enhanced federal funding for medicaid enterprise projects...hma 7 enhanced funding for medicaid...

HMAHealthManagement.com

March 22, 2017

Enhanced Federal Funding for Medicaid Enterprise

Projects

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Webinar sponsor Aging & DisabilityIDDBehavioral HealthHousing & HomelessInformation & ReferralNational & Local Non-ProfitsNo Wrong Door

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Coordinating Care Across the Continuum

Mediware.com/human‐services

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Introduction

• This presentation will provide States with key insight into requesting and maintaining enhanced federal funding for Medicaid Enterprise IT projects.

• States will learn the steps to requesting and maintaining federal funding for planning, implementing and maintaining IT solutions.

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Introductions

• About HMA• Presenters

– Juan MontanezPrincipalWashington, DC

– Wade MillerPrincipalAtlanta

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Presentation “Disclaimer”

• Today’s discussion only covers current law, regulations, sub-regulatory guidance and CMS funding approval and oversight processes.

• Times …..they are “a changing”: new President, HHS Secretary, CMS Administrator.

• The AHCA has provisions re: enhanced funding for Medicare enterprise IT – but these provisions could change between now and the time AHCA becomes law (if it does)…

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Enhanced Funding for Medicaid Enterprise Projects – OverviewGENESIS

• Public Law 92-603 (1972): requires that each State Medicaid program have a Medicaid Management Information System (MMIS) to enhance claims payment accuracy and efficiency and standardize Federal reporting– Main goal: increase program fiscal responsibility

• An MMIS can, and often is, more than just a collection of software and IT hardware – It is very often an information systems/business process

management solution that encompasses multiple functions as prescribed by federal law and regulation

• MMIS capabilities may be acquired:– Through a broad fiscal agent (FA) contract – Through an agreement with another State – By building an in-house/homegrown solution (“state-operated”)– By configuring or as needed customizing and integrating COTS

or open-source solutions

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Enhanced Funding for Medicaid Enterprise Projects – OverviewCHANGES IN ENHANCED FUNDING AVAILABILITY

• Federal law provides for an enhanced Federal match rate up to 90 percent of the costs to develop and implement (DDI/ACD) an MMIS and 75 percent of the costs to maintain and operate (M&O/O&M) an MMIS

– Systems must be meet Federal requirements (State Medicaid Manual Part 11) and pass “certification” by CMS for state to qualify for enhanced funding for operations/maintenance costs

• April 2011 rule– Extends enhanced match to eligibility determination functionality (there are some

time period limitations for DDI enhanced match)– Requires all future MMIS development to conform to seven standards and

conditions (7SCs) for Medicaid enterprise system development – Within 38 months of rule issuance, every state were supposed to develop a

roadmap/'transition plan' where it articulates to CMS how and by when the seven standards and conditions will be met

• 2012: Medicaid IT Architecture (MITA) version 3.0 released – States expected to update MITA self-assessments within 12 months of publication

of MITA 3.0

Recent rule revisions and related sub-regulatory guidance made changes in the April 2011 rule permanent and confirmed a State’s ability to access these funds without cost allocation requirements for select purposes through 2018.

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Enhanced Funding for Medicaid Enterprise Projects – OverviewMMIS FUND USES – FUNCTIONS/APPLICATIONS

– Beneficiary Enrollment – Provider Enrollment– Provider Reimbursement Terms and Rules– Care Management – Service Authorization (Transaction Management)– Claims Processing/Payments to MCOs-ASOs-ACOs-etc.– Fraud/Abuse Monitoring Tools (Surveillance and Utilization

Review/Program Integrity)– Cost Avoidance and Third Party Recovery/TPL– Decision Support/Analytics– Management and Compliance Reporting– Immunization Registry – Electronic Health Record (EHRs)– Interfaces to Other Systems (e.g. E&E, APCD)

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Enhanced Funding for Medicaid Enterprise Projects – OverviewMMIS FUND USES - CIRCUMSTANCES

Y2K

HIPAA

ACA

ICD‐10

??????Whatever the

future might hold…

HITECH

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Enhanced Funding for Medicaid Enterprise Projects – OverviewEXPANSION OF ENHANCED FUNDING OPPORTUNITIES –

HITECH ACT• Medicaid EHR Incentive Program establishment and administration: 90%

– Attestation– Payments– Audit– Reporting/compliance

• Meaningful Use (MU) enablement IT: 90% DDI/ACD, 75% M&O/O&M – IT/IM solutions designed to enable providers to meet MU requirements

• Medicaid-focused Health Information Exchange: 90% DDI/ACD + implementation – Investments in HIE IT and related implementation and provider onboarding services – Data exchange infrastructure essential for providers to achieve MU– Funds cannot be used for HIE operations

State Medicaid HIT Plan (SMHP): expected to lay out state agency’s goals for “all of the above”

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Enhanced Funding for Medicaid Enterprise Projects – OverviewMITA: WHAT IS IT, AND WHERE DOES IT FIT IN THE

ENHANCED FUNDING “LIFE CYCLE”

• MITA IS AN INFORMATION SYSTEM DESIGN FRAMEWORK…– A comprehensive set of guiding principles, standardized

terms and definitions, models and tools that serve as a blueprint for states to use as they design IS solutions for their Medicaid enterprises

– Centered around three architectures:• Business• Technical• Information

CMSCMS

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Enhanced Funding for Medicaid Enterprise Projects – OverviewMITA: WHAT IS IT, AND WHERE DOES IT FIT IN THE


• ...AND A BUSINESS TRANSFORMATION INITIATIVE.– A very different (for most) way of presenting and facilitating a shared understanding of

the functions of a medical assistance/insurance affordability program.

