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D. PROJECT ABSTRACT SUMMARY

Title: New Mexico Level Two Health Insurance Exchange Establishment Grant
CFDA #: 93.525

FON #: IE-HBE-12-001

Applicant: New Mexico Health Insurance Exchange (NMHIX)

Address:

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

Congressional Districts Served: NM 1, 2, 3

Contact: Amy Dowd, Chief Executive Officer
Phone: (505) 314-5300 Fax: (505) 998-3814 Email: adowd@nmhix.com
Website: www.BeWellNM.com Category of Funding: Level Two
Project Dates for Project Completion: January 1, 2015 December 31, 2017
Goals for Level Two Establishment Grant Application:
New Mexico is applying for a Level Two Health Insurance Exchange Establishment Grant solely
to:
Enhance functionality of technology systems after the initial launch to improve the
customer shopping experience, including broker notifications and alerts, ability for
consumer to select QHP which offers best coverage for consumers prescriptions, and
a centralized provider directory technology capability.
Cover the additional cost of the recent CMS design changes for enhanced integration
with HSD/Medicaid. Please note that this is not rework.
Cover the costs to be incurred as a result of pushing the go-live date of the individual
exchange to 10/1/2015.
New Mexico is a hybrid Exchange through 2015 with the SHOP operated by the NMHIX and
individual exchange operated by the Federally-facilitated Exchange. NMHIX is in the process
of developing its own individual platform to be complete for open enrollment beginning
October 1, 2015. NMHIX is working with HSD to develop a CMS-compliant eligibility
verification process.
This requested funding will allow continued implementation of the NMHIX for the period
January 1, 2015 through December 31, 2017. Ongoing maintenance and operations of the
SHOP, starting in 2015, and ongoing maintenance and operations of the Individual Exchange,
starting in 2016, will not be covered by this grant. Additionally, this grant is requested solely

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

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NEW MEXICO HEALTH INSURANCE EXCHANGE LEVEL TWO GRANT

TABLE OF CONTENTS
A. STANDARD FORMS (electronic)
B. REQUIRED LETTERS OF SUPPORT......................................................................................... 1
LETTER FROM GOVERNOR MARTINEZ. 1
LETTER FROM NEW MEXICO DIVISION OF INSURANCE. 3
LETTER FROM HUMAN SERVICES DEPARTMENT/ MEDICAID AGENCY....4
C. APPLICANTs APPLICATION COVER LETTER.. 6
D. PROJECT ABSTRACT SUMMARY. 7
TABLE OF CONTENTS 9
ACRONYMS.... 11
E. PROJECT NARRATIVE12
a. DISCUSSION OF EXISTING EXCHANGE PLANNING AND PROGRESS.13
1. Background Research.........13
2. Legal Authority and Governance...13
3. Stakeholder Consultation......15
4. Long-term Operational Costs...16
5. Program Integration...16
6. Business Operations of the Exchange.17
7. IT Gap Analysis and Exchange IT Systems...17
8. Reuse, Sharing, and Collaboration...17
9. Organizational Structure.. 19
10. Program Integrity..... 24
11. Affordable Care Act Requirements ... 24
12. SHOP.... 24
b. PROPOSAL TO MEET PROGRAM REQUIREMENTS. 26
1. Current Exchange Pathway. 26
2. States Strategy to Complete the Exchange Activities 26
3. States Strategy to Address Early Benchmarks in Section I.4 45
4. Proposed Solution for IT System .... 45
5. IT Seven Standards and Conditions... 51
6. Organizational Structure... 51
7. Coordination with the Federal Government on Exchange Activities.. 51
8. Strategies for Reuse, Sharing, Collaboration for NMHIX Activities with the
Federal Exchange and Other States.51

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

and Abuse and Provide Oversight of Cooperative Agreement Funds and the
Exchange..... 51
10. Challenges That May Affect Progress in Work Plan 52
11. SHOP... 52
F. WORKPLAN.. 53
G. BUDGET AND BUDGET NARRATIVE 56
H. ADDITIONAL LETTERS OF AGREEMENT AND/OR DESCRIPTION(S) OF PROPOSED/EXISTING
PROJECT .60
I. DESCRIPTION OF KEY PERSONNEL AND ORG CHART..61
J. COST ALLOCATION METHODOLOGY62
K. DOCUMENTATION SUPPORTING ELIGIBILITY OF APPLICANT (LEVEL TWO EXCHANGE
ESTABLISHMENT ONLY) ...81

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ACRONYMS
ACA or PPACA
AHBE
APTC
CSR
FPL
GSA
HSD
IAD
IHCIA
ISD
ISD2R
MAD
MMIS
MAGI
NAIC
NMHIA
NMHIX
NMMIP
OHCR
OSI
PSC
QHP
RFP
SCI
SDLC
SERFF
SHOP
SOA

Patient Protection and Affordable Care Act

American Health Benefits Exchange
Advance Premium Tax Credits
Cost Sharing Reductions
Federal Poverty Limit
Governmental Services Agreement
New Mexico Human Services Department
New Mexico Indian Affairs Department
Indian Health Care Improvement Act
Income Support Division
Integrated System Delivery Replacement Project
New Mexico Medical Assistance Division
Medicaid Management Information System
Modified Adjusted Gross Income
National Association of Insurance Commissioners
New Mexico Health Insurance Alliance
New Mexico Health Insurance Exchange
New Mexico Medical Insurance Pool
New Mexico Office of Health Care Reform
Office of the Superintendent of Insurance
Professional Services Contract
Qualified Health Plan
Request for Proposals
State Coverage Insurance
Software Development Life Cycle
System for Electronic Rate and Form Filing
Small Business Health Options Plan
Service Oriented Architecture

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E. PROJECT NARRATIVE
INTRODUCTION
The Affordable Care Act (ACA) allows states to develop Health Insurance Exchanges to help
individuals and small businesses purchase health insurance. The New Mexico Health Insurance
Exchange (NMHIX) has been designed to be high quality, cost-efficient, self-sustaining, and
tailored to meet the diverse needs of New Mexicans.
New Mexico faces many challenges in developing and implementing NMHIX, including health
workforce shortages, language and cultural barriers, significant poverty, poor educational
attainment, rural and remote areas, and a majority of its small businesses do not offer health
insurance to employees.
Of New Mexicos population of two million, Medicaid covers approximately 530,000
individuals, Medicare covers 300,000 and 430,000 are uninsured. Of the uninsured, an
estimated 175,000 may become eligible for Medicaid and up to 211,433 for NMHIX between
2014 and 2020. An estimated 171,557 uninsured individuals will enroll in 2014; approximately
89,000 through Medicaid expansion, and 82,557 in the NMHIX.
The New Mexico Legislature passed the New Mexico Health Insurance Exchange Act, during
the 2013 Regular Session, and Governor Susana Martinez signed the Act on March 28, 2013.
New Mexico applied for and, on November 29, 2011, received a Level One Health Insurance
Exchange Establishment Notice of Award of $34.3 million to develop the NMHIX. An additional
grant of $18.6 million was awarded to New Mexico in July 2013. These initial grants were
awarded to the New Mexico Human Services Department (HSD) and have now been
transferred to the NMHIX as required by statute through a Change of Grantee of Record
process.
The NMHIX was also awarded a third Level One grant totaling $69.4 million on 1/22/2014.
NMHIX is requesting a No Cost Extension to increase the duration of this grant to 12/31/2015.
This grant was awarded on 1/22/2014 with an end date of 12/31/2014.
New Mexico is a hybrid Exchange through 2015 with the SHOP operated by the NMHIX and
utilization of the federal platform for individual enrollments. NMHIX is in the process of
developing its own individual platform to be complete for open enrollment beginning October
1, 2015. NMHIX is working with HSD to develop a CMS-compliant eligibility verification
process.
Through this proposal, New Mexico seeks $97.9 million for continued implementation of the
NMHIX for the period January 2015 December 2017. Ongoing maintenance and operations
of the SHOP, starting in 2015, and ongoing maintenance and operations of the Individual
Exchange, starting in 2016, will not be covered by this grant. Additionally, this grant is

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requested solely for the costs required for IT functionality and integration with HSD, will not
be used for rework.

a. Discussion of Existing Exchange Planning and Exchange Establishment Progress

1. Key Findings of Background Research
New Mexico conducted in-depth planning and research activities during the initial Level One
grant planning period. Enrollment projections indicate the following projected take-up for the
NMHIX for both the individual and SHOP markets:
Membership Count Projected at End of Open Enrollment
10/2014- 10/2015- 10/2016- 10/2017- 10/2018- 10/20193/2015
3/2016
3/2017
3/2018
3/2019
3/2020
Individual
SHOP
Total Members
Member Months

10/20203/2021

38,333

60,564

76,416

121,654

127,737

134,124

140,830

600

650

700

750

800

850

900

38,933

61,214

77,116

122,404

128,537

134,974

141,730

460,000

681,248

859,562 1,084,548 1,368,423

1,436,844

1,508,686

* 2014 restated down based on actual results through September 2014

2. Legal Authority and Governance

Governance and Exchange Structure--The NMHIX was created by the New Mexico Legislature
in 2013 as a quasi-governmental nonprofit entity to Provide qualified individuals and qualified
employees with increased access to health insurance in the state and shall be governed by a
board of directors constituted pursuant to the provisions of the New Mexico Health Insurance
Exchange Act (the Act). The legal authority for establishment of the Exchange is provided in
the Act, which was submitted as part of the second Level 1 grant application and is on file at
CCIIO. The NMHIX is governed by a 13-member board of directors that was appointed in April
2013; the members have outstanding qualifications and will comply with state and federal
conflict of interest requirements.
Composition of the Governing Body and Selection Process-- By statute, the NMHIX Board has
13 voting directors:

The Superintendent of Insurance or his designee.

Six directors appointed by the Governor (including the secretary of HSD, a health
insurance issuer, and a consumer advocate).
Six directors appointed by the Legislature (with three appointed by the president pro
tempore of the senate including one health care provider, and three appointed by the

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speaker of the house of representatives including one health insurance issuer. One of
the directors appointed by the president pro tempore and one of the directors
appointed by the speaker shall be from a list of at least two candidates provided by the
minority leader of the senate and the minority leader of the House of Representatives.

