Project Approach & 2012 Release Plan - SERFF · 5/3/2012 · © 2012 National Association of Insurance Commissioners Project Approach & 2012 Release Plan Bridget Kieras, Manager

© 2012 National Association of Insurance Commissioners

Project Approach & 2012 Release Plan

Bridget Kieras, Manager III, SERFF/OPTins

Jon Sink, Business Analyst II, SERFF/OPTins

May 3, 2012


Release Timeline - 2012

• Summer – Release for EHBs and State Generated Messages

• 3rd Quarter – Potential Release for Configuration Features

• December – Major Release for QHP Submission and Review



• 1st Quarter – Potential Release(s) for Additional QHP Certification Features

• 2nd & 3rd Quarter – Release(s) for QHP Renewal and Decertification

• 4th Quarter – Potential Release(s) for Additional Features for all KBRs


Other Activities

• Training for states and insurers

• Implementation activities

• Support for integration points

• Continued development of business requirements

• Outreach and education for stakeholders

• Regression testing for existing functions


Integrating with SERFF

• Separating processes to minimize risk to either SERFF or the Plan Management module

• Integration should be virtually seamless, although plans and filings will be segregated

• Reusing concepts to minimize analysis and development efforts and decrease training needs


What It Means

• Single login for SERFF users, but similar functions for plans and filings may be separate

• Filing concepts can be reused for plans, but this is not required

• SERFF and the Plan Management module can be released independently


Prioritizing Features

• Project team works with various stakeholders to identify, define, and prioritize features

• Prioritization is an ongoing process

• Tackle the critical and high priority features first

• Always keep Exchange milestones in sight


Defining Priorities

• Critical – Feature or activity is crucial for Plan Management and there is no viable alternative

• High – Feature or activity is crucial for Plan Management but has viable (if not ideal) alternative


Defining Priorities

• Medium– Feature or activity is important for Plan Management but has acceptable alternative

• Low– Feature or activity is beneficial but not necessary to Plan Management


Organizing Features

• Features are organized by Key Business Requirements (KBRs)

• Fifteen KBRs outlined in project scope

• Features for a given KBR may span releases

• Features may be referred to as activities, use cases, or user stories


Delivering Functionality

• Define requirements through collaboration with stakeholders

• Use mock-ups, prototypes, and other tools to illustrate functionality

• Work iteratively, revisiting and refining as requirements and guidance evolve


Testing Opportunities

• Most testing will be done by the SERFF Project Team

• Web services or other integration services will be tested in a Beta environment

• User acceptance testing will be constrained by time and resources


Critical Features

• Included in releases between now and December 2012

• Focus on KBRs 1, 2, 3, 4, 5, 6, 12, 13, 14, and 15

• Based on what we know today and may change

• Many of these in development, even though requirements and guidance still evolving


KBRs with 2012 Deliverables

• KBR 01 – Standards (Filing Rules)

• KBR 02 – State Configuration & Settings

• KBR 03 – QHP Submission

• KBR 04 – QHP Data

• KBR 05 – Industry Reusability


KBRs with 2012 Deliverables

• KBR 06 – QHP Review & Certification

• KBR 12 – Security

• KBR 13 – Web Services & Integration

• KBR 14 – Ancillary Features

• KBR 15 – SHOP


Remaining KBRs

• KBR 07 – Plan Renewal

• KBR 08 – Plan Changes

• KBR 09 – Decertification

• KBR 10 – Compliance

• KBR 11 – Operational


KBR 01 – STANDARDS

The system shall provide functionality to publish and view state and federal standards related to QHPs and other Exchange business functions.


KBR 01 Critical Elements

• Ability for states to configure or describe their requirements for QHPs, including Essential Health Benefits and submission instructions

• Ability for insurers to review state QHP requirements prior to and during plan submission

• Adherence to federal regulations


QHP General Instructions

• Highly flexible tool for states to provide information and instructions to insurers

• Will act as a container for other components, like the Essential Health Benefits

• Likely to start simple and enhance through successive releases


KBR 02 – STATE SETTINGS

The system shall provide the states with the ability to configure the features offered as part of SERFF Plan Management.



• Ability for states to enable Plan Management

• Tracking of Exchange model used by participating states

• Configuration for payment of QHPs via Electronic Funds Transfer (EFT)


Enabling Plan Management

• SERFF support team will work with states on enabling Plan Management

• Exchange Model setting may impact some functions, including integration points

• State instances not using Plan Management will not see Plan Management features


Collecting QHP Fees

• States will have a setting to indicate whether they charge fees for QHPs

• States can provide textual instructions related to fee submissions


KBR 03 – QHP SUBMISSION

The system shall allow insurers to construct a QHP submission based on

SERFF filings.



