IMPLEMENTATION ADVANCE PLANNING DOCUMENT

Transcription

1 IMPLEMENTATION ADVANCE PLANNING DOCUMENT Oklahoma Health Care Authority Medicaid Eligibility System Project Online Enrollment November 21, 2011 Submitted by the Oklahoma Health Care Authority On behalf of the State of Oklahoma Page i

2 Table of Contents 1 PLANNING ACTIVITIES Background Insure Oklahoma Online Enrollment Medicaid Management Information System (MMIS) Reprocurement Early Innovator Grant STATEMENT OF NEED AND OBJECTIVES Statement of Purpose Contract Approach and Scope Description of Business Need Medicaid Information Technology Architecture (MITA) Maturity Capabilities Member Management Gap Analysis ACA and Online Enrollment Gap Analysis State System Modifications State Approach in Collaborating with the State Exchange REQUIREMENTS AND ALTERNATIVES ANALYSIS Requirements Analysis Statement of Alternative Considerations Alternatives considered: Alternative 1 Continue to operate the current Eligibility Determination System Advantages Disadvantages Alternative 2 - Enhance and expanded current System Advantages Disadvantages Alternative 3 - Acquire another State s system Advantages Disadvantages Alternative 4 - Procure a vendor s eligibility determination solution Advantages Disadvantages Rating the Alternatives Summary of Findings Alternative 4 - Unfeasible Rejected Selected Alternatives Alternative 2 - Enhance and Expand As-Is System Alternative 3 - Acquire Another State s system Feasibility Conclusion COST BENEFIT ANALYSIS Cost Benefit Analysis (CBA) Methodology Assumptions Summary of Cost Findings Comparison of Options Design, Development, and Implementation Page ii

3 Alternative 2 OHCA OE Enhancement Alternative 3 Transfer system Alternative 4 COTS solution System Integrator Commercial Off-the-Shelf Software Licenses & Hardware Alternative 2 - OHCA OE Enhancement Alternative 3 Transfer system Alternative 4 COTS solution PROJECT ORGANIZATION Personnel Resource Statement Project Governance Advisory Committees Executive Steering Team (EST) Executive Sponsor Tasks Executive Steering Team Tasks Steering Committee Project Management Office Project Team Description of Key Project Staff Independent Verification & Validation (IV&V) Operations Staff NATURE AND SCOPE OF THE PLANNED ACTIVITIES Project Management Fiscal Agent Project Management Milestones Scope of Work (SOW) Deliverables Gate Reviews PROPOSED ACTIVITY SCHEDULE Project Roadmap Activities Deliverables PROPOSED BUDGET Resource needs by Category... Error! Bookmark not defined. 8.2 Design Development and Implementation Budget... Error! Bookmark not defined. 9 PERIOD OF USE... ERROR! BOOKMARK NOT DEFINED. 10 COST ALLOCATION PLAN... ERROR! BOOKMARK NOT DEFINED Estimated State and Federal Cost Distribution... Error! Bookmark not defined. 11 SECURITY AND INTERFACE REQUIREMENTS ENHANCED FUNDING CONDITIONS Oklahoma Agrees with Medicaid IT Supplement Standards Page iii

4 13 ASSURNACES CONCLUSION WORKS CITED APPENDIX A: MITA MATURITY TABLE APPENDIX B: SCOPE OF WORK AND BUDGET ESTIMATE LIST OF FIGURES AND TABLES Figure 1: Member Management MITA Capabilities... 7 Figure 2: Iterative Alternatives Screening Process...15 Figure 3: Project Organization...26 Figure 4: Medicaid Eligibility System Roadmap...39 Table 1: Feasibility Summary...20 Table 2: Summary of Cost Projections...23 Table 3: Integrated System Cost Estimate Based on Request for Information...23 Table 4: OHCA Executive SteeringTeam...28 Table 5: Steering Committee...29 Table 6: PMO and Project Team Members...30 Table 7: Operations Staff...34 Table 8: Project Activities...40 Table 9: Project Deliverables...41 Table 10: Estimated Project Staffing Expenditures Calendar Year th Qtr Error! Bookmark not defined. Table 11: Estimated Project Staffing Expenditures cont. Calendar Year Error! Bookmark not defined. Table 12: Eligibility Determination Sub-Project estimated costs Calendar Year th Qtr Error! Bookmark not defined. Table 13: Eligibility Determination Sub-Project estimated costs cont. Calendar Year Error! Bookmark not defined. Table 14: Cost Activity Equivalent Project Allocation Calendar Year th Qtr Error! Bookmark not defined. Table 15: Cost Activity Equivalent Project Allocation cont. Calendar Year Error! Bookmark not defined. Table 16: CMS 64 Estimated Reporting Cost Calendar Year th Qtr Error! Bookmark not defined. Table 17: CMS 64 Estimated Reporting Cost cont. Calendar Year Error! Bookmark not defined. Table 18: Federal Funds Participation (FFP) Calendar Year th Qtr Error! Bookmark not defined. Table 19: Federal Funds Participation (FFP) cont. CY Error! Bookmark not defined. Table 20: Assurances to CMS...47 Table 21: FFP Yearly Summary & Conclusion...48 Page iv

