73050004_RFI.docx

CalHEERS System Request for Information (RFI) May 10, 2024 California Healthcare Eligibility, Enrollment, & Retention System (CalHEERS) Office of Technology and Solutions Integration 2329 Gateway Oaks, Suite 100 Sacramento, California 95833

May 10, 2024 Request for Information (RFI)

SUBJECT: RFI # 73050004, California Healthcare Eligibility, Enrollment, & Retention System (CalHEERS), System Development, Maintenance & Operations (SDMO) 1 Purpose of the RFI The California Health and Human Services Agency (State), Office of Technology and Solutions Integration (CalHHS OTSI) is releasing this RFI for the following purpose:

· Purpose 1 - Determine the level of vendor interest for an upcoming procurement for acquisition of the System Integrator (SI) for CalHEERS and identification of barriers vendors might face in responding. (See questions in section 9.1)

· Purpose 2 - Understand how vendor experience compares to important topic areas for CalHEERS. (See questions in section 9.2)

· Purpose 3 - Understand vendor needs around transition of the CalHEERS SDMO services. (See questions in section 9.3)

· Purpose 4 - Identify opportunities to improve the CalHEERS system and services, such as emerging security trends, cloud efficiency and cost optimization tools, data sharing and data fabric architecture, artificial intelligence, machine learning and newly emerging innovations, technologies, methodologies or services. (See questions in section 9.4)

Please read this RFI document thoroughly and adhere to the response submission guidelines.

Questions that are submitted for clarification under Section 4.1 of this RFI, will be considered and if needed, an addendum to the RFI will be released by CalHHS OTSI.

Please do not include any proprietary information or any specific solutions in your response to this RFI.

RFI Disclaimer The intent of this RFI is to obtain information for planning purposes and does not constitute a solicitation for goods and services. A response to this RFI is not an offer and cannot be accepted by the State to form a binding contract. Vendor completion of this RFI will be performed at no cost to the State.

Information gathered as a result of this RFI may be used in the development of an upcoming Request for Proposal (RFP) for CalHEERS SDMO services and assist the State in identifying potential issues and risks related to the requirements of the RFP.

Participants are admonished that the responses to this RFI are the property of the State and may be subject to the California Public Records Act (Government Code section 7920.00 et seq.). The State is not requesting a solution via this RFI, rather intends to validate State objectives and refine requirements for an upcoming RFP to best utilize bidder and State resources on the project.

Submitting a response to this RFI will not enhance the review of that respondent’s proposal(s) to any future solicitations. Not submitting a response to this RFI will not prohibit a response to any future solicitations, nor disadvantage the evaluation of a response to any future solicitation. By submitting a response to this RFI, a responding vendor is implicitly agreeing with these conditions.

2 Background The Affordable Care Act of 2010, known as federal health care reform, required states to establish Health Benefit Exchanges and provide the opportunity for states to expand Medicaid coverage for individuals to obtain affordable health care coverage.

The CalHEERS Project began in June 2012, with the system being implemented approximately 15 months later on October 1, 2013. The CalHEERS system development involved two project sponsors: Covered California (CoveredCA) and Department of Health Care Services (DHCS), and various program partners. CalHEERS is an automated system that supports the maintenance, operations, and on-going business of CoveredCA and DHCS in the capacity of eligibility and enrollment into insurance affordability programs through its online portals and streamlines the use of resources.

On September 16, 2019, CalHEERS executed the contract for SDMO services which finished transitioning to a new vendor in May 2020.

2.1 Understanding the CalHEERS Project

In support of our sponsor and consumers, CalHEERS validates eligibility using data interfaces with Centers for Medicare & Medicaid Services (CMS), the Internal Revenue Service (IRS), and Franchise Tax Board (FTB). Once eligibility is determined, the information in support of enrollment into eligible insurance programs is transmitted via Electronic Data Interchange (EDI) 820/834 batch transactions with contracted health and dental care plan providers.

In support of the Department of Health Care Services (DHCS) and consumers, the CalHEERS validates eligibility for Medi-Cal assistance programs Modified Adjusted Gross Income (MAGI). CalHEERS also provides data used for determining potential eligibility to other public programs such as, County Children’s Health Initiative Program (C-CHIP), Medi-Cal Access Program (MCAP), or referrals to non-MAGI Medi-Cal, California Food Assistance Program (CalFresh), and California Work Opportunity and Responsibility to Kids (CalWORKs). All information is passed via the Electronic Health Information Transfer (eHIT) with the California Statewide Automated Welfare System (CalSAWS).

3 RFI Key Action Dates and Times Listed below are the RFI Key Action Dates and Times by which actions should be taken or completed. If CalHHS OTSI finds it necessary to change any of these dates, an addendum or an updated RFI will be posted on the State’s eProcurement website:

https://caleprocure.ca.gov/pages/index.aspx

TABLE 1, RFI KEY ACTION DATES

4 Vendor RFI Instructions

4.1 Submitting Questions about the RFI

Vendors must submit questions regarding this RFI via e-mail by the specified date and time in Section 3, RFI Key Action Dates and Times. Questions should be submitted via email to the contact person listed in Section 4.3, Contact Information.