Coordination with HSDthe statute requires the Medical Assistance Division of HSD to
cooperate with the NMHIX to share information and facilitate transitions in enrollment
between the Exchange and Medicaid.
Coordination with OSI The Act charges the Superintendent of Insurance with promulgating
rules necessary to implement and carry out the NMHIX, including rules to establish the criteria
for certification of Qualified Health Plans (QHPs) offered on the exchange. NM OSI has the
regulatory responsibility for licensing Qualified Health Plan (QHP) issuers and reviewing and
approving QHP policies. On April 15, 2013, DOI released its submission guidelines for qualified
health plans (QHPs). The Act expressly prohibits the NMHIX from duplicating, impairing,
enhancing, supplanting, infringing upon or replacing the powers, duties, or authority of the
superintendent, including the superintendents authority to review and approve premium
rates pursuant to the provisions of the NM Insurance Code. Carriers are required to offer Silver
and Gold levels of coverage, and must offer at least one statewide plan at each metal level for
which the carrier submits a plan. Carriers can offer plans in either the individual Marketplace
or SHOP, and will not be required to offer the same plan in both Marketplaces. Final guidelines
were promulgated in August 2013. Five companies have been certified as QHPs for individual
plans, four companies for SHOP, and two companies for dental coverage. During 2014, one
of those carriers certified for both individual and SHOP left the market, and a new company
entered the individual market. Thus, going into 2015 Open Enrollment, New Mexico has three
plans certified as QHPs for SHOP, and five carriers certified as QHPs for the individual
exchange.
Coordination with Native AmericansCoordination with Native Americansthe Act requires
designation of a Native American liaison to assist the Board in developing and ensuring
implementation of communication and collaboration between the NMHIX and Native
Americans in the state. Currently the Native American Coordinator serves as the Native
American Liaison and is expected to be officially designated as Native American Liaison at the
November Board of Directors meeting.
The Native American liaison will serve as the contact person between the NMHIX and the New
Mexico Native American Nations, Tribes, and Pueblos and will ensure that training is provided
to the staff of the NMHIX to ensure cultural competency, understanding of Indian health laws,
and other Native American issues. The Act also allows permissive language for the
establishment of a Native American Service Center to ensure that the NMHIX is accessible to
all Native Americans, complies with the provisions of the Indian Health Care Improvement Act
and Indian-specific provisions of the ACA, and facilitates meaningful, ongoing consultation with
Native Americans.

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NMHIX has officially convened a Native American Advisory Committee that has officially
developed and implemented a Guiding Principles and Protocols. This document includes
provisions for proper communication with Native American leadership and communities as
well Guidelines for proper Collaboration efforts. The Native American Advisory Committee
convened every month for the first half of 2014 and every other month thereafter.
NMHIX and its partners have also established a Native American Enrollment Counselor
Network statewide. Currently there are sub-agreements with every federally recognized
Native American tribe in New Mexico providing for on-site Enrollment, outreach and education
on each reservation.
Other Governance Strategies
To ensure that the NMHIX has an accountable and transparent governance structure, is staffed
with competent leadership, and is in compliance with requirements of the statute, the NMHIX
Board of Directors:
a) Conducts monthly public meetings, adhering to NM Open Public Meetings law.
b) Implemented Conflict of Interest Policies (for both board members and NMHIX staff).
c) Maintains, posts, and updates an Exchange website with meeting agendas, minutes,
and other materials related to Exchange activity and operations.
d) Develop a Plan of Operations shortly after the Exchange was established and updated
it at the board first anniversary meeting.
e) Maintains communication with NM Medicaid/HSD and NM OSI.

3. Stakeholder Consultation
Prior to the creation of the NMHIX, the Human Services Department held public stakeholder
meetings beginning in December 2010 and continuing through December 2012. HSD created
the NMHIX Exchange Advisory Task (ATF), composed of 14 members, and NMHIX Advisory
Work Groups, composed of 12-18 members. The Task Force and Work Groups represented a
variety of perspectives, including consumers, tribal representatives, large and small employers,
self-employed, health care providers, hospitals, insurance carriers, brokers, government
leaders and agencies, underserved populations, and other community representatives. These
members acted in an advisory role to inform and provide recommendations in the following
areas:

Essential Health Benefits

Outreach, Education, Adoption, and Enrollment
Employer Participation
Exchange Market Regulation
Native Americans

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Program Integration
Financial Sustainability
Legislative

Public attendance was encouraged at every meeting, dial-in phone numbers were provided,
and press releases were submitted to newspapers of general circulation and posted on the
HSD website to encourage participation. An email box was created to allow public comments
and acknowledge requests for information through email.
The NMHIX statute requires establishment of the following advisory groups:
a) Stakeholders, including health insurance issuers, health care consumers, health care
providers, health care practitioners, brokers, qualified employer representatives and
advocates for low-income or underserved residents;
b) Advisory committee made up of members insured through the NMHIA and the NMMIP
to make recommendations to the board regarding the transition of each organizations
insured members into the Exchange; and
c) Advisory committee made up of Native Americans, some of whom live on reservations
and some of whom do not live on a reservation, to guide the implementation of Native
American-specific provisions of PPACA and federal Indian Health Care Improvement
Act.
d) Public input is solicited at every NMHIX board meeting and additional listening sessions
are being held.

4. Long Term Operational Costs

The Act provides that the Board may generate funding, including charging assessments or
fees, to support its operations in accordance with provisions of the NMHIX solely for the
reasonable administrative costs of the exchange. NMHIX Board of Directors has established a
Finance Committee which is responsible for financial sustainability, budget development and
review of monthly financials. NMHIX recently completed a Financial Sustainability Plan
proposal after having 6 Finance Committee meetings, solicitation of public comment, and a
Public Finance Committee Meeting. NMHIX expects to attain financial self-sustainability in
January 1, 2016 for the Individual Exchange and January 1, 2015 for the SHOP operations. The
recommended revenue source that has been approved by the Finance Committee and will be
presented to the Board of Directors on November 21, 2014 is a broad assessment of all health
insurance carriers in the state. Prior to approval at the December 2014 Board Meeting, the
financial sustainability plan will be posted for 30 days for public comment.

5. Program Integration
Program Integration --The NMHIX will continue to work with all stakeholders to address any
issues that could have an impact on the development and implementation of the NMHIX. The

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NMHIX relies on the HSD ASPEN Medicaid eligibility verification engine and, with HSD, is in the
development phase of the IT system development life cycle.
Memoranda of Understanding the Act requires HSD and MAD to cooperate with the NMHIX.
A second MOU was also developed with HSD in May 2014 for purposes of providing a
mechanism for moving federal funds received by NMHIX to HSD for costs associated with
design, development, and implementation of an information technology (IT) system that
facilitates eligibility, advance premium tax credit, and cost sharing reduction determinations
through the ASPEN Medicaid System.
A MOU was also developed with New Mexico Office of Superintendent of Insurance (NM OSI)
for purposes of providing a mechanism to support regulatory and quasi-regulatory activities
carried out by NM OSI in support of the NMHIX and New Mexicos implementation of the
Affordable Care Act with funds received by NMHIX. ACAs Blue Print activities related to Plan
Management were delegated to NM OSI by the New Mexico statute.

6. Business Operations of the Exchange

Business Operations of the Exchange were described at length in the 3rd Level One
Establishment Grant Request which was awarded on 1/22/2014 (HBEIE 140193).
7. IT Gap Analysis and Exchange IT Systems
The NMHIX utilizes GetInsureds Commercial Off-The-Shelf (COTS) product for Marketplace
functions and ASPEN for Medicaid functions. New Mexico has conducted detailed gap analysis
of both the systems against what is required to implement full State Based Marketplace. Based
on the identified gaps design and development work has begun to close those system gaps.
Establishment Reviews by CCIIO/OIS
The following establishment reviews have been conducted by CCIIO to date:
An establishment review was conducted in October 2012. New Mexico received
conditional approval for its State Based Exchange in January 2013.
SHOP Design and Operational Readiness Reviews on September 26, 2013
Project Baseline (Planning) Review of the Individual Marketplace on February 11, 2014
Detailed Design Review of the Individual Marketplace on April 10 11, 2014
Final Design Review of the Individual Marketplace on June 10 11, 2014.

8. Reuse, Sharing, and Collaboration

New Mexico will inform and assist other states through various means, including HHS Learning
Collaborative and User Groups. Beyond reuse and sharing of IT, New Mexico is committed to
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leverage existing infrastructure and re-purpose business functions and processes to maximize
resources and is working with other states to determine how aspects of their systems can be
replicated in New Mexico. This is demonstrated through the partnership with the State of
Idaho in sharing in the cost of certain functionality described within this request.

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

New Mexico Health Insurance Exchange

Board of Directors
Organizational Chart

Chief Executive
Officer
Amy Dowd
Executive Assistant
Lisa Garcia

Human Resources
Manager
Michelle Brooks

Advisory Committees

Chief Financial Officer

Anita Schwing

Sr. Accountant
Genelyn McFarlane
Accountant Kimberly
Llamas

Reconciliation Specialist
TBD

Director of Communications
and Marketing
Linda Wedeen

Broker Relations Manager

In Recruitment
Native American Coord.
Scott Atole

Native American Liaison

TBD

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Customer Service Center

Director
Michael Dineen

Customer Support
staff/walk in center
TBD
Shop Support
Teresa McLane
Shop Support
In Recruitment

Admin. Assistant
Tracy Gwash

Information Technology
Director Raj Shethia

Technical Analyst
Karen Galbreath
Business/Technical Analyst
In Recruitment

Compliance Officer
Yolanda Miles

Key Personnel
Amy Dowd Chief Executive Officer, NMHIX, August 2014. Amy Dowd started her career in
healthcare working for a regional BlueCross BlueShield health plan in operations where she held
leadership positions in membership and billing, enterprise program management office, and
vendor relations. She was also a national practice health care consultant at Ernst & Young LLP,
advising several of the largest national health insurance carriers on Affordable Care Act strategy,
implementation, and compliance. Amy has over 20 years of experience leading large-scale
technology and operational improvement projects across the private, public, and non-profit
sectors. Amy has a Bachelor of Science degree, and holds Project Management Professional
certification.
Amy started working on the Idaho Health Insurance Exchange, now known as Your Health Idaho,
in 2010 leading efforts to define options for implementing an exchange in Idaho. Since May of
2013, she has served as Executive Director of Your Health Idaho, which achieved the second
highest exchange enrollment per capita in the nation within four months of launch. Amy recently
joined the New Mexico Health Insurance Exchange (NMHIX) as the newly appointed Chief
Executive Officer (CEO). She is currently working with the NMHIX Board, staff and key stakeholders
to continue NMHIX on a path to success.
Anita SchwingChief Financial Officer, NMHIX, September 2013. Ms. Schwing brings over 20 years
of financial management experience, including ten years in New Mexico managed care. She
previously worked four years as Chief Financial Officer at Coventry Health Cares Medicaid
Managed Care Organization, in St. Louis, MO. Prior to that, she was Chief Financial Officer at
Molina Healthcare of New Mexico (four years), Controller at Cimarron Health Plan (4 years), and
Director of Finance at Lovelace Health Plan (two years). She also worked seven years for CIGNA
Corporation, in Philadelphia, PA. Ms. Schwing has served on the Board of the New Mexico Medical
Insurance Pool, as well as the Board of the New Mexico Health Insurance Alliance. She is a
Certified Public Accountant, and has a Master of Business Administration degree from Temple
University, Philadelphia, PA.
Raj Shethia Director of Information Technology, NMHIX, November 2013. Mr. Shethia came to
the NMHIX after working at Lovelace Health Plan for seven years in various IT roles, including over
two years as the Technical Lead, Chief Architect and Subject Matter Expert on the Health Insurance
Exchange/Marketplace implementation for the health plans integration with the Federal and New
Mexico Health Insurance Marketplace. He also served as Lovelaces representative on NMHIXs
Information Technology and Integrated Services RFP evaluation team, providing the opportune
introduction to full participation as an employee. Mr. Shethia has a Master of Science in Software
Engineering from the University of Houston, and a Bachelor of Engineering in Computer Science
from the University of Mumbai. In addition, he holds a Masters Certificate in Project Management
from the University of New Mexico as well as a Certificate in Supervisor Academy from Central
New Mexico Community College.

