 No Need to develop EDMSintegration. Functional

35 The Contractors Solution shall sendnotification of alternative verification optionsto User and/or Assisters when electronicdocuments are not available. (7)

Exhibit A ExAIII(c)(2)(H)(ii)


Functional

36 The Contractors Solution shall ensureUsers shall have the ability to providealternative verification documents.

Exhibit A ExAIII(c)(2)(H)(iii)


Functional

37 The Contractors Solution shall ensure that

Assisters have the ability to manually verifyuploaded documents via query to the StateEDMS system, subject to appropriate role-based authorities.

Exhibit A ExA

III(c)(2)(H)(iv)

1 No Need to develop EDMS

integration.

Functional

38 The Contractors Solution shall allowAssisters to enter case notes that can beassociated both to an individual User and tothe Users electronic case file. Assisters willuse the standard IBM Cram functionality tomeet this requirement.

Exhibit A ExAIII(c)(2)(I)

1 Assister/Ability tocreate case noteson a linkedindividual oremployee.(Internal Only)

Yes Only Internal CSR will haveaccess to case notes.

Functional

39 The Contractors Solution will provide asignature mechanism (e.g. check box) tomeet State provided requirements.

Exhibit A ExAIII(c)(2)[sic]should beExA III(c)(3)


IND400 Yes The online applicationprovides an OOTB methodfor a user to accept/signprior to submission.

Functional


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Transaction

Process

Model

COTS

Ind.


40 Determine eligibility for InsuranceAffordability Programs advance paymentsof the premium tax c redit, cost-sharingreductions, MAGI Medicaid, CHIP, State-established Insurance AffordabilityPrograms related initiatives (e.g., BasicHealth Program or additional premiumincentives as defined in the ACA), andpotential exemptions from the individualmandate.

Exhibit A ExA III(d) 1 1: ReceiveInbound Requests;3: SendInformation toTrading Partners;4: Process

Appeals;5: Perform IdentityMatching;6: Perform DataVerification;8: PerformEligibility;9: Determine TaxCredits;

15: SendNotification;19: Process

Applications;20: ProcessEnrollments;23: PerformEligibilityReevaluation;25: ProcessExemptions;27: InitiateRenewal

IND390IND480

IND490

IND500

Yes This high level requirementis satisfied by multipleOOTB areas of the HCRproduct as well asintegration with otherModules of the overall HIXsolution.

Functional


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Transaction

Process

Model

COTS

Ind.


41 The Contractors Solution will develop rulesfor and deploy a rules engine to determineeligibility for Insurance AffordabilityPrograms: advance payments of thepremium tax credit, cost-sharing reductions,MAGI Medicaid, CHIP, State-establishedInsurance Affordability Programs relatedinitiatives (e.g., Basic Health Program oradditional premium incentives as defined inthe ACA), and potential exemptions fromthe individual mandate. Determinationsmust be made according to State providedrequirements.

Exhibit A ExA III(d)(1) 1 9: Determine TaxCredits;8: PerformEligibility

IND390IND480

IND490

IND500

Yes Federal rules for MAGI,CHIP and InsuranceAssistance are providedOOTB.

Functional

42 The Contractors Solution shall facilitatereferrals and transfers to the Medicaid

agency or its designee for individuals whorequire or request a non-MAGI eligibilitydetermination.

Exhibit A ExAIII(d)(1)(A)


IND400

IND480

IND490

IND500

No Integration with Module 7 isnecessary to facilitate the

referral process withexternal systems.

Functional

43 The Contractors Solution shall beconsistent with the requirements of withSection III, Part e of this Exhibit.

Exhibit A ExAIII(d)(1)(B)

1 8: PerformEligibility

IND480

IND490

IND500

Yes The OOTB HCR produceprovides federally compliantrules in a manner that willallow them to be updated orexpanded at a future dateusing the Curam Rulesframework.

Functional

44 The Contractors Solution will use the rulesengine for Module 1.

Exhibit A ExAIII(d)(1)(C)

1 8: PerformEligibility

IND480

IND490

IND500

Yes The OOTB HCR productprovides federally compliant

rules in a manner that willallow them to be updated orexpanded at a future dateusing the Curam Rulesframework.

Functional


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Transaction

Process

Model

COTS

Ind.


45 The Contractors Solution shall supportState specified requirements regarding theinteraction of the MAGI Medicaid programand other non-MAGI Medicaid programs sothat individuals are not incorrectly denied orterminated due to MAGI Medicaid eligibilitystatus.

Exhibit A ExA III(d)(2) 1 8: PerformEligibility IND480IND490

IND500

No Curam OOTB providesfederal requirements;additional staterequirements will beconfigured.

Functional

46 The Contractors Solution shall determineeligibility for individual mandateexemptions.

Exhibit A ExA III(d)(3) 1 8: PerformEligibility;25: ProcessExemptions

Yes The HCR product rulesprovide the ability todetermine eligibility forExemptions OOTB.