The following should be included in the e-mail inquiry:

· On the subject line of the e-mail, include: RFI #73050004, CalHEERS SDMO – Vendor Questions;

· Include the table below in the body of the email:

· Vendor name, contact person, telephone number, and e-mail address, as part of the sender’s contact information.

At the sole discretion of the State, vendors may be contacted for clarification of any inquiry received. The State may respond to questions directly to the vendor or if deemed necessary, release an updated RFI.

4.2 RFI Response Format and Submission

Responses to this RFI are due by the date and time stated in Section 3, RFI Key Action Dates and Times.

Responses must be submitted via e-mail to the State’s contact identified in Section 4.3, Contact Information, and must include the following information in the e-mail subject line: RFI #73050004 CalHEERS SDMO Response.

A vendor’s response shall contain the following:

1. A signed cover letter that includes the following:

a. Vendor name, address, and telephone number; and

b. Contact information including the name, title, address, phone number, and e-mail address of the vendor’s primary contact person for this RFI.

2. The vendor’s response to Section 9, CalHEERS RFI Questions.

Vendors are encouraged to answer all questions. If a vendor elects not to respond to a particular question, please specify why.

NOTE: Vendors must submit responses to Section 9, maintaining the numbering in the section.

Vendors shall not include marketing materials in their response.

The total response should not exceed 50 pages.

4.3 Contact Information

The RFI responses and all correspondence and/or questions related to this RFI shall be directed to the State Procurement Official:

Shannon Benton Office of Technology and Solutions Integration Phone: 916-634-2874 E-mail Address: CalHEERS_Procurement@otsi.ca.gov

5 CalHEERS Business Overview CalHEERS is a web-based system that supports a combination of public-facing and State administrator portals, backend validation, and transfer of information supporting both CoveredCA and DHCS programs. The CalHEERS key business function is to provide an integrated experience for consumers seeking healthcare and affordability assistance as follows:

· Allow consumers to respond to a single set of eligibility determination criteria either on their own via the web portal or by utilizing consumer assistance services such as:

· Selecting a Certified Assister or Certified Insurance Agent via the web portal,

· Using the online help within the Web Portal,

· Contacting a CoveredCA Service Center staff via online chat or a toll-free phone line,

· Locating and requesting assistance from their closest DHCS county assistance office, or

· Submitting an application via U.S.P.S mail or via fax;

· Serve as the single consolidated system supporting eligibility, enrollment, and retention for insurance affordability programs administered by both CoveredCA and DHCS;

· Interface with federal and state services to verify application information to support automated real-time eligibility determinations;

· Present eligibility determination results to consumers and, if determined eligible, provide options for subsidies enabling more affordable coverage for consumers;

· Electronically transfer consumer enrollment electronic verification and eligibility determination factors between the CalHEERS and CalSAWS via the electronic Health Information Transfer (eHIT) interface;

· Allow consumers to shop for health plans and make side-by-side comparisons of the different options available via CalHEERS;

· Provide Electronic Data Information (EDI) 834 transaction processing to health insurance carriers; and

· Provide financial management and carrier invoicing capabilities, including the initial and retroactive calculation of premium assessments to carriers.

The system functions are comprised of the following components depicted in the business flow diagram of the CalHEERS solution:

Figure 1: CalHEERS Business Model Overview

6 CalHEERS Architecture The CalHEERS Architecture design is aligned to the Centers for Medicare & Medicaid Services (CMS) Medicaid Information Technology Architecture (MITA) Technical Architecture and Eligibility Reference Architecture (ERA).

The CalHEERS runs in Amazon Web Services (AWS) utilizing AWS Content Delivery Network (CDN) and AWS Network Load Balancer (NLB), and AWS Storage. It has been modernized to a containerized, open source, and lightweight architecture utilizing 3 Scale Gateway + Fuse, Smarty Streets-USPS, JWS Tomcat, ForgeRock, RedHat Fuse and Aurora PostgreSQL.

CalHEERS System Request for Information (RFI) May 10, 2024 To further increase flexibility, the system uses lightweight services containerized on a Red Hat OpenShift Container platform using the strangler fig pattern. The Red Hat OpenShift platform is based on Kubernetes and includes a suite of open-source development, operations, and management tools that integrate with both AWS and the other management tools in use within CalHEERS today.

CalHEERS RFI 73050004_Final (5.2.24) Page 3 of 40

Figure 2: CalHEERS Architecture

CalHEERS System Request for Information (RFI) May 10, 2024

CalHEERS RFI 73050004_Final (5.2.24) Page 3 of 40

6.1 CalHEERS System

There are three core applications that make up the CalHEERS which support the capabilities of the CalHEERS Architecture that rely on each other for services and data.

· Eligibility – A custom application referred to as Health Benefit Exchange (HBX)

· Enrollment – A custom application referred to as Plan Choice and Assister Portal (PCAP)

· Billing Engine – A custom application referred to as Accenture Billing Engine (ABE)

The system is designed to support a flexible number of users and concurrent sessions depending on high peak public access. During the most recent annual Renewal and Open Enrollment period, the CalHEERS was configured to support 134,000 users a day with 10,500 concurrent logged on user sessions.

