Common use of Demonstration of Past Progress in Exchange Planning Core Areas Clause in Contracts

Demonstration of Past Progress in Exchange Planning Core Areas. This section should describe and quantify, where possible, progress the State made in Exchange planning activities. This includes but is not limited to the discussion points highlighted below: Background Research: Discuss the research conducted, including key findings and plans that resulted from this research. Stakeholder Consultation: Discuss partnerships with various stakeholders and how public input into the Exchange planning process was gained, such as State HIT Coordinators and the State’s health information exchange program, State officials, representatives of State Agencies, employers, insurers, advocacy groups, and consumer groups. State Legislative/ Regulatory Actions: Discuss the progress made toward the creation of the necessary legal authority to establish and operate an Exchange that complies with Federal requirements available at the time of the application and provides for establishment of governance and Exchange structure Governance: Discuss the progress made toward establishing the administrative structure (State agency, quasi-governmental agency, or non-profit organization) and governance structure of the Exchange (composition of governing body, conflict of interest standards, selection process). Program Integration: Discuss how coordination with the State insurance regulatory entity (e.g. Department of Insurance), State Medicaid, CHIP, other State health subsidy programs, and other health and human services programs as appropriate, has been carried out during the planning process, and outcomes of these coordination efforts. Include planning activities related to streamlining eligibility and enrollment, and coordinating with the State Department of Insurance on issues including the financial stability of insurance companies, certification of plans, rate review, State licensure, solvency, and market conduct. Discuss any efforts that have taken place or may be planned to facilitate coordination with other specific health and human services programs. Exchange IT Systems: Discuss steps taken toward the first phase of development of Exchange IT systems in accordance with the most current Federal IT guidance. Please reference Appendix D as well. including compliance with the standards adopted by the Secretary under Section 1561 of the Affordable Care Act. Discuss steps taken to ensure a modular, flexible approach to systems development, including use of open interfaces and exposed application programming interfaces; the separation of business rules from core programming; and the availability of business rules in both human and machine readable formats. Financial Management: Describe the financial management infrastructure the Exchange has established for financial management of the Exchange and Exchange grants using Planning grant funds (or other funds made available by the State for this purpose). Program Integrity: Discuss planning activities related to auditing, financial integrity, oversight, and prevention of fraud, waste and abuse. Health Insurance Market Reforms: Discuss progress in implementing Insurance Market Reforms under Subtitles A and C of the Affordable Care Act. Providing Assistance to Individuals and Small Businesses, Coverage Appeals, and Complaints: Discuss planning efforts related to ensuring individuals have access to assistance services in the State. Business Operations/ Exchange Functions: Discuss the planning activities leading to the development of goals, milestones and timeframes for each function of the Exchange, to the extent that there is sufficient Federal guidance to do so at the time of the application. This includes: Certification, recertification, and decertification of qualified health plans Call center Exchange website Premium tax credit and cost-sharing reduction calculator Quality rating system Navigator program Eligibility determinations for Exchange participation, advance payment of premium tax credits, cost-sharing reductions, and Medicaid Seamless eligibility and enrollment process with Medicaid and other State health subsidy programs Enrollment process Applications and notices Individual responsibility determinations Administration of premium tax credits and cost-sharing reductions Adjudication of appeals of eligibility determinations Notification and appeals of employer liability Information reporting to IRS and enrollees Outreach and education Free Choice Vouchers Risk adjustment and transitional reinsurance SHOP Exchange-specific functions

Demonstration of Past Progress in Exchange Planning Core Areas. This section should describe and quantify, where possible, progress the State made in Exchange planning activities. This includes but is not limited to the discussion points highlighted below: Background Research: Discuss the research conducted, including key findings and plans that resulted from this research. Stakeholder Consultation: Discuss partnerships with various stakeholders and how public input into the Exchange planning process was gained, such as State HIT Coordinators and the State’s health information exchange program, State officials, representatives of State Agencies, employers, insurers, advocacy groups, and consumer groups. State Legislative/ Regulatory Actions: Discuss the progress made toward the creation of the necessary legal authority to establish and operate an Exchange that complies with Federal requirements available at the time of the application and provides for establishment of Exchange governance and Exchange structure Governance: Discuss the progress made toward establishing the administrative structure (State agency, quasi-governmental agency, or non-profit organization) and governance structure of the Exchange (composition of governing body, conflict of interest standards, selection process). Program Integration: Discuss how coordination with the State insurance regulatory entity (e.g. Department of Insurance), State Medicaid, CHIP, other State health subsidy programs, and other specific health and human services programs as appropriate, has