Functional

47 The Contractors Solution shallautomatically determine requiredverifications, per State provided

requirements

Exhibit A ExA III(d)(4) 1 6: Perform DataVerification

No Evidence Verification isprovided OOTB but willneed to be configured for

State specific needs.

Functional

48 The Contractors Solution will inform Usersof eligibility determination results,reductions in eligibility and benefits, andprocessing delays. Communications toUsers shall meet all notice andcorrespondence requirements including butnot limited to, security, data privacy, appealrights, and federal and state noticerequirements. (7)

Exhibit A ExA III(d)(5) 1 15: SendNotification;8: PerformEligibility

IND390

IND480

IND490

IND500

No Integration with Module 7will provide the ability totrigger and generate statedefined correspondence.

Functional

49 The Contractors Solution shall displayeligibility and exemption information to

Assisters. (7)

Exhibit A ExA III(d)(6) 1 8: PerformEligibility;25: ProcessExemptions

IND480

IND490

IND500

Yes The HCR product providesthe ability to view eligibilityand exemption data OOTBto users and Assisters.

Functional

50 The Contractors Solution will interfaceMAGI Medicaid/CHIP eligibility informationto DHS systems as required.


1 3: SendInformation toTrading Partners;23: PerformEligibilityReevaluation

Yes Integration with Module 7will provide the ability tosend information to externalsystems.

Functional


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Transaction

Process

Model

COTS

Ind.


51 The Contractors Solution shall allowAssisters to view more detailed informationon eligibility calculations including, but notlimited to, income calculations. Assisterswill use the standard IBM Cramfunctionality to meet this requirement.

Exhibit A ExAIII(d)(6)(B) 1 19: ProcessApplications No Case Managementfunctionality is providedOOTB and will beconfigured using role basedsecurity to allow specificusers access to specificcase related information.

Functional

52 The Contractors Solution shall acceptappeals information in accordance withagreed upon business requirements.

Exhibit A ExA III(d)(7) 1 4: ProcessAppeals

No Integration with Module 7 isneeded to access appealrelated status information.

Additional state relatedrequirements need to bedefined to allow for thedisplay of specific Appealrelated data.

Functional

53 The Contractors Solution shall ensureUsers will be informed of appeal process.


1 4: ProcessAppeals



Functional

54 The Contractors Solution will accept andtransfer information to appropriate appealsmanagement entity.


1 4: ProcessAppeals


Additional state relatedrequirements need to be

defined to allow for thedisplay of specific Appealrelated data.

Functional


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Transaction

Process

Model

COTS

Ind.


55 The Contractors Solution will receiveinformation from appeals managemententity on status/outcomes for display onUser account page.


1 4: ProcessAppeals



Functional

56 The Contractors Solution shall ensuresupport of continued coverage undercertain circumstances pending an appealand support overpayment determinationfunctionality if User loses appeal.

Exhibit A ExAIII(d)(7)(D)

1 4: ProcessAppeals


Additional state relatedrequirements need to bedefined to allow for thedisplay of specific Appeal

related data.

Functional

57 The Contractors Solution will allow for anddetermine renewal of eligibility andexemptions according to State providedrequirements.

Exhibit A ExA III(d)(8) 1 27: InitiateRenewal;

Yes Curam OOTB provides theability to re-determineeligibility.

Functional

58 The Contractors Solution will determineeligibility and exemption changes during acoverage year according to federal andstate requirements.

Exhibit A ExA III(d)(9) 1 13: ProcessIndividualChanges;23: PerformEligibilityReevaluation

Yes Curam OOTB provides theability to determineeligibility based on updateddata (user provided orobtained through externalsources.)

Functional

59 The Contractors Solution will support Usersreporting changes via the Solutions

established interfaces.

Exhibit A ExA III(d)(10) 1 13: ProcessIndividual

Changes

Yes Curam OOTB provides amethod for a user/assister

to provide updated datawhich can be used to re-determine eligibility.

Functional


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60 The Contractors Solution shall bedesigned, developed and implemented tosupport future scaling to and extensibility toinclude future eligibility determination andtransfer of data for additional health careprograms and human services programsincluding, but not limited to Temporary

Assistance for Needy families (TANF),Cash Assistance, Supplemental Nutrition

Assistance Program (SNAP), Child CareAssistance (CCA) and Child Support.

Exhibit A ExA III(d)(11) 1 8: PerformEligibility

IND480

IND490

IND500

Yes The OOTB HCR productprovides federally compliantrules in a manner that willallow them to be updated orexpanded at a future dateusing the Curam Rulesframework.

Functional

61 The Contractors Solution shall supportcase assignment functionality inaccordance with State providedrequirements. The solution will provide

basic organizational unit assignment andbasic work queue assignment functionality.