• Ability for insurers to build QHP filings, including holding in draft and submitting

• Validations on required data and attachments

• Support for state specific requirements

• Cross reference to approved forms


Creating a QHP

• ‘Plans’ will be a new type of submission, distinct from ‘filings’

• Insurers will use a wizard to create a plan

• Data and attachments will be different, but workflow will be like filings

• Insurers can hold plans as draft until they are ready to submit


Referencing Forms

• Insurers will have the ability to list one to many forms to be used with the plan being filed

• The plan submission will have links to these forms if filed in SERFF

• This may be extended to Rate Schedule Items and Supporting Documentation


State Specific Requirements

• At a minimum, insurers will have the ability to create new ‘Supporting Documentation’ for a filing

• States can provide guidance on format and content of these attachments as needed

• Intent is to offer flexibility to meet a wide variety of needs


QHP Validations

• Fielded data must be of proper type and length

• Required fields must be populated

• Rate and Benefit files must be included and must meet format and validation rules


KBR 04 – DATA

The system shall allow insurers to supply the full range of QHP data needed for certification and eventual inclusion on an Exchange.



• Collecting benefit and rate data necessary to certify QHPs and populate the Exchange portal

• Standardizing data definitions and file layouts


Data Collection

• Exploring both XML and Excel options

• Insurers will upload files to specified locations on a plan, via the SERFF web interface


Standardization

• Working with states, insurers, and CCIIO to define the data elements necessary for a QHP

• Data may be collected in uploaded files or via fields in SERFF

• Data must be standardized if it is to be shared and understood across systems


KBR 05 – INDUSTRY REUSABILITY

The system shall allow insurers to configure reusable company and plan

information.



• Collect of additional data elements related to the company entity offering the plan

• Minimize duplicate data entry for insurers


Company Attributes

• HHS Issuer ID will be moved to company profile

• Discussing validation strategies with CCIIO

• Additional attributes, such as websites and consumer hotlines, being discussed


KBR 06 – QHP REVIEW

The system shall provide functionality to allow state regulators to review QHPs and provide a determination on their suitability for the Exchange.



• Navigation between rate/form filings and plans

• Ability for states to track and manage plan submissions

• Functionality to support communication and correction of issues by insurers

• Ability for states to certify plans according to state specific needs


Navigation

• Plans will have references to supporting forms, and possibly rate/rule and supporting information

• States will see related form status directly on the plan

• Hyperlinks will support navigation between filings and plans


Managing Plans

• State and insurers will have views and search features to find and track plans

• Basic updates and reviewer/author assignment will be available


Correspondence

• Ability for states to communicate issues to insurers

• Ability for insurers to make corrections and updates to fielded data and attachments


Certification

• Two step process to allow distinction between approval and certification

• Ability for users to perform one or both functions

• Communication of status to insurers and Exchanges


KBR 12 – SECURITY

The system shall provide additional security to control access to data and

functions.



• Ability for states and insurers to control which users can submit QHPs, authorize fees, certify plans, or take other actions

• Ability to limit access to data to authorized users


QHP Roles

• Create and Submit QHPs

• Review QHPs

• Read-Only

• Certify QHP

• Transmit to Exchange


Data Security

• Data in SERFF protected by user authentication

• Users restricted to certain sets of data based on roles and ‘instance’ access


KBR 13 – WEB SERVICES

The system shall provide secured web services and/or other mechanisms to allow Exchange applications to retrieve data from SERFF or send data to SERFF.



• Ability for stakeholder systems to share data for Plan Management functions

• SERFF will both send and receive data

• Each state Exchange will have different needs

• CCIIO, as the facilitator of some Exchanges, will have specific requirements


Sharing Data

• Passing of data between systems will be facilitated by the established standards

• Web services the anticipated method for state Exchanges to send and receive data


Two Way

• SERFF will collect plan data and send it to Exchange systems

• Exchange systems will return data to SERFF, including confirmations and status updates


KBR 14 – ANCILLARY FEATURES

The system shall support normal form/rate review functions for plans in a

manner similar to the way filings are supported.