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Linda Wedeen Director, Communications and Outreach, NMHIX, October 2014. Ms. Wedeen has
been in the Strategic Marketing and Communications for more than 30 years. Her areas of
expertise include: Executive Communications, Strategic Planning, Brand Awareness and
Development, Community Connections Lobbying, and Program and Vendor Management. Ms.
Wedeen recently joined the New Mexico Health Exchange as Director, Communications and
Outreach to lead a strategic team of vendors and staff to ensure success during the November
2015 Open Enrollment period and into the future.
Previously Ms. Wedeen worked with a number of corporations and private entities including the
New Mexico Cancer Center Foundation, Hewlett Packard, First Community Bank, and AT&T. Ms.
Wedeen has also owned her own consulting firm focusing on Strategic Planning and Evaluation.
Additionally, Linda has an extensive community network through her association with many local,
state and national organizations.
Yolanda Miles Compliance Officer, NMHIX, June 2014. Ms. Miles brings 25 years of experience in
the health insurance industry. She held the positions of Director of Enrollment & Eligibility and
Director of Project Management prior to joining NMHIX. Ms. Miles is exceptionally knowledgeable
about all operational, IT, and compliance aspects of Commercial, Medicare Advantage, and
Medicaid lines of business. She has worked with governmental and regulatory agencies for several
years to ensure program compliancy based on product and line of business. Ms. Miles is certified
as a Project Management Master and was awarded the Circle of Excellence award in her previous
positions. She attended University of New Mexico and New Mexico State University.
Michael Dineen Customer Service Director, NMHIX, October 2013. Mr. Dineen will oversee call
center and customer support operations as well as SHOP operations. He has more than 15 years
of call center experience, specializing in technology and healthcare. Prior to joining NMHIX, Dineen
worked with America Online, T-Mobile and Lovelace Health Plan. He has a strong focus on the
customer experience and customer service.

Michelle BrooksHuman Resources Manager, NMHIX, January 2014. Ms. Brooks brings over ten
years of Human Resources Management experience to the NMHIX. She is experienced in
recruitment, policy and procedure development and compliance, compensation and benefits,
team building, supervision and leadership, employee relations, and workers comp. Ms. Brooks
has a Bachelor of Science in Business Management with a concentration in Human Resources from
the University of Phoenix. She is an active member of the Human Resource Management
Association (HRMA) and the Society of Human Resources Management (SHRM).
Scott AtoleNative American Coordinator, NMHIX, September 2013. Mr. Atole is an enrolled
member of the Jicarilla Apache Nation, is responsible for facilitating communication and
collaborative efforts with Native American communities and leadership in New Mexico to address
health care coverage and health insurance issues. Mr. Atole has earned a Bachelors of Science in
Education & Community Health at the University of New Mexico and is currently completing a
Masters of Public Administration/Health Policy and Administration. Mr. Atole has twenty years of

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experience in working at multiple levels with diverse populations to identify and engage a variety
of health education and prevention initiatives, research, curriculum development and health
program administration. Professional experience includes UNM-MPH & MPA Research,
Albuquerque Area Indian Health Board Program Manager, Health Educator/Prevention Specialist
and IHS Community Health Program(s). In addition to previous appointments to the American
Cancer Societys Advisory Group, the New Mexico State Tobacco Advisory Committee, and the NM
Statewide Strategic Planning Committee and Native American Workgroup. Mr. Atole also serves
as the Jicarilla Apache delegate to the New Mexico Department of Healths American Indian Health
Advisory Committee.
Karen Galbreath--Technical Analyst, NMHIX, February 2014. Mrs. Galbreath is primarily focused on
providing ongoing analysis, maintenance, and technical and functional support for application
systems throughout the organization. She brings over 15 years of experience in the healthcare
industry, including 2 years at Lovelace Health plan, and 6 years at UNM Health Science Center.
She has a Masters Degree in Information Systems.
Genelyn McFarlane--Senior Accountant, NMHIX, September 2014. Ms. McFarlane has over 14
years of experience in Finance, Accounting and Retail Management. Prior to joining NMHIX, she
was the Accounting Supervisor for Pueblo De Cochiti. Managing over 30 Federal and State Grants,
Ms. McFarlane has an extensive knowledge in budgeting, analysis, auditing, payroll, accounting,
federal and state grants. In addition, she was the Finance Manager for Foothill Community Health
Center in San Jose, CA. She has experience in private, public and non-profit organizations. Ms.
McFarlane earned her Bachelor degree in Accounting from San Jose State University.
Kimberly LlamasAccountant, NMHIX, December 2013. Ms. Llamas brings over 15 years of
experience in accounting, including 9 years with Delta Dental of New Mexico. Since coming to
NMHIX, she has participated in the development of reconciliation processes for the premiums
billed on the SHOP marketplace. In this role, she will work with the carriers in the 820/834
reconciliation processes for both SHOP and Individual Marketplaces. She is also responsible for
accounts payable, vendor contract tracking and encumbrance reconciliation, and fixed assets.
Ms. Llamas has a Bachelors Degree in Business Accounting from the University of Phoenix.
Lisa Garcia Executive Assistant, NMHIX, August 2013. Ms. Garcia has served in this position since
August 1, 2013. Prior employment was at the New Mexico Institute of Mining and Technology as
the Executive Assistant to the Vice President for Research and Economic Development where she
was responsible for the management of the Division and the research entities within the Division
for over 16 years. Prior to that she was the Office Manager for the Center on Aging within the
Population Research Institute at Pennsylvania State University for four years. She brings extensive
knowledge of planning, management and customer service to her position at the Exchange. Ms.
Garcia earned an Associate of Science from New Mexico Institute of Mining and Technology in
2007.

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Tracy Gwash--Administrative Assistant, NMHIX, January 2014. Since coming the NMHIX, Ms.
Gwash has received her Healthcare Guide Certification and Presumptive Eligibility Determiner
Certificate. Prior to coming to the Exchange, Mrs. Gwash was Office Manager/Assistant to the
Director at New Mexico Press for over 13 years. She brings extensive knowledge of planning,
management and customer service to her current position. Mrs. Gwash earned her Medical
Receptionist Certificate from Franklin Medical College. Mrs. Gwash also earned a Medical billing
and Coding Degree from the University of New Mexico.

Key Board Members:

James R. Damron, M.D., FACR, NMHIX Board Chair - Dr. Damron is an attending radiologist at UNM,
Health Science Center, School of Medicine and teaches in the specialty of Clinical Mammography,
overseeing radiology residents and providing lectures to medical students on state and federal
health policy issues. Prior to UNM, he was President of Santa Fe Radiology, P.C., providing
diagnostic radiology imaging services in Santa Fe for 30 years before he retired. Dr. Damron
received his Medical Degree from Indiana University School of Medicine, his radiology training at
the University of Kentucky Medical Center and completed a Nuclear Medicine Fellowship at the
University of New Mexico. He is Board Certified by the American Board of Radiology and the
American Board of Nuclear Medicine. He is a Fellow in the American College of Radiology. Dr.
Damron has been associated with numerous state and national professional organizations and
boards and is the author of several peer-reviewed articles.
He has received several national awards, such as the Capitol Dome award and the Physicians
Award for Outstanding Service from ACS, the 2006 Physician of the Year award from the National
Republican Congressional Committee and the NRCC 2007 Congressional Order of Merit. He also
serves on the NM Coalition for Literacy Board, the St. Vincent Hospital Foundation Board and has
served on other numerous community boards, state committees and task forces. Dr. Damron was
the Republican Nominee for Governor in 2006 and a candidate for Lt. Governor in 2010.
Jason Sandel, NMHIX Vice-Chair- is a native of Farmington, New Mexico and was elected to the
Farmington City Council in March of 2006. Jason Sandel is the Executive Vice-President of Aztec
Well Servicing and its subsidiaries in Aztec, New Mexico. He is the 3rd generation of the Sandel
family to dedicate himself to the company and the community. Jason attended the University of
New Mexico where he received a B.A. in Political Science and served as a Senior Leadership Analyst
for the New Mexico State Senate. Along with his appointment to the Board of the New Mexico
Health Insurance Exchange, Jason serves as the Vice-Chairman of the New Mexico Medical
Insurance Pool, immediate past President of the Four Corners Safety Council, member of the New
Mexico Oil and Gas Executive Committee, former member of the Statewide Economic
Development Commission, and was honored with the Paul Harris award by the San Juan Rotary
Club.

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

graduate of Creighton University, with 35 years of experience in the insurance industry. He joined
Consolidated Agency, his fathers independent insurance agency, purchased it ten years later and
expanded it to four locations employing 82 people and servicing nearly 15,000 customers. He
served on the New Mexico Workers Compensation Assigned Risk Pool Board of Governors, the
Patient Compensation Administration Board of Directors, and was elected president of the
Independent Insurance Agents of New Mexico. In 1998, Poe & Brown, a national insurance broker,
purchased the business. He was named vice president. His responsibilities included new business
production, development of specialized insurance programs, and agency acquisitions. He joined
New Mexico Mutual in 2002 and later named Vice President of Government and Industry Affairs.
He is a member of the Leadership New Mexico Class of 2007, former board member of the Rocky
Mountain Insurance Information Association, and past president of the NM Insurance Association.

10. Program Integrity

The NMHIX hired a Compliance Office in June 2014 to focus on program, system, and financial
controls within the operating system and business processes of the Exchange. Additionally, the
NMHIX was subject to its first A-133 and financial statement audit in September 2014, with a
favorable audit opinion. Financial and internal controls have been developed to ensure that the
NMHIX can account for grant funds in accordance with CMS expectations. The NMHIX will
continue adhere to HHS financial monitoring activities for the Level Two Establishment Grant.
NMHIX successfully completed a business assessment by CMS in July 2013.
11. Affordable Care Act Requirements
Health Insurance Market Reforms--The Department of Health and Human Services (HHS)
determined that New Mexico had an effective rate review program as of August, 2011.
12. SHOP
Summary of States Small Group Market--New Mexicos current small group market has
approximately 60,500 covered lives with $277 million in earned premiums. Market shares are as
follows:
Carrier
Members (2011) Market Share Earned Premium (2011)
Share
Blue Cross Blue Shield of NM
19,566
32.4%
$100,722,000
Lovelace Health Plan
16,355
27.1%
$ 68,451,360
Presbyterian Health Plan
17,821
29.5%
$ 74,432,580
United Health Care
6,693
11.1%
$ 33,202,618
Total
60,435
100%
$276,858,558

Page 24 of 121

Market
36.4%
24.7%
26.9%
12.0%
100%

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

SHOP--An Employer Participation work group held extensive meetings to work on various SHOP
issues and provide recommendations. Issues reviewed included participation requirements,
definition of small business, adverse selection issues, defined contribution, premium
aggregation, and plan selection.
The NMHIX utilized the information from the stakeholders in designing the NMHIX SHOP program
with the following features:

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

in November and December 2013 when there will be no participation requirement).
Minimum employer contribution of 50 percent.
Employers select a metal level and a reference plan as a cost parameter and then
employees may select plans from within that metal level.

