MEDICAID IT FUNDING OPPORTUNITIES & RESPONSIBILITIES

ELIGIBILITY, ENROLLMENT, EDUCATION & ENGAGEMENT

Fully Utilizing Funding Opportunities and Efficiencies through

Leveraging ARRA-HITECH and ACA Options

Maximizing Enrollment 2011 State Meeting Eligibility and Enrollment Systems Transformation:

Building on Lessons and Work in Maximizing Enrollment to Get Ready for 2014

Patricia MacTaggartMay 19, 12:30 – 1:30

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MEDICAID OPPORTUNITIES & RESPONSIBILITIESConcerns – Context – Concepts – Completion

• Concerns: – Multiple Alabama Health IT Activities & Limited Human

and Financial Resources– Challenging Timelines & Fully Utilizing Federal Dollars

• Context:– Medicaid & CHIP Eligibility, Enrollment, Education &

Engagement Policy and Health IT in Service Delivery & Payment Transformation

– Eligibility/Demographics, Education & Engagement as Component of Health Information Exchange

– Eligibility as Core to Evolving Health Insurance Exchange

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MEDICAID OPPORTUNITIES & RESPONSIBILITIESConcerns – Context – Concepts – Completion

• Concepts– MITA: Medicaid Information Technology

Architecture/Framework – ARRA HITECH: Health Information Exchanges (HIEs) , Electronic

Health Record Systems (EHRs) & Meaningful Use (MU)– Patient Protection and Affordable Care Act (ACA): Health Care

Reform, Including Health Insurance Exchanges (HIEs)

• Completion: – Implementation– Next Steps

AdequateProcesses

AdequateExecution

AdequateFinancial &

QualityOversight

Adequate Policy

AdequateInfrastructure

& Co

vera

ge

Paym

ent

Eligibility

Service Delivery

Decision Making Is Even Tougher

When the State Has Little Money

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MULTIPLE ALABAMA HEALTH IT ACTIVITIES Framing The Need – Framing The Benefit

• Interests are the Same Interests are Competing - or Aligned When Not “Horizontal Integration” the Same

• Consumer Centric Only Simplified Eligibility: Medicaid Access Requirements, Enrollment to Medical Homes,

Engagement & Education

• Fully Utilizing Federal Efficiencies Are Not Needed $$ Saves

• Rip and Replace is Not Rip and Replace is Bad Goal Administrative Simplification,

No More Paper & Standardization Private/National

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Oversight on right care at right time at appropriate price from appropriate provider

What provider/service deliveryoption will provide the care?

Health Care Services Delivery Mechanism Determined

Services Provided & Paid

Validation of Services Delivered & EOB

Who is health care purchased for?Eligibility

What Coverage is state willing to purchase?What will an individual’s benefit be?

Consumer Seeks Eligibility Coverage/Benefits Determined

Feedback

Feedback

•MCO•Partial MCO•PCCM•Provider within PCCM•Care Mgmt

Delivery Model

•PA•Pre-cert•Authorization for treatment•Service Provider•Where provided•Drug Formulary

Receive Service

•Rate methodology•RBRVS, DRG, etc.•Claim Paid•Person responsible•Pay for Performance

Service Paid

•Home•Institution• Hospital• NH• ICF-MR• Group Home

Where Provided

•Financial Mgmt•Transaction•Financial Reporting•Audits•Premium Invoice•TPL

Financial Oversight

•SPA/Waivers•Adm. Policies•Budget Accounting•Reporting•Contract Mgmt•Feedback

Program Mgmt/Gov’t oversight

•Consumer Information strategies•Provider information strategies•F&A/Program integrity•Performance measures•Information Mgmt•Performance Mgmt•Grievance and appeals

Quality Oversight*

•Co-pays•Cost sharing•Caps/Limitations•Individual and Family•Plan of Care•Treatment Plan

Limitations* (*Individual and Family)

•SPA Services•HCBW Services•Basic Services•Preventative Services•LTC Institution• ICF-MR• NH• Psych-Group• Home•Home Care•Alternative 1115 Waiver•EPSDT•Administrative

Coverage

•Programmatic•Basic

*Temporary

Categorical*

•ADLS•Diagnostic/Clinical•Pre-Adm NH Screening

Functional

•Medicaid¤•SCHIP¤•PH Funded¤•MH/SA Grants¤•State only funded programs¤•Not Eligible

Financial (Hierarchical)

