Vermont is a small state with just 660,00 residents, but getting the health insurance exchange here ready in time for the rollout of Obamacare in 2014 is still a very big job.
Mark Larson, the chief of the Department of Vermont Health Access (DVHA), likens the last few months to mobilizing for a prolonged state of emergency.
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"On some level, we have to work as if we are operating in a limited time frame to respond to a crisis," Larson said.
His staff at the DVHA has grown by 50 percent to 180, and they've brought in a team of consultants nearly as big from CGI Group, with subcontractors from Oracle and KPMG.
They've all just moved into a new 26-thousand square foot office space, where they are literally working hand in hand now on the design and implementation of the all pieces that have to come together in the online marketplace that will serve as the gateway for people to access insurance under the Affordable Care Act (ACA).
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"Often times the focus is on the website," said Melissa Boudreault, VP of State Health Solutions at CGI Group, who is leading the buildout effort. "Really what it takes to build an exchange is bringing together different technologies — everything from how people shop to how you create bills."
Boudreault has done much of it before. She was one of the founding directors of the Massachusetts health exchange when it launched in less than six months in 2006. But the work she's doing now in Vermont has added complexity.
Making the system simple
"One of the significant elements of the ACA was the move to a highly simplified eligibility model," she said.
They are most focused on developing the infrastructure that will let people determine whether they're eligible for Medicaid or for a federal tax credit when to buy private insurance when they sign up for coverage. Current Medicaid and Medicare programs don't integrate eligibility and access in one place.
"Of all the things that are being done in the exchanges that move to simplified eligibility is probably the most sweeping change because it allows states to move to an administration simplification that wasn't ever possible before," Boudreault said.
There's a lot riding on CGI getting the systems right for the start of enrollment season. A lot of Americans will be using its exchange interfaces to access coverage.
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In addition to Vermont, CGI building state exchanges in Massachusetts, Colorado and Hawaii. It is also building the default federal state exchange which will serve millions of individuals and small businesses in more than 30 states whose leaders have opted out of building their own exchange.
"The federal exchange is already starting to do testing and draw information from carriers," Boudreault said. She's confident they'll make the October deadline to have all exchanges up and running.
Beyond the buildout
Vermont Commissioner Mark Larson is confident about the progress on his state's exchange, but he's also preparing in case there are problems.
"We're trying to streamline years of, frankly, inefficient business practices," Larson said. "We're also trying our best to make sure we have contingency plans, to make sure if certain functions need back-up that those back-ups will be in place."
None of it comes cheap. The state has tapped nearly $150 million in federal grants to build and run the exchange in the first year, and to do widespread outreach.
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The next phase of the rollout is to contract with and train social service and small business groups to serve as navigators, who will make individuals and small firms aware of the exchanges and eventually help them navigate the enrollment process.
The state estimates it will $18 million a year to maintain and run the exchange and outreach programs. After the first year, they'll fund it through a tax on insurance claims.
When I pointed out that revenues may come up short of revenues, if people become healthier and file fewer claims, Commissioner Larson smiled.
"Of all the problems to have, that would be an okay one."
"This is a public private partnership," said Larson. "Ideally, when we merge those areas together we create something that is very special."
—By Bertha Coombs; Follow her on Twitter: @coombscnbc