And President Barack Obama
's former chief technology officer says the problems arise from HHS' decision to build powerful security protection into the site.Kentucky
exchange website, which has used CGI Federal, is considered one of the most successful state-run exchanges. It has attracted more than 5 million Web page views from nearly 238,000 unique visitors; more than 211,000 of those visitors performed pre-screenings to determine their qualifications for expanded state Medicaid coverage or federal subsidies. So far, 36,623 applications have been started and 25,710 were completed with 12,700 individuals enrolled in coverage.
That takes only a small bite out of the state's uninsured
population of 640,000, but it's a start, said Chris Clark, technology program manager at the office of administration and technology services of the Kentucky Cabinet for Health and Family Services, the state agency that developed the state exchange.
Clark said Deloitte is Kentucky's prime systems integration vendor, but that firm subcontracted to CGI Federal, which provides multiple component parts in the system. CGI Federal, the U.S. subsidiary of the Canadian CGI group, is the embattled lead contractor for the federal marketplace that's serving 36 states that chose not to run their own exchange.
CGI did the plan management system to bring insurers' plans to the exchange, Clark said. CGI designed Kentucky's plan shopping function, an off-the-shelf product. CGI also did Kentucky's financial management component, billing employers for their monthly premiums in the Small Business Health Options program exchange for small business owners.
Clark said Deloitte has done an “excellent” job and CGI has been “great.” He declined to comment on problems with the federal exchange or CGI.
“We've met what was a very aggressive deadline; that has to be one of the most complex systems I've ever been involved with,” he said.
CGI Federal did not respond to requests for comment.
Accenture, the prime contractor in California's state-run exchange, also helped Kentucky in the early planning stages, Clark said. The California exchange also uses CGI technology, according to published reports.
There were a few glitches in Kentucky's exchange. There was an issue with account creation and the large volume of people who came to kynect on the first day the exchange opened, said Jill Midkiff, executive director of the office of communications of the Cabinet for Health and Family Services. The site, though, never went down and preliminary screening and shopping worked well, she said.
“To correct the problem, we added additional servers to meet the account creation demand and added CPUs (central processing units, in effect, more computing power) to one of the servers,” Midkiff said.
The identity proofing piece is where the federal exchange website also has had serious problems, said Aneesh Chopra, co-founder and executive vice president of Hunch Analytics, an Arlington, Va., technology firm, who previously served as the Obama administration's first White House chief technology officer. That grew out of HHS' decision to build in strong security, he said.
All businesses that offer Web-based services make judgments on how secure they want their customer transactions to be, Chopra said. “What HHS chose to do was err on the side of more security,” he said. “They chose to run a validation process and use industrial strength tools, so validation took more (computing resources).”
That step was engineered to handle about 60,000 accounts at the same time, Chopra said. “But then they had seen upwards of 250,000 account creations at the same time. That's nearly four to five times more volume. It doesn't matter how many website hits it gets. What matters is how many account requests they get. It turns out that to correct this, they have to make both software and hardware adjustments. That's why it's taking weeks, not days, to fix.”
In Kentucky, when consumers first come to the site, they go through a pre-screening, which gathers basic information, Clark said. Behind all that there is technology called a business rules engine. It looks at the person's age, county of residence, smoking status, size of the family and income, then goes through these variables to determine eligibility for various public subsidies including a federal premium tax credit.
“As a household, you make one application as a family,” he said. “It may well be my children could be eligible for (the state children's health insurance program), my wife might be eligible for Medicaid and I might be eligible for financial assistance.”
The pre-screening is anonymous, Clark said. “Once I know what I'm eligible for, the next step is to create an account. One of the first things we do is create this account and do remote identity proofing.”
Once consumers fill out an account application, there are a number of verifications with the federal data hub, including income, citizenship, lawful residence, whether the person is incarcerated, Social Security number and date of birth. That's done by communicating with the federal hub.
Connectivity with the federal site has been “very successful,” Clark said. “I'm reading the articles about the failures. But on identity proofing, we have 92% pass-through rate.” Clark said he's pleased with that rate.
The outcome of all of that is the eligibility determination, he said. “We're able to determine eligibility in about 10 seconds. Once they understand their eligibility, it's time to go shopping. They submit their application, online. We take them immediately to shop. We have financial assistance.” That task is performed in Kentucky, not through the federal data hub.
“When we actually do the enrollment, we'll do an enrollment transaction with the insurance company,” he said. Once the consumer is enrolled, the Kentucky exchange sends that enrollment transaction to HHS using the ASC X 12 834 standard. The site has a “slider” that allows enrollees to adjust how much of the federal premium tax credit is to be applied to the premium and paid directly to the insurer and how much to leave for determination at the end of the year, when enrollees know how much their total income will be—so they don't have to pay back the IRS for any excess tax credit payments.
“Oct. 1 for us was just the beginning,” Clark said. “We're focusing on 640,000 uninsured in (Kentucky). Our goal is to get as many of those enrolled that we can.”
, which also is using CGI technology, after the first five days of open enrollment more than 43,600 Californians had gone to their state-run exchange website and either completed applications or produced partial applications, according to the Los Angeles Times.
“They just put out second-week stats,” said Anthony Wright, executive director at Health Access, California, a statewide healthcare consumer advocacy coalition.
In the second week of operation, Covered California had 1.5 million unique visitors and more than 94,000 applications started, Wright said. The state's call center has fielded “hundreds of thousands of calls,” he said.
“Things are working,” Wright said. “Obviously, it's going much better than the federal exchange.”
Because all online functions would not be ready by Oct. 1, California “triaged” its program, Wright said. Well before the Oct. 1 federal start date, the California exchange had gone live with online shopping and a calculator to determine subsidies. On Oct. 1, California added connection to the federal hub for identity proofing, income verification and subsidy eligibility checking.
But for now, Californians are mailed insurance application packets to perform the final task of enrollment, which might explain the dearth of final enrollment data from the state. The plan, Wright said, is to have that function backed into the online exchange by the end of the year.Follow Joseph Conn on Twitter: @MHJConn