5 Table 22: MMIS Reprocurement Contract SOW and Budget...53 Table 23: Contract Amendment SOW and Budget...54 Page v

6 LIST OF ACRONYMS The following acronyms are used throughout this document: Implementation Advance Planning Document Acronym ACA ACS AMAES APD API AVRS BA BENDEX BPM BPR BRE CBA CCB CCIIO CFR CHIP CIO CMS COO COTS CS DDI DHMSAS DOI DSS EHR EI ESB ESC ESI EST EVS FA FFP FFY FPL FTE HHS HIE Definition Affordable Care Act Advanced Computer Systems Activity and Management Automated Environmental System Advance Planning Document Application Programming Interfaces Automated Voice Response System Business Analyst Beneficiary and Earnings Data Exchange Business Process Models Business Process Redesign Business Rules Engine Cost Benefit Analysis Change Control Board Center for Consumer Information and Insurance Oversight Code of Federal Regulations Children s Health Insurance Program Chief Information Officer Centers for Medicare & Medicaid Services Concept of Operations Commercial Off-the-Shelf Customer Service Design, Development, and Implementation Department of Mental Health and Substance Abuse Department of Insurance Decision Support System Electronic Health Record Eligibility Interface Enterprise Service Bus Employment Security Commission Employer Sponsored Insurance Executive Steering Team Eligibility Verification System Fiscal Agent Federal Financial Participation Federal Fiscal Year Federal Poverty Level Full-Time Employee Health and Human Services Health Information Exchange Page vi

7 HIPAA HIT HIX HP HPES HRSA IAPD IAPDU ICD ID IO IP IS IT IV&V JAD LDHH MAGI MCI MECT MESP MITA MITS MMIS NC FAST OCIIO OCR OE OESC OHCA OK OKDHS OMB OSDMHSAS PCCM PCP PI PM Health Insurance Portability and Accountability Act Health Information Technology Health Insurance Exchange Hewlett-Packard Hewlett-Packard Enterprise Systems Health Resources and Services Administration Implementation Advance Planning Document Implementation Advance Planning Document Update Interface Control Document Identification Insure Oklahoma Individual Plan Information Systems Information Technology Independent Verification & Validation Joint Application Design Louisiana Department of Health and Hospitals Modified Adjusted Gross Income Master Client Index Medicaid Enterprise Certification Toolkit Medicaid Eligibility System Project Medicaid Information Technology Architecture Medicaid Information Technology Supplement Medicaid Management Information System North Carolina Families Accessing Services Through Technology Office of Consumer Information and Insurance Oversight Optical Character Recognition Online Enrollment Oklahoma Employment Security Commission Oklahoma Health Care Authority Oklahoma Oklahoma Department of Human Services Office of Management and Budget Oklahoma Department of Mental Health and Substance Abuse Services Primary Care Case Management Primary Care Provider (Physician) Program Integrity Project Manager Page vii

8 PMI PMO PPACA PT QA QTR RFI RFP ROI SAVE SC SCHIP SDLC SDX SHADAC SMD SME SMM SOA SOAP SOLQI SOW SSA SS-A SSN SVES TANF TBD TPA UAT WEDI XML Project Management Institute Project Management Office Patient Protection and Affordable Care Act Project Team Quality Assurance Quarter Request for Information Request for Proposal Return on Investment Systematic Verification of Eligibility Steering Committee State Children s Health Insurance Program Systems Development Life Cycle State Data Exchange State Health Access Data Assistance Center State Medicaid Director Subject Matter Expert State Medicaid Manual Service Oriented Architecture Simple Object Access Protocol State Online Query Scope of Work Social Security Administration State Self-Assessment Social Security Number State Verification Exchange System Temporary Assistance for Needy Families To Be Determined Third Party Administrator User Acceptance Testing Workgroup for Electronic Data Interchange Extensible Markup Language Page viii

9 1 PLANNING ACTIVITIES 1.1 Background 1.2 Insure Oklahoma In 2003 and 2004, Oklahoma received Health Resources and Services Administration (HRSA) State Planning Grant funds. With unprecedented support from the Governor and State Legislature, Oklahoma s initiative was to comprehensively collect and analyze the availability of health insurance across the state, as well as to develop and implement a premium assistance program. The state, alongside the University of Minnesota's State Health Access Data Assistance Center (SHADAC) staff, used this process to develop new health care coverage information regarding Oklahoma businesses, individual attitudes, and opinions on the accessibility and affordability of health insurance and healthcare. By 2005, Oklahoma successfully launched Insure Oklahoma (IO), the state s first premium assistance program. IO serves two populations, employees of small businesses through employer sponsored insurance (ESI), and workers without attainable ESI coverage through an Individual Plan (IP). The Oklahoma Legislature subsequently authorized a significant expansion of the IO program for children in The launch included web portals for small business and employees to apply online for Insure Oklahoma productions 1.3 Online Enrollment The Oklahoma Health Care Authority (OHCA) received a $6.3 million dollar Transformation Grant through the Centers for Medicare and Medicaid Services (CMS) in October of 2007 to utilize the experience gained from the Insure Oklahoma project to develop a web based online application and eligibility determination system in order to improve the ease and efficiency of enrollment. 1 Originally known as No Wrong Door, the process allows potential members to apply for SoonerCare electronically. SoonerCare is Oklahoma s Medicaid product. During 2007, OHCA began developing SoonerCare Online Enrollment (OE) in an effort to reach those potentially qualified for coverage and improve the efficiency of SoonerCare. The OE process creates a single-point-of-entry intake that results in the applicant s real-time eligibility determination. OE went live in September Over 500,000 SoonerCare members now have the opportunity to enroll for coverage in the privacy of their own home, or in a variety of community partner locations where they may also obtain technical assistance. As of June, 2010, Oklahoma had enrolled 50,000 newborns in SoonerCare automatically (nearly 2,000 babies each month) using another web application ENB1. This online enrollment process takes five minutes, compared to 60 minutes under the paper-based process. The process ensures not only prompt enrollment of newborns, but also consistent interpretation of eligibility rules and has reduced the average time to add a newborn to the SoonerCare system to 3.5 days. Effective in September 2010, OHCA assumed responsibility for determining Medicaid eligibility for certain groups of individuals under SoonerCare. The entire process will be phased in over a period of time, starting with the groups who have no asset test and use income declaration: 1 The Henry J. Kaiser Family Foundation, published at: Page 1