• State fees can be collected electronically

• System logging of all key milestones

• Search and views of plans


Collecting Fees

• State fees can be collected electronically

• Will have option to reference a check payment

• Insurers and states will have a report reflecting all money sent and received

• Functionality to support sending additional fees post-submission will be in place


Logging

• Logging of…. – Submission of plan

– Correspondence sent

– Certification of plan

• User will have view of all logged events on plan

• Helpful for tracking and reporting


Search & Views

• Basic search functionality will be in place to aid in finding plans

• Views in the SERFF workspace will be implemented – Sortable columns

– Open plans for insurers

– Assigned plans for states


KBR 15 – SHOP

The system shall provide functionality to support both individual and small group market plans (SHOP).


Individual vs. SHOP

• No significant difference in the submission or review process

• Expected differences in mid-year plan changes

• Analysis will continue to be done, and development will be specific when warranted


Keep up to date on SERFF’s Plan Management project at

http://www.serff.com/hix.htm

Preparing for 2013: Issues and Planning

Bridget Kieras, Manager III, SERFF/OPTins

May 3, 2012


• 1st Quarter – Potential Release(s) for Additional QHP Certification Features

• 2nd & 3rd Quarter – Release(s) for QHP Renewal and Decertification

• 4th Quarter – Potential Release(s) for Additional Features for all KBRs

2013 Critical Path

• Complete any high priority features for QHP Certification not released in 2012

• Complete critical and high priority features for QHP Renewal and Decertification

• Complete critical and high priority features for other Exchanges operations, as needed

• Introduce additional features by priority

KBR 01 - STANDARDS

The system shall provide functionality to publish and view state and federal standards related to QHPs and other Exchange business functions.

KBR 01 Decisions & Issues

• Critical and high priority needs met in 2012

• At this time, TOIs and Sub-TOIs are believed unnecessary for plan submission

• The need for Submission Requirements is expected, but may not be delivered by December

KBR 01 Enhancements

• Expanded support for configuring EHBs and state mandated benefits

• More searching and sorting features

• Refinement of QHP General Instructions

• Closer integration with Filing Rules for standard filing submissions

KBR 02 – STATE SETTINGS

The system shall provide the states with the ability to configure the features offered as part of SERFF Plan Management.


• Fee amounts will not be automatically calculated

• Undetermined whether ability to direct QHP fees to a separate account than filing fees will be delivered by December

KBR 02 Enhancements

• Additional settings to control and streamline workflow

• More configuration options for accepting additional data sets

• Increased visibility of state differences to insurers

KBR 03 - QHP SUBMISSION

The system shall allow insurers to construct a QHP submission based on

SERFF filings.


• Multi-state plan creation may not be available by December

• Considering options for dealing with forms filed on another industry instance

• Uncertain if Submission Requirements will be delivered by December

• Considering options for transaction fees

QHP Transaction Fees

• Hoping to implement a less complex transaction model for QHPs

• Considering a flat transaction fee per submission

• Discussing ability to collect transaction fees via EFT (ACH Debit) at submission vs billing monthly

KBR 03 Enhancements

• Increased validation of uploaded data sets

• Enhanced support for Exchange contacts

• QHP State Specific Fields

• Ability to clone a QHP for resubmission

KBR 04 - DATA

The system shall allow insurers to supply the full range of QHP data needed for certification and eventual inclusion on an Exchange.


• Detailing data elements of benefits and rates is ongoing

• Unsure what additional data sets may need to be collected in SERFF

KBR 04 Enhancements

• Enhanced validation for uniform data sets, including rates and cost sharing

• Collection of additional data or data sets, as needed

KBR 05 - INDUSTRY REUSABILITY

The system shall allow insurers to configure reusable company and plan

information.


• The role of ‘Product’ as a way to organize data has not been determined

• Some reusability features may need to be postponed until after the December release

KBR 05 Enhancements

• Additional attributes for companies and contacts

• More reusability features for data sets and other common elements of a QHP filing

KBR 06 - QHP REVIEW

The system shall provide functionality to allow state regulators to review QHPs and provide a determination on their suitability for the Exchange.


• Correspondence will be similar to filings, but may not be as robust in early releases

• Some correspondence may still happen outside of SERFF

• Different workflows by state or Exchange model will need to be supported

KBR 06 Enhancements

• Additional correspondence options or controls for QHPs

• Tighter integration between filings and QHPs

• More tools support for state specific workflows

KBR 07 – QHP RENEWAL

The system shall support the processes of QHP renewal/recertification and

voluntary withdrawal of a plan from the Exchange.