The CalHEERS security services perform authorization and access management utilizing ForgeRock, 3 Scale, and Fuse verification processing ensuring that consumers accessing the CalHEERS application are authenticated, authorized, and identity proofed.

The CalHEERS Decision Services engine provides encapsulation and isolation of complex business rules using Drools which is the Red Hat Decision Manager, Decision Services which is consumed real-time, and via batch for internal and external business decision automation.

The CalHEERS technical architecture represents a composition of multiple enterprise, technology, security, and systems architectures that form a best of breed framework to support all aspects of the application.

6.2 Eligibility - HBX

The Health Benefits Exchange (HBX) is a customized software product that provides the core program functionality for fulfilling the requirements of determining eligibility for insurance affordability programs, based on policy guidance from the CoveredCA and DHCS.

The consumer-facing front-end system provides access for individuals, families, and enrollment assisters to input application information for individuals applying for insurance affordability programs. This component also allows consumers to shop for health plans and make side-by-side comparisons of the different plans available in CoveredCA.

The CalHEERS solution leverages HBX, which is designed and configured to meet the business needs for MAGI eligibility processes. The HBX system from the consumer and agency perspective first does Remote Identify Proofing (RIDP) for all consumers creating accounts and accessing the system. RIDP utilizes the federal data service hub (FDSH) and Experian. If real-time RIDP is not possible, alternative methodologies employed by county social services offices, service center representatives, coupled with Experian support, provide consumers the ability to ID proof.

6.3 Enrollment - PCAP

The Plan Choice and Assister Portal (PCAP) is a custom software product that provides the marketplace capabilities for the Individual Shop and Compare, Assister Management, Plan Management, and Qualified Health Plan Agencies, Agents, and Enrollment specialists.

6.4 Billing Engine - ABE

The Accenture Billing Engine (ABE) is a commercial customized software product that provides the capabilities for the Financial Management business area. This includes billing, collections, and reconciliation.

6.5 Integration and Interfaces

The CalHEERS system supports an Enterprise Integration Architecture. The Integration Application Style uses Service Oriented Architecture (SOA) Architectural Styles, Service Oriented Modeling and Architecture (SOMA), Model Driven Architecture (MDA), and Extensible Markup Language (XML) Schema design best practices, including National Information Exchange Model (NIEM), using two methodologies: (1) Service Identification Framework (SIF) and (2) end-to-end business process analysis and modeling methodology.

The CalHEERS services adhere to the Web Services Interoperability (WS-I) standard and are based on the Service Contract Specification providing interoperability guidance for core web services specifications such as Service Oriented Application Protocol (SOAP), JavaScript Object Notation (JSON), web Services Definition Layer (WSDL), and Universal Description, Discovery, and Integration (UDDI).

Where the CalHEERS does not interconnect via web Services, the system provides reusable, non-invasive connectivity with end applications. Connectivity is provided through interface adapters that are either uni- or bi-directional with transport services supporting Hypertext Transfer/Transport Protocol (HTTP(S)) and Secure File Transfer Protocol (SFTP).

6.5.1 Carrier Support

The CalHEERS project is responsible for carrier support within the CalHEERS and includes ensuring the quality and technical accuracy of the carrier interfaces as well as supporting the carriers themselves. Support activities include monitoring, reviewing, supporting, testing, and communicating changes to the CalHEERS portal application, system interfaces, and supporting software. It also includes changes and/or upgrades to the technical architecture and infrastructure as it relates to the CalHEERS carrier interfaces to the carriers. Some of the more common support functions with carrier support include:

· Supporting Federally mandated changes with interface

· Reviewing transmission of the 834 EDI files to carriers

· Troubleshooting of the inbound and outbound TA1s/999

· Monitoring and troubleshooting data reconciliation processes

· Development of the monthly CMS carrier workbooks

· Monitoring and reporting for the CMS reports

· Supporting annual plan loading for Qualified Health and Dental Plans

· System change request and testing and validation coordination

6.5.2 CalSAWS Collaboration

The CalHEERS Project collaborates and works with the California Statewide Automated Welfare System (CalSAWS). The system provides coordination of consumer health information and request for benefits between the CalHEERS and CalSAWS. The activities include communicating changes made to eHIT and other interfaces that are used to transmit data to and from the CalSAWS system. Our CalSAWS partners are included in all aspects of the Systems Development Lifecyle (SDLC) processes.

6.5.3 Medi-Cal Eligibility Data System (MEDS) Interface

MEDS is the designated eligibility data repository for various health and public assistance programs including insurance affordability programs. The eligibility rules engine in both CalHEERS and CalSAWS sends updates to MEDS regarding the eligibility for the respective programs each system manages.

The CalHEERS to MEDS interface is comprised of both real-time web services and scheduled batch processes. Together, these systems implement the data transfer necessary to update MEDS with data collected from the CalHEERS.

6.6 CalHEERS Testing

CalHEERS is under a constant state of change supporting multiple concurrent releases providing the following types of testing including but are not limited to unit, integration, system, performance/load, end-to-end, regression, User Acceptance Testing (UAT), stakeholder/advocate testing, smoke, and Americans with Disabilities Act (ADA) compliance testing.