10 families with children, pregnant women, and individuals requesting only family planning services. Part of our eligibility rules and grievance rules are revised to incorporate these new methodologies to apply for eligibility. In addition, eligibility for these three groups will no longer be retroactive to the first day of the month of application but will be effective the date of application or later. 1.4 Medicaid Management Information System (MMIS) Reprocurement In November 2009, OHCA awarded a contract to Hewlett Packard Enterprise Services (HPES) for an MMIS Takeover with Enhancements. The reprocurement contract includes an enhancement for additional OE application and business rule automation and integration as well as eligibility determination for other Medicaid populations. Some of the significant activities for the enhancement include: 1. Integration of the Interchange (ice) web application functions with the InRule Business Rules Engine (BRE). 2. Automation of the Systematic Alien Verification of Eligibility (SAVE) process between OHCA and the Department of Homeland Security. 3. Implementation of new business processes and business rules to enable OE to process medical eligibility applications for other State and Federal programs, including but not limited to TANF, Aid to the Aged, Blind, and Disabled, and IO. 4. The addition and maintenance of a data exchange system with other State or Federal agencies for information on members in State custody, tribal enrollments, and/or on other State assistance programs as determined by the State. 5. Creation and maintenance of real-time data exchange with the Social Security Administration (SOLQI State Online Query) for EVS-217 and SVES (SSN verification and enumeration) and BENDEX and SDX and others as determined by the State. 1.5 Early Innovator Grant An Early Innovator Grant application was submitted to Office of Consumer Information and Insurance Oversight (OCIIO) for review on December 22, The Oklahoma Early Innovator Grant was awarded to OHCA on February 2, The grant proposal included OHCA s planning activities to redesign the Online Enrollment application to enable the enrollment of the ACA mandated populations and meet the known CMS and CCIIO guidelines at the time. Subsequently the State of Oklahoma legislature reviewed the grant in light of the local environment and the Governor of Oklahoma returned the grant award to CMS in April Requirements for the redesign of the Online Enrollment system that were planned for the Early Innovator Grant and any subsequent standards and guidance that has been issued by CMS will be included in this project. 2 STATEMENT OF NEED AND OBJECTIVES In October 2007 the Oklahoma Health Care Authority (OHCA) was awarded a Medicaid Transformation Grant for $6.3 million from the Centers for Medicare and Medicaid Services and began the SoonerCare Online Enrollment (OE) project. The basis for the project was to improve efficiency and provide a better customer experience for those who potentially qualified for coverage and improve the efficiency of determining eligibility for SoonerCare members. Page 2

11 The project resulted in implementation of the state s first electronic enrollment system for Oklahoma Medicaid members to enroll in SoonerCare. The OE system is a comprehensive web-based eligibility system that utilizes a relational data base and business rules engine to determine Medicaid eligibility. The OE project provides the capability to do online enrollment and real-time eligibility determinations with the efficiency and flexibility to combat the rapid rates of change that exist in the current healthcare environment and successfully improve the efficiency of SoonerCare. The OE system now enables potential members to apply for Oklahoma Medicaid via the internet. The OE process creates a single-point-of-entry for completing an application and business logic that determines whether the applicant is qualified for SoonerCare. This process is highly-adaptable and removes many of the enrollment obstacles for thousands of Oklahomans which previous processes could not effectively address. OE went live in September 2010 and currently services over 500,000 SoonerCare members who now have the opportunity to enroll for coverage in the privacy of their own home, or in a variety of community partner locations where they may also obtain technical assistance. 2.1 Statement of Purpose OHCA is considering the benefits and risks associated with a fully custom software development effort as well as the use of an existing technology framework to accelerate development and/or some combination of the two. Due to the timeline of complying with the Patient Protection and Affordable Care Act (PPACA), the State is most interested in leveraging previous IT investments and upgrading the OE eligibility system currently in place in Oklahoma in preparation for increased enrollment and the need to interface with the Oklahoma Health Insurance Exchange when it becomes available. OHCA submits this Implementation Advance Planning Document (IAPD) to notify the Centers for Medicare & Medicaid Services (CMS) of the State s proposed information technology (IT) activity and to request enhanced federal funds for a significant system redesign of the State s current Online Eligibility system. The Design, Development and Implementation (DDI) project will include: A redesign of the current database and web application to change the system from an application (household) centered architecture to a person centered architecture. Controls to be included will help to ensure Medicaid benefits are managed effectively for the benefit of qualified recipients. Implementation of an Enterprise Service Bus (ESB) to expand the use of web services and to link the multiple applications in an SOA; including links with other agencies, the Health Information Exchange (HIE), and the Health Insurance Exchange (HIX). Enterprise Architecture provisions for additional layers of classification architecture. Potential classification may include person encounter, agency, and others to be identified. These should also be included as keys for alternate views and access. Modularization and decoupling of business rules in the current Business Rules Engine (BRE). Decoupling of customer identification and authentication from eligibility services; State level electronic master person index (empi) to include Security and Identity Management Page 3

12 services; multiple agency and service line eligibility will be identified for potential future expansion. Implementation of Workflow and an associated Business Process Modeling tool to document and further automate eligibility business processes and incorporate the expanding populations into OE. Conducting Business Process Modeling and Business Process Redesign (BPR.). The redesigned system is being planned to comply with the Seven Conditions and Standards as outlined by CMS and CMS Guidance for Exchange and Medicaid Information Technology (IT) Systems Version 2.0. OHCA is, in addition to system development costs described above, requesting enhanced Federal funding for ongoing operations. The system will be based on the Medicaid Information Technology Architecture (MITA) Maturity Model (MITA Framework Version 2.01) principles and Service Oriented Architecture (SOA) Integration Framework. The proposed system will modernize existing system functionality to provide recipients a golden standard of customer care. The golden standard is a consistent look and feel across stakeholders and seamless customer service with consistent metrics to measure and continuously approve the customer experience. The proposed system will also significantly enhance the ability for providers to have prompt access to member eligibility and enrollment information and to ensure that eligible individuals receive the health care benefits to which they are entitled and that providers are reimbursed promptly and efficiently. In submitting the IAPD, the State will present the MITA State Self-Assessment (SS-A) used in conjunction with the submission of the 2010 MMIS Reprocurement IAPD). The MITA SSA was produced in 2009 and updated during the preparation of the EHR Incentive Program IAPD. 2.2 Contract Approach and Scope Oklahoma intends to leverage its 2010 MMIS Fiscal Agent contract for the implementation of the eligibility system redesign. The contract currently includes the operation of the existing eligibility system, Online Enrollment, along with the approved enhancements acquired during the 2010 MMIS Fiscal Agent reprocurement process. The contract does include some of the system architecture components (ESB, BRE, Workflow Engine) that will be leveraged for the eligibility project as well as established rated for the development activities. The original contract has a phased implementation of the system enhancements through October 31, The initial operations period begins January 1, 2012 and continues through June 30, 2016 with an optional one-year extension, through June 30, Description of Business Need Under the Patient Protection and Affordable Care Act (PPACA), a national expansion of Medicaid eligibility will take effect on January 1, 2014, extending coverage to an estimated 16 million Americans and more by Within Oklahoma the expansion of Medicaid eligibility is estimated to increase by 51.2 percent. The effect of this increase will raise OHCA s Medicaid enrollees from the current 825,000 to 1,058,400 by 2019 (Holahan & Headen, 2011). In addition, the health reform law requires a coordinated system for determining eligibility for Medicaid and subsidies for coverage offered through new insurance exchanges and ensuring appropriate use of resources for the benefit of qualified recipients. With these new demands on Medicaid eligibility and enrollment processes, and continuing strains on state resources Page 4

13 stemming from the financial crisis of , the impetus to streamline and automate Medicaid systems has never been greater. The OE system development began in late 2007 and, after historical data on all current recipients was transferred, the new system was implemented in September 7, Since the system s launch, more than half of new applications have come directly through the online enrollment system; the remainder are part of a common benefits application submitted to the Oklahoma Department of Human Services (OKDHS). Future interoperability between the OHCA and OKDHS will enable enhanced data sharing between the two, and potentially additional agencies, and will provide better, more comprehensive services to Oklahoma users. The upgrades to the system have moved Oklahoma towards a single comprehensive application for public medical programs. Currently, the online enrollment system is able to process SoonerCare applications for children, families, and pregnant women, as well as for adults who may be eligible only for family planning or behavioral health services, all in a single application. The scheduled Phase II of OE will expand the application to include the Oklahoma Cares program, which provides coverage for Breast and Cervical Cancer, and the Insure Oklahoma premium assistance program. The online processes that Oklahoma has designed and implemented so successfully for SoonerCare give the state a strong foundation on which to build a single, integrated online application and enrollment process necessary for health coverage through Medicaid and CHIP, as well as be well-poised to connect with the new health insurance exchange as may either be developed by Oklahoma legislative leaders or provided by the federal government, as required by PPACA in FFY 2014, beginning October of The resulting functionality is an interoperable, MITA-compliant, ACA-compliant, modular system for determining eligibility and enrolling people in real-time providing Oklahomans golden standard of access to Medicaid eligibility. Discussions have been initiated with OKDHS with regard to collaboration on systems development. Indications are that they will look to OHCA to lead the development of these modules. The project will provide the flexibility to incorporate OKDHS and potentially other agency member identification and authentication services, connectivity to the ESB, and access to the rules/integration engine. Future details will be addressed as the process matures. 2.4 Medicaid Information Technology Architecture (MITA) Maturity Capabilities In 2009 Oklahoma conducted a MITA State Self-Assessment of the Medicaid program. The majority of business processes in the Member Management business area were assessed at a MITA Maturity Level 1, with one at a Level 2. The long-term Maturity Level goal for Member Management is Level 3. This will involve implementing the eligibility process as a shared service and utilizing WEDI standards and interfaces within the Agency and for data exchanges with external entities. Enabling automated verification and the immediate availability of updates to data sharing partners and the consolidation or federation of the many systems that currently make up the member information data store will be required. A summary of the findings from the assessment is included in Appendix A. Originally, the assessment of the OE enhancement was going to be compared to the MITA Framework 3.0 capabilities in order to stay current with the most recent iteration of the Page 5

14 Framework. However, the release of MITA Framework 3.0 has been delayed at of the time of submission of this document so it was decided to use the MITA Framework 2.01 capabilities. Currently, the plan for OE enhancement would increase many MITA capabilities in the Member Management business area. The primary drivers for these capability increases include: Incorporating eligibility determinations for additional populations in OE. Updating the data model to standardize the data used across multiple agencies. This will allow OE to process a greater number of eligibility determinations across those agencies. Utilizing an automated rules engine to enforce and enhance policy implementation and enhance automated workflow. Implementing a statewide empi to create a Master Data Management (MDM) capability and reduce the number of duplicate enrollment data sets. Implementing a comprehensive Security and Identity Management component that will enhance member identification and authentication as well as program integrity. Creating a central access point for all eligibility related communications and outreach. The majority of this would involve online and web based communications and automated alerts. The automated alerts would serve as a reminder to members when their eligibility is about to expire as well as information regarding other programs the member may be eligible for. Integrating Service Oriented Architecture (SOA) and an Enterprise Service Bus (ESB) to allow fully automated data exchange and service reusability. The following graphic shows the hierarchy of the member Management business area and business processes, as well as which of the major capabilities in each Member Management business process will increase in maturity from the enhancement of the OE. The capabilities listed here are equivalent to a MITA Maturity Level 3. Page 6

15 Member Management ME01 Determine Eligibility Applications are Submitted Electronically Application Data is Standardized Across all Agencies Multiple Eligibility Pathways are Merged to a Single Electronic Standard Process Application Data is Automatically Verified Externally ME02 Enroll Member Applications are Submitted Electronically Agencies Use Standard Interfaces for Enrollment Data Exchage Verification and Validation Data is Automated Use of Business Rules is Maximized ME03 Disenroll Member Data Delivery is Primarily Automated Data Exchange is Standardized Across all Agencies Consistent Use of Automated Business Rules ME04 Inquire Member Eligibility X12 HIPAA Data Transactions are Utilized Agencies Collaborate to Create a Single Source for Eligibility Inquiry Member Information is Integrated via Member Registry (MCI) ME05 Manage Member Communication Member Communications are Primarily Electronic Program Information is Always Available Regardless of Source Requests and Responses are Standardized ME06 Manage Member Grievance and Appeal Standard Interfaces are Used for Appeals Triggers ME07 Manage Member Information Use of a Rules Engine Increases Accuracy of Data Daily Eligibility Updates are Available in Real Time and are Fully Automated Standardized Data, Business Rules, and Logic Member Information is Integrated via Member Registry ME08 Perform Population and Member Outreach Outreach Ensures that Members are Informed of All Programs Eligible For All Eligibility Materials are Available Through Web Portals Members Can Access All Materials Regardless of Channel Outreach Materials are Standardized Across All Agencies Figure 1: Member Management MITA Capabilities Page 7

16 2.5 Member Management Gap Analysis OHCA, like many Medicaid agencies, is dependent upon receipt of member eligibility from multiple external sources. The agency (OHCA) currently uses the OE system to determine Medicaid eligibility for 75% of the state s Medicaid populations. The remainder is more specialized populations and is contracted to other state agencies for determination. Enrollment data is then submitted to OHCA electronically to aid in the determination eligibility for those populations. Because Oklahoma is a 209b state requiring a separate Medicaid determination from SSA s determination, the state of Oklahoma does not currently receive eligibility directly from the Social Security Administration (SSA). The Oklahoma Department of Mental Health and Substance Abuse Services (OSDMHSAS) can enroll clients directly. OHCA currently determines eligibility in-house for the Insure Oklahoma program, which helps small businesses provide health insurance for their employees. The applicant must supply documentation and a premium payment in order for coverage to actually start. OHCA uses an online application that processes member application in-house as a function of the FA for the Insure Oklahoma program; the Premium Assistance subsystem within MMIS processes the applications and determines eligibility. With the exception of the SoonerCare population served by OE and the Insure Oklahoma population, the eligibility determination is currently a manual process. The State does not currently have a standard electronic application that can be used across multiple public assistance programs. The opportunity to create an interoperable, reusable eligibility system will help bridge this gap. OHCA intends to standardize application components (services) that can be shared over an ESB and achieve interoperability using a federated hub and rules engine (integration engine). An additional design objective is to integrate with a multiagency or state person identification/authentication application (empi).oe has standardized and streamlined the application of policy for eligibility determination for its applicants which can be shared with other partners for consistent application of Medicaid policy. Oklahoma does not currently have a statewide electronic master person index (empi); the addition of an empi will aid all agencies data steward functions when attempting to align persons across systems. For the Insure Oklahoma members, the application and eligibility determination process is automated (i.e., the application is submitted and eligibility is determined online). Documentation for verification and validation must still be submitted in hard copy and manual reference checks are currently performed for Insure OK. If a paper application for Insure Oklahoma is submitted, the data is entered online by a Third Party Administrator (TPA). Once an application is filed for Insure Oklahoma, a member file is sent to OKDHS for assignment of a member identification number and to determine if the member is currently active for Title XIX. A return response, which includes the member ID number, is sent from OKDHS to the Premium Assistance subsystem within MMIS. To disenroll an Insure Oklahoma member, OHCA sends a disenrollment file to OKDHS to generate the Department of Human Services Eligibility System transaction back to MMIS instead of updating disenrollment directly in MMIS. This system was put in place prior to OE. One of the planned enhancements is to integrate the IO system to OE, eliminating the need for IO case and member ID assignment to be done at OKDHS. Oklahoma has mitigated the newborn enrollment problem that is prevalent in some States by automating newborn notification. Oklahoma s Electronic Newborn (enb1) system transmits birth information on a child born to a SoonerCare-eligible mother before the child leaves the hospital and expedites the child s eligibility determination. The hospital checks the mother s Page 8

17 status and uses the enb1 system to notify OHCA of the birth and adds the baby to the mother s case. The baby s Primary Care Provider (PCP) is identified within the enb1 system and, once MMIS receives notification of the selected PCP, MMIS puts the provider on the pre-selection list. Babies receive their own identification number and are not put under the mother s identification number. In addition to the pregnant women category, eligibility for newborns born to undocumented, ineligible, and eligible aliens can be transmitted through the enb1. Currently, member eligibility inquiry is done by batch HIPAA 270 and 271 transactions, swipe cards, Internet, and via phones. Users who dial-in can either speak directly to a person or use the Automated Voice Response System (AVRS). Eligibility inquiry for a newborn is done online at the hospital by using the enb1 system. OKDHS handles eligibility-related communication with members for whom they determine eligibility. OHCA s SoonerCare Eligibility Unit handles eligibility-related communication for those members who apply through Online Enrollment. OHCA Member Services handles other types of member inquiries along with SoonerCare Eligibility Unit comprised of out stationed OKDHS employees, plus some HP staff. In addition, OHCA is responsible for handling multiple member communications, including approval and denial/discontinuance letters for the Insure Oklahoma population, Explanation of Benefits (EOBs), SoonerCare managed care information, credible coverage letters, prior authorization notices, welcome letters, newborn letters, and multiple other letters of communication. OHCA performs outreach by phone, television, print media, broadcast, internet, etc., to targeted populations. Responsibility for member grievances and appeals is shared between OKDHS and OHCA, each handle any grievances and appeals for decisions made by their eligibility systems, while OHCA handles those related to claims and prior authorizations. Insure Oklahoma is also responsible for all grievance and appeals for its members. With both agencies responsible, coordination of policy changes resulting from grievance and appeals can be difficult and a manual process that is not integrated with the MMIS ACA and Online Enrollment Gap Analysis The OHCA has conducted preliminary analysis of the potential populations served on 1/1/14 as a result of the Affordable Care Act Medicaid expansions. There are approximately 200,000 newly qualified adults (age 19 through 64 years) and 50,000 woodwork children (0 through 18 years) anticipated to be eligible for SoonerCare coverage on 1/1/14, using the new Modified Adjusted Gross Income (MAGI) method. The OHCA is currently defining how the MAGI method will be utilized and what changes to online enrollment will be necessary to accommodate the required change. These estimates consider most, if not all, of this potential population is currently uninsured according to the Census Bureau, Current Population Survey (CPS), As a result, the majority of the 250,000 potentially served could utilize online enrollment for their Medicaid eligibility determination just as children, pregnant women, and families with children do today. A very small number of the 200,000 adults (currently estimated at <3 percent) could fall within the blind or disabled category, though in order to be included in the estimates these people would be disabled, would not have yet had a disability determination, and/or be without any form of insurance (public or private) in the 2009 CPS data. The OHCA believes this sub-group to be very, very small and insignificant. As a result of the few members affected, high costs and resources involved, and degree of difficulty to incorporate the blind and disabled population into Page 9