Exhibit A ExA III(d)(12) 1 No Work queues and workflowwill be configured to meetstate specific needs.

Functional

62 The Contractors Solution will supporteligibility determinations for time periodsprior to the date an application wassubmitted(though no earlier than October 1,2013), as well as for past, current andfuture calendar months based on Stateprovided requirements and the extent ofrules available in Module 1.

Exhibit A ExA III(d)(13) 1 1: ReceiveInbound Requests;8: PerformEligibility

IND480

IND490

IND500

Yes The HCR solution providesan OOTB method todetermine retroactive andfuture functionality.

Functional

63 The Contractors Solution will accept andprocess applications via the Solutionsestablished interfaces and through directentry by Assisters. Assisters will use thestandard IBM Cram functionality to meetthis requirement.

Exhibit A ExA III(d)(14) 1 19: ProcessApplications;20: ProcessEnrollments

IND400 Yes The OOTB HCR productprovides an onlineapplication that can beused directly or by

Assisters.

Functional


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64 The Contractors Solution will support Stateprovided MAGI Medicaid/CHIP specificrequirements including those associatedwith, determination of cost effective healthinsurance and medical support per federaland state requirements.


IND390

IND480

IND490

IND500

Yes The OOTB HCR productprovides federally compliantrules in a manner that willallow them to be updated orexpanded at a future dateusing the Curam Rulesframework.

Functional

65 The Contractors Solution captures up to 15data elements associated with a third partyliability and make them available to theMedicaid/CHIP agency.

Exhibit A ExA III(d)(16) 1 3: SendInformation toTrading Partners;19: Process

Applications

IND400 No State specific data relatedto TPL will need to beconfigured as part of theonline application.Integration with Module 7 i snecessary to transfer thisinformation to externalsystems.

Functional

66 The Contractors Solution will support thereceipt and processing of notifications fromthe Medicaid/CHIP agency regardingchanges in Medicaid/CHIP eligibility (e.g.,from MAGI to non-MAGI).

Exhibit A ExA III(d)(17) 1 23: PerformEligibilityReevaluation

No Integration with Module 7 isnecessary in order tosupport the receipt of datafrom external sources.

Functional

67 The Contractors Solution will support themanual receipt of a referral from the StateMedicaid Agency and determine eligibilityfor the Insurance Affordability Programs.

Exhibit A ExA III(d)(18) 1 1: ReceiveInbound Requests;19: Process

Applications;8: PerformEligibility

IND390IND400

Yes Curam OOTB provides amethod to enter anapplication online which willbe used to determine/re-determine eligibility.

Functional

68 The Contractors Solution will supportpresumptive eligibility processing per

agreed upon requirements. The Contractorwill provide up to 160 hours of work insupport of presumptive eligibility.

Exhibit A ExA III(d)(19) 1 No Details for the presumptiveeligibility solution will be

clarified during pre-sprint/sprint activities

Functional

69 The Contractors Solution will transition aUser determined presumptively eligible to afull determination per agreed uponrequirements. Contractor support is asincluded in the previous requirement.

Exhibit A ExA III(d)(20) 1 No Details for the presumptiveeligibility solution will beclarified during pre-sprint/sprint activities

Functional


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70 The Contractors Solution shall notify MAGIMedicaid/CHIP applicants/enrollees of otherbenefits they may apply for as per Stateprovided requirements. The Contractor willsupport this requirement for the webchannel. The Contractor will support theother channels determined necessary bythe state based on mutual agreement.

Exhibit A ExA III(d)(21) 1 15: SendNotification

IND380

IND480

IND490

IND500

No Screening requirements willbe configured to meet stateneeds. Integration withModule 7 will be necessaryto trigger notifications to besent.

Functional

71 The Contractors Solution shall interact withMedicaid/CHIP systems in support ofidentity management features to send andreceive data

Exhibit A ExA III(d)(22) 1 2: ManageAuthentication;5: Perform IdentityMatching

No Integration with Module 7 isnecessary in order tosupport the receipt/transferof data from and to externalsources.

Functional

72 The Contractors Solution shall issue a

unique MNHIX User identifier and maintainUser uniqueness. (7)

Exhibit A ExA

III(d)(22)(A)

1 2: Manage

Authentication;5: Perform IdentityMatching

No User account creation and

management will be donein collaboration with Module7.

Functional

73 Based upon established criteria, theContractors Solution shall validate a Usersexistence with the Minnesota Department ofHuman Services MMIS systems.


1 5: Perform IdentityMatching

No User account creation andmanagement will be donein collaboration with Module7.

Functional

74 For Users currently known to MMIS, theMNHIX will use the existing identifier,known as the MMIS recipient identifier inaddition to the MNHIX identifier.

Exhibit A ExAIII(d)(22)(B)(i)


No User account creation andmanagement will be donein collaboration with Module7.