Significant effort is invested to support interface partner testing [CalSAWS, MEDS, EDI/834 Carrier, CMS, FTB and IRS]. There are more interface partners supported by the CalHEERS system, but they represent unidirectional/inbound data flow.

6.7 CalHEERS Batch Processing

CalHEERS supports batch processing and consists of over 200 jobs supporting plan management, billing, notices, scheduled reporting (FTB, IRS, CMS), and enrollment processing via carrier interfaces (EDI/834). Batch processing is primarily supported by Autosys, but also supplemented by CRON, database, and Enterprise Grid Management job scheduling.

6.8 CalHEERS Data Warehousing, Analytics, and Reporting

The CalHEERS Data Warehouse (DW) data management system is designed to enable and support business intelligence (BI) activities, especially analytics. The CalHEERS DW supports self-service reporting, canned reports, and dashboards across varied subject areas: Eligibility, Application, Enrollee, Enrollments, Submitted Individual, and Delegations. The high-level architecture can be divided into Information Producer, Data Acquisition, CalHEERS Data Analytics Platform, and Information Consumers. HBX and GI databases are used as source systems for Data Warehouse. Data Acquisition is handled via Extract-Transform-Load (ETL) process which will be carried out leveraging Databricks (Spark jobs using PySpark programming).

The CalHEERS data analytics Platform includes AWS S3 as data lake, Snowflake as provisional layer, Tableau as data analytics, and visualization layer.

In addition to project level reporting that are used by CalHEERS and its partners, DHCS and CoveredCA both support data warehouses that consume data feeds from CalHEERS data systems through ETL and direct connect.

6.9 CalHEERS IRS Reporting

State-Based Marketplaces (SBM) must report to the IRS on a monthly and annual basis. To support monthly/annual reporting, the SBM executes periodic processing of the business data collected in the SBM Database and generates files in the IRS-defined format.

The CalHEERS is required to adhere to CMS Business Services Definitions (BSD) and IRS §36B(f)(3) which requires monthly and end-of-year reporting for individuals or family members who enroll, in a Qualified Health Plan (QHP) through the Marketplace. To comply with these requirements, CalHEERS has a defined number of batch jobs to support this effort.

6.10 CalHEERS 1095 Processing

The Affordable Care Act added section 6055 to the Internal Revenue Code, which provides that every provider of minimum essential coverage will report coverage information by filing an information return with the IRS and furnishing a statement to individuals. The information is used by the IRS to administer – and for individuals to show compliance with – the individual shared responsibility provision in section 5000A.

The CalHEERS complies by providing all CoveredCA subscribers, active or terminated, a 1095-A form annually for tax reporting purposes. The CalHEERS annually generates approximately 1.5 million 1095-A notices. Job queuing, coordination, and communications with the CalHEERS print vendor is critical to the success of this annual effort.

6.11 CalHEERS 3895 Processing

Beginning with tax year 2020, the state of California requires residents and their dependents to obtain qualifying health care coverage, also referred to as Minimum Essential Coverage (MEC). Individuals who purchase a qualified health care plan through CoveredCA, the California health insurance marketplace, may be eligible to receive financial assistance to help pay the insurance premiums, known as the Premium Assistance Subsidy (PAS).

The amount of PAS available to a household is calculated when the taxpayer enrolled in the qualified health care plan based on the projected household income for the year. Advance Premium Assistance Subsidy (APAS) paid throughout the year will need to be reconciled at the end of the year with the actual PAS allowed based on the actual household income for the year, less federal Premium Tax Credit (PTC) amounts. The decision to provide the California premium summary is made on a year-by-year basis by CoveredCA.

The CalHEERS complies with the CoveredCA request in determining eligibility for APAS and providing the applicable tax reporting documents required to claim the subsidy on the California Tax Forms. CoveredCA subscribers, active or terminated, are provided with a 3895 form annually for tax reporting purposes. If CoveredCA opts to not provide the subsidy in any given year, CalHEERS must continue to provide access to historical documents and regenerate them for the consumers upon request.

6.12 Notifications and Print Processing Systems

As part of normal CalHEERS operations, notices and forms must be generated and sent to a variety of CoveredCA consumers. Notices are mailed to consumers to request an action be taken or to provide a status update of an individual’s application, enrollment, or eligibility. Notices are produced in identified threshold languages, Braille, and Large Font.

Consumers send application and verification documents to a dedicated PO Box or fax number for processing, and once these documents are received, they are scanned and sent to CalHEERS and become visible in the consumers case record. In addition to notices sent to consumers, CalHEERS generates MAGI notices that are sent to CalSAWS who then send them through their mail services provider for printing, stuffing, and mailing. The CalHEERS System Integrator is responsible for the performance of its subcontractor and provides direct oversight of outbound and inbound print processing.

6.13 Security Architecture

The CalHEERS enterprise security framework provides a structured approach to establish the baseline controls across the broader CalHEERS and the security functions necessary to be aware of CalHEERS’ current security posture. It also facilitates the analysis of processes, governance, interfaces, and technical capabilities employed by the CalHEERS while aligning with federal and state-level standards.