18 online enrollment, the OHCA does not plan to transition the Blind and Disabled populations into Online Enrollment prior to 1/1/14. Rather, the blind and disabled populations may first be screened through online enrollment and if found qualified under MAGI criteria will be certified eligible for SoonerCare. However, if members of this population fail the MAGI screen, a full eligibility certification process for blind and disabled (which is used today) will be performed. This full eligibility certification process is conducted by the Oklahoma Department of Human Services staff and eligibility information is shared with the OHCA for inclusion in the MMIS. The Insure Oklahoma, Oklahoma Cares breast and cervical cancer waiver, and SoonerPlan family planning populations (dependent upon their income level) will become eligible for either SoonerCare (under the MAGI criteria) or the Health Insurance Exchange on 1/1/14. Enrollment through the existing Insure Oklahoma system is currently expected to continue through September of The OHCA is still in the process of determining appropriate transition plans specific to Insure Oklahoma Employer Sponsored Insurance (ESI) and Individual Plan (IP) populations, into either SoonerCare or the Health Insurance Exchange (dependent upon the member s income level). State Fiscal Year 2011 estimates indicate of the approximately 39,000 served by Insure Oklahoma, 57 percent have income levels at or below 138 percent of the federal poverty level, and will become qualified for SoonerCare on 1/1/14. These Insure Oklahoma members will largely utilize online enrollment for their eligibility determination on 1/1/14. The remaining 43 percent of Insure Oklahoma members will become covered through the Health Insurance Exchange. Oklahoma Cares will continue enrollment through the Oklahoma Department of Human Services through September of 2013, and then transition to either SoonerCare (under the MAGI criteria) via Online Enrollment or the Health Insurance Exchange. State Fiscal Year 2011 estimates indicate of the approximately 6,000 served by Oklahoma Cares, 92 percent have income levels at or below 138 percent of the federal poverty level, and will become qualified for SoonerCare on 1/1/14. These Oklahoma Cares members will largely utilize online enrollment for their eligibility determination on 1/1/14. The remaining 8 percent of Oklahoma Cares members will become covered through the Health Insurance Exchange. SoonerPlan will continue enrollment through online enrollment through September of 2013, and then transition to either SoonerCare (under the MAGI criteria) via Online Enrollment or the Health Insurance Exchange. State Fiscal Year 2011 estimates indicate of the approximately 30,000 served by SoonerPlan, 88 percent have income levels at or below 138 percent of the federal poverty level, and will become qualified for SoonerCare on 1/1/14. These SoonerPlan members will continue to utilize online enrollment for their eligibility determination on 1/1/14. The remaining 12 percent of SoonerPlan members will become covered through the Health Insurance Exchange. Transition plans for each of these populations are being created to ensure coordinated coverage. 2.6 State System Modifications Historically, the Member Management business area was dominated by manual processes and a lack of automated data exchange with other agencies. Online Enrollment started OHCA on the path of automated data exchange and eligibility automation, but much more can be done. In the future OHCA intends to increase its maturity level for each business process. The agency is working toward this goal through the enhancement of the OE system as explained below. OHCA has completed the first phase of a new MMIS subsystem and web application, Online Enrollment, which includes an online web application and automated eligibility determination system with a business rules engine. OE also performs automated data exchanges. The first phase of OE was implemented in September 2010 and includes the following coverage groups: Page 10

19 Children from newborns to 19 years of age up to 185% of the FPL. Pregnant women up to 185% of the FPL. Adults with minor children up to 18 years old or younger up to 37% of the FPL. Individuals 19 years of age or older seeking family planning services up to 185% of the FPL. Individuals seeking behavioral health services up to 200% of the FPL. This first phase incorporates a large majority, approximately 75% of Oklahoma s 700,000 active members of the SoonerCare population into the system. With the implementation of OE an applicant can submit either a paper or online application. Paper applications are scanned with Optical Character Recognition (OCR) for partial data entry, with the remainder of the data manually entered into the online system by an OHCA or contracted employee, to go through the rules engine. Applicants can apply for SoonerCare from home or at other agencies, such as the Oklahoma Department of Health (OSDH) and OKDHS. Applicants, who go to OSDH and OKDHS, can have their data entered in those agencies respective systems and have that information is sent to the OE system through a standard XML transaction with the eligibility decisions being made by the OE Rules engine. The intent is for OE to quickly determine eligibility with minimal human intervention and to serve as an outreach method to inform applicants about other State services for which they may qualify. Approval and denial notices are generated from OE for those coverage groups residing within the system. Grievances and appeals are handled by the agency responsible for determining eligibility for that specific segment of the population. The consensus from the participants in the MITA sessions in 2009 was that there was a desire to create a collaborative, streamlined, and more efficient eligibility determination process that would ensure online eligibility, BRE based eligibility determinations, data matches, and a flexible system that includes functionality to support an expanding client population. To achieve these objectives, participants identified the following needs to improve the Member Management business area. Items 1 through 5 listed below have been accomplished with the initial implementation of the OE system. 1. OHCA has created a database to store eligibility data and created an online eligibility determination system that includes a streamlined and more efficient business process, including the ability to change member data without relying on a third party to transmit the data. 2. The Online enrollment process allows potential members to apply for SoonerCare electronically through a web-based online application and for eligibility to be determined using a rules-based eligibility determination system and is compliant with the 10/1/2013 MAGI requirement of PPACA. 3. The MMIS has the ability to make updates or create application data through ice panels, rather than solely through Online Enrollment web application. 4. The OE systems receives application data and member change data from multiple partners, both State/City/Federal agencies and community partners through the direct sending and receiving Extensible Markup Language (XML) files. Page 11

20 5. The OE system includes a client numbering system (Note: it is not a fully functional Master Person Index). Items 6 through 22 will be included in the baseline requirements and completed during the DDI phase of the Medicaid Eligibility and Enrollment system project. 6. Seamless, fully interoperable, and automatic data exchange system with both Federal and State entities; Enterprise Service Bus (ESB) to allow exchange of data from various entities and subsystems within the OK MMIS; incorporate architecture application services, ESB, SOA, and enterprise data management. The OE system will be interoperable with the federal data services hub, envisioned as part of the federal exchange, and operational by 1/1/ Capability to accept eligibility and disenrollment data directly from SSA, if Oklahoma becomes a 1634 State. This is contingent on state legislation and the system will be flexible enough to handle any situation. 8. Develop and deploy a modular, reusable eligibility determination service and enrollment service; as well as other Medicaid specific services. The ESB will be utilized to coordinate and publish the web services. This will create the interoperability condition for the seamless coordination and integration with the Health Insurance Exchange (HIX) and the ability to leverage technology to other agencies and states. 9. Automate Medicare buy-in process to maximum capability. 10. Implement an electronic Master Person Index, including sharing of client identification number data with other agencies. This would be developed and deployed as a service utilizing the ESB. 11. Implement a Security and Identity Management component which, in conjunction with the empi, will facilitate the Master Data Management capability necessary to create the master customer record. 12. Automated Asset Verification system as mandated by Federal law. 13. Create the ability for eligibility application process to generate an electronic application for another agency program. 14. Upfront online eligibility screening process to notify applicants they are ineligible early in the process, before completion of the entire application. 15. Capability for members to make changes online affecting real time modifications to demographic data and their PCP. 16. The capability for members to enter data and provide information at technology-related outreach sites or mediums such as mobile devices. 17. Leading industry technology (such as a Digital Card) and the ability for members to inquire on their own eligibility. 18. Centralized location for all letters that are generated and sent to members; Ability to inquire on a specific member to see which letters have been generated or sent with capability to view, recreate, stop, or resend the letter. 19. Automate appeals and make the process interoperable across agencies. 20. Ability to search for outreach materials based on targeted populations. Page 12

21 21. Use of additional media for outreach, such as Digital Video Discs (DVDs), with members who have disabilities and limitations or for populations needing more information or help with getting information. 22. Incorporate links, interfaces, or file exchanges as services that can be used to validate eligibility information, e.g., birth and death registries, Oklahoma Employment Security Commission (OESC), Department of Homeland Security, Department of Corrections, SSA, State revenue files, and the future Federal Data Services Hub. 2.7 State Approach in Collaborating with the State Exchange With the return of the Early Innovator Grant, Oklahoma is now in the planning stage for the health insurance exchange. OSDH is responsible and working with OHCA and DOI to develop a strategy and approach while waiting for further guidance from the Oklahoma legislature. In the interim, and due to the short timeframe, OHCA has identified the need to restructure its eligibility and enrollment processes so that it will be ready to interface with the state and/or federal insurance exchange. The OE system will be designed to be interoperable with the exchange by leveraging, expanding, and modularizing the eligibility determination system and business rules. By creating eligibility and enrollment web services with shared services for each major business process contained therein; the product will be compatible with an HIX. That is, regardless of what solution Oklahoma chooses for the HIX any exchange or partner can use the eligibility and enrollment services through the enterprise service bus. Page 13

22 3 REQUIREMENTS AND ALTERNATIVES ANALYSIS 3.1 Requirements Analysis The approach to requirement analysis is an iterative process. Traceability and mapping are key components throughout this iterative process as it is the Agency s goal to: 1. Document the business need. 2. Ensure the solution will eliminate all identified gaps. 3. Meet federal regulations. 4. Acquire enhanced funding. 5. Become MITA compliant. 6. Ensure CMS certification. The identification of baseline system requirements has been completed. The new requirements to meet the CMS Conditions and Standards will be identified and a mapping exercise will be conducted to identify any gaps that would need to be addressed before moving into Joint Application Design (JAD) sessions. Business process modeling will be conducted for the current and any new eligibility business processes. These business process models will be used to evaluate and improve efficiency and quality and, to the degree possible, automated the development process. To provide further detail and reassurances the baseline requirements will be documented in the JAD sessions. The MITA goals and maturity levels identified in the MITA assessment will map to the system requirements. 3.2 Statement of Alternative Considerations The aim of the Feasibility Study and Alternative Analysis is to objectively and rationally uncover the strengths and weaknesses of the existing business or proposed solutions in order to identify the opportunities and threats as presented by the environment, the resources required to carry through, and ultimately the prospects for success. (Georgakellos & Marcis, 2009) Potential alternatives were identified associated with identified advantages and disadvantages to each, and then ranked accordingly. A progressive narrowing during the review of possible alternatives, using experience and best judgment in determining the advantages and disadvantages helped to identify the alternatives that were the most feasible. The focus of our feasibility study maintained that the Eligibility system must meet all pertinent CMS certification requirements, be MITA/SOA compliant, and include functionality to support all the project goals identified during requirements analysis. The scope of the project includes the development of all necessary interfaces to systems and business process modeling. Conceptually, the review process is similar to the diagram in Figure 2, which exemplifies how multiple alternatives are screened multiple times through the lens of those reviewing the alternatives. As indicated, logically, this is a funneling or narrowing down process. Page 14