CBA (Other exams): Health Plan Enrollment Platform: Requirements Before Procurement

Produce a value stream map first, then a capability-to-stage mapping, a heat map, and a business architecture requirements package. The value stream map should cover member enrollment from application through effective coverage, including eligibility verification, plan selection, evidence of coverage, payment setup, and notification. At each stage, capture value items, cycle time, error types, and the systems and vendors involved. Map the existing capabilities to those stages; the capability map alone cannot show where the 12% error rate originates. Heat-map the capabilities for error impact, call-center demand, regulatory exposure, and change feasibility. Then derive business requirements as statements of what each stage must achieve, not as platform features. Use the Business Motivation Model to record the Medicare Advantage goal, the regulatory assessments from the audit, and the objective of reducing avoidable calls. The order matters because procurement needs a scope that is traceable to stages and capabilities; a feature list produced in eight weeks would harden assumptions before the value stream is understood.

The team should explicitly separate business architecture from solution architecture. Business architecture defines the value stream stages, the capabilities required, the information exchanged, and the business requirements and constraints. The digital enrollment platform is a solution that will be selected and designed later. The team can give procurement a requirement set that says, for example, that eligibility verification must provide a verifiable response within a defined time and must retain evidence for audit; it should not specify screen flows or vendor modules. If the CIO wants a solution architecture, the team should route that to solution architecture with business architecture as input. The reasoning is that a platform-first approach would let the vendor define the operating model, which is especially risky when business owners already disagree about handoffs. The team should also identify which requirements are regulatory must-haves so they are not traded away during procurement.

Resolve ownership at the value stream stage level, not by existing department charts. Use the value stream map to define each stage's outcome and then assign a stage owner accountable for the handoff into and out of that stage. The business interaction matrix can make visible where eligibility, enrollment, billing, and vendors exchange information and where accountability is unclear. Create a RACI that distinguishes accountable stage owner from responsible performers and consulted compliance. The regulatory audit findings should be treated as non-negotiable constraints on evidence of coverage and timely notification, with a named compliance partner. Governance should include a value stream owner who chairs a cross-functional operating group during the nine-month platform program. The reasoning is that handoff failures are usually ownership gaps, not technology gaps; if the platform is procured before ownership is clarified, the new system will automate the ambiguity.