Furthermore, the framework focuses on protecting the sensitive data CalHEERS will be processing, transmitting, and storing. It is the foundation of the data protection and privacy activities in compliance with industry standards, best practices, and regulations governing data protection. The risk management and operational activities within the framework provide the necessary processes and procedures to support the data protection effort, all of which are operated within the governance and compliance structure of the framework.

Guidelines and compliance drivers CalHEERS must adhere to include IRS Publication 1075, FIPS 140-2 (Federal Information Processing Standard), and MARS-E v2.2 (Minimum Acceptable Risk Safeguards for Exchanges) which is derived from NIST SP 800-53 rev 4 (National Institute of Standards and Technology). Effective 2025, MARS-E retires and will be replaced by ARC-AMPE (Acceptable Risk Controls for ACA, Medicaid, and Partner Entities), which is derived from NIST SP 800-53 rev 5, final effective date pending.

7 Current Maintenance and Operations Services Maintenance and Operations Integrated Delivery Framework (O&M Section 1-2)

Figure 3: Maintenance and Operations Integrated Delivery Framework

The System Development Maintenance and Operations Integrated Delivery Framework identifies the four main activities or operational groups that serve as the baseline methodology for the Maintenance and Operations (M&O) Phase of the CalHEERS Project.

· Manage Service: The operational areas that define the interface between the State and the SI and govern all aspects of service delivery.

· Deliver Service: The operational areas focused on delivering specific services, which can be classified as infrastructure, application, or business process areas.

· Manage Service Delivery: The operational areas focused on verifying that an appropriate level of service and performance has been and is being provided.

· Support Operations: The operational areas that provide tangible resource support to the other operational areas.

SDMO team members are responsible for implementing, maintaining, and continuously improving the material in each operational area as the project grows and matures.

The CalHEERS mission is to provide an integrated eligibility, enrollment, and retention solution that supports our sponsor organizations in delivering health services to consumers in collaboration with business partners throughout California.

To support the SDMO, the CalHEERS project is a 24/7 support structure utilizing both on-shore and off-shore resources.

The CalHEERS team consists of State and contractor staff which is flexible to address the sponsor initiatives and provide ongoing System maintenance and operations. The current staffing levels are reflected in the diagram below:

Figure 4: Layout of CalHEERS Team

7.1 Development Approach

The CalHEERS software development approach currently leverages the methodology, activities, and outcomes described across each phase of the System Development Lifecycle (SDLC) depending on the Waterfall/Agile/Hybrid approach taken for the respective effort. Each development approach has a focus on human centered design, user experience, and decision logic.

The CalHEERS software development approach utilizes a methodology tailored for designing, developing, testing, implementing, operating, and maintaining of the CalHEERS Project. Once the development team has completed building the code, it goes through various quality gate checks starting with running SonarLint plugin on developers’ machine, SonarQube rules on the assembly test environment, security vulnerability scans through Static Application Security Testing (SAST), and Dynamic Application Security Testing (DAST) scans using Fortify tool.

Code developed by CalHEERS development team is tested in several phases for quality assurance.

All IP addresses used in CalHEERS applications are referenced using name resolution and are not hardcoded in the code.

The CalHEERS application development team follows coding standards while implementing changes to the application. Most updated coding standards are documented in a Code Review checklist. CalHEERS development team leads review code changes done for every system modification (SM) in accordance with the code review checklist.

The CalHEERS SDLC is composed of both waterfall and agile/iterative development methodologies.

There are five types of releases that occur as part of the release management process.

· Feature Release – Implementation of new features, change requests, enhancements, and technical configurations but can include defect fixes.

· Maintenance Release – Implementation of defect fixes.

· Data Warehouse Only Release – Two types: Data Warehouse Expedited Sprint Release and Data Warehouse Priority Release

· Agile Release – Agile Releases includes New Functionality Change Requests (CRs) which will follow Agile CR process and defects.

· Priority Release – Implementation of critical defect fixes and workarounds in order to address urgent business needs.

Each calendar year, the SI and the State agree on the cadence of the release of code into the CalHEERS production environment. The types of releases supported are Feature Release, Maintenance Release, Data Warehouse Only Release, Agile Release and Priority Release. Additionally, the project supports multiple Priority Releases that are restricted in scope which do not impact our partners but allow the project flexibility for change and defect fixes throughout the year.

8 CalHEERS Future Contract and Roadmap Under the direction of the CalHEERS sponsors (CoveredCA and DHCS), CalHHS OTSI is currently in contract with Deloitte Consulting, LLP (DLT) for enhancement and M&O of CalHEERS. The existing SDMO Contract expires in June 2027. The State intends to conduct a competitive procurement for the next SDMO contract, which will provide for continued enhancement and M&O of CalHEERS, providing a system with continued flexibility to meet the needs of California.

The anticipated term of the next contract will be within the range of five (5) to ten (10) years.