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b. PROPOSAL TO MEET PROGRAM REQUIREMENTS

1. Current Exchange Pathway
On December 14, 2012 New Mexico submitted its Blueprint application to HHS to operate a
State-Based Exchange and the Blueprint was conditionally approved on December 31, 2012
and additional conditional approval was received in July 2013. The State of New Mexico has
elected to operate a hybrid health insurance marketplace where initially the State will operate
its own SHOP marketplace and utilize the Federally Facilitated Marketplace (FFM) for the
Individual marketplace. Starting October 1, 2013 NMHIX has begun the process of developing
a state-based individual marketplace with the aim to Go-Live for 2016 Open Enrollment. Once
New Mexico is live with core marketplace functionality in 2015 New Mexico will continue to
add capabilities to support our goal to increase enrollment and enhance self-sustainability.
2. States Strategy to Complete the Exchange Activities
The chart below shows the status of the NMHIX activities as a State-Based Exchange:
EXCHANGE ACTIVITIES
Legal Authority and
Governance

Consumer and Stakeholder

Engagement and Support

Eligibility and Enrollment

STATUS
New Mexico has enabling legislation creating the NMHIX to operate the
Exchange and SHOP SB221.
To ensure the NMHIX has an accountable and transparent governance
structure, is staffed with competent leadership and is in compliance with
applicable conflict of interest provisions, the NMHIX Board of Directors
conducts monthly public meetings, adheres to open public meeting laws,
developed a Plan of Operations, and implemented a Conflict of Interest
Policy, Procurement Policy, and Communication Policy.
Advisory groups will be continued through the NMHIX throughout the
development and implementation of the NMHIX to ensure stakeholder
engagement and support. A comprehensive outreach and education plan
has been developed that ensures culturally and linguistically appropriate
materials and ensures access to information and enrollment for individuals
with disabilities. A website has been developed in English and Spanish. A
Health Care Guide program with associated training requirements and
broker roles has been developed.
NMHIX has implemented its SHOP eligibility and enrollment system.
NMHIX is coordinating with HSD on eligibility and enrollment which will
be documented through regular meetings between the NMHIX and
HSD staff. NMHIX plans to have the capacity to accept and process
applications for the individual market by October 1, 2015. NMHIX is
working with HSD to develop appropriate exchange interfaces.
GetInsured is developing a system for NMHIX enrollment with capacity
for notices, verifications, privacy and security protections, storing and
processing documents, determine eligibility for enrollment in QHPs, to

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process QHP selections and terminations, and comply with required

reporting to HHS. See more in the section below as this grant request
focuses on this blueprint core area.
Plan Management

NMs enabling legislation delegated to the Office of the Superintendent

of Insurance (OSI) the authority to certify and oversee QHPs and is
coordinating with the NMHIX. The NMHIX has a plan management
system to support the collection of QHP issuer and plan data and
facilitate the certification and renewal process and integrate with other
Exchange business areas.

Risk Adjustment and

Reinsurance

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

SHOP

The NMHIX SHOP system allows for the enrollment and billing of
employer groups and employees, online invoice payment capability as
well as premium aggregation and remittance to insurance carriers. It
also has required electronic reporting functionality.

Organization and Human

Resources

The NMHIX has hired core staff and continues to hire additional staff
for performance of NMHIX activities.

Finance and Accounting

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

management plan through its Finance Committee. A Financial
Sustainability Plan Proposal is scheduled to be presented at the
November 21, 2014 Board of Directors Meeting for approval and
adoption.
NMHIX is exploring functionality and options in the
technology solution that will ensure financial sustainability beyond
2015-2016, by enhancing consumer facing functionality.

Technology

The NMHIX has contracted with Get Insured to ensure adequate

technology infrastructure and bandwidth, and to achieve essential
functionality for all NMHIX activities.

Privacy and Security

The NMHIXs IT solution ensures required privacy and security within

the technology solutions.

Oversight,
Monitoring,
and Reporting

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

requirements.

Contracting, Outsourcing,
and Agreements

NMHIX has contracted with Get Insured and PCG for ongoing
development of the Exchange; Xerox for the Call Center and SES for
IV&V functions.

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Consumer and Stakeholder Engagement

The NMHIX is implementing a process for a formal Advisory Committee to obtain consumer
and stakeholder input and engagement as required by statute. Each of the NMHIX outreach
and enrollment partners are being asked to provide a representative to serve on the initial
Advisory Committee for one year. The Advisory Committee meets quarterly to provide input
and feedback to the NMHIX with the first meeting held December 2013. The meetings have
been held in various locations around the state to allow broad geographic input during public
comment portions of the meetings. The Committee is being structured to allow representation
from various stakeholders including consumers, business groups, providers, brokers, QHPs,
enrollment partners, and others. The NMHIX will continue to enhance the stakeholder
engagement process as the NMHIX is implemented.
Outreach, Education, and Enrollment Program
The comprehensive outreach and education program that began in 2013 will continue to be
implemented throughout the state in 2014 for 2015 open enrollment. An assessment of the
effectiveness of the initial outreach and education activities will be conducted after the first
90 days of open enrollment to refine and expand outreach, education, and marketing activities
as necessary. Ongoing activities will include the following components:

Outreach and education with ACI, New Mexico Association of Counties, Albuquerque
Hispano Chamber of Commerce, New Mexico Green Chamber of Commerce, UNM and
NMSU and the higher education system, and additional contracts for hard-to-reach
populations.
Additional outreach will be conducted based on a comprehensive assessment of initial
strategies. In January 2014, NMHIX will review all strategies and results and make
modifications and expansion of activities as necessary to increase enrollment. It is
anticipated that significant recalibration of messaging and additional media and
strategies will be necessary due to the federal technology delays.
Implementation of a series of focus groups in spring 2014 to assess reasons why people
may have not signed up for coverage and exploration of alternative strategies to
generate enrollment.
Continued implementation of significant in-reach for existing patients of clinics and
hospitals, as well as outreach. Over 60,000 postcards will be mailed in early November
to reach as many patients as possible. Additional postcard strategies are being
developed for use at events with signature authorizations by consumers to allow a
Health Care Guide to call them back to provide information and help them sign up for
coverage.
Development of additional strategies with diverse partners, such as Rotary, Kiwanis,
schools, trade associations (restaurants, retail, credit unions, banks, realtors, utilities,
homebuilders, etc.)

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Ongoing marketing and media activities in partnership with BVK and local marketing
partners, including TV, radio, print, billboards, and social media. In January 2014,
NMHIX reviewed all marketing and media strategies and results and made
modifications to increase enrollment. The campaign was refreshed to run again in
late summer 2014 for the second open enrollment period. Weekly press
releases and public relations.
Enrollment activities will continue through contracts with NMPCA, NAPPR, and other
enrollment entities. The enrollment network and capacity will be assessed on an
ongoing basis and additional enrollment sites added as necessary. Performance goals
with enrollment metrics will be established for each county in the state and monitored
and additional resources will be targeted to counties not meeting enrollment goals.
Group training sessions will also be implemented to accommodate enrollment demand
in the shortened timeframe due to the federal technology issues.
Targeted Native American assistance programs will also continue to be implemented
to serve New Mexicos Native American population in partnership with NAPPR and the
Navajo Nation.
To support the second open enrollment period, NAPPR opened a Walk-In Center in
Albuquerque on a pilot basis, which may be taken state-wide if found to be effective,
to provide specialized technical assistance and support to New Mexicos Native
population. This Walk-In Center will also serve the non-Native population as well, with
enrollment guides from NMPCA

NMHIX will use a variety of methods to assess enrollment and outreach strategies, including
consumer surveys that will be completed after each interaction with a Health Care Guide,
reviews of decreased number of uncompensated care patients at clinics, hospitals, and with
County Indigent Funds, social media feedback, media metrics, and feedback solicited by all
outreach partners. NMHIX will monitor enrollments bi-weekly through reports from NMPCA,
NAPPR, and UNMHSC and with monthly reports from CCIIO.

Eligibility and Enrollment NMHIX is building an ACA compliant marketplace IT system that
supports an online single-streamlined application process to provide consumers with access
to Insurance Affordability Programs and an online tool to shop and enroll in commercial
insurance. The Customer Service Center shall also support a mail room function in the event
that a consumer prefers to complete a paper application. The mail room will mail the
applications to individuals as well as employees who request a paper application to enroll in a
small employer and/or individual benefit plan. The mail room will also receive completed paper
applications. The New User Open Enrollment exhibit below shows high level design flow of our
planned integrated eligibility and verification system.

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New Mexico is developing an Integrated Eligibly and Verification System based on principles
laid out in Guidance for Exchange and Medicaid Information Technology (IT) Systems version 2.0.
New Mexico has developed a single streamlined application (based on CMS SSAp guidelines)
and a Single Rules Engine that can be used by consumers who apply for either QHP on the
individual marketplace and for insurance affordability programs.
Upon entry into New Mexicos integrated shared portal, enrollees will be asked if they wish to
complete an insurance affordability assessment (anonymous shopping). If an enrollee decides
they do not want to pursue financial application path, he or she will be asked to provide
information on a shorter version of single streamlined application and guided thru process to

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enrollee in QHP. New Mexico will send a web services query a Shared Data Services HUB for
verification of enrollees information as required in 45 CFR part 155.
For enrollees who wish to pursue financial application path, NMHIX will seamlessly transition
to insurance affordability single streamlined application that will collect the required data from
enrollees and family members. New Mexico will send a web services query a Shared Data
Services HUB for verification of enrollees information as required in 45 CFR part 155.
The system has capacity to assist consumers with disabilities or with limited English proficiency
that comply with all applicable federal policies and laws, through the following features:
User friendly, plain English, web portal with mouse-over help feature
508-compliant web portal for the visually impaired
Text Telephone (TTY) services for the hearing impaired
Third-party language translation services for individuals with limited English proficiency
Applications and supporting materials, notices, and correspondence in multiple
languages upon request.
New Mexico will develop a system that is able to generate and send correspondence in
electronic formats, print correspondence onto standardized paper, and provide services for
sending notices, which includes folding, postage, and delivering correspondence.
Additionally New Mexico IT System will be able to accept and process updates, and responses
to redeterminations from applicants and enrollees (see figure below that shows high level
design flow).

