Innovations Committee. Modernizing Medicaid: Medicaid Managed Care Program and Technology Toolkit

Transcription

1 Innovations Committee Modernizing Medicaid: Medicaid Managed Care v1.0, April 26, 2013

2 Table of Contents 1. Overview and Instructions Seven Conditions and Standards Considerations by MITA Business Area MITA Business Area Business Relationship Management (BR) MITA Business Area Care Management (CM) MITA Business Area Contractor Management (CO) MITA Business Area Eligibility and Enrollment Management (EE) MITA Business Area Financial Management (FM) MITA Business Area Member Management (MM) MITA Business Area Operations Management (OM) MITA Business Area Performance Management (PE) MITA Business Area Plan Management (PL) MITA Business Area Provider Management (PM) Appendix 1: Glossary of Acronyms Appendix 2: CMS Medicaid Enterprise Certification Toolkit (MECT) Managed Care Requirements Contributors PSTG Innovations Committee Page 2

3 1. Overview and Instructions In order to help State s work through the challenging process of identifying their high-level Medicaid program needs and goals when implementing a Managed Care payment model, this Medicaid Managed Care is designed using the Medicaid Information Technology Architecture (MITA) Framework v.3.0 to create a series of checklists. These checklists provide requirements considerations for procuring a replacement or upgrade of existing state technologies. Occasionally, in the analysis of what is needed for additional technologies to support a managed care program, it is important to clarify what is expected of the Managed Care Organizations (MCOs) that will be providing services as part of the program. Checklists are organized as follows: MITA Business Area Business Category Business Process Only Business Areas, Business Categories, and Business Processes that are impacted by the implementation of a Managed Care model are included in the checklists. Considerations are divided into three primary categories: these are State considerations for changes needed to administer the Managed Care Program, procure services of a Fiscal Agent or Technology vendor, or procure MCO services, as consistent with federal regulations. these are services to be performed by a Fiscal Agent during the Operations phase. these are requirements of the technology solution, module or enhanced functionality needed to support the Managed Care Program. A list of federal requirements for Medicaid Management Information Systems (MMIS) is included in Appendix 2. The full Medicaid Enterprise Certification Toolkit can be found at Statistics-Data-and-Systems/Computer-Data-and-Systems/MMIS/MECT.html. Page 3

4 2. Seven Conditions and Standards To achieve an improvement in the procurement process, reduce project cost and increase speed to market, an understanding of and alignment with the Seven Conditions and Standards as outlined by CMS in April of 2011, is essential. This is broader than the implementation of functionality to support the implementation of a Managed Care payment model, but is an important baseline for any Medicaid System Modernization. The Seven Conditions and Standards are: 1) Modularity Standard use of a modular, flexible approach to systems development 2) MITA Condition requires states to align to and advance increasingly in MITA maturity for business, architecture, and data 3) Industry Standards Condition ensures states align with, and incorporate, industry standards 4) Leverage Condition promotes solution sharing, leverage, and reuse of Medicaid technologies and systems within and among states 5) Business Results Condition supports accurate and timely processing of claims (including claims of eligibility), adjudications, and effective communications with providers, beneficiaries, and the public 6) Reporting Condition requires states to produce transaction data, reports, and performance information 7) Interoperability Condition ensures seamless coordination and integration with the Exchange (whether run by the state or federal government), and allows interoperability with health information exchanges, public health agencies, human services programs, and community organizations providing outreach and enrollment assistance services Assessment Approach: As part of the MITA State Self-Assessment process, it is important that states evaluate each of the technology components against the Seven Conditions and Standards. It is also important to understand as Medicaid agencies shift to Managed Care payment models, to what extent MCOs technology adheres to these conditions to ensure interoperability. The following is a high level example of considerations for the assessment process: Understanding the Current Environment and the Future Vision As-Is and To-Be analyses are typical and necessary steps to evaluating the current technology environment and what is needed to support future business needs. Stakeholder Interviews Interview stakeholders impacted by the technology initiative with modularity and initiative specifics as the focus. Gap Analysis Document what is needed to improve the current technology environment compared to the Seven Conditions and Standards objectives, and identify recommendations to bring the environment into compliance. Planning Procedures Develop and share templates for capturing information for the requirements for each of the Seven Conditions and Standards. Compliance Plan Develop a compliance plan to include the requirements of either commercial-off-the-shelf (COTS) or custom built solution in the Advanced Planning Document (APD) and subsequent Request for Proposals (RFP). Page 4