8.1 Potential System Changes/Enhancements

Potential system changes/enhancements planned for the next contract may include:

· State and/or Federal statute changes

· Sponsor-driven program changes

· State and/or county business process or system improvement changes

· Interface changes

· Infrastructure changes (e.g., upgrades)

· Changes related to maturing the system

· Staffing requirements to support current and future system functionality

· Reduction of downtime for system maintenance

· Advancements in sponsor/project reporting offering more self-service capabilities to operational and analytical data

· Alignment to MITA 3.0 Framework for business, technology, architecture, and data

· Reports and forms changes

· Taking advantage of SOA and APIs

· Assess and recommend more efficient and less costing cloud hosting options

· Self-service opportunities

· Enhanced mobile access supporting various platforms and interfaces

· Consideration of other software development methodologies

8.2 CalHEERS Vision and Roadmap

The CalHEERS vision statement is:

CalHEERS will provide a consumer-friendly experience and support the right benefit design and choices, with correct eligibility, and result in efficient work processes for the workforce.

Five business goals were identified to support prioritization of CalHEERS:

· Ensure consumers receive accurate and timely eligibility determinations and correct plan enrollment initially and during any change or renewal event

· Ensure business partners are able to receive, exchange and reconcile appropriate consumer information on a timely basis

· Appropriately equip authorized end users with tools necessary to serve consumers effectively and to handle exception situations

· Provide consumers and end users with an improved consumer experience

· Ensure the technical infrastructure is properly maintained, current, secure, and supports capacity demands and completion of business goals. [footnoteRef:2] [2: IAP 24 Month Roadmap Overview http://www.dhcs.ca.gov/Documents/IAP_24_Month_Roadmap_Overview.pdf]

The CalHEERS Insurance Assistance Program (IAP) 24 Month Plan Roadmap can be found at the following location: https://www.dhcs.ca.gov/Pages/AB1296EligibilityExpansion.aspx

8.3 Transition of Maintenance and Operations Services

The following describes an initial list of SDMO Services to be provided in the next contract:

· Project management and Organizational Change Management

· Maintenance via change requests

· Maintenance (program support)

· Operations support

· Transition-in/out

· System requirements management

· Deliverables

9 CalHEERS RFI # 73050004 Questions

9.1 Purpose 1 - Vendor Interest and Barriers to Responding to a Future Request for Proposal (RFP)

1. Please indicate whether or not your company would consider bidding on a future CalHEERS SDMO RFP for services described in this RFI.

2. What are the barriers that would prevent your company from responding to a future RFP and recommend how the State might remove those barriers?

3. Given the State’s current hybrid workplace environment, how would this impact your company’s ability to respond to a future RFP?

4. Please describe the documentation that your company would need in a Bidders’ Library to develop a response to a future RFP?

5. Partnerships - What existing partnerships do you currently have that could be utilized to bring newer technologies or services to the CalHEERS?

9.2 Purpose 2 - Understand How Vendor Experience Compares to Important Topic Areas for CalHEERS.

Given the importance of the topic areas below, how would you characterize your company’s qualifications and what qualification recommendations, if any, would you offer that the State should consider adding to the future CalHEERS RFP?

a. Consumer & Agent/Assister facing

b. Available (24x7) x365 and 99.999% uptime

c. Multiple interfaces & data exchanges

d. Subject to seasonal demand

e. Hosted within cloud services

f. Solution Specific – Maintaining industry standard, innovative software solutions focused on those executing in the cloud and via open source (including database, identity management, business rules engine, business process management, etc., as shown in Figure 2 above).

9.3 Purpose 3 – Vendor Transition Needs

1. Given a one (1) year period of overlap with the final year of the incumbent contract, what assumptions, constraints and risks related to transition would you identify when considering submitting a response to a future RFP?

2. What information would you find relevant to be included as part of the Incumbent Contractor’s Transition-Out plan (executed within the final year of their contract)?

9.4 Purpose 4 – Opportunities to Improve the CalHEERS System and Services

1. Security – With the composition of CalHEERS including 3rd party interfaces, subsystems, software as a service (SAAS), platform as a service (PAAS), print venders, and a service center, what emerging cybersecurity solutions, innovations, or protocols does your company recommend, taking into consideration the trends of implementing Artificial Intelligence (AI) and the increased threat of cybercrime?

2. Cloud – What technologies or innovations should the State consider for improving Cloud efficiencies (solution and cost)?

3. Artificial Intelligence (AI) - What technologies or innovations in the areas of data sharing, data fabric architecture, AI, and machine learning should the State consider for improving CalHEERS?

4. Emerging Technology & Innovation - What newly emerging technologies or innovations should the State consider for CalHEERS?

5. What other services would your company like the State to consider adding to assist in the State’s development of a future CalHEERS RFP?

6. What public/private experience do you have with both monitoring customer behavior and refining a solution for improved user experience and customer conversion (e.g., streamlining decision making, nudging, etc.)?

7. What experience does your company have with improving the consumer experience via enhancements to the consumer journey, user interface, and choice architecture of a solution?

8. What experience does your company have with providing Call Center services, including service center and Interactive Voice Response (IVR) solutions?

9.5 Wrap Up

Please share any feedback, suggested requirements, or other information your company would consider important for the State to consider with respect to the CalHEERS project and its procurement of SDMO services.