• The ability for an insurer to request and a state to process QHP renewals

• Support for voluntary withdrawal of a QHP from an Exchange after certification

QHP Renewal

• Process anticipated to be similar to QHP Initial Certification

• Functionality to support reuse of existing QHP components will ease the process

• Federal and state timelines may vary

Voluntary Withdrawal

• Support allowable voluntary withdrawals

• Anticipate insurer initiates and state or Exchange (or both) must acknowledge or approve

• Potentially needed during first plan year

KBR 08 – PLAN CHANGES

The system shall support the process of filing plan changes outside of the annual renewal/recertification window.


• Recognition of allowed plan changes

• Support for differences in allowed plan changes by market type (individual or SHOP)

• Controls on submission and approval of plan changes within these constraints

Plan Changes • Allowed changes will be different for

individual vs small group plans

• Will need to assess impact of changes related to Rate/Form filings

• Multiple avenues may be available depending on the type of change

KBR 09 - DECERTIFICATION

The system shall support the process of decertification of an insurer and/or one or more of an insurer’s plans.


• Decertification is a regulatory action

• Decertification can happen at the insurer or the plan level

• Decertification may not be an activity that happens in SERFF, but SERFF will need to know and respond to decertification actions

Decertification

• Implementation of a user interface control to indicate decertification, with supporting date and comments fields

• Web services to allow authorized applications to advise SERFF of a decertification

• Updates to QHPs when the insurer is decertified

KBR 10 – COMPLIANCE MONITORING

The system shall support the necessary functions or information needs related to monitoring compliance and enforcement agencies.

Compliance Monitoring

• Scope of compliance monitoring has not been fully defined

• Anticipate SERFF would support compliance monitoring with existing or additional data collection and/or processes

• Supporting data provided via web services and/or reporting functions

KBR 11 – OPERATIONAL DATA

The system shall support necessary functions or information related to collecting operational data.

Collecting Operational Data

• Scope of operational data has not been fully defined

• Anticipate SERFF would support this function with existing or additional data collection and/or processes

• Supporting data provided via web services and/or reporting functions

KBR 12 - SECURITY

The system shall provide additional security to control access to data and

functions.


• Existing granularity of SERFF roles and permissions will be extended to QHPs processes

• Existing controls over access to data are sufficient for QHP processes

• All core security measures will be implemented by December 2012

KBR 13 - WEB SERVICES

The system shall provide secured web services and/or other mechanisms to allow Exchange applications to retrieve data from SERFF or send data to SERFF.


• Web services are preferred data exchange mechanism for NAIC applications

• Differing Exchange data needs will be a challenge

• Uniform data package and push model API being proposed for state Exchanges

Uniform Data Package

• Define a consistent set of data to be transmitted for all state Exchanges

• Recipient systems will process and persist only the data they need

• State DOIs may act as an intermediary to adapt data for a state Exchange

Push Model API

• Avoids resource intensive and inefficient ‘polling’ mechanisms

• SERFF user role has control over timing of the transmission

• Supports multiple transmissions if needed

• Entire plan sent with each transmission

Partnership & FFE Exchanges

• Working closely with CCIIO to define special needs and requirements for FFE and Partnership Exchanges using SERFF for QHP Certification

• Integration points and business processes may be different from state Exchanges

KBR 14 - ANCILLARY FEATURES

The system shall support normal form/rate review functions for plans in a

manner similar to the way filings are supported.


• SERFF has a number of tools and features that support filing activity

• These can be expanded to QHPs where it makes sense

• Timing will be according to effort and priority

KBR 14 Enhancements

• Expanded Search and Views for QHPs

• Messaging for QHP actions and updates

• PDF Pipeline for QHPs

• Support for Public Access on QHPs

• Export Tool and Reporting Options

KBR 15 - SHOP

The system shall provide functionality to support both individual and small group market plans (SHOP).

SHOP Requirements

• No significant differences in the submission or review process have been identified

• Analysis will continue and development will be specific when warranted

Questions?