Functional

75 For Users not already known to MMIS, theMNHIX system will be responsible for

assigning a unique MMIS recipient identifierto be used by MMIS and the MNHIX, inaddition to the MNHIX identifier.

Exhibit A ExAIII(d)(22)(B)(ii

)


No User account creation andmanagement will be done

in collaboration with Module7.

Functional


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76 The Contractors Solution shall provide aperson search function and will allow thereconciliation of User account issues. Thecontractor will provide up to 160 hours ofwork in support of person, person splittingand synchronization with MMIS.



No IBM Cram will providesupport for 160 hours.

Functional

77 If, after the assignment of an MMISidentifier, a person is found to be the sameas another person, the MNHIX will providethe functionality for merging the personsmultiple identities and appropriatelycommunicating with MMIS.

Exhibit A ExAIII(d)(22)(C)(i)



Functional

78 If a single identified person is determined tobe two persons, the MNHIX will be

responsible for splitting the person andappropriately communicating with MMIS.

Exhibit A ExAIII(d)(22)(C)(ii

)



Functional

79 The Contractors Solution shall supportAdministrative program maintenanceincluding, federal poverty level changes perState provided ACA requirements.


Yes IBM Cram has thecapability to maintain therate tables used byeligibility rules with timeperiod specific data OOTB.

Functional

80 The Contractors Solution will support batchprocessing for known events that will affecteligibility including, but not limited to,Medicaid/CHIP age changes. The MNHIXshall determine eligibility and document onany enrolled individual the action taken perState provided requirements.


IND480

IND490

IND500

No IBM Cram has the abilityto re-determine eligibilityOOTB based on changes toinformation. State specificscenarios surroundingmass change functionalitywill need to be defined.

Functional

81 The Contractors Solution shall allowContractor to design, develop and generatereports for programmatic and operationalmanagement per federal and staterequirements.

Exhibit A ExA III(d)(25) 1 No BTI/BT Needed No Functional


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82 The Contractors Solution shall supportinteraction with Income and EligibilityVerification System (IEVS), New Hire, andPublic Assistance Reporting InformationSystem (PARIS) match processes, perState provided requirements. Contractorsscope for this requirement is limited to 80hours of work throughout the Project.


No IBM Cram will create theweb service registry tointegrate with Module 7 insupport of this functionality.

Functional

83 The Contractor's Solution shall provide theability to redetermine Medicaid/CHIPeligibility for past periods and to provide anotice to individuals when the individualwas previously found eligible/ineligible inerror. The Contractors solution will supportredetermination of eligibility for past periods

as standard functionality and rules definedin the system.

Exhibit A ExA III(d)(27) 1 15: SendNotification;1: ReceiveInbound Requests;8: PerformEligibility

IND480

IND490

IND500

Yes IBM Curam OOTB providesthe ability to re-determineeligibility. Integration withModule 7 will allow relevantnotices to be generatedrelated to changes ineligibility.

Functional

84 Provide functionality to allow Assisters tomanage the cases of individuals, familiesand households, and employers andemployees associated with the Assister.

Exhibit A EXA III(f) 1 1: ReceiveInbound Requests;5: Break the Linkwith Individuals orEmployees thatwill no longer be

Assisted;6: Perform DataVerification;8: PerformEligibility;13: Process

IndividualChanges;14: Manage

Assister Linkageto Individual;15: SendNotifications;19: Process

Applications

IND390

IND400

No Portions of this high-levelrequirement are covered byOOTB and configurablefunctionality. Additionalportions will need to be builtto integrate with the overall

Appeals solution.

Functional


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85 The Contractors Solution shall provideagreed upon case managementfunctionality across Insurance AffordabilityPrograms. Assisters will use the standardIBM Cram functionality to meet thisrequirement.

Exhibit A EXA III(f)(1) 1 19: ProcessApplications

Yes Case Managementfunctionality is providedOOTB and will beconfigured using role basedsecurity to allow specificusers access to specificcase related information.

Functional

86 The MNHIX will provide functionality toallow Assisters to perform actions on behalfof Users.


IND400 Yes Case Managementfunctionality is providedOOTB and will beconfigured using role basedsecurity to allow specificusers access to specificcase related information.

Functional

87 The Contractors Solution shall provideAssisters case management functionsnecessary for them to perform necessaryactions within the MNHIX. These actionsinclude: completing an application,manually verifying a users documentation,sending a user a notice or othercommunication, completing an eligibilityredetermination/ renewal, or reportingchanges in information related to eligibilitydeterminations. (1, 2, 3)

Exhibit A EXAIII(f)(2)(A) 1 19: ProcessApplications;8: PerformEligibility;15: SendNotifications

IND390

IND400

IND480

IND490

IND500


Functional

88 The Contractors Solution shall provideability for individuals to terminate arelationship with an Assister which resultsin the Assister immediately losing allaccess rights to the Users information onthe MNHIX. Revocation of access rights willbe provided by a call to a Contractorprovided routine or similar function. (7)

Exhibit A EXAIII(f)(2)(B)

1 14: ManageAssister Linkageto Individual;5: Break the Linkwith Individuals orEmployees thatwill no longer be

Assisted

Yes The HCR solution providesa method OOTB for anindividual to disassociatethemselves from an

Assister.