CMSCMS

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Enhanced Funding for Medicaid Enterprise Projects – Overview7SCs: WHAT ARE THEY, AND WHERE DO THEY FIT IN THE


1. Modularity Standard modular, flexible yet normalized approach to systems development including the use of open interfaces, exposed APIs, separation of standardized business rule definitions from core programming, and availability of standardized business rule definitions in both human and machine-readable formats.

2. MITA Condition align to and advance in MITA maturity.

3. Industry Standards Condition align with and incorporate “industry standards”: HIPAA security, privacy and transaction standards; accessibility standards in section 508 of the Rehab Act; standards and protocols required per ACA Secs. 1104 and 1561, etc.

4. Leverage Condition solutions should promote sharing, leverage, and reuse of technologies and systems within and among States. Includes: multi-state efforts, availability for reuse, ID of open source, cloud-based and COTS products.

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Enhanced Funding for Medicaid Enterprise Projects – Overview7SCs: WHAT ARE THEY, AND WHERE DO THEY FIT IN THE


5. Business Results Condition systems should support accurate and timely transaction processing and effective communications with providers, beneficiaries and the public.

6. Reporting Condition solutions should inherently produce transaction data, reports, and performance information that contribute to program evaluation, continuous improvement in business operations, transparency, and accountability. Includes automatic generation of reports and capture of audit information as well as interfaces with designated federal repositories or hubs

7. Interoperability Condition systems must ensure seamless coordination and integration with Health Benefit Exchanges and allow interoperability with Health Information Exchanges, public health agencies, human services programs, and community organizations providing outreach and enrollment assistance services.

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Enhanced Funding for Medicaid Enterprise Projects – OverviewENHANCED FUNDING “LIFE CYCLE” ILLUSTRATED

CMSCMS

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Enhanced Funding for Medicaid Enterprise Projects – OverviewOTHER CONSIDERATIONS

• Recent rule revisions are designed to compel states to:– Avoid from scratch system build/development– Avoid monolithic information systems– Utilize COTS and open-source solutions as modules– Employ a “system integrator” to splice modules into a cohesive “whole”– Avoid “over-customization” of modules to facilitate reuse and lower TCO

• Recent rule revisions also call for a different “certification” process for information systems/system “modules”

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Elaboration – Key Process Steps

• It starts with a problem or idea or federal regulation that needs to be solved.

• Medicaid Enterprise Stakeholders discuss the desired outcome at a high level.

• Single State Agency files a Planning APD for Enhanced Federal Funding.

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Elaboration – Key Process Steps - Planning

• Planning APD – Steps and Decisions– Visioning – What do you want or need to do

and how is it envisioned to improve the enterprise.

– Project Organization and Governance– Resources – What staff do you have that can be

partially or fully allocated to the project?– Project Management – Internal or vendor?– Internal Owner(s) of Planning APD

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Elaboration – Key Process Steps – Planning • Planning APD Document Template (45 CFR 96.610 (a) (2)) includes

the following sections:– Cover letter– Statement of Needs and Objectives– Project Management Plan

• Scope• Organization and Resources• Planning Schedule• Planned Procurement or Solicitations

– Proposed Planning Budget and State\Federal Cost Allocation– Commitment to conduct problem needs assessment, feasibility study,

alternatives analysis, cost\benefit analysis– Commitment to define functional requirements– Assurances to Federal Government– Acquisition Summary– State Certification – CMS Budget Tables by Federal Fiscal Year

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• Federal Review Process

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PAPD Receipt and

Initial Review

Federal Partner

Questions

Approval no later than 60 days

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• Planning APD Approved – Now What ?

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1. Set up Project Management2. Organize Team3. Hire Consultant Help – if needed4. Finalize Visioning5. MITA Assessment (If Applicable)6. Alternatives Analysis7. IAPD Development8. Solicitation or Other Acquisition

Vehicle.

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• Planning Phase primarily used to determine what approach to modernization or system replacement should be followed.

• MITA State Self-Assessment, Development of RFP and IAPD are key Milestones.

• Planning Phase ends when you have contracted with a partner (vendor or State).

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Elaboration – Key Process Steps – Planning

• MITA Assessment– As discussed previously, this is a key activity for

States to share their vision, assess their current state and indicate their desired future state.

– Business Processes , Data, and Technology defined and assessed as they exist and future state.