Page 31 of 121

Page 32 of 121

Call CenterThe New Mexico initial Call Center (currently primarily a referring call center) will
be expanded to accommodate all Call Center activities once the Individual Marketplace is
implemented in October 2015. It will be capable of assisting New Mexicans with questions
related to open enrollment, eligibility, plan selection, complaints, and all NMHIX activities.
NMHIX will issue a RFP for a comprehensive call center for its State Based Exchange for both
individual and SHOP full functionality.
Plan Management
The Superintendent of Insurance has authority over all health insurance plans sold in New
Mexico. OSI is responsible for plan management functions, including QHP certification, of the
NMHIX solution. OSI and the NMHIX have developed a standard QHP contract whereby issuers
certify that they will comply with all applicable state and federal laws, regulations, and
guidelines. In the event of an adverse event or adverse finding from a periodic assessment that
may affect a QHPs certification status, OSI coordinates support to resolve the issue. OSI will
notify NMHIX to remove the QHP from sale upon finding cause to decertify a QHP. OSI is
responsible for the management of the consumer complaint process for QHPs, including
complaints referred from the call center, and will coordinate among internal units as needed
to resolve consumer complaints or identify potential compliance issues. SERFF will be used to
record all QHP administrative data. The QHP service area must cover a minimum geographical
area that is at least an entire county or group of counties, unless the NMHIX determines that
serving a smaller geographic area is necessary, nondiscriminatory, and in the best interest of
the qualified individuals and employers. The QHP service area must be established without
regard to racial, ethnic, language, health-status related factors, or other factors that exclude
specific high utilizing, high cost, or medically-underserved populations. OSI ensures that the
QHP has made its provider directory available for online publication (or has provided the
source of online publication) and has indicated providers who are no longer accepting new
patients according to PPACA 156.230(b). Rating areas are a consideration in the QHP review
process. A third party actuary assists the state in defining rating areas for QHPs.
OSI ensures QHP compliance with market reform rules in accordance with all applicable
regulations and guidance. New Mexico currently has a small number of carriers and a total of
56 plans offered on the NMHIX. OSI provides all QHP certification for the NMHIX. New Mexico
has a new CO-OP plan, New Mexico Health Connections, which is offering plans on the NMHIX.
DOI will provide recommendations to CMS on whether the CO-OP plan meets NMHIX
standards for a QHP to assist CMS in its decision to deem CO-OP as certified to participate
according to 42 CFR 156.520 (e).
OSI is responsible for oversight of the licensure, solvency, and market conduct of issuers who
submit QHPs to be offered on the NMHIX. Market conduct exams will be conducted every 3
years and compliance issues will be addressed. QHPs may be decertified or withdrawn in the
course of ongoing or periodic monitoring or as the result of an adverse event reported to OSI.
If there is a voluntary company/issuer withdrawal from the state, the company must give the
state 180 days notice. For QHP individual plan withdrawal, OSI sends notification to the

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consumers. For SHOP plan withdrawal, OSI will coordinate with the NMHIX to send
notifications to the employers.
Risk Adjustment and Reinsurance
New Mexico is utilizing the federal system for risk adjustment and reinsurance.
SHOP
NMHIX has implemented the SHOP program and will continue to refine operations. The SHOP
is fully compliant with regulatory requirements of 45 CFE Sec. 155, Subpart H. The NMHIX
SHOP is performing premium aggregation. IRS reporting capabilities are in progress and are
expected to be functional in time for 2014 reporting.
Organization and Human Resources
NMHIX has hired key staff, including a Chief Executive Officer, Chief Financial Officer, IT
Director, Compliance Officer, Native American Coordinator, Customer Service Director,
Director of Marketing and Outreach as well as support staff.
Finance and Accounting
NMHIX hired a CFO in September 2013. The NMHIX purchased a fund accounting system to
provide the necessary control and reporting capabilities required for the grant. The NMHIX
has been through two budget seasons, an A-133 and financial statement audit, and has
received approval from the NMHIX Finance Committee to take their Financial Sustainability
Plan Proposal to the Board of Directors for approval. Financial policies and procedures have
been developed to provide the financial control structure desired for grant management and
reporting.

Technology
The State of New Mexico has elected to operate a hybrid health insurance marketplace where
initially the State will operate its own SHOP marketplace and utilize the Federally Facilitated
Marketplace (FFM) for the Individual marketplace. Starting October 1, 2013 NMHIX has begun
the process of developing a state-based individual marketplace with the aim to Go-Live for
2016 Open Enrollment.
Once New Mexico is live with core marketplace functionality in 2015 New Mexico will continue
to add capabilities to support our goal to increase enrollment and enhance self-sustainability.
General theme for types of enhancement work that will be undertaken in 2016 and 2017 are:
Catalyze enrollment through active and increasing participation of brokers
Broaden distribution opportunities maximally through a range of enrollment options

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

NMHIX has retained the services of GetInsured (GI) to implement both the SHOP marketplace
and the Individual marketplace. NMHIX produced a set of functional requirements for the
SHOP and Individual marketplace systems that were incorporated into the Request for
Proposals (RFP) to which GI responded. NMHIX has retained the services of Public Consulting
Group (PCG) to assist with various aspects of implementing the SHOP and Individual
marketplaces, including a Project Management Office (PMO). In addition NMHIX has
contracted with Software Engineering Services (SES) as an Independent Verification and
Validation to oversee the design, development, and implementation of the marketplace
functions.
Among the functions of the PMO and IV&V are to work with GI to ensure that:
o Standard industry Systems Development Life Cycle (SDLC) protocols are followed,
including iterative and incremental development methodologies.
o Requirement specifications, analysis, design, code, and testing are developed and
carried out in accordance with CMS/CCIIO requirements and generally accepted
professional practice.
o The design takes advantage of a Web Services Architecture and Service Oriented
Architecture approach for design and development.
o The services description/definition, services interfaces, policies and business rules
are published as required and the solution provides role-based access to underlying
data.
o The solution adheres to standards published by the Office of the National
Coordinator (ONC) and the National Institute of Standards and Technology (NIST).
o The GI system is interoperable and integrated with State Medicaid/ Childrens
Health Insurance Program (CHIP) programs and is able to interface with HHS and
other data sources in order to verify and acquire data as needed.
o The GI system achieves any required interoperability with other health and human
services programs for purposes of coordinating eligibility determinations, referrals,
verification or other functions.
Systems Design
New Mexicos IT Solution will be created to insure more New Mexicans while fostering
competitiveness, encouraging efficiency, and creating sound individual and small employer
private health insurance choices. Qualified individuals and small employers will be able to
shop, compare, and choose a Qualified Health Plan (QHP) as well as apply for other insurance
affordability programs. The IT System will:
1. Create an integrated Health Insurance Exchange that provides the following
functionalities:
a. Integrated Individual Eligibility & Enrollment
b. SHOP Eligibility & Enrollment

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c. Determination of Eligibility for Individual Federal Subsidy of Insurance

Premium, Advanced Premium Tax Credit (APTC), Cost Sharing Reduction (CSR)
as well integrate with HSD system for other Insurance affordability programs
d. Carrier and Plan Certification and Recertification
e. Monitor Carrier and Plan Certification Compliance
f. Display Carrier Ratings by Price and Quality (Star Rating)
g. Maintain Operational Data
h. Process Change in Plan Enrollment Availability
i. Premium Processing/Payment Aggregation
j. Issuer Payment Transfers
k. Web Portals architecture for Call Center CSRs, Navigators, Tribal Assistance,
Marketing/Outreach Personnel, Agents and Brokers
l. Receive, Process and Retain Client Correspondence
m. Management of Exchange Operations
n. Identity and account management
o. Federal, State and Management Reporting
p. Interface with Shared Data Hub
2. Meet as prudently as possible the critical deadlines associated with Health Care Reform
requirements set forth in the PPACA and New Mexico related regulations.
3. Provide integrated screening, choice, coordination, eligibility and enrollment; aligning
systems to support health plan selection; and aggregating payments.
4. Implement a modern technology that meets New Mexicos business needs, is flexible
to changing requirements, and is easily maintainable.
The high level major factors that have influenced the technical design of the proposed system
are:
ACA Section 1561 standards
MITA 3.0 framework and guidelines
Security, privacy and operational standards required by HIPAA, HITECH, NIST, FIPS and
IRS standards
Providing a first class customer experience.
Maintaining cross-program integration so that consumers continue to enjoy a breadth
of on-line support
Being able to offer on-line, real-time eligibility determination and enrollment
capabilities
Providing seamless integration of systems to provide efficient and effective service
delivery
Relevant Standards
The relevant standards that will be followed by NMHIX and its supporting solutions are:
ACA Section 1561 standards for enrollment
ACA Section 1104 operating rules for each HIPAA transaction

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National Information Exchange Model (NIEM) common language

MITA 3.0 standards for reusable components and modularity
Service Oriented Architecture (SOA) standards
HIPAA (5010 compliant)
HITECH
NIST
FIPS
Federal
security
standards
for
cloud
computing
environments
(http://www.gsa.gov/portal/category/102371)
NIST standards for Disaster recovery and Continuance of Operations Program (COOP)
(http://csrc.nist.gov/publications/nistpubs/800-34-rev1/sp800-34-rev1_errataNov11-2010.pdf)
ADA Section 508 and W3C standards for disability support
Limited English Proficiency (LEP) standards

Design Goals for New Mexico Solution:

Design principles for New Mexico solution are in line with Guidance for Exchange and Medicaid
Information Technology (IT) Systems version 2.0.
The following are the design goals and its supporting solutions:
System design that is consistent with section 1561 guidelines
System design to achieve first class consumer experience
System and interface design to achieve real-time and seamless integration with Federal
and State systems (web services)
Design that will allow maximum reusability for other states
System design to achieve real-time and seamless integration with relevant state portals
System design that is consistent with HIPAA (5010), NIST, HITECH, FIPS and IRS
guidelines and standards
System design that accommodates the accessibility guidelines by ADA section 508 and
W3C
Application of MITA 3.0 standards as appropriate
System design that accommodates the Limited English Proficiency (LEP) guidelines
Agile Development based methodology
Active and ongoing participation of the stakeholders and Subject Matter Experts
(SMEs) throughout the design and development phases
Working prototype based development approach (AGILE Development)
Clear integration and maintenance expectations expressed in RFP for vendors to
understand and comply with
Service Oriented Architecture (SOA) that is consistent with MITA
Services managed on an Enterprise Service Bus (ESB)
Rules engine that follow the 1561 Standards and is a loosely coupled service that can
support re-use
System architecture based on open standards

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Reusable services and system components

Flexible architecture that can easily incorporate change and new features
Highly available and highly scalable architecture
Robust disaster recovery

High Level Architecture

NMHIX solution is based on a service-oriented architecture (SOA) that defines common
business and technical services that are loosely coupled and can be modified relatively easily
to accommodate changing business and regulatory needs. This architecture is consistent with
CMS guidelines that define the key business processes, functional groupings and underlying
services. The GetInsured exchange architecture is developed as a modular system consisting
of open source components and libraries wherever appropriate. Business rules and process
workflows are built as separate components that support and enable the core engine of the
exchange to be extended and configured with ease. GetInsureds SOA-based architecture is
scalable and provides a degree of customization without the need to make costly and complex
changes.

GetInsured exchange architecture is consistent with the CMS Technical Reference Architecture
(TRA), the Medicaid Information Technology Architecture (MITA) and the Exchange Reference
Architecture. Business process and technical services are exposed using standard, defined
interfaces. These services interoperate based on a formal definition that is independent of the
underlying platform and programming language. The interface definition hides the
implementation of the language-specific service. Key to these services is their loosely coupled
nature i.e., the service interface is independent of the implementation.