been carried out during the planning process, and outcomes of these coordination efforts. Include planning activities related to streamlining eligibility and enrollment, and coordinating with the State Department of Insurance on issues including the financial stability of insurance companies, certification of plans, rate review, State licensure, solvency, and market conduct. Discuss any efforts that have taken place or may be planned to facilitate coordination with other specific health and human services programs. Exchange IT Systems: Discuss steps taken toward the first phase of development of Exchange IT systems in accordance with the most current Federal IT guidance. Please reference Appendix D as well. , including compliance with the standards adopted by the Secretary under Section 1561 of the Affordable Care Act. Please reference Appendix D as well. Discuss steps taken to ensure a modular, flexible approach to systems development, including use of open interfaces and exposed application programming interfaces; the separation of business rules from core programming; and the availability of business rules in both human and machine readable formats. Financial Management: Describe the financial management infrastructure the Exchange has established for financial management of the Exchange and Exchange grants using Planning planning grant funds (or other funds made available by the State for this purpose). Program Integrity: Discuss planning activities related to auditing, financial integrity, oversight, and prevention of fraud, waste and abuse. Health Insurance Market Reforms: Discuss progress in implementing Insurance Market Reforms under Subtitles A and C of the Affordable Care Act. Providing Assistance to Individuals and Small Businesses, Coverage Appeals, and Complaints: Discuss planning efforts related to ensuring individuals have access to that assistance services are provided to individuals and small businesses in the State. Business Operations/ Exchange Functions: Discuss the planning activities leading to the development of an implementation plan that lays out goals, milestones and timeframes for each function of the Exchange, to the extent that there is sufficient Federal guidance to do so at the time of the application. This includes: Certification, recertification, and decertification of qualified health plans Call center Exchange website Premium tax credit and cost-sharing reduction calculator Quality rating system Navigator program Eligibility determinations for Exchange participation, advance payment of premium tax credits, cost-sharing reductions, and Medicaid Seamless eligibility and enrollment process with Medicaid and other State health subsidy programs Enrollment process Applications and notices Individual responsibility determinations Administration of premium tax credits and cost-sharing reductions Adjudication of appeals of eligibility determinations Notification and appeals of employer liability Information reporting to IRS and enrollees Outreach and education Free Choice Vouchers Risk adjustment and transitional reinsurance SHOP Exchange-specific functions

Demonstration of Past Progress in Exchange Planning Core Areas. This section should describe and quantify, where possible, progress the State has made in Exchange planning activities. This includes but is not limited to the discussion points highlighted below: Background Research: Discuss the research conducted, including key findings and plans that resulted from this research. Stakeholder Consultation: Discuss partnerships with various stakeholders and how public input into the Exchange planning process was gained, such as State HIT Coordinators and the State’s health information exchange program, State officials, representatives of State Agencies, employers, insurers, advocacy groups, and consumer groups. State Legislative/ Regulatory Actions: Discuss the progress made toward the creation of the necessary legal authority to establish and operate an Exchange that complies with Federal requirements available at the time of the application and provides for establishment of governance and Exchange structure Governance: Discuss the progress made toward establishing the administrative structure (State agency, quasi-governmental agency, or non-profit organization) and governance structure of the Exchange (composition of governing body, conflict of interest standards, selection process). Program Integration: Discuss how coordination with the State insurance regulatory entity (e.g. Department of Insurance), State Medicaid, CHIP, other State health subsidy programs, and other health and human services programs as appropriate, has been carried out during the planning process, and outcomes of these coordination efforts. Include planning activities related to streamlining eligibility and enrollment, and coordinating with the State Department of Insurance on issues including the financial stability of insurance companies, certification of plans, rate review, State licensure, solvency, and market conduct. Discuss any efforts that have taken place or may be planned to facilitate coordination with other specific health and human services programs. Exchange IT Systems: Discuss steps taken toward the first phase of development of Exchange IT systems in accordance with the most current Federal IT guidance. Please reference Appendix D as well. well including compliance with the standards adopted by the Secretary under Section 1561 of the Affordable Care Act. Discuss steps taken to ensure a modular, flexible approach to systems development, including use of open interfaces and exposed application programming interfaces; the separation of business rules from core programming; and the availability of business rules in both human and machine readable formats. Financial Management: Describe the financial management infrastructure the Exchange has established for financial management of the Exchange and Exchange grants using Planning grant funds (or other funds made available by the State for this purpose). Program Integrity: Discuss planning activities related to auditing, financial integrity, oversight, and prevention of