5 Other Considerations Implement Service Oriented Architecture (SOA) principles; upgrade core MMIS to have an open, reusable technology that separates Presentation, business, Data Layers and replace with Enterprise Service Bus (ESB) designed by the State IT and Technology Staff. Page 5

6 3. Considerations by MITA Business Area This section includes Checklists of Requirements Considerations organized by MITA Business Area, using the MITA Framework 3.0. (THIS PAGE LEFT BLANK INTENTIONALLY) Page 6

7 3.1. MITA Business Area Business Relationship Management (BR) MITA 3.0 Business Area Business Relationship (BR) Business Category: Business Relationship Management BR01 Establish Business Relationship The Establish Business Relationship business process encompasses activities undertaken by the State Medicaid Agency (SMA) to enter into business partner relationships. Agreements are between state agency and its partners, including collaboration amongst intrastate agencies, the interstate and federal agencies. It contains functionality for interoperability, establishment of inter-agency service agreements, identification of the types of information exchanged, and security and privacy requirements. These include Trading Partner Agreements (TPA), Service Level Agreements (SLA), and Memoranda of Understanding (MOU) with other agencies; Electronic Data Interchange (EDI) agreements with providers, Managed Care Organizations (MCOs), and others; and Centers for Medicare & Medicaid Services (CMS), other federal agencies, and Regional Health Information Organizations (RHIO) Statewide or Medicaid Business Relationship Management Requirements Considerations Has the State established EDI agreements specific to the MCOs? Develop EDI agreement to address the State s MCO requirements None Identified Document Management System: Manage document development and version control Yes No Page 7

8 Workflow Management System: Provide the ability define and manage a series of document development, editing and approval activities Provide the ability to facilitate automatic distribution and escalation of work 3.2. MITA Business Area Care Management (CM) MITA 3.0 Business Area Care Management (CM) Business Category: Case Management CM01 Establish Case The Care Management, Establish Case business process uses criteria and rules to: Identify target members for specific programs. Assign a care manager. Assess the member s needs. Select a program. Establish a treatment plan. Identify and confirm provider. Prepare information for communication. Statewide or Medicaid Case Management Requirements Considerations Are there state required case management services that may impact the Managed Care population? Does the state require case management for Yes No [Example NJ: the state is required manage lead-burdened children from the point the child is determined to have elevated lead levels until those lead levels are reduced to a predefined level. This targeted population is almost exclusively enrolled in managed care and the State takes responsibility for notifying the MCO when they have a member who is lead burdened. In turn, the MCO is required for establishing the case.] Page 8

9 targeted programs or other populations? Will the state allow the MCO to define its own case management targets? Define requirements for additional payments (i.e. Kick Payments) for higher risk/cost populations. Data Analytics and Business Intelligence Services: Identify target member populations Define the care management cases required by the MCOs Statewide Health Information Exchange: Allow access to member's health information for target population identification EPSDT Requirements Considerations Will the State offer the MCO supplemental compensation for specific case management services such as the traditional EPSDT screening? None Identified Claims Administration/Financial Management Services: Provide the ability to process additional/multiple payments to MCOs Prepare and process payment adjustments, as appropriate None Identified Data/Information Requirements Considerations Has case management information that will be required from the MCOs during the Establish Case process been defined? Yes No Yes No Page 9

10 Identify the minimum information required to establish a case Establish reporting requirements to ensure that the MCO provides sufficient information for contract monitoring Define data submission requirements including SLAs for timeliness and accuracy of data submission Data Analytics and Business Intelligence Services (sample requirements): Evaluate the case management information provided by the MCOs Develop monitoring reports to ensure that SLAs are met Develop monitoring reports for case establishment None Identified Communication Requirements Considerations Does the state have any requirements for communicating with any stakeholders during the Establish Case process? Will the state require the MCOs to develop and distribute communication? Will the State specify requirements and SLAs for customer support? Define communication required to during the Establish Case process Define requirements for review and approval of communication prior to distribution Define requirements and SLAs for customer support (first call resolution rate, percent of dropped calls, etc.) Data Analytics and Business Intelligence Services (sample requirements): Provide monitoring tools and reporting that evaluates the efficacy of communication efforts Yes No Page 10