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D-4.1-1 - DEL - Strategic Plan_V6.0.pdf

California Healthcare Eligibility, Enrollment, and Retention System

(CalHEERS)

D-4.1-1 – DEL - Strategic Plan March 13, 2023

Version 6.0

CalHEERS Project March 13, 2023

D-4.1-1 – DEL – Strategic Plan Version 6.0

Table of Contents

1. INTRODUCTION AND BACKGROUND

1.1 Message from the Director

1.2 Introduction

1.3 Accomplishments

2. REQUIREMENTS

3. STRATEGIC PLAN PROCESS AND APPROACH

3.1 Leveraging The Zoom Out and Zoom in Framework

4. ZOOM OUT

4.1 Mission and Vision

4.2 Future of State-Based Marketplaces and the Health Care Market

4.2.1 Five Key Disruptors in the Future of Health Care

4.3 Focus Areas

5. ZOOM IN

5.1 Strategic Priorities

5.2 Action Plans

5.2.1 Focus Area 1: Be secured, faster, better, and cost-effective

5.2.2 Focus Area 2: Continue to operate as “one team”

5.2.3 Focus Area 3: Enable innovation and continuous improvement

5.3 Action Plan Activity Timeline

6. CONCLUSION

7. ASSUMPTIONS, CONSTRAINTS, AND RISKS

7.1 Assumptions

7.2 Constraints

7.3 Risks

8. APPENDIX

8.1 Strategic Planning Sessions

Table of Figures Figure 1: 2022 Accomplishment Highlights Figure 2: Strategic Plan Development Process

Figure 3: Overview of New Strategic Priorities and Updated Sections Figure 4: Strategic Plan Blueprint (Each corresponding step in the CalHEERS Strategic Plan development process increases in level of detail) Figure 5: CalHEERS Strategic Plan Mission and Vision Figure 6: Five key disruptors in the future of health Figure 7: CalHEERS Focus Areas Figure 8: CalHEERS Focus Areas and Strategic Priorities 2022-2023 Figure 9: Action Plan Matrix Diagram Figure 10: Action Plan Activity Timeline

Table of Tables Table 1 Strategic Priority 1 Table 2 Strategic Priority 2 Table 3 Strategic Priority 3 Table 4 Strategic Priority 4 Table 5 Strategic Priority 5 Table 6 Strategic Priority 6 Table 7 Strategic Priority 7 Table 8 Strategic Priority 8 Table 9 Strategic Priority 9 Table 10 Strategic Priority 10 Table 11 Strategic Priority 11 Table 12 Strategic Priority 12 Table 13 Strategic Planning Sessions

1. INTRODUCTION AND BACKGROUND

1.1 Message from the Director

The California Health Care Eligibility, Enrollment, and Retention System (CalHEERS) celebrated its 10th Open Enrollment period in 2023 with a record-breaking 1.9 million Californians selecting a health care plan. CalHEERS has served as a trusted source for affordable, high-quality health care for one-in-three Californians by streamlining resources for people and businesses to shop, compare, and identify health coverage that meets their unique needs. Over the past year, the CalHEERS Project reached several milestones and accomplishments including:

• Successful 2023 Open Enrollment (OE) with a stable system that saw more than 5.8M users visiting CalHEERS since the start of OE with more than 72,000+ users at peak.

The high-performing and stable system provided a positive experience for users with 46% fewer tickets this OE compared to last year and zero critical or serious incidents.

• Elevated the security posture of the CalHEERS Platform to safeguard the privacy and security of millions of Californians through the migration of 9.5 million users to a modern secure solution that improves technical and operational efficiency, while improving the end user experience with faster performance.

• Modernized our technology platform to make CalHEERS more secure, nimble, modular, and flexible to handling new changes and respond quickly to the evolving needs of consumers and regulatory updates.

• Continued to invest in analytics to drive decision making about research priorities and better understanding user behavior through data.

• Prioritized research to drive and deliver user-centric changes that reflect the unique needs of Californians through Human Centered Design (HCD) initiative that drive insights that serve as the foundation for future design changes to improve CalHEERS.

• Continued to focus on innovation by bringing together Project leaders, Sponsors and key stakeholders to explore the art of the possible and learn from leading technology companies across California.

As we revised the CalHEERS Strategic Plan for 2023 and beyond, our Project has been reminded of the tangible progress we have collectively made toward reaching our vision of becoming the most customer centric portal and a trusted leader in providing health care to Californians. We look forward to building on this momentum and continue innovating and modernizing the platform to better serve the millions of families and small businesses that rely on CalHEERS every year.

Yours in partnership, Acting Project Director and Deputy Project Director

1.2 Introduction

The CalHEERS Strategic Plan is a living document that serves as a roadmap and guide to implement, support, and track progress across thirteen Strategic Priorities. The goal of the Strategic Plan is to align resources and efforts across the CalHEERS Project to deliver industry-leading health care to Californians by focusing on three major Focus Areas:

1. Be secured, faster, better, and cost-effective

2. Continue to operate as “one team”

3. Enable innovation and continuous improvement

The 2023-2024 CalHEERS Strategic Plan revision is the third update of the formal deliverable which first began in 2021. The Strategic Plan revision process confirms the Project’s alignment with the broad objectives and values of CalHEERS Project Sponsors and trusted stakeholders and partners. CalHEERS Project Sponsors include Covered California (Covered CA) and the California Department of Health Care Services (DHCS). The CalHEERS ecosystem includes a variety of important stakeholders and partners including the California Office of Systems Integration (OSI), County Welfare Directors Association (CWDA), California Statewide Automated Welfare System (CalSAWS), and the Service Employees International Union (SEIU).