fraud, waste and abuse. Health Insurance Market Reforms: Discuss progress in implementing Insurance Market Reforms under Subtitles A and C of the Affordable Care Act. Providing Assistance to Individuals and Small Businesses, Coverage Appeals, and Complaints: Discuss planning efforts related to ensuring individuals have access to assistance services in the State. Business Operations/ Exchange Functions: Discuss the planning activities leading to the development of goals, milestones and timeframes for each function of the Exchange, to the extent that there is sufficient Federal guidance to do so at the time of the application. This includes: Certification, recertification, and decertification of qualified health plans Call center Exchange website Premium tax credit and cost-sharing reduction calculator Quality rating system Navigator program Eligibility determinations for Exchange participation, advance payment of premium tax credits, cost-sharing reductions, and Medicaid Seamless eligibility and enrollment process with Medicaid and other State health subsidy programs Enrollment process Applications and notices Individual responsibility determinations Administration of premium tax credits and cost-sharing reductions Adjudication of appeals of eligibility determinations Notification and appeals of employer liability Information reporting to IRS and enrollees Outreach and education Free Choice Vouchers Risk adjustment and transitional reinsurance SHOP Exchange-specific functions

Demonstration of Past Progress in Exchange Planning Core Areas. This section should describe and quantify, where possible, progress the State made in Exchange planning activities. This includes but is not limited to the discussion points highlighted below: Background Research: Discuss the research conducted, including key findings and plans that resulted from this research. Stakeholder Consultation: Discuss partnerships with various stakeholders and how public input into the Exchange planning process was gained, such as State HIT Coordinators and the State’s health information exchange program, State officials, representatives of State Agencies, employers, insurers, advocacy groups, and consumer groups. State Legislative/ Regulatory Actions: Discuss the progress made toward the creation of the necessary legal authority to establish and operate an Exchange that complies with Federal requirements available at the time of the application and provides for establishment of Exchange governance and Exchange structure Governance: Discuss the progress made toward establishing the administrative structure (State agency, quasi-governmental agency, or non-profit organization) and governance structure of the Exchange (composition of governing body, conflict of interest standards, selection process). Program Integration: Discuss how coordination with the State insurance regulatory entity (e.g. Department of Insurance), State Medicaid, CHIP, other State health subsidy programs, and other specific health and human services programs as appropriate, has been carried out during the planning process, and outcomes of these coordination efforts. Include planning activities related to streamlining eligibility and enrollment, and coordinating with the State Department of Insurance on issues including the financial stability of insurance companies, certification of plans, rate review, State licensure, solvency, and market conduct. Discuss any efforts that have taken place or may be planned to facilitate coordination with other specific health and human services programs. Exchange IT Systems: Discuss steps taken toward the first phase of development of Exchange IT systems in accordance with the most current Federal IT guidance. Please reference Appendix D as well. , including compliance with the standards adopted by the Secretary under Section 1561 of the Affordable Care Act. Please reference Appendix D as well. Discuss steps taken to ensure a modular, flexible approach to systems development, including use of open interfaces and exposed application programming interfaces; the separation of business rules from core programming; and the availability of business rules in both human and machine readable formats. Financial Management: Describe the financial management infrastructure the Exchange has established for financial management of the Exchange and Exchange grants using Planning planning grant funds (or other funds made available by the State for this purpose). Program Integrity: Discuss planning activities related to auditing, financial integrity, oversight, and prevention of fraud, waste and abuse. Health Insurance Market Reforms: Discuss progress in implementing Insurance Market Reforms under Subtitles A and C of the Affordable Care Act. Providing Assistance to Individuals and Small Businesses, Coverage Appeals, and Complaints: Discuss planning efforts related to ensuring individuals have access to that assistance services are provided to individuals and small businesses in the State. Business Operations/ Exchange Functions: Discuss the planning activities leading to the development of an implementation plan that lays out goals, milestones and timeframes for each function of the Exchange, to the extent that there is sufficient Federal guidance to do so at the time of the application. This includes: Certification, recertification, and decertification of qualified health plans Call center Exchange website Premium tax credit and cost-sharing reduction calculator Quality rating system Navigator program Eligibility determinations for Exchange participation, advance payment of premium tax credits, cost-sharing reductions, and Medicaid Seamless eligibility and enrollment process with Medicaid and other State health subsidy programs Enrollment process Applications and notices Individual responsibility determinations Administration of premium tax credits and cost-sharing reductions Adjudication of appeals of eligibility determinations Notification and appeals of employer liability Information reporting to IRS and enrollees Outreach and education Free Choice Vouchers Risk adjustment and transitional reinsurance SHOP Exchange-specific functions