11 Develop/produce monitoring reports that demonstrates actual performance measured against SLAs None Identified Systems/Software Requirements Considerations Does the State have minimum requirements for Case Management that may impact the MCOs selection of Case Management systems or software? Should the State provide a single Case Management system for use by the State and all MCOs? Define Case Management information and reporting requirements Define State minimum requirements Specify preferred or required software None identified Case Management System: Case notes functionality Document indexing Automatic notification settings triggered on calendar or frequency Work queue management feature Yes No MITA 3.0 Business Area Care Management (CM) Business Category: Case Management CM02 Manage Case Information The Manage Case Information business process uses state-specific criteria and rules to ensure appropriate and cost-effective medical, medically-related social and behavioral health services are identified, planned, obtained and monitored for individuals identified as eligible for care management services under such Page 11

12 programs as: Medicaid Waiver program case management Home and Community-Based Services (HCBS) Other agency programs Disease management Catastrophic cases Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Immunizations for children and adults Statewide or Medicaid Care Management Requirements Considerations N/A None Identified None Identified None Identified EPSDT Requirements Considerations Will the State offer the MCO supplemental compensation for specific case management services such as the traditional EPSDT screening? Define requirements for additional payments (i.e. Kick Payments). Claims Administration/Financial Management: Provide the ability to process additional/multiple payments to MCOs Prepare and process payment adjustments, as appropriate None Identified Data/Information Requirements Considerations Yes No Yes No Page 12

13 Has case management information that will be required from the MCOs during the Establish Case process been defined? Identify the minimum information required to establish a case Establish reporting requirements to ensure that the MCO provides sufficient information for contract monitoring Define data submission requirements including SLAs for timeliness and accuracy of data submission Data Analytics and Business Intelligence Services (sample requirements): Evaluate the case management information provided by the MCOs Develop monitoring reports to ensure that SLAs are met Develop monitoring reports for case establishment None Identified Yes No MITA 3.0 Business Area Care Management (CM) Business Category: Case Management CM03 Manage Population Health Outreach The Manage Population Health Outreach business process is responsible for the implementation of strategy to improve general population health. The State Medicaid Agency (SMA) identifies target populations or individuals for selection by cultural, diagnostic, or other demographic indicators. The inputs to this business process are census, vital statistics, immigration, and other information sources. This business process outputs materials for: Campaigns to enroll new members in existing health plan or health benefit. New health plan or health benefit offering. Modification to existing health plan or health benefit offering. It includes production of information materials Page 13

14 and communications to impacted members, providers, and contractors (e.g., program strategies and materials, etc.). The communication of information includes a variety of methods such as , mail, publication, mobile device, facsimile, telephone, web or Electronic Data Interchange (EDI). Statewide or Medicaid Case Management Requirements Considerations Will the State require the MCOs to perform portions of this process? Has the state defined a strategy to monitor MCOs to ensure that their outreach efforts are ethical and are not enticing specific populations to select the MCO? Define requirements and responsibilities for MCOs to perform outreach. Define the parameters for outreach, ensuring that MCOs are not providing enticements to specific populations. Define desired health outcomes, as applicable. Data Analytics and Business Intelligence Services: Provide/perform the ability to evaluate MCO outreach efforts. Produce reporting to assist the MCOs in identifying target populations Statewide HIE: Provide access to member's health information for target population identification Data/Information Requirements Considerations Does the State require the MCO(s) to perform the Manage Population Health Outreach process? If so, will the State facilitate securing access to State data sources (e.g. vital statistics)? Yes No Yes No Page 14

15 Identify data sharing opportunities and facilitate data sharing agreements. Define requirements for data submission including SLAs for timeliness and accuracy of data submission Data Analytics and Business Intelligence Services: Provide State information to MCOs to facilitate their outreach efforts. Produce monitoring reports to ensure that SLAs are achieved Develop and execute business processes and produce reports that evaluate efficacy of outreach efforts Data Analytics and Business Intelligence Services: Develop monitoring reports to ensure that SLAs are achieved Develop reports that evaluate efficacy of outreach efforts Communication Requirements Considerations Will the state require the MCOs to develop and distribute outreach information materials and communication? Will the State specify requirements and SLAs for customer support? Define requirements for review and approval of information materials and communication prior to distribution Define requirements and SLAs for customer support (first call resolution rate, percent of dropped calls, etc.) Data Analytics and Business Intelligence Services (sample requirements): Provide State information to MCOs to facilitate their outreach efforts. Develop and produce monitoring reports to ensure that SLAs are achieved Yes No Page 15