Consumer: Eligibility Medicaid Agency

It’s Complicated Even When It’s Automated

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MEDICAID & CHIP ELIGIBILITY, ENROLLMENT, EDUCATION & ENGAGEMENT POLICY & HIT

•Eligibility:• Systems Funding: Design, development, installation or

enhancement (DDI) of a state eligibility determination & redetermination and/or enrollment system at 90% federal-10% state for DDI up to 2015 and 75% federal-25% state for ongoing operation.• Move to MAGI (Income and Household) (Modified Adjusted

Gross Income)

•Data on Performance: CHIPRA Quality Measures for Children, MU Measures, ACA Quality Measures for Adults, HCBS Measures for Waivers, PQRI Measures

Get the Data Once & Use It Multiple TimesDuplication of IT Systems Will No Longer Be Funded

MEDICAID & CHIP ELIGIBILITY, ENROLLMENT, EDUCATION & ENGAGEMENT POLICY & HIT: SERVICE DELIVERY & PAYMENT

TRANSFORMATIONTriple Aim: Better Care, Better Health, Lower Costs

• Medical Home Pilots -Accountable Care Plans: how do they link for eligibility and enrollment?

• Integration:– Physical and Behavioral Health– Integration Public-Private: Premium Based Subsidies– Integration Medicare-Medicaid: Standardized Assessment, Extensive

Data Analysis & Sharing, Financial Incentives for Quality

• Reimbursement Reforms: Primary Care Payments, Access

• Return on Investment Value of Investment 8Design for Future – Not for Today

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ELIGIBILITY/DEMOGRAPHICS, EDUCATION & ENGAGEMENT AS COMPONENT OF HEALTH

INFORMATION EXCHANGE• EHR: Electronic Health Record (across health organizations)

• HIE: Health Information Exchange (across providers, purchasers, regulators) & Health Insurance Exchange (health benefit exchange)

• Health IT: Health Information Technology (EHRs, HIEs, Registries, Tele-health)

• PHR: Personal Health Record

• COWS: Computer on Wheels (hospitals and clinics)• MU: Meaningful Use – Access to personal clinical information

e-Everything: Giving Up the Paper & The Way We Work Paper Based –

Work Arounds Don’t Need to Move Forward

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HEALTH INFORMATION EXCHANGE AS INFRASTRUCTURE FOR ELIGIBILITY

• Identity Management: – Master Patient Index– Provider Directory

• Secure Messaging

• HIE “Gateways”

• Privacy and Security

• National Standards: Terminology & Approach (Medicare, SSA, IRS)

• Project Management: Accountability and Singular/Aligned Structure

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ELIGIBILITY AS CORE TO EVOLVING HEALTH INSURANCE EXCHANGE

•Authority: need to see State Authority

•Implementation is really July 2013• •Single Integrate Pathway • Easy for Individuals to Explore Health Coverage Options• Individuals can Quickly and Accurately Enroll into Coverage

• Financing Plan: matching governance• Exchange: 100% FFP for IT Infrastructure for

Insurance for those components• Medicaid: 90/10 authority have today

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ELIGIBILITY AS CORE TO EVOLVING HEALTH INSURANCE EXCHANGE

•Common systems and High Levels of Integration: No “Gap” in Coverage: Governance and Accounting

• Non-Dual Disabled May Not Be “Coded” Disabled

Medicaid138% FPL

Basic Health Plan139% to 200%

Tax Subsidy138% to 400%

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MITA: MEDICAID INFORMATION TECHNOLOGYArchitecture & Framework

• Member Management: Eligibility, Enrollment & Outreach & Consumer Communication & Information, Grievance/Appeal

• Provider Management: Enrollment, Communication & Information &

Grievance/Appeal

• Operations Management: Authorization, Claims Mgmt & Payment

• Care Management: Individual & Population

• Program Integrity Management: Requirements & Management

• Contractor Management: Health Services & Administration

• Program Management: Drug Formulary, Benefit Package, Goals, Objectives, Policy, Budget, SPAs, FFP, MMIS, I-APD

• Business Relationships Management: Establish, Manage & TerminateCost Allocation Plan , SMHP

ADDITIONAL ACA IMPACTS

New Requirements on States & Providers

•Administrative Simplification & Program Integrity Provisions•Interfaces with HIEs (Information & Insurance)

Medicaid/Medicare Changes• Provider Rates-Incentives-Penalties• Payment Methodologies•Service Delivery Innovations

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Increased Volume • Transactions• Providers