Functional


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89 The Contractors Solution will includecustomizable dashboard functionality for

Assisters, to allow Assisters to view thefollowing key metrics, including applicationsand renewals in queue, appeals, actionstaken, and referrals. The functionality mustallow for individual caseworker or casebank caseworker support where case bankcaseworker support allows a caseworker toaccess the next case in a queue of casesnot yet assigned.

Exhibit A EXAIII(f)(2)(C)


IND400 No Work queues and workflowwill be configured to meetstate specific needs.

Functional

90 The Contractors Solution shall allowAssisters to send notices and letters toUsers for special circumstances, using pre-populated templates with the ability to

incorporate free-form text. The Solutionmust store a copy of the notice and letter tothe same extent as other noticerequirements.

Exhibit A EXAIII(f)(2)(D)

1 15: SendNotification

Yes Integration with Module 7will be necessary to allowfor the triggering andgeneration of state specific

communications.

Functional

91 The Contractors Solution shall allowAssisters to manually verify information thatis not verified electronically or throughreasonable compatibility.

Exhibit A EXAIII(f)(2)(E)


Yes Assisters will use OOTBevidence verificationfeatures to meet thisrequirement.

Functional

92 The Contractors Solution or related thirdparty tools will generate data and reportsneeded to notify and process Useractivities.

Exhibit A EXA III(f)(3) 1 BI/ReportingRequirement

No As long as the data alreadyexists in IBM Cram MAXIMUS will be able togenerate the data andreports.

Functional

93 Enrollment trends Exhibit A EXAIII(f)(3)(A)

1 BI/ReportingRequirement


Functional


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94 Eligibility determination outcomes Exhibit A EXAIII(f)(3)(B)



Functional

95 Plan selection choices Exhibit A EXAIII(f)(3)(C)



Functional

96 Premiums Exhibit A EXAIII(f)(3)(D)


No As long as the data alreadyexists in IBM Cram MAXIMUS will be able togenerate the data and

reports.

Functional

97 Assist Assisters Exhibit A EXAIII(f)(3)(E)



Functional

98 User assistance Exhibit A EXAIII(f)(3)(F)



Functional

99 User feedback and satisfaction Exhibit A EXAIII(f)(3)(G)


No As long as the data alreadyexists in IBM Cram

MAXIMUS will be able togenerate the data andreports.

Functional

100 Other reports defined during businessrequirement gathering sessions

Exhibit A EXAIII(f)(3)(H)



Functional


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101 The Contractor shall allow the creation ofad hoc reports by State Business

Administrators through the standardreporting tool or third party dynamicreporting software.


No As long as the data alreadyexists in IBM Cram -MAXIMUS will be able togenerate the data andreports.

Functional

102 The Contractors Solution shall generatedata and reports needed to comply withfederal audit and oversight requirements.



Functional

103 The Contractors Solution will generate dataand reports needed to comply with federalMNHIX, Medicaid/CHIP and Quality controlinitiatives.

Exhibit A EXAIII(f)(5)(A)


No As long as the data alreadyexists in IBM Cram MAXIMUS will be able togenerate the data and

reports.

Functional

104 The Contractors Solution will establishlinking relationship between individuals,family/households, employers, employees,

Assisters, insurers and health careproviders and shall be displayed asappropriate.


IND400 Yes The OOTB onlineapplication asksrelationship relatedquestions. AdditionallyOOTB Case Managementfunctions allow other partiesto be associated to acase/participant.

Functional

105 The Contractors Solution will havefunctionality to reassess and determineeligibility based on new circumstances.(1,2, 3, 4, 5 )

Exhibit A EXA III(f)(7) 1 13: ProcessIndividualChanges

Yes Curam OOTB provides theability to re-determineeligibility.

Functional


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106 The Contractors Solution will provideaccount case management functions for themanagement of Users by Assisters.

Exhibit A EXA III(f)(8) 1 14: ManageAssister Linkageto Individual;5: Break the Linkwith Individuals orEmployees thatwill no longer be

Assisted;1: ReceiveInbound Requests

No Case Managementfunctionality is providedOOTB and will beconfigured using role basedsecurity to allow specificusers access to specificcase related information.

Functional

107 The Contractors Solution will beresponsible for assigning a case identifierfor MNHIX participants coming through theExchange, using a format that is mutuallyagreed-upon and a process that assures

the case identifier is not duplicated.