16 Statewide HIE: Provide access to member's health information for target population identification None Identified MITA 3.0 Business Area Care Management (CM) Business Category: Case Management CM04 Manage Registry The Manage Registry business process receives a member s health outcome information, prepares updates for a specific registry (e.g., immunizations, cancer, disease) and responds to inquiries with response information. In the context of MITA, a medical registry consolidates related records from multiple sources (e.g., intrastate, interstate or federal agencies) into one comprehensive data store. This data store may or may not reside within the Medicaid information system. Statewide or Medicaid Case Management Requirements Considerations Will the MCO be required to submit information to update specified registries? Will the MCO be required to use registries? For example, will the MCO be required to access the immunization registry to ensure that members are compliant with all appropriate immunizations? Define MCO requirements for use of and update to registries. Identify data sharing opportunities and facilitate data sharing agreements. None Identified None Identified Yes No Page 16

17 Data/Information Requirements Considerations Has the state defined what registry information will be required from the MCOs during the Manage Registry process? If the State requires the MCO to share registries, will the State facilitate securing access to State registries? Define minimum information required to manage registries Define requirements for data submission including SLAs for timeliness and accuracy of data submission Define reporting requirements to assure that the MCO provides sufficient information for contract monitoring and outcomes measurement Data Analytics and Business Intelligence Services (sample requirements): Provide the ability evaluate the registry information provided by the MCOs Develop and produce monitoring reports to ensure that SLAs are achieved Develop and produce monitoring reports for manage registry process and related quality and care monitoring Statewide HIE: Support and manage secure access to member's health information for quality and care monitoring Yes No MITA 3.0 Business Area Care Management (CM) Business Category: Case Management CM05 Perform Screening and Assessment The Perform Screening and Assessment business process is responsible for the evaluation of member s health information, facilitating evaluations and recording results. This business process assesses for certain health and behavioral health conditions (e.g., chronic illness, mental Page 17

18 health, substance abuse), lifestyle and living conditions (e.g., employment, religious affiliation, living situation) to determine risk factors. This business process: Establishes risk categories and hierarchy, severity, and level of need. Screens for required fields. Edits required fields. Verifies information from external sources if available. Establishes severity scores and diagnoses. Associates with applicable service needs. Health Information Exchange (HIE) verifies a member s health information. Statewide or Medicaid Case Management Requirements Considerations Will the state require MCOs to perform specified screening and assessment services? Will the state allow the MCO to define unique screening and assessment criteria? Define screening and assessment requirements for target populations, health conditions or other specified criteria. Data Analytics and Business Intelligence Services: Identify target populations and define the screening and assessment information required by the MCOs Statewide HIE: Provide access to member's health information for target population identification Data/Information Requirements Considerations Is there specific screening information the State will require from the MCOs during the Perform Screening and Assessment process? Yes No Yes No Page 18

19 Is there specific assessment information the State will require from the MCOs during the Perform Screening and Assessment process? Define data interface requirements and SLAs for data transmission and processing Data Analytics and Business Intelligence Services (sample requirements): Develop monitoring reports for the screening and assessment process and related quality and care monitoring Develop monitoring reports to ensure that SLAs are met Statewide HIE: Provide access member's health information for quality and care monitoring None Identified Page 19