– Must be completed and submitted with the request for Implementation funding (IAPD).

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Elaboration – Key Process Steps - IAPD

• Implementation Advanced Planning Document (IAPD)– Funding request for the project you have decided

to pursue.– CMS approval required before any solicitation or

agreement can be made.– Describes the project, history and planning

activities, estimated resources, estimated IT costs, etc..

– Includes the use of Standard Template

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• IAPD – Requirements – 45 CFR 95.610 (b)– IAPD Template

• Section I: Executive Summary• Section II: Results of Activities Included in the PAPD• Section III: Statement of Needs and Objectives of the IAPD• Section IV: Requirements analysis, feasibility study, and Alternative

Considerations• Section V: Cost Benefits Analysis• Section VI: Personnel Resource Statement• Section VII: Description of the Nature and Scope of Activities• Section VIII: Proposed Project Schedule• Section IX: Proposed Budget• Section X: Statement of Expected Duration• Section XI: Cost Allocation Plan for Implementation Activities• Section XII: Security, Interface, Disaster Recovery, and Business

Continuity Planning• Section XIII: Conditions and Standards for Receipt of Enhanced FFP• Section XIV: IAPD Required Federal Assurances

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• Additional IAPD Requirements:– Submission of MITA 3.0 Self-Assessment Documents– Confirmation and Description of how proposed project

meets CMS - 7 Standards and Conditions– Project Mitigation Plan – part of cost benefit analysis

and is a living document that must be updated.– Identification of Key Staff emphasized

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Elaboration – Key Process Steps -Acquisition

• Acquisition Vehicle – RFP, ITN, RFR etc.– Written using State template(s)– Part of the planning phase, after project scope and approach are

finalized.– Requires prior approval from CMS in most cases (> $500,000).– State to State Agreements require CMS review and approval– Issued by the Medicaid Single State Agency– Evaluation Plan – generally submitted to CMS for approval

prior to RFP release.– Conclusion of Evaluation and selection of vendor or State to

State Agreement signals end of Planning Phase.– Update required to IAPD: actual contracted costs.

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Elaboration – Key Process Steps – Operations APD

• Operations APD 45 CFR 95.610 (c )(3)– Filed with CMS at implementation or just slightly before.– Sometimes referred to as “Maintenance and Operations”

(M&O) APD– Enhanced funding (75%) available for Medicaid

Enterprise systems including both “MMIS” and Integrated Eligibility Systems.

– Available after CMS determines system is “certified” and meets 7 Standards and Conditions.

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Elaboration – Key Process Steps – Operations APD

• OAPD required contents include:– Summary of Activities– Acquisitions– Annual Budget

• Document State functions for which enhanced funding can be requested - examples include:– Maintenance and Routine System updates– Customer Service – as applicable

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Elaboration – Key Process Steps – APD Updates

• APD Updates – Planning, IAPD, OAPD

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• Planning APD Update – due yearly until you are in Implementation

• Implementation APD Update – due at contract signing and yearly thereafter until project is complete

• OAPD – due yearly once you are in operations for any module or system.

• Due 60-90 days prior to APD end date to CMS to ensure timely approval.

• Changes to APD –due within 60 days

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Project Examples

• Enhanced Funding can be used/has been used for:– “Modular” MMIS – Module upgrade or replacement– Solution as a Service or Business as a Service projects– State Shared Solution.– Integrated Eligibility Systems– Other HIT related Projects

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Project Examples • Modular MMIS

– Several States working toward a modular, phased approach to modernizing the entire MMIS

– Modules are certified as the go live and show stable operation – allowing States to move into M&O mode for those components.

– Could be just a few pieces outsourced as long as alignment with 7 Standards and Conditions.

– CMS is not looking for a lot (if any) custom development.

• “Shared” MMIS with Another State – Promotes Re-Use; potentially significantly cheaper.

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Project Examples

• Modernize Integrated Eligibility Systems.– Several states have implemented modern

solutions for ACA and continue to add additional programs.

– Cover programs beyond Medicaid/CHIP eligibility determination including:

• SNAP• TANF• Child Care• LIHEAP\LIEAP• WIC

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Project Examples“Pushing the envelope”

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Example Enhancedfunding source*

EHR for a specific state program/agency MMIS

All Payer Claims Databases (APCDs) or similar large-scale health data repositories

MMIS

Population health analytics solution MMIS

Statewide provider directory MEDICAID HIT

EHR-to-HIE interfaces for Medicaid providers MEDICAID HIE

Quality measure aggregator/broker MEDICAID HIT

* Grant funding (e.g. State Innovation Model/SIM) has also been used for these types of projects/investments.

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Key Takeaways “The money is there”: funding opportunities and options are available.

Understanding requirements for accessing and making optimal use of funds is important.

Having a coherent, cohesive plan for how the funds will be used is imperative. E.g. “MMIS go-forward plan” MITA roadmap and SMHP are important elements of this plan

Do not forget about resources required to implement and support IT investments. Sustainability is key

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Questions

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THANK YOU!

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