Exhibit A EXAIII(f)(8)(a)

1 No Need additional informationto determine which BTI thisshould map to.

Functional

108 For cases currently known to MMIS, theMNHIX will use the existing case identifieras the MMIS case identifier.

Exhibit A EXAIII(f)(8)(b)

1 No Need additional informationto determine which BTI thisshould map to.

Functional

109 The Contractors Solution shall allowAssisters to perform actions on behalf of anindividual.

Exhibit A EXA III(f)(9) 1 14: ManageAssister Linkageto Individual;5: Break the Linkwith Individuals orEmployees thatwill no longer be

Assisted;1: ReceiveInbound Requests


Functional

110 The Contractors Solution shall allowAssisters to have the ability to add anarrative to a case and track and maintainchanges over time.

Exhibit A EXA III(f)(10) 1 19: ProcessApplications;13: ProcessIndividualChanges


Functional


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111 The Contractors Solution will allow Users

and Assisters to maintain and access ahistory of notices that have been sent to abeneficiary.

Exhibit A EXA III(f)(11) 1 19: Process

Applications;13: ProcessIndividualChanges

No Case Management

functionality is providedOOTB and will beconfigured using role basedsecurity to allow specificusers access to specificcase related information.

Functional

112 The Contractors Solution will allowAssisters the ability to maintain and accessa record history of a Users eligibility statusover time.



Functional

113 The Contractors Solution shall allow anAssister to be assigned to an accountand/or have access to an accountaccording to role-based security controls.

Exhibit A EXA III(f)(13) 1 19: ProcessApplications Yes Case Managementfunctionality is providedOOTB and will beconfigured using role basedsecurity to allow specificusers access to specificcase related information.

Functional

114 Determine eligibility for non-MAGI Medicaidand other state health care programsaccording to federal and state requirementsand timeliness and performance standards.

The Contractors Solution is not required tohave the functionality described under thisPart e. Nonetheless, the Contractors

Solution under this contract shall bedesigned, developed and implemented in amanner that permits the scalability andfuture implementation of the requirementsunder this Part e.

Exhibit A ExA III(e) 1 The highlighted text in theRequirement Textdescribes how this is not arequirement for thiscontact. Therefore, no GapSolution is required.

Functional


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115 The Contractors Solution will develop rules

for and deploy a rules engine to determineeligibility for non-MAGI Medicaid and otherstate health care programs. Alldeterminations must be made according tofederal and state requirements andtimeliness and performance standards.The rules engine design and architecturemust also be able to integrate with andscale to support the eligibility determinationof additional Human Services programs toinclude integration with other eligibilitydetermination systems.

Exhibit A ExA III(e)(1) 1 Perform Eligibility

[SharedTransaction]

No This is a sub-requirement

for requirement 114, andtherefore no Gap Solutionis required.

Functional

116 The Contractors Solution will automaticallydetermine required verifications and provide

notice of verifications needed to User.

Exhibit A ExA III(e)(2) 1 Individual/PerformEligibility

No This is a sub-requirementfor requirement 114, and

therefore no Gap Solutionis required.

Functional

117 The Contractors Solution will inform Usersof eligibility determination results,reductions in eligibility and benefits, andprocessing delays. Communications toUsers shall meet all notice andcorrespondence requirements including butnot limited to, security, data privacy, appealrights, and federal and state noticerequirements. (7)

Exhibit A ExA III(e)(3) 1 Perform DataVerification

[SharedTransaction]

No This is a sub-requirementfor requirement 114, andtherefore no Gap Solutionis required.

Functional

118 The Contractors Solution will communicateeligibility information to Assister. (7)

Exhibit A ExA III(e)(4) 1 Send Notification

[Shared

Transaction]

No This is a sub-requirementfor requirement 114, andtherefore no Gap Solution

is required.

Functional

119 The Contractors Solution will interface non-MAGI Medicaid and other state health careprograms eligibility information to DHSsystems as required.

Exhibit A ExAIII(e)(4)(A)

1 Perform Eligibility

[SharedTransaction]


Functional


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120 The Contractors Solution will incorporate

eligibility results that allow appropriateUsers to view more detailed information oneligibility calculations including, but notlimited to, income calculations.

Exhibit A ExA

III(e)(4)(B)

1 Individual/Process

Enrollments

Yes This is a sub-requirement


Functional

121 The Contractors Solution will accept andprocess appeals and coordinate wherenecessary across Modules.

Exhibit A ExA III(e)(5) 1 Individual/ProcessAppeals


Functional

122 The Contractors Solution will have thecapability for Users to be informed ofappeal process.


1 Individual/ProcessAppeals


Functional

123 The Contractors Solution will accept andtransfer information to appropriate appealsmanagement entity.

Exhibit A ExAIII(e)(5)(B)



Functional

124 The Contractors Solution will receiveinformation from appeals managemententity on status/outcomes for display onUser account page.