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Web service interoperability protocols provide seamless and automatic connections from one
software application to another (Financial Management, Plan Management, Plan Selection,
etc.).
Web Service Definition Language (WSDL), Universal Description, Discovery and Integration
(UDDI) and Simple Object Access Protocol (SOAP) are the fundamental pieces of the SOA
infrastructure. WSDL is used to describe the service; UDDI, to register and look up the services;
and SOAP, as a transport layer to send messages between service consumer and service
provider.
SOAP, WSDL, and UDDI protocols define a self-describing way to discover and call a method in
a software applicationregardless of location or platform. Data is converted into XML request
and response documents and moved between software modules using HTTP or message based
protocols.
Business services are maintained in the exchange by a registry that acts as a directory listing.
Applications can look up the services in the registry, get the WSDL for the service that has the
description, and invoke the service using SOAP. Universal Description, Definition, and
Integration (UDDI) are the standard used for service registry. Business Services are published
to a public or private UDDI web services registry. The web services registry is used by exchange
software modules to discover and interact with each other.
Application Architecture
The goal of this project is to produce a user-friendly, web-based system which supports
principles of the Medicaid Information Technology Architecture (MITA) and open standards
wherever possible. The use of an enterprise architecture shall allow the separate, standalone
systems to communicate using exposed, shared services through a common architecture. SOA,
coupled with open standards-based-software components, will have a prominent role in the
implementation of the enterprise architecture required by the NMHIX. The NMHIX SOA will be
used to facilitate functional re-use and data sharing among loosely coupled services and
business objects. Services will be loosely coupled to reduce system dependencies and selfcontained pieces of business functionality deployed as discrete pieces of code and/or data
structures that can be reused.
The NMHIX, GetInsured, solution foundation is Service-Oriented Architecture (SOA) with a
design pattern that is based on loosely-coupled software components providing application
functionality as services to other software components. These software components can be
upgraded on a regular basis to avoid obsolescence without affecting the rest of the system.
The GetInsured solution uses modern web technologies such as Representational State
Transfer (REST), predominate web API design tool, and Web Services. Additionally the software
solution is based on the latest software design frameworks. The components and libraries
comprising these frameworks are kept current with the latest features.

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Security and Privacy Architecture

Security services will provide the safeguards to protect the Exchange from threats that could
lead to the loss of confidentiality of data, the loss of data integrity, the unavailability of data
or services and/or any unauthorized use of Exchange resources.
Accounting of Disclosures Report
The following diagram depicts how accounting of disclosure reports can be tracked and
provided to an individual.

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Figure 30: Accounting of Disclosures Report

View / Access

Exchange Operations
Staff
MS Exchange

View / Access

Protected Health
Information (PHI)

Data Store

Reporting
Engine

Broker

View / Access

Accounting of
Disclosures
Report

Other Users

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule
requires covered entities and business associates to account for disclosures of
protected health information to carry out treatment, payment, and health care
operations if such disclosures are through an electronic health record. Pursuant to
both the HITECH Act and its more general authority under HIPAA, the Department
proposes to expand the accounting provision to provide individuals with the right to
receive an access report indicating who has accessed electronic protected health
information in a designated record set.
http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/index.html
Whenever NMHIX administrative staff view or access PHI (Personal Health
Information), the action is captured by and stored as part of the audit logging
functionality. The data is stored and reports are provided when requested by
individuals, in accordance with the requirement.
PHI/PII in Transit
The following diagram depicts how GetInsured secures all health information (PHI or
PPI Personal Identifiable Information) in transit, rendering it unusable, unreadable,
or indecipherable to unauthorized individuals. This is done in accordance with the

Page 41 of 121

technology and methodology specified by the Secretary of the Federal Department

of Health and Human Services in the guidance issued under section 13402(h)(2) of
the American Recovery and Reinvestment Act of 2009 (P.L. 111-5), or any update to
that guidance.
Figure 31: PHI / PII in Transit
** Secure File Transfer Protocol
(SFTP) or other secure transmission
method for data transfers.

Data
Transmissions

SFTP**

Protected Health
Information (PHI)

MS Exchange

Encryption Method

Data Storage
Protected Health
Information (PHI)
Protected Health
Information (PHI)

Data Field
Encryption

SSL Encryption

Web Services

GetInsureds solution will provide the ability for web service providers and
service consumers to interact, and will implement security for transport and
messaging via web services.
o The Solution will utilize SSL as an encryption method to help ensure
data confidentiality prior to data transmission via web services.
Within the solution, PHI will not be transmitted via email.

Physical Security
GetInsureds solution will maintain strict physical access controls to safeguard all
areas where sensitive data could be accessed. This includes, but is not limited to the
following physical safeguards:

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

Page 42 of 121

o Access to sensitive areas within the office space (i.e., the server
room) will be gained using role-based security with the AES.
o The AES will have independent battery backup sufficient to keep
the office secure in the event of power failure until such time as
normal power is resumed or the backup generator cycles on.
All doors and common areas (i.e., break room, conference rooms, the
call-center floor, etc.) will be monitored via IP security cameras.
o The security camera system will record 100% of activity 24x7 and
retain 2 weeks of recordings on disk.
All exterior doors will be connected to an alarm system.
o This alarm system will be remotely managed and will allow for
one-touch emergency calling to the Police, Fire, and Ambulance.
The call center will have a small server room located such that all walls
are interior to the office space and extend through the plenum for firesafety reasons.
The server room will contain all security-related management equipment,
and access will be granted solely to IT services and upper management
staff.

Monitoring (including Intrusion Detection)

Intrusion detection will monitor access to the Exchange resources maintain logs and
issue alerts related to unauthorized access. Unauthorized access also includes the
prevention and monitoring for malware and/or malicious software within the
confines of Exchange computer systems. This live protection of the Exchange servers
shall be centrally managed and provide for at least:
Audit data regarding threats and attacks including false positives;
Continual updates to the protection/detection mechanisms and algorithms to
ensure proper detection and response;
Procedures and methods to isolate and neutralize an active threat in order to
protect Exchange resources.
The Alert Logic Threat Management system monitors the GetInsured solution
as hosted in the Rackspace Environment. The system is used to detect external
and internal threats. When it detects an incident, Alert
Logic's ActiveWatch service provides expert guidance from its Security
Operations Center (SOC), staffed round the clock by Alert Logic security analysts.
Integrated vulnerability scanning helps identify possible points of entry and
correct them, and assists with meeting regulatory compliance requirements.

Page 43 of 121

The figure below visually depicts the Alert Logics threat management system.
Figure 25: Alert Logic Threat Management System

The Alert Logic Log Manager automatically aggregates, normalizes, and stores log data
from GetInsureds environment. It also features log searches, forensic analysis, and
report creation through real-time or scheduled analysis.
LogReview, a service enhancement to Log Manager, provides daily event log monitoring
and review by a team of Alert Logic security professionals.
Figure 32: Alert Logic Log Manager

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

Page 44 of 121

Contracting, Outsourcing, and Agreements

NMHIX has contracted with GetInsured and PCG for ongoing development of the Exchange. In
2014, NMHIX contracted with Software Engineering Systems (SES) for the independent
verification and validation (IV&V) efforts. NMHIX has contracted with Xerox for the Call Center
and with NMPCA and NAPPR for enrollment functions. Additional local partners and
consultants are being utilized for implementation of the outreach and education plan.
3. States Strategy to Address Early Benchmarks in Section I.4
Please see the New Mexico Blueprint document for information on early benchmarks.

4. Proposed Solution for Exchange IT Systems

The NMHIX SHOP Exchange is fully functional. The individual exchange functions will be
implemented in 2015. The NMHIX will have the following functionalities:
a. Individual Eligibility & Enrollment
b. Individual Responsibility Exemption
c. Small Business Health Options Plan (SHOP) Eligibility & Enrollment
d. Verify Eligibility for Individual Federal Subsidy of Insurance Premium
e. Data Exchanges/Interfaces
f. Carrier and Plan Certification and Recertification
g. Monitor Carrier and Plan Certification Compliance
h. Establish Issuer and Plan Renewal and Recertification
i. Review Rate Increase Justifications
j. Display Carrier Ratings by Price and Quality
k. Maintain Operational Data
l. Process Change in Plan Enrollment Availability
m. Advanced Payments in Premium Tax Credit and Cost Sharing Reduction
n. Premium Processing/Payment Aggregation
o. Data Collection
p. Risk Adjustment and reinsurance (to be provided through federal services)
q. Issuer Payment Transfers
r. Call Center Module
s. Navigator Module
t. Broker Module
u. Client Correspondences
v. Management of Exchange Operations
w. Federal and Management Reporting
x. Interface with Federal Data Hub
y. Interface with Medicaid (Aspen)
z. Interface with NAIC SERFF

Page 45 of 121

An intuitive web portal (including mobile device access) through which New Mexico residents
can access subsidized and unsubsidized health insurance including: Individual enrollment and
plan selection and SHOP portal supporting plan selection and enrollment for small employers
and their employees in qualified SHOP health plans.
Back office functions include:
Interface with the integrated eligibility and verification engine
Use system components to provide for monthly window for American
Indians/Alaska Natives (AI/AN) to enroll in Plans
Determine tax credit and subsidy credits for enrollees
Use system components to facilitate enrollments into qualified health plans
Use system components to certify and manage insurance issuer, health plan and
provider data
Provide financial management components (such as: billing, receivables, general and
subsidiary ledgers, premium aggregation, reporting, reconciliation, reduced costsharing for AI/AN individuals enrolling in QHP)
Allocate cost for system utilization between NMHIX and Medicaid
Have reporting and business analytics capability
Provide identity and account management
Have document/content management
Provide notification services
New Mexico is developing an Integrated Eligibly and Verification System based on principles
laid out in Guidance for Exchange and Medicaid Information Technology (IT) Systems version
2.0. New Mexico has developed a single streamlined application (based on CMS SSAp
guidelines) and a Single Rules Engine that can be used by consumers who apply for either QHP
on the individual marketplace and for insurance affordability programs.
Upon entry into New Mexicos integrated shared portal, enrollees will be asked if they wish to
complete an insurance affordability assessment (anonymous shopping). If an enrollee decides
they do not want to pursue financial application path, he or she will be asked to provide
information on a shorter version of single streamlined application and guided thru process to
enrollee in QHP. New Mexico will send a web services query a Shared Data Services HUB for
verification of enrollees information as required in 45 CFR part 155.
For enrollees who wish to pursue financial application path, NMHIX will seamlessly transition
to insurance affordability single streamlined application that will collect the required data from
enrollees and family members. New Mexico will send a web services query a Shared Data
Services HUB for verification of enrollees information as required in 45 CFR part 155.
The business and functional requirements for processing and screening applications,
determining eligibility, renewing eligibility, and handling appeals includes the following core
processes:
Prepare Initial Individual Application