20 MITA 3.0 Business Area Care Management (CM) Business Category: Case Management CM06 Manage Treatment Plan and Outcomes The Manage Treatment Plan and Outcomes business process uses federal and state specific criteria and rules to ensure that the providers/contractors chosen and services delivered optimizes member and member population outcomes. It includes activities to track and assess effectiveness of the services, treatment plan, providers/contractors, service planning and coordination, episodes of care, support services, and other relevant factors. It also includes ongoing monitoring, management, and reassessment of services and treatment plans for need, appropriateness, and effectiveness, and monitoring of special member populations (e.g., pregnant women and children, and HIV/intravenous drug users). Health Information Exchange (HIE) monitors a member s health information. Statewide or Medicaid Case Management Requirements Considerations Are there state required treatment plan and outcomes management services that may impact the Managed Care population? Do these cases require documented treatment plans and outcomes measurement? Does the state require treatment plans for targeted programs or other populations? Will the state allow the MCO to define their own treatment plan and outcomes targets? Define Treatment Plan and Outcomes requirements. Data Analytics and Business Intelligence Services: Yes No Page 20

21 Identify target members Develop monitoring reports for the manage treatment plan and outcomes process and related quality and care monitoring Statewide HIE: Provide access to member's health information for quality and care monitoring Statewide HIE: Provide access to member's health information for quality and care monitoring Data/Information Requirements Considerations Will the State require the MCOs to provide specific treatment plan information during the Manage Treatment Plan and Outcomes process? Will MCOs be responsible for exchanging treatment plan information with each other when Members move from MCO to MCO? Will the State be the conduit to information exchange among the MCOs? Define minimum treatment plan and outcomes information required Define requirements for information transfer with the goal of using standard transactions such as HIPAA EDI or HL7 Define reporting requirements to assure that the MCO provides sufficient information for contract monitoring and outcomes measurement Define requirements for data submission including SLAs for timeliness and accuracy of data submission. Data Analytics and Business Intelligence Services (sample requirements): Evaluate the treatment plan information provided by the MCOs Develop monitoring reports to ensure that SLAs are met Develop monitoring reports to manage the treatment Yes No Page 21

22 plan and outcomes process and related quality and care monitoring Develop data exchange information (extracts, reports) if the State becomes the conduit for information exchange among the MCOs EDI Translator: Capture and transmit HIPAA compliant transactions MITA 3.0 Business Area Care Management (CM) Business Category: Case Management CM07 Authorize Referral The Authorize Referral business process is responsible for referrals between providers that the State Medicaid Agency (SMA) approves for payment, based on state policy. Examples are referrals by physicians to other providers for laboratory procedures, surgery, drugs, or durable medical equipment. The SMA uses this business process primarily for Primary Care Case Management programs where additional approval controls deemed necessary by the state. Most States do not require this additional layer of control. Statewide or Medicaid Case Management Requirements Considerations Will the state impose any requirements relating to MCO referrals? Define requirements for MCO to handle any internal referrals within their networks. Define SLAs and Performance Metrics to protect the members from undue administrative burden that might hinder their access to care Data Analytics and Business Intelligence Services: Evaluate the referral information provided by the MCOs Develop monitoring reports to ensure that SLAs are met Develop monitoring reports for the authorize referral Yes No Page 22

23 process and related quality and care monitoring Statewide HIE: Provide access to member's health information for quality and care monitoring Data/Information Requirements Considerations Will the State require specific referral information from the MCOs during the authorize referral process? Will MCOs be responsible for exchanging referral information with each other when Members move from MCO to MCO? Will the State be the conduit to information exchange among the MCOs? Define minimum referral information required Define requirements for information transfer with the goal of using standard transactions such as HIPAA EDI or HL7 Define reporting requirements to assure that the MCO provides sufficient information for contract monitoring and outcomes measurement Define requirements for data submission including SLAs for timeliness and accuracy of data submission. Data Analytics and Business Intelligence Services (sample requirements): Evaluate the referral information provided by the MCOs Develop monitoring reports to ensure that SLAs are met Develop monitoring reports for the authorize referral process and related quality and care monitoring Develop data exchange information (extracts, reports) if the State becomes the conduit for information exchange among the MCOs EDI Translator: Capture and transmit HIPAA compliant transactions Yes No Page 23