SERFF Project Q&A


Plan Management Data in SERFF

Bridget Kieras, SERFF Manager III

May 3, 2012


Importance of Data

• QHP review process will be more data intensive

• The data collected will help populate the consumer shopping portal

• Reports will be needed to monitor QHP and Exchange operations


Data Challenges

• Data will be coming from a number of different sources

• Data collected for QHP will need to be shared across applications

• Insurers and states have a variety of processes and business needs


Standardizing Data

• Technology Study Group (TSG) discussions around data definitions and issues

• Consultation with states working on Exchanges

• Guidance from CCIIO

• Input from consumer advocacy groups, vendors, and other interested parties


Uniform Data Sets

• Insurer

• Plan/Product

• Benefits and cost sharing

• Rates

• Formulary

• Quality Data


Supporting State Specific Needs

• Allow states or state Exchanges to individualize data collection and processes

• Support needs of Exchange operations handled by CCIIO

• Minimize burden to insurers


Potential State Differences • Requirements to facilitate review of

rates and forms and certification of QHPs

• Data collection outside of SERFF supported file uploads

• Review and certification workflows and division of responsibilities


Data Collection Methods

• SERFF Application Fields – User entered – System generated

• XML – Validation of the format – Display to user

• Excel – Standard templates


Processing the Data


Questions?

Keep up to date on SERFF’s Plan

Management project at



Updated Project Scope and Timeline

Joy Morrison, Asst Dir., SERFF/OPTins

May 3, 2012


Exchange Components

• Exchanges have five components: • Eligibility

• Enrollment

• Plan Management

• Consumer Assistance

• Financial Management

• Our focus is on Plan Management


Key Assumptions

• States will continue to regulate health insurance or play a key role in product review/approval

• Exchange solutions should minimize the regulatory burden

• State insurance regulators wish to use existing information technology investments vs. building new ones


Project Objectives

• G01 Enhance SERFF so that states can use it to meet their plan management functions and retain sole authority over regulating health plans in the individual and small group markets

• GO2 Streamline the process for insurers submitting plans for inclusion on an Exchange


Project Objectives

• GO3 Support integration between applications involved in Exchange operations

• GO4 Provide flexibility to the states in how SERFF is used for Plan Management

• GO5 Minimize duplicative data entry


SERFF Role and Approach

• Leverage existing system

• Assist states in certifying QHPs

• Facilitate integration

Industry SERFF Plan

Management

Other Data Sources State DOIs, State Agencies,

Exchanges

CCIIO

Consumer


CCIIO Collaboration

• Meet the deadline

• Share the information

• Reduce the regulatory burden


Using SERFF with Exchange Models

• Fully Facilitated Exchange Model

• Partnership Model

– State handles QHP Certification

– State handles all of Plan Management

• State Exchange





Risk Management

• Risk Assessment

– Aggressive Timeline

– Evolving Business Requirements

– Many Stakeholders


Risk Management

• Enhancement Prioritization

• Iterative Development

• Code Separation


Scope Decisions

• Notice of Intent/Insurer Cert-Out of Scope

• QHP submissions include

– benefits and rates data-In Scope

– formulary data-In Scope

• Network Adequacy-Out of Scope

• Compliance Data-Out of Scope


Questions?




SERFF Release Summer 2012

Thea Cook, Implementation Manager SERFF/OPTins

May 3, 2012


Overview

• First of several releases for SERFF Plan Management

• Two major enhancements

– State Generated Messages

– EHB Configuration-Part 1


State Generated Messages

• Introduced in 2011

• 17 State instances currently set up to use

• State specific messages sent to industry

• Similar to a subscription process



• Currently limited to two business types – LAH, PC

• Business type expansion for ACA – Life, Annuities, Health separated

– Three options for Health • All Health, ACA related, Exchange related

• Functionality guided by a role



• Importance of the feature

– Timely

– State controls the message

• How it works

– Link on the Message Center to generate

– Messages sent to industry user’s SERFF Message Center




• Migrating subscription options after the split

• Insurers need to subscribe

• Implementation team efforts toward adoption

– Who uses it now?

– Newsletter

– Education for states


Essential Health Benefits

• Configuration of EHBs

• The basics

– Guidance from CCIIO allows state flexibility

– Each state to select a benchmark plan



• How it works in SERFF

– Target-Source for 10 benefit categories

– List of services

– Notes fields for additional state information

• First step towards QHP Filing Rules

• Will be on a new QHP tab




• Summer release – Informational only

• Subsequent releases – Integration with CCIIO

– Validation of benefit file upload

– Refine service attributes

– Enhanced validation


Questions?



Documents

Project Approach & 2012 Release Plan - SERFF · 5/3/2012 · © 2012 National Association of Insurance Commissioners Project Approach & 2012 Release Plan Bridget Kieras, Manager