Page 46 of 121

Verify Individual Citizenship, Status as a National or Lawful Presence

Determine Individual Exchange
Verify Individual Incarceration Status
Renew Individual Eligibility and
Appeal Individual Eligibility
Verify whether an Individual is a Native American (NA/IA)
Verify Individual Residency in Exchange Service
Verify Eligibility for Other Public Minimum Essential Coverage
Verify Income
Qualify Individual for Enrollment Period
Communicate Eligibility Determination and Coordinate Enrollment
Determine Individual Exemption Eligibility
Renew Individual Exemption Eligibility
Change Reporting
Access to Referral

The New Mexicos Individual Enrollment processes will coordinate seamlessly with its
Individual Eligibility processes. For QHP selections, the NMHIX system will be responsible for
creating enrollment transactions and providing them directly to insurance issuers or allowing
the individual to complete enrollment directly through the insurance issuers websites. The
IT System will track all health plan enrollments for individuals who have applied for coverage
through the Marketplace. It will also be responsible for reporting enrollment, as required by
CMS, to the Federal Data Services Hub.
The NMHIX Plan Management function consists of the following core elements:
Establish Issuer and Plan Initial Certification and Agreement
Monitor Issuer and Plan Certification
Establish Issuer and Plan Renewal and Recertification
Maintain Operational Data
Process Change in Plan Enrollment
Review Rate Increase Justifications
NMHIX intends to leverage the SERFF system from the NAIC for the following functions:
Marketing Standards
Accreditation and Quality
Notice of Intent
Reporting Requirements
QHP and state mandate standards
Submission at Plan Level
Indication of Metal Level
Verification of Metal Level
Quality measures
Benefit Package

Page 47 of 121

Cost Sharing and Limits

Rating Tables
Final Determination
Issuer and QHP Status
Renewal and Certification
Decertification of Issuer
Decertification of Plan
SHOP Plan Changes
Individual Plan Changes

Once New Mexico is live with core marketplace functionality in 2015 New Mexico will continue
to add capabilities to support our goal to increase enrollment and enhance self-sustainability.
General theme for types of enhancement work that will be undertaken in 2016 and 2017
include:
Catalyze enrollment through active and increasing participation of brokers;
Broaden distribution opportunities maximally through a range of enrollment options;
Enhance ease of use by users, particularly for New Mexico specific user communities.
New Mexico is looking to implement following enhancements:
Centralized Provider Directory
Prescription Search
Provider Network Stats - Narrow Networks
Provider Maps
Ability to purchase adult dental without QHP
Personalized Plan Scores
Anonymous Shopping for Employers
Automated Reminders
Direct Enrollment Module (EVaaS)
Operational User Alerts -- Part I for Brokers and CSRs (Customer Life-cycle
Management)
Operational User Alerts -- Part II for NMHIX administration
Batch Enrollment Engine from SHOP to Individual Exchange
Consumer Assistance Toolset: PDF proposal creators, notifications to designated CC
of any change to consumer record, scenario analysis for each family.
Advanced Layered, In-context Help
Native mobile apps for iOs and Android for Employees (iPhone, iPad)
Capability to make differing enrollment choices per family member
Scenario and Prospect Management Workbench for Brokers
PDF Proposal Creator, Rapid employer engagement tool
Brokers and CSRs: Advanced Reporting & Analytics (optional feature with Scenario and
Prospect Management Workbench)
Broker Agency Module
Advanced Enrollment Counselor Search

Page 48 of 121

Enrollment Entity Setup Process Enhancements

Enrollment Counselor certification and learning management integration
Enrollment Counselor self-ticket creation and management
Operational User Alerts -- Part III for Brokers (Customer Life-cycle Management)
Enrollment Counselor recertification or renewal automation
Agent License monitoring and action system
Advanced access to Enrollment Counselor functions to the Enrollment Entity
Agent employer relationship lifecycle - multiple notifications

Page 49 of 121

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

Page 50 of 121

Nov-17

Dec-17

Sep-17

Oct-17

Jul-17

Aug-17

Jun-17

Apr-17

May-17

Mar-17

Jan-17

Feb-17

Dec-16

Oct-16

Nov-16

Sep-16

Jul-16

Aug-16

Jun-16

Apr-16

May-16

Mar-16

Jan-16

Feb-16

Dec-15

Oct-15

Nov-15

Sep-15

Jul-15

Aug-15

Jul-15

Jun-15

Apr-15

May-15

Mar-15

Jan-15

NMHIX Timelines

Feb-15

Figure: Timeline to implement enhancements to New Mexicos IT System

5. IT Seven Standards and Conditions

Please see the New Mexico Blueprint document for information on Exchange IT systems.
6. Organizational Structure
The NMHIX organizational chart is shown on page 16. NMHIX has implemented an MOU with
HSD and an MOU with OSI to delineate the roles and responsibilities.
7. Coordination with the Federal Government on Exchange Activities
New Mexico will coordinate with the federal government on all its development and
implementation activities.
8. Strategies for Reuse, Sharing, Collaboration for NMHIX Activities with the Federal Exchange
and Other States
As outlined in agreements with HHS, all Exchange systems and system components financed
with federal funds are non-proprietary, utilize open architecture standards, and permit re-use
by other states and jurisdictions. New Mexico will inform and assist other states through
various means, including HHS Learning Collaborative and User Groups. Beyond reuse and
sharing of IT, New Mexico is committed to leverage existing infrastructure and re-purpose
business functions and processes to maximize resources and is working with other states to
determine how aspects of their systems can be replicated in New Mexico. Specifically,
Marketplace IT solution is being used by Idaho and Mississippi State Based Marketplace. New
Mexico has collaborated with these SBMs and is in process of forming a formal users group.
As we look at self-sustainability, New Mexico will continue to collaborate with Idaho and
Mississippi SBMs to continue to enhance Marketplace IT solution on a join cost basis via its
Marketplace technology vendor GetInsured.

9. Strategies to Ensure Financial Integrity Mechanisms to Prevent Fraud, Waste, and Abuse and
Provide Oversight of Cooperative Agreement Funds and the Exchange
New Mexico has administrative policies and statutory and regulatory provisions to ensure
appropriate financial management of grant funds. Grant funds are administered following
comprehensive written procedures and procedures approved by the NMHIX Finance
Committee. This includes internal controls and oversight to make sure the system disburses,
tracks, and accounts for grant disbursements. New Mexico will ensure NMHIX program
operations and management integrity, and that federal cooperative agreement dollars are
expended as budgeted in its cooperative agreements and contracts.

Page 51 of 121

10. Challenges That May Affect Progress in Work Plan

New Mexico is monitoring key indicators on a daily basis through its PMO. Weekly project
meetings are conducted to review progress towards meeting identified milestones. Issues are
Risk are escalated as appropriate to New Mexico Leadership.
11. SHOP
Market ChallengesOver 85 percent of New Mexicos small businesses have fewer than 50
employees and many have never purchased health insurance.
Strategic SHOP Plan--NMHIX has successfully implemented its SHOP program. Three major
insurers in New Mexico have been certified as SHOP QHPs.

Page 52 of 121

F. Work Plan
NMHIX has retained the services of GetInsured (GI) to implement both the SHOP marketplace
and the Individual marketplace. NMHIX produced a set of functional requirements for the
SHOP and Individual marketplace systems that were incorporated into the Request for
Proposals (RFP) to which GI responded. NMHIX has retained the services of Public Consulting
Group (PCG) to assist with various aspects of implementing the SHOP and Individual
marketplaces, including a Project Management Office (PMO). In addition NMHIX has
contracted with Software Engineering Services (SES) as an Independent Verification and
Validation to oversee the design, development, and implementation of the marketplace
functions.
Among the functions of the PMO and IV&V are to work with GI to ensure that:
o Standard industry Systems Development Life Cycle (SDLC) protocols are followed,
including iterative and incremental development methodologies.
o Requirement specifications, analysis, design, code, and testing are developed and
carried out in accordance with CMS/CCIIO requirements and generally accepted
professional practice.
o The design takes advantage of a Web Services Architecture and Service Oriented
Architecture approach for design and development.
o The services description/definition, services interfaces, policies and business rules
are published as required and the solution provides role-based access to underlying
data.
o The solution adheres to standards published by the Office of the National
Coordinator (ONC) and the National Institute of Standards and Technology (NIST).
o The GI system is interoperable and integrated with State Medicaid/ Childrens
Health Insurance Program (CHIP) programs and is able to interface with HHS and
other data sources in order to verify and acquire data as needed.
o The GI system achieves any required interoperability with other health and human
services programs for purposes of coordinating eligibility determinations, referrals,
verification or other functions.

Page 53 of 121

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

Task Name

Start

Finish

Phase II Individual and SHOP Enhancements

On Going PMO Services
OSI QHP Review dates
CMS/CCIIO/IRS - Reviews
Planning Review Meeting
Design Review Meeting
Final Design Review Meeting
Operation Readiness Review
Internal Readiness Review
IRS Visit
Business Area Development
Identify NMHIX owner for each Functional area
Review and signoff of JAD documents
Mail Room Operations
2.0 Consumer and Stakeholder Engagement and Support
3.0 Eligibility and Enrollment
8.0 Finance
10.0 Privacy & Security
11.0 Oversight, Monitoring, & Reporting
12.0 Policies and Procedures Documentation
Phase II - Technical
Requirements and Design Validation
External Dependencies
Interfaces/Integration Planning
Infrastructure
Interfaces - Connectivity
CP3 Demo for CMS
OIG Audit
Release 0 & 1 (Plan Mgt, Agents, Entities/Assisters) and Release 1 (Pre-screener, Anon.Shop. & Acc. Creation)
NMHIX SHOP
Release 2 (Public Launch - Open Enrollment)
2014 Cycle
Check point 2 (Account Creation, SSA data verification rule engine and HUB interface)
Check point 3 (Plan Selection, Financial Management, Eligibility)
Check point 4 (Carrier Interfaces, Individual Portal)
Check point 5 (Admin Portal, Reporting)
COTS Deferred Items 2.1 & 2.2
INITIAL MEC interface QA (MMIS/Xerox)
SIT Verification interface formal test (FDSH) - CMS Hub Testing
Product Assessment
2015 Cycle
External Dependency: Additional HSD data needs [place holder]
External Dependency: CMS Verification Flow Changes (Assessing risk to CMS new changes and possible rework)
Validate Sprint Schedule
New Mexico Specific Components
Develop Test Plan (UAT / SIT)
Review Content (SSAp Only)
Develop Training plan
Develop System Integration testing (SIT) Test Cases
Performance and Stress Test
UAT prep - R2, Deferred, CR items
UAT - R2, Deferred, CR items
Stakeholder Assessment (GI will maintain a testing server enviornment)
Training [ R0, R1 and R2 training]
FFM Renewals & Data Migration [Place Holder]
2015 Enhancements [Place Holder]
Deploy Release 2 to pre-production environment [Place Holder]
Client Review before public launch
DELIVERABLE: Provide Final Release 0 and 1 Notes to client
Client approval to deploy R0 & R1 to production
Deploy Releases 0 and 1 to production
Release 0 and Release 1 - public launch
DELIVERABLE: Provide Final Release 2 Notes to client
Stabilization Period / Launch
Deploy Release 2 to production environment at the same time as R0 & R1 (Option 1 - based on an October OE)
NMHIX Requested Production Based Testing
Plan validation by carriers [MOVE to 2015]
Release 2 - PUBLIC LAUNCH
Release 2 Transition to production
Operational Normalization
Release XX - to be determined
Deferred 2.3 - 2015 Renewals [Place holder]
Deferred 2.3 - CMS / IRS reports (H36 monthly / H41 yearly)
Deferred 2.3 - Test CMS / IRS reports (H36 monthly / H41 yearly)
Project Closure