24 Statewide HIE: Support and manage secure access to member's health information for quality and care monitoring MITA 3.0 Business Area Care Management (CM) Business Category: Case Management CM08 Authorize Service The Authorize Service business process encompasses both a pre-approved and postapproved service request. This business process focuses on specific types and numbers of visits, procedures, surgeries, tests, drugs, therapies, and durable medical equipment. Its primary use is in a fee-for-services setting. Statewide or Medicaid Case Management Requirements Considerations Will the state impose any requirements relating to MCO authorizations? Define requirements for MCO to handle any authorizations within their networks and external to their network. Define SLAs and Performance Metrics to protect the members from undue administrative burden that might hinder their access to care Data Analytics and Business Intelligence Services: Evaluate the authorization information provided by the MCOs Develop monitoring reports to ensure that SLAs are met Develop monitoring reports for the authorize service process and related quality and care monitoring Statewide HIE: Provide access to member's health information for quality and care monitoring Data/Information Requirements Considerations Will the State require specific authorization Yes No Yes No Page 24

25 information from the MCOs during the authorize service process? Will MCOs be responsible for exchanging authorization information with each other when Members move from MCO to MCO? Will the State be the conduit to information exchange among the MCOs? Define minimum service authorization information required Define requirements for information transfer with the goal of using standard transactions such as HIPAA EDI or HL7 Define reporting requirements to assure that the MCO provides sufficient information for contract monitoring and outcomes measurement Define requirements for data submission including SLAs for timeliness and accuracy of data submission. Data Analytics and Business Intelligence Services: Evaluate the authorization information provided by the MCOs Develop monitoring reports to ensure that SLAs are met Develop monitoring reports for the authorize service process and related quality and care monitoring Develop data exchange information (extracts, reports) if the State becomes the conduit for information exchange among the MCOs EDI Translator: Capture and transmit HIPAA compliant transactions Statewide HIE: Provide access to member's health information for quality and care monitoring MITA 3.0 Business Area Care Management (CM) Business Category: Case Management CM09 Authorize Treatment Plan The Authorize Treatment Plan business process encompasses both a prior authorization and postapproved treatment plan. The State Medicaid Page 25

26 Agency (SMA) uses the Authorize Treatment Plans primarily in the care coordination setting where the care management team assesses the member s needs, decides on a course of treatment, and completes the treatment plan. Statewide or Medicaid Case Management Requirements Considerations Will the state impose any requirements relating to MCO treatment plans? Define requirements for MCO to handle any treatment plans within their networks and external to their network. Define SLAs and Performance Metrics to protect the members from undue administrative burden that might hinder their access to care Data Analytics and Business Intelligence Services: Evaluate the treatment plan information provided by the MCOs Develop monitoring reports to ensure that SLAs are met Develop monitoring reports for the authorize service process and related quality and care monitoring Statewide HIE: Provide access to member's health information for quality and care monitoring Data/Information Requirements Considerations Will the State require the MCOs to provide specific treatment plan information during the authorize treatment plan process? Will MCOs be responsible for exchanging treatment plan information with each other when Members move from MCO to MCO? Will the State be the conduit to information exchange among the MCOs? Yes No Yes No Page 26

27 Define minimum treatment plan information required Define requirements for information transfer with the goal of using standard transactions such as HIPAA EDI or HL7 Define reporting requirements to assure that the MCO provides sufficient information for contract monitoring and outcomes measurement Define requirements for data submission including SLAs for timeliness and accuracy of data submission. Data Analytics and Business Intelligence Services (sample requirements): Evaluate the treatment plan information provided by the MCOs Develop monitoring reports to ensure that SLAs are met Develop monitoring reports for the authorize treatment plan process and related quality and care monitoring Develop data exchange information (extracts, reports) if the State becomes the conduit for information exchange among the MCOs EDI Translator: Capture and transmit HIPAA compliant transactions Statewide HIE: Provide access to member's health information for quality and care monitoring Page 27

28 3.3. MITA Business Area Contractor Management (CO) MITA 3.0 Business Area Contractor Management (CO) Business Category: Contractor Information Management CO02 Manage Contractor Communication The Manage Contractor Communication business process receives requests for information, appointments, and assistance from contractors (e.g., managed care, at-risk mental health or dental care, primary care physician) such as inquiries related to modifications in Medicaid Program policies and procedures, introduction of new programs, modifications to existing programs, public health alerts, and contract amendments, etc. This business process includes the log, research, development, approval, and delivery of routine or ad hoc messages. The State Medicaid Agency (SMA) communications a variety of methods such as , mail, publication, mobile device, facsimile, telephone, web or Electronic Data Interchange (EDI). NOTE: The Manage Contractor Communication business process handles current contractors by providing assistance and responses to individual entities, i.e., bi-directional communication. The Perform Contractor Outreach business process targets both prospective and current contractor populations for distribution of information regarding programs, policies, and other issues. Other examples of communications include: Pay for performance communications performance measures could affect capitation payments or other reimbursements. Incentives to improve encounter information quality and submission rates. Statewide or Medicaid Contractor Information Management Requirements Considerations Will the state explore multiple communication avenues to manage communication with the MCOs such as forums, regularly scheduled meetings, etc.? Yes No Page 28