Exhibit A ExAIII(e)(5)(C)



Functional

125 The Contractors Solution will supportcontinued coverage under certaincircumstances pending an appeal andsupport overpayment determinationfunctionality if User loses appeal.

Exhibit A ExAIII(e)(5)(D)



Functional

126 The Contractors Solution will allow for anddetermine renewal of non-MAGI Medicaidand other state health care programseligibility according to federal and staterequirements.

Exhibit A ExA III(e)(6) 1 Initiate Renewal No This is a sub-requirementfor requirement 114, andtherefore no Gap Solutionis required.

Functional

127 The Contractors Solution will determinenon-MAGI Medicaid and other state healthcare programs eligibility changes accordingto federal and state requirements.

Exhibit A ExA III(e)(7) 1 No BTI/BT Needed No This is a sub-requirementfor requirement 114, andtherefore no Gap Solutionis required.

Functional


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128 The Contractors Solution will support Users

reporting changes via the internet, phone,mail, and in-person and through othercommonly available electronic means andperform a full eligibility redetermination.

Exhibit A ExA III(e)(8) 1 Process Individual

Changes

No This is a sub-requirement


Functional

129 The Contractors Solution will support non-MAGI Medicaid and other state health careprograms eligibility determinations for timeperiods prior to the date an application wassubmitted, as well as for past, current andfuture calendar months per federal andstate requirements.


Functional

130 The Contractors Solution will accept andprocess non-MAGI Medicaid and other

state health care programs applications viaall methods per federal and staterequirements.

Exhibit A ExA III(e)(10) 1 No BTI/BT Needed No This is a sub-requirementfor requirement 114, and


Functional

131 The Contractors Solution will support anddetermine eligibility for non-MAGI Medicaidand all other state health care programs perfederal and state requirements including,but not limited to:


Functional

132 non-MAGI Medicaid and other state healthcare programs income and assetmethodologies,


1 No BTI/BT Needed No This is a sub-requirementfor requirement 114, andtherefore no Gap Solutionis required.

Functional

133 functionality to support determination and

notification of recipient premium anddefined contribution amounts for statespecified programs, (6,7)

Exhibit A ExA

III(e)(11)(B)

1 No BTI/BT Needed No This is a sub-requirement


Functional

134 functionality to link premium paymentresults and support for good causedeterminations for premium payments forstate specified programs, (6,7)



Functional


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135 special rules for Medicaid payment of long-

term care services such as but not limitedto, the home equity limit, annuityrequirements, determination ofuncompensated transfers and penaltyperiods, level of care requirements, andlong-term care spend downs, and

Exhibit A ExA

III(e)(11)(D)



Functional

136 determination of cost effective healthinsurance and medical support.

Exhibit A ExAIII(e)(11)(E)


Functional

137 The Contractors Solution will support anasset assessment for married individualswho may need to apply for Medicaid paid

long-term care services per federal andstate requirements regardless if a Medicaidapplication is eventually filed.

Exhibit A ExA III(e)(12) 1 No BTI/BT Needed No This is a sub-requirementfor requirement 114, andtherefore no Gap Solution

is required.

Functional

138 The Contractors Solution will supportreferral for Long-Term Care Consultations ifthe User identifies as potentially having aneed for long-term care services.


Functional

139 The Contractors Solution will identify andreport third party liability to DHS.


Functional

140 The Contractors Solution will support thereceipt and processing of notifications from

the DHS regarding changes in non-MAGIMedicaid and other state health careprograms eligibility.

Exhibit A ExA III(e)(15) 1 No BTI/BT Needed No This is a sub-requirementfor requirement 114, and


Functional


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141 The Contractors Solution will support the

determination and notification of a spousalcontribution for an individual whose spouseis receiving long-term care services fromMedicaid and certain state health careprograms per state requirements. (6)

Exhibit A ExA III(e)(16) 1 No BTI/BT Needed No This is a sub-requirement


Functional

142 The Contractors Solution will support liensand life estate functionality.


Functional

143 The Contractors Solution will notify non-MAGI Medicaid and other state health careprogram applicants/enrollees of otherbenefits they must apply for and track and

act on response or non-response perfederal and state requirements.


Functional

144 The Contractors Solution will interoperatewith Medicaid/CHIP systems in support ofidentity management features to send andreceive data


Functional

145 The Contractors Solution shall issue aunique MNHIX User identifier and maintainUser uniqueness. (7)



Functional

146 Based upon established criteria, theContractors Solution shall validate a Usersexistence with the Minnesota Department of

Human Services MMIS systems.

Exhibit A ExAIII(e)(19)(B)

1 No BTI/BT Needed No This is a sub-requirementfor requirement 114, andtherefore no Gap Solution

is required.

Functional

147 For Users currently known to MMIS, theMNHIX will use the existing identifier,known as the MMIS recipient identifier inaddition to the MNHIX identifier.

Exhibit A ExAIII(e)(19)(B)(i)

1 Identity Matching

[SharedTransaction]


Functional


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148 For Users not already known to MMIS, the

MNHIX system will be responsible forassigning a unique MMIS recipient identifierto be used by MMIS and the MNHIX, inaddition to the MNHIX identifier.

Exhibit A ExA

III(e)(19)(B)(ii)



Functional

149 The Contractors Solution shall provide aperson search function and will allow thereconciliation of User account issues.Contractor support effort is included as partof the requirements in the person searchrequirements listed previously.



Functional

150 If, after the assignment of an MMISidentifier, a person is found to be the sameas another person, the MNHIX will provide

the functionality for merging the personsmultiple identities and appropriatelycommunicating with MMIS.

Exhibit A ExAIII(e)(19)(C)(i)

1 No BTI/BT Needed No This is a sub-requirementfor requirement 114, andtherefore no Gap Solution

is required.

Functional

151 If a single identified person is determined tobe two persons, the MNHIX will beresponsible for splitting the person andappropriately communicating with MMIS.

Exhibit A ExAIII(e)(19)(C)(ii)


Functional

152 The Contractors Solution will support non-MAGI Medicaid and other state health careprograms maintenance including, but notlimited to, federal poverty level changes perfederal and state requirements.


Functional

153 The Contractors Solution will support batch

processing for known events that will affecteligibility including, but not limited to,Medicaid age changes. The MNHIX shalldetermine eligibility and document on anyenrolled individual the action taken perfederal and state requirements.



Functional


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154 The Contractors Solution will generate

reports for programmatic and operationalmanagement per federal and staterequirements.



Functional

155 The Contractors Solution will supportIncome and Eligibility Verification System(IEVS), New Hire, and Public AssistanceReporting Information System (PARIS)match processes and the overpaymentprocesses per federal and staterequirements.


Functional

156 The Contractors Solution will supportacceptance of reports of suspected fraud,referral to designated entities, and

overpayment processes per federal andstate requirements.

Exhibit A ExA III(e)(24) 1 No BTI/BT Needed No This is a sub-requirementfor requirement 114, andtherefore no Gap Solution

is required.

Functional

157 The Contractors Solution will support thedetermination, calculation and notificationof overpayments for Medicaid/CHIP perfederal and state requirements.


Functional

Table 4 - Module 1 - Individu al Eligibili ty and Exemption Gaps


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3. Module 2 - Individual Enrollment

The Individual Enrollment Module (Module 2) encompasses MNHIX functions which facilitate health benefit plan enrollment, and as applicable,

selection of specific health care providers through the MNHIX.

Module 2 must also interface with other MNHIX Modules and must function to communicate health plan enrollment and provider selectioninformation with insurers and/or the Medicaid/CHIP agency.


Transaction

Process

Model

COTS

Ind.


158 The MNHIX shall facilitate health planenrollment and as applicable selection ofspecific health care providers forindividuals/households/families and employeeseligible to use the MNHIX

Exhibit A ExA IV(a) 2 20: ProcessEnrollments

IND 530

IND 540

NA Header Requirement Functional

159 The MNHIX will provide functionality to allowAssisters (approved by the User) to performactions on behalf of Users.

Exhibit A ExAIV(a)(2)(B)

2 1: Receiveinbound requests

IND 260 Yes Functional

160 The Contractors Solution will providefunctionality to allow a User to select a healthplan for other members of their household.

Exhibit A ExA IV(a)(2)(C )

2 20: ProcessEnrollments

IND 530

IND 540

Yes Individuals or Assistersmay select plans forothers.

Functional

161 The Contractors Solution will assist with theplan selection for employees under a definedcontribution plan, ability to use pretax dollars forthe purchase. (3, 4)

Exhibit A ExAIV(a)(2)(F)


Yes OOTB supports bothSHOP plans and definedcontributions.

Functional

162 The Contractors Solution will only allowenrollment in the appropriate metal level plansfor initial and renewal enrollment periods.(4)

Exhibit A ExAIV(a)(2)(G)


IND 530

IND 540

Yes Plan information will beobtained through Module4.

Functional

163 The Contractors Solution have the capability todisplay and selection of MNHIX health plans,making it available for Users who have notentered any User-specific information

Exhibit A ExA IV(a)(1) 2 20: ProcessEnrollments

IND 260 No Shared Transaction -Configuration to sendanonymous shopper backto Module 1 for registration

Functional

164 The Contractors Solution will allow enrollmentonly in a health plan when the applicant hasbeen determined eligible.

Exhibit A ExA IV(a)(2) 2 20: ProcessEnrollments

IND 560 Yes OOTB will allow enrollmentafter determined eligiblewith Module 1 integration.

Functional


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Transaction

Process

Model

COTS

Ind.


165 The Contractors Solution will make theselection and display of health pl

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