New Aged & Disabled Consumer Benefits & State Opportunities

•Dependent Adults up to 26 on Parent’s Plans even Married (2011)•No Pre-existing Condition Exclusions for Children (2011)• Prohibitions against Lifetime Benefit Caps & Rescissions (2011)•Preventive Care Coverage & No Cost-Sharing Medicare (2011)

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IMPLEMENTATIONConcepts Transformed Into Actions

• Financing Strategies:– Services and State Administration State Strategies– Cost Allocation

• Responsibility to Validate Value - Metrics for Success:– MU Measures for Ambulatory and Hospital– Clinical and Outcomes: Success Rate in Treatment– Productivity: Absenteeism and Presenteeism– Consumer Experience: CAHPS

• Cross Initiative Implementation Strategies:No Current IT Infrastructure Supports the Needs of Tomorrow:

What has to be done 2014 – What Gets Phased In

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Category DescriptionInterface State interfaces of a Health Information Exchange (HIE)--

(e.g., labs, registries, PH databases, emergency preparedness, etc.) needed for providers to reach MU.

Data Mgmt

Creation/enhancement of a Data Warehouse/Repository (cost allocated), for evaluation and data analysis for federal and state reporting, as well as external and internal management that complies with HIPPA Privacy and Security requirements related to authorization to data, access to data types and functions, role permissions, ability to further designate third parties, and security to prevent breaches.

Identity Mgmt

Development of a Master Patient Index (cost allocated).

HIT POTENTIALLY ELIGIBLE FOR MEDICAID FUNDING FOR CROSS INITIATIVE IMPLEMENTATION

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Category DescriptionProvider

MgmtProvider Help-Line/Dedicated E-mail Address/Call Center (hardware, software, staffing)

Operations Mgmt

System associated with the collection and verification of MU data from providers’ EHRs and Data Analysis, Oversight and Auditing and Reporting on EHR Adoption and MU as well as regular Medicaid oversight activities

Program Integrity

System and resource costs to develop, capture, and audit provider attestations for MU, including e-signature. Systems related to fraud and abuse prevention activities, such as interfaces with the Board of Medical Quality Assurance (BMQA) for licensing status.

HIT POTENTIALLY ELIGIBLE FOR MEDICAID FUNDING FOR CROSS INITIATIVE IMPLEMENTATION

Initiative HIE (Information)

HIE (Insurance) Meaningful Use

Other HC Reform (adjustments to

private insurance changes/Medicare-

accountable plans/payment

reform)

Medicaid Eligibility

Expansions

e-signature Provider & consumer

Consumer, provider, insurer

provider Consumer, provider, consumer

Secure single-entry web portal / external “face

Provider & consumer

Consumer, provider, insurer

Provider ???? Provider & consumer

Security to meet National Requirements

(authorization, authentication, access, auditing, encryption

clinical and administrative

data

Administrative data

Clinical and administrati

ve data

Administrative, potentially clinical data

(payment reform both)

Administrative

Privacy (HIPAA/Medicaid) clinical and administrative

data

Administrative data

Clinical and administrati

ve data

Administrative, potentially clinical data

(payment reform both)

Administrative

Identify Mgmt (patient, provider, entity)

Provider/entity Consumer, provider, entity

provider Variable consumer

Data Repository Metadata Actual data

Potentially yes Eventually Potentially Potentially

Intake yes yesReporting (federal & state for

financial & quality, Yes yes yes Potentially yes

Review: State HIT Infrastructure Needs Across Health Care Reform Initiatives

State HIT Infrastructure Needs Across Health Care Reform Initiatives

Initiative HIE (Information) HIE (Insurance) Meaningful Use

Other HC Reform

Medicaid Eligibility

Expansions

Rules Engine & Business Intelligence

Potentially yes yes Depends on initiative

yes

Interfaces with federal agencies

Eventually – VA facilities, DoD

facilities

Yes – eligibility verifications IRS,

etc.

NLR Depends on initiative

Yes –income IRS, citizenship

SSA, etc.

Interfaces with other state

agencies

State as provider (PH, MH, State

hospitals), State as Regulator,

State as Purchaser (State

Employees/ Medicaid)

Exchange – Medicaid

TBD Exchange/Medicaid

Aligning with National Standards

Yes- opportunity Yes – mandate

Yes-mandate

TBD Yes-mandate

ICD-10 and 5010 yes Overlaps/yes

TBD

SOA Yes Yes yes yes yes

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OPPORTUNITIES & RESPONSIBILITIESConcerns - Context – Concepts - Completion