Mon 6/24/13
Mon 6/24/13
Sat 3/1/14
Tue 2/11/14
Tue 2/11/14
Wed 4/9/14
Tue 6/10/14
Mon 8/3/15
Mon 8/10/15
Mon 8/17/15
Mon 2/3/14
Tue 4/1/14
Thu 3/27/14
Tue 4/1/14
Wed 3/12/14
Tue 2/4/14
Tue 4/1/14
Tue 4/1/14
Mon 2/3/14
Fri 7/25/14
Mon 12/16/13
Tue 1/14/14
Fri 4/4/14
Mon 2/17/14
Mon 1/27/14
Wed 1/29/14
Fri 7/11/14
Tue 1/28/14
Mon 12/23/13
Mon 9/1/14
Mon 12/16/13
Mon 12/16/13
Mon 2/3/14
Mon 2/3/14
Mon 4/7/14
Mon 12/16/13
Mon 6/30/14
Thu 5/8/14
Wed 5/14/14
Mon 10/20/14
Thu 5/8/14
Mon 9/29/14
Mon 2/9/15
Tue 12/30/14
Mon 10/6/14
Mon 1/5/15
Tue 1/13/15
Mon 4/6/15
Thu 5/8/14
Mon 8/3/15
Mon 2/2/15
Sat 12/27/14
Mon 5/11/15
Mon 6/1/15
Sun 10/12/14
Mon 3/9/15
Wed 3/25/15
Mon 8/10/15
Mon 8/17/15
Mon 8/24/15
Wed 8/26/15
Fri 9/4/15
Mon 8/31/15
Mon 9/14/15
Mon 8/24/15
Fri 9/4/15
Mon 7/6/15
Fri 10/2/15
Mon 10/5/15
Mon 10/19/15
Wed 7/1/15
Wed 7/1/15
Mon 11/2/15
Mon 11/2/15
Mon 10/19/15

Fri 1/15/16
Fri 1/15/16
Sun 8/31/14
Wed 8/19/15
Tue 2/11/14
Thu 4/10/14
Wed 6/11/14
Tue 8/4/15
Wed 8/12/15
Wed 8/19/15
Thu 10/15/15
Fri 5/2/14
Fri 11/14/14
Mon 1/12/15
Thu 10/15/15
Thu 10/1/15
Fri 11/28/14
Fri 10/3/14
Mon 4/20/15
Wed 1/28/15
Fri 1/1/16
Thu 2/19/15
Wed 8/26/15
Wed 5/6/15
Fri 8/14/15
Thu 10/1/15
Fri 7/11/14
Mon 5/26/14
Wed 11/19/14
Fri 1/1/16
Mon 11/2/15
Thu 2/12/15
Fri 6/13/14
Fri 7/11/14
Wed 11/26/14
Wed 9/10/14
Fri 1/23/15
Fri 11/7/14
Tue 7/15/14
Thu 2/12/15
Mon 11/2/15
Fri 3/6/15
Fri 8/14/15
Tue 12/30/14
Fri 9/4/15
Mon 2/2/15
Fri 3/13/15
Fri 5/1/15
Mon 11/2/15
Fri 10/2/15
Fri 3/13/15
Fri 6/12/15
Fri 6/26/15
Wed 8/5/15
Fri 9/25/15
Fri 8/28/15
Wed 4/1/15
Fri 8/14/15
Fri 8/21/15
Tue 8/25/15
Thu 9/3/15
Fri 9/4/15
Mon 8/31/15
Fri 9/25/15
Thu 9/3/15
Thu 10/1/15
Wed 9/2/15
Fri 10/2/15
Fri 10/16/15
Fri 12/11/15
Fri 1/8/16
Tue 10/13/15
Fri 1/8/16
Fri 1/8/16
Fri 1/15/16

Page 54 of 121

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

Page 55 of 121

Nov-17

Dec-17

Sep-17

Oct-17

Jul-17

Aug-17

Jun-17

Apr-17

May-17

Mar-17

Jan-17

Feb-17

Dec-16

Oct-16

Nov-16

Sep-16

Jul-16

Aug-16

Jun-16

Apr-16

May-16

Mar-16

Jan-16

Feb-16

Dec-15

Oct-15

Nov-15

Sep-15

Jul-15

Aug-15

Jul-15

Jun-15

Apr-15

May-15

Mar-15

Jan-15

NMHIX Timelines

Feb-15

Timeline to implement enhancements to New Mexicos IT System

G. BUDGET AND BUDGET NARRATIVE

a Salaries
b Fringe Benefits
c Total Personnel Costs
d Equipment
e Supplies
f Travel
g Construction
h Other
i Contractual
j Total Direct Costs

$
$
$
$
$
$
$
$
$
$

97,975,535
97,975,535

New Mexico requests $97.9 million in federal funding for a Level Two Establishment grant for
the period January 1, 2015 through December 31, 2017.
New Mexico received $34.3 million for an initial Level One grant in November 2011. This grant
is in the process of being closed.
New Mexico also received $18.6 million as an additional (2nd) Level One grant in July 2013.
This grant is still open and has a balance of $4.0 million remaining. A No Cost Extension was
requested in September 2014, which increased the duration to 10/14/2015.
New Mexico received $69.4 million for the 3rd Level One grant, awarded January 22, 2014. A
No Cost Extension is being requested to December 31, 2015. Approximately 80% of this grant
is encumbered by contracts.

Budget detail is provided for each expenditure area as follows:

Salaries and Wages

Total $0
Exchange Establishment Grant: $0
Funding other than Establishment Grant $0
Sources of Funding: Level 1 grant
Funding for Salaries and Wages that are eligible for grant funding is provided by existing grant
HBEIE140193, and is discussed in the No Cost Extension for that grant.

Page 56 of 121

Fringe Benefits
Total $0
Exchange Establishment Grant: $0
Funding other than Establishment Grant: $0
Sources of Funding: Level 1 Grant
Funding for Fringe Benefits that are eligible for grant funding is provided by existing grant
HBEIE140193, and is discussed in the No Cost Extension for that grant.

Equipment
Total $0
Exchange Establishment Grant: $0
Funding other than Establishment Grant: $0
Sources of Funding: Level 1 Grant
Funding for Equipment is provided by existing grant HBEIE140193, and is discussed in the No
Cost Extension for that grant.

Supplies
Total $0
Exchange Establishment Grant: $0
Funding other than Establishment Grant: $0
Sources of Funding: Level 1 Grant

Funding for Supplies is provided by existing grant HBEIE140193, and is discussed in the No Cost
Extension for that grant.

Travel
Total $0
Exchange Establishment Grant: $0
Funding other than Establishment Grant: $0
Sources of Funding: Level 1 Grant
Funding for Travel is provided by existing grant HBEIE140193, and is discussed in the No Cost
Extension for that grant.

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Other
Total $0
Exchange Establishment Grant: $0
Funding other than Establishment Grant: $0
Sources of Funding: 0 Level 1 Grant
Funding for other is provided by existing grant HBEIE140193, and is discussed in the No Cost
Extension for that grant.

Contractual
Total $97,975,535
Exchange Establishment Grant: $97,975,535
Funding other than Establishment Grant: $0
Contractual services include the following:
Budget Items in Level 2 Grant
System Core Functionality
Costs for CMS Single Door
Delay in Implementation of Individual Exchange
DDI Impact
Renewal/Data Migration for Individual Exchange
CMS June 2014 Approved Verification Flow
Portion of Change Orders
Contingency for additional CMS changes

$
$
$
$
$
$
$
$

48,779,480
32,236,297
2,591,667
2,758,380
7,500,000
765,000
621,702
2,723,010

Grand Total - Level 2

97,975,535

1. Get Insured system functionality These improvements to the core system functionality are
intended to enhance the consumer experience to facilitate enrollment growth and ultimately
benefit financial sustainability. They include:
a) Centralized Provider Directory technology capability to search for and identify provider
b) Prescription Search that enables the consumer to enter the names of prescriptions and
then shop for plans based on coverage for that prescription.
c) Anonymous Shopping for Employers this is a new tool that allows employers to enter
minimal data and browse the plans and prices available for their business without
creating an account or going through eligibility

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2.
3.

4.
5.
6.

d) Automated Reminder emails for incomplete employer tasks

e) CAP Enhancements and Policy Search the capability to search for enrollments by issuer
enrollment ID, by name of subscriber and other characteristics.
f) Direct Enrollment Module that can allow for carriers to easily integrate with NMHIX. This
will encourage greater participation by carriers.
g) Operational User Alerts for brokers, customer service reps and NMHIX administration
System wide alerts for a range of stakeholders for 360 degree service of the customer.
h) Batch Enrollment Engine from SHOP to Individual Exchange this will allow brokers or
employers to quickly model likely eligibility for the Individual Exchange for employee
dependents based on Employer offer of coverage to dependent.
i) Provider Network Stats to allow consumers to visualize the depth of provider networks
in their zip codes across plans through simple visualization tools.
j) Provider Maps Geo maps of provider networks
k) Ability to purchase adult dental without QHP
l) Personalized Plan Scores
CMS Single Door - The cost estimated for development of a single financial application to
meet CMS requirement of a fully integrated approach with HSD.
Delay in implementation of Individual Exchange In July 2014 Board meeting, the Board
voted to delay the implementation of the Individual Exchange due to concerns about
schedule slippage.
DDI Impact Infrastructure and hosting server for the individual exchange delay.
Renewal/Data Migration cost of moving enrollees from the Federal platform to the State
Individual exchange this is expected to be a manual process.
Remaining costs include the CMS Verification Flow, Contingency and Change Orders.

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

PROPOSED/EXISTING PROJECT
None to report

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I. DESCRIPTION OF KEY PERSONNEL AND ORG CHART

See Page 19

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J Cost Allocation Methodology

Attached below is a draft Cost Allocation Methodology. NMHIX will continue to work closely
with HSD to finalize the cost allocation detailed methodology based on the integrated Single
Door approach.

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K. DOCUMENTATION SUPPORTING ELIGIBILITY OF APPLICANT (LEVEL TWO

EXCHANGE ESTABLISHMENT ONLY)
1. New Mexico Senate passed a Bill-221NMHIX that provides necessary legal authority to
NMHIX to establish and operate an Exchange that complies with Federal requirements
available at the time of the application. See attached below copy of SB221
2. New Mexico Senate passed a Bill-221NMHIX that established a governance structure for
the NMHIX Exchange. See attached below copy of SB221
3. Initial plan discussing long-term operational costs of the Exchange See below attached
draft NMHIX Financial Sustainability Plan

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Senate Bill-221NMHIX

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Financial Sustainability Plan

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