Together as “one team,” the CalHEERS ecosystem is focused on innovating and delivering a customer-centric portal that meets the unique needs of millions across the Golden State.

In addition to the annual revision, the Strategic Plan includes quarterly progress reports updated by Strategic Priority owners at Project Governance Joint Management Meetings (JMM).

Quarterly progress reports actively measure progress toward Strategic Priorities through a “one team” effort with OSI and leaders where updates are compiled and communicated across the CalHEERS ecosystem.

The Strategic Plan also provides Project teams with a means to navigate, prioritize, and align resources, partners, and our organizational culture toward common goals and objectives. The value and benefits of a comprehensive CalHEERS Strategic Plan allow CalHEERS to:

• Measure and evaluate progress against Strategic Priorities and outcomes,

• Account for changing conditions in the broader health care landscape evaluating major disruptors and key trends in the marketplace,

• Leverage ongoing updates to revise tactics, make key investments, and determine areas ripe for innovation, and

• Communicate accomplishments to Sponsors and key stakeholders at a regular cadence.

Lastly, the Strategic Plan aligns with the System Development, Maintenance & Operations (SDMO) Project Workplan and provides an overview of major activities and Strategic Priorities over the next two calendar years. Some key additions included in this year’s revision include two new strategic priorities focused on security and health equity; and an updated perspective on the future of State-Based Marketplaces and key disruptors affecting the health care sector.

1.3 Accomplishments

The CalHEERS Project continues to build momentum as it innovates and modernizes the platform to meet the unique needs of our Project Sponsors and Californians. 2022 was marked by several major highlights and milestones including a successful 10th Open Enrollment and innovative improvements in security and technology. The following list (Figure 1) represents key highlights and accomplishments from 2022 categorized by Strategic Plan Focus Area.

The first step in the Strategic Plan development process begins with a series of “pre-work” sessions with CalHEERS leadership to review major updates and align on a broad approach toward revising the document. The next step looks at the strategic materials of Project Sponsors, Covered CA and DHCS, along with Center for Medicare and Medicaid Services (CMS) and the Center for Consumer Information and Insurance Oversight (CCIIO). This year, the first phase resulted in major updates to the Strategic Priorities including the addition of two new priorities and a streamlined approach that addressed redundancies. The two new Strategic Priorities focused on security (Strategic Priority 1) and health equity (Strategic Priority 9).

Moreover, feedback generated through the quarterly progress reports identified redundancy among several priorities which resulted in streamlined priorities focused on Project communications (Strategic Priority 5) and a priority focused on optimizing the use of Project resources to meet the needs of Sponsors (Strategic Priority 8). The collaborative working sessions with CalHEERS leadership leveraged existing meetings and reviewed inputs ranging from the SDMO workplan, the Statement of Work, the 24-month Strategic Roadmap, and other sources including feedback from quarterly progress reports. The result produced 12 Strategic Priorities categorized across three Focus Areas that sharpen the CalHEERS approach toward measuring and tracking progress.

In addition to leadership discussions, the Project reviews strategic materials from CalHEERS Sponsors including DHCS and Covered CA such as Strategic Plans, Annual Reports, and other related documents that illustrate Project Sponsors’ objectives and values. Beyond Project Sponsors, CalHEERS also reviewed Center for Medicare and Medicaid Services (CMS) and the Center for Consumer Information and Insurance Oversight (CCIIO) guidance and frameworks to inform the key disruptors section of the Strategic Plan. These materials are leveraged throughout the revision process to ensure CalHEERS is aligned to our Project Sponsors’ strategic priorities such as prioritizing health equity, improving the consumer experience, and making innovative investments in security and technology.

Figure 3: Overview of New Strategic Priorities and Updated Sections

The Strategic Priorities are further refined and developed by Strategic Priority owners with input and feedback from State Chiefs. The Strategic Priorities include related activities and key performance indicators (KPIs) that are updated so that they remain relevant and meaningful.

Concurrently, research is completed on the disruptors and future of state-based marketplaces, located in section 4.3. This section provides CalHEERS with a forward-looking outlook of potential trends that may affect the Project and are relevant to keeping CalHEERS abreast of the emerging disruptions ranging from new technologies to macroeconomic forces. As a living document, the CalHEERS Strategic Plan consistently tracks progress through quarterly progress reports that are communicated across the Project ecosystem. The Strategic Plan is shared at project governance meetings including the Project Steering Committee (PSC), Joint Management Meetings (JMM), and through the CalHEERS Connection newsletter which is shared with Project Sponsors, key stakeholders, and partners.

3.1 Leveraging The Zoom Out and Zoom in Framework

The CalHEERS Strategic Plan leverages the Zoom Out and Zoom In strategic planning approach as an organizational framework. The Zoom Out and Zoom In framework leverages two parallel time horizons to focus on different levels of detail: Zoom Out at 3-5+ years and Zoom In at 6 to 24 months. By directing the attention of CalHEERS toward activities within these two different time horizons, CalHEERS can realize immediate strategic impacts and reach long-term objectives.