29 Will the state establish SLAs to ensure their communication performance with the MCOs? Define requirements and SLAs for contractor communication support (first call resolution rate, percent of dropped calls, etc.) None Identified Customer Relationship Management: Provide a central repository for capturing and managing contractor contacts and the resolution of those contacts. Web Portal with chat and secure features to serve as an information conduit to the MCOs Data Analytics and Business Intelligence Services: Develop monitoring reports to ensure that SLAs are met MITA 3.0 Business Area Contractor Management (CO) Business Category: Contractor Information Management CO03 Perform Contractor Outreach The Perform Contractor Outreach business process is responsible for sending information such as public health alerts, new programs, and/or modifications in the Medicaid Program policies and procedures. For prospective contractors (e.g., managed care, atrisk mental health or dental care, primary care physician), States Medicaid Agency (SMA) develops contractor outreach information for prospective contractors identified by analyzing Medicaid business needs. For currently enrolled contractors, information may relate to public health alerts, public service announcements, and other objectives. The SMA communicates contractor outreach information by a variety of methods such as , mail, publication, mobile device, facsimile, Page 29

30 telephone, web or Electronic Data Interchange (EDI). The SMA produces, distributes, tracks, and archives all contractor outreach communications according to state rules. Statewide or Medicaid Contractor Information Management Requirements Considerations Are there specific communication avenues state will use to share information (policies, program issues, etc.) with the MCOs? Will the state require receipt confirmation from the MCOS for specified information? Develop a communication plan and/or matrix to identify types of communication, method of delivery, frequency and other appropriate requirements for communication. Customer Relationship Management: Identify potential outreach/ communication opportunities. Data Analytics and Business Intelligence Services: Identify potential outreach/ communication opportunities. Customer Relationship Management: Provide a central repository for capturing and managing contractor contacts and the resolution of those contacts. Yes No MITA 3.0 Business Area Contractor Management (CO) Business Category: Contractor Information Management CO05 Produce Solicitation The Produce Solicitation business process gathers requirements, develops a solicitation (e.g., Request for Information (RFI), Request for Quotation (RFQ), or Request for Proposals (RFP)), receives approvals for the solicitation, and releases for response. Statewide or Medicaid Contractor Information Management Requirements Considerations Is the RFP aligned with MITA To-Be and Yes No Page 30

31 Road Map? Clearly articulate the procurement goals and objectives. The more states know about their own business processes, the more effective the RFP will be. Focus requirements more on outcomes than specific system requirements. Establish objectives and describe the vision of the operations of the MMIS for the vendor community. The vendors then conduct requirements elicitation during DDI. Maintain a forward looking focus. Consider reengineering the existing program processes and policies first and then capturing the requirements. Write requirements which address the future state, and don t merely replicate the current business practices. Identify desired results not processes. Use SLAs to manage vendor performance instead of restrictive requirements. Invite competition by developing minimum experience requirements and evaluation criteria that recognize COTS products and software solutions that are implemented and in production in the broader health industry (commercial environment), as well as systems implemented in the public sector. Provide RFP response templates for vendors to complete. Minimize the weighting primarily on procurement costs, since many states then negate to identify the total cost of allocation. Identify requirements that the state feels are optional or nice to have as such in the RFP. None Identified None Identified [Example: OH has a cost evaluation method that attempts to calculate a value score. The cost score = total cost divided by technical points awarded, to come up with dollar per technical point score] Page 31

32 MITA 3.0 Business Area Contractor Management (CO) Business Category: Contractor Information Management CO06 Award Contract The Award Contract business process utilizes requirements, advanced planning documents, requests for information, request for proposal, and sole source documents to request and receive proposals, verify proposal content against Request for Proposal (RFP) or sole source requirements, apply evaluation criteria, designate contractor/vendor, post award information, entertain protests, resolve protests, negotiate contracts, and notify parties. In some States, this business process makes a recommendation of award instead of the actual award itself. NOTE: The State Medicaid Agency (SMA) requires billing agents, clearinghouses, or other alternate payee (as defined by the Secretary) to register. Statewide or Medicaid Contractor Information Management Requirements Considerations Is this a multi-state or regional contract? Time and materials contract? Firm fixed price contract? Define new contract terms to incent performance and recognize technology advancements and explore alternative contract types. Consider breaking the procurement into at least two phases: phase 1 - requirements and design and phase 2 development and implementation. Review managed care vendor market to determine what technical functions the state must conduct, that the state can share with managed care entities, or that the state could contract with an MCO to conduct on behalf of the state. Consider multiple vendor arrangements. As we are moving to more modular, componentized procurements, States should explore what contract language needs to be Yes No Page 32

33 included in each contract to ensure cooperation and successful delivery. a) Review Vendor Liability Clauses. When developing a price proposal, a vendor must weigh many variables, including the scope of work, as well as the financial risks associated with penalty and liability provisions. Contract terms that increase a vendor s financial risk will inherently increase the vendor s price. b) Location Flexibility to Leverage Existing or Share Administrative Services. Contract provisions may disallow leveraged offerings available to similar entities within the Federal and private sectors. To capitalize on these leveraged offerings and reduced fee schedules, we recommend the RFP provisions that do not place geographical restrictions on the location of the data center; call center, and other clerical supported services. Consider Value-based pricing models. The incentive aspects of value based pricing offer States with an effective tool that rewards vendor creativity, innovation, and extra effort. The most rewarding concepts for value based pricing include pricing models offering additional revenue-generating opportunities or the potential for costsavings or cost avoidance. None Identified None Identified MITA 3.0 Business Area Contractor Management (CO) Business Category: Contractor Information Management CO07 Manage Contract The Manage Contract business process receives the contract award information, implements contractmonitoring procedures, updates contract if needed, and continues to monitor the terms of the contract throughout its duration Statewide or Medicaid Contractor Information Management Requirements Considerations Yes No The overall process may not be impacted by Page 33

34 introducing Managed Care, but the requirements defined in the contract will facilitate contract monitoring. Develop detailed requirements, SLAs and performance measures to provide clear guidelines for determining contract health. Project and Program Management Services: Provide project and program management or to supplement and support state staff Data Analytics and Business Intelligence Services: Develop monitoring reports to ensure that SLAs are met Develop contract monitoring reports Page 34

35 MITA 3.0 Business Area Contractor Management (CO) Business Category: Contractor Information Management CO08 Close Out Contract The Close Out Contract business process begins with an expired contract or an order to terminate a contract. The business process ensures the obligations of the current contract are complete and the turnover to the new contractor proceeds according to contractual obligations. Statewide or Medicaid Contractor Information Management Requirements Considerations The overall process may not be impacted by introducing Managed Care, but the requirements defined in the contract will facilitate this process. Develop detailed contract turnover and transition requirements to ensure that the transition can be completed without adverse impact to the State and the members of the MCOs None Identified None Identified Yes No MITA 3.0 Business Area Contractor Management (CO) Business Category: Contractor Information Management CO09 Manage Contractor Grievance and Appeal The Manage Contractor Grievance and Appeal business process handles contractor (e.g., managed care, at-risk mental health or dental care, primary care physician) appeals* of adverse decisions or communications of a grievance. The Manage Contractor Communication business process initiates a grievance or appeal. The State Medicaid Agency (SMA) logs and tracks the grievance or appeal; it triages to appropriate reviewers; it researches it; it may request additional information; it schedules and Page 35

36 conducts a hearing in accordance with legal requirements; and it makes a ruling based upon the evidence presented. Staff documents and distributes results of the hearings, and adds relevant documents to the contractor s information. Agency formally notifies contractor of the decision. This business process supports the Manage Performance Measures business process by providing information about the types of grievances and appeals it handles; grievance and appeals issues; parties that file or are the target of the grievances and appeals; and the dispositions. This information used to discern program improvement opportunities, which may reduce the issues that give rise to grievances and appeals. Based on the appeal business process, if a contractor wins an appeal that impacts or clarifies a Medