Modernization of Eligibility Determination Systems and Processes. Medicaid Innovations Forum Orlando, FL 2013

Transcription

1 Modernization of Eligibility Determination Systems and Processes Medicaid Innovations Forum Orlando, FL 2013 February 2013

2 What we will Attempt to Accomplish Today Brief History of Future Eligibility Determination Systems Discussion of Current ACA Goals, Strategies, Ideas and Solutions Case Study MariChris, LLC did in Analyzing Alabama Eligibility System Innovation Works.Seriously! Collaboration with a State Medicaid Office and MMIS Software Development Company IT Produced Real ROI results and a win for State Medicaid as well as the population it serves. Let s Get Started!

3 Medicaid Money Machine

4 Who is impacted? Stakeholders - Medicaid applicants/members/recipients and beneficiaries, Tax Payers and State Health and Human Services organizations.

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11 One size does not fit all!

12 Key Challenges: Business Shrinking budgets and Limited Staff Shifting paradigms Innovation in Business Process - Traditional vs. Current System Data Sharing Exchanges and Interoperability Increased capacity Health literacy Changing Laws States are "...forced to recognize but not prepared to manage."

13 HITECH & PPACA Issues: Standards and certifications EHR Meaningful Use Privacy and Security Electronic Eligibility and Enrollment Clinical Reporting & Informatics "Information-driven healthcare "Plenty of data but no information"

14 It is easy to build systems that are hard to use, but much harder to build systems that are easy to use! Bruce Whitehead, Architect/SME MariChris Eligibility Determination and Traceability Solutions

15 At MariChris, we understand the complexity of the Medicaid/MMIS development environment. We understand that there are 50 States and 50 individual MMIS solutions!

16 Login Project / Account CMS Certification MITA BA MITA BP Business Area or Subsystem Process [GSD Object] Business Requirements CK LIST MITA SBP Data Elements Use Cases [DSD Object] Change Logs Pages / Screens / Reports Business Rules Error Messages Legend: MITA 3.0 XREF Certification REQ Validation DESIGN TESTING TRACKING System Integration Testing Test Case [Unit/Sys Testing] Test Script Test Result Ops Readiness Testing Defect Logs

17 The sheer number and complexity of financial and medical assistance benefit programs that exist today often make it difficult for administrators to determine eligibility, and for providers to initiate needed care to their patients in a timely manner.

18 UnivERS Is a comprehensive eligibility technology solution that solves this problem and works with any financial or medical assistance program, including all programs supported through the Medicaid Management Information Systems (MMIS) and Public Health programs.

19 Our UnivERS (Universal Eligibility Response System) design began in 2003 after CMS issued its letter, dated July 2002, on the Future of Eligibility Determination Systems. At that time, there were only five (5) items or bullet points. Today there are seven (7), with little change to the original five (5). Now called: CMS 7 Standards or Requirements of all new Eligibility Determination systems.

20 MariChris Design, Development and Testing Timelines:

21 Timelines 2004 UnivERS was created as a Client Server solution running under MS SQL-Server 2000 / ADP 2007 RulesXpress Eligibility Determination Engine was created 2007 AVA developed, allowing low-literate and non-englishspeaking applicants to apply for Medicaid and CHIP by themselves 2010 UnivERS & RulesXpress migrated to MS SQL-Server 2008 r2 and ASP.NET

22 Timelines 2011 front-end web-based data collector created in.net 2012 linked to UnivERS creating Ucore front-end to silo mainframes [FAMAS] 2012 mmagi Calculator, Modified Adjusted Gross Income module created 2013 RulesXpress and DVRE, RulesXpress and TraceIT to be converted to a Cloud Shared service offerings UnivERS Mobile to be created using Windows 8 pro and the MS Surface Tablet

23 Timelines As you can see from the above timeline, more than eight (8) years of development have been invested in this Modular Design and Development that the industry now calls, a SOA Architected Solution. Our system is Methodology Independent.

24 Service Oriented Architecture / Interoperability of UnivERS DATA VALIDATION PRELIM DETERMINATION DATA CAPTURE DVRE RULES ENGINE FINANCIAL CALC FINAL DETERMINATION RulesXpress FORMAL VERIFICATION RULES ENGINE CASE DISPOSITION ENROLLMENT

25 Now eligibility, for ever changing financial and medical assistance programs, can be determined in real time and without delay, as the application process is being conducted. Ability to create and manage any number of active programs No technical skills or support are required to create and manage benefit program rules Rule sets can be added, modified, end dated, or inactivated at anytime Application data collected can be applied to any eligibility program or benefit plan System can seamlessly match applicants to all available programs System supports comprehensive patient inputs, workflow management and caseload management capability

26 Healthcare reform as defined by PPACA Online eligibility applications and renewals must use simplified rules The decision must be rules based Use electronic databases to validate or verify customer of household financial statements Use electronic signatures Interface with the HIE and HIX s with a seamless transition between programs

27 Reduction of redundant data entry across eligibility programs Decreased processing time for changes and redeterminations Minimization of the need for technical assistance Increased level in employee productivity Lower participants' reliance on face-to-face agency contact Any Door Access Provide convenient access to policy and procedural guides

28 Characteristics of the UnivERS Eligibility Determination Solution that make it easily adaptable to changing needs and conditions: Modular architecture based on a collection of open systems components that offer both flexibility and expandability Flexible design integrates services across agency and program boundaries, inviting implementation of new access channels Rules-based applications provide an adaptable framework of functional components that permit rapid deployment of new service delivery models and implementation of new policy requirements Web-based or Client Server user interface enhances user experience and requires minimum training Tailored components ensure system is aligned with your goals and processes

29 Should Innovatively provide: An integrated solution that includes Medicaid, S-Chip, SNAP, TANF, WIC, etc. An integrated solution which will focus on bringing Medicaid and Public Health under one umbrella when Determining Eligibility. An integrated universe for all of the citizens of the State Enterprise.

30 Reduce redundant data entry across benefit programs Decrease processing time for changes and redeterminations Minimize the need for technical assistance Raise employee productivity Lowers participants' reliance on face-to-face agency contact Give convenient access to policy and procedural guides Save on cost through operational efficiency and reduced labor/contractor staff

31 State of Alabama Case Study Discussion Number of New Enrollees Number of Case Workers Dollar Savings on Case Worker Reduction Improved Job Satisfaction and Job Enrichments

32 Innovation Works.Seriously! Collaboration with a State Medicaid Office and MMIS Software Development Company IT Produced Real ROI results and a win for State Medicaid as well as the population it serves. State of Michigan & CNSI Congratulations

33 MariChris and the AIM Alliance are an Innovative Eligibility Determination Solutions Team. READY NOW, FOR 2014 and Beyond!

34 MariChris, LLC 116 Grand Oaks Drive St. Augustine FL (919) Take on Modernizing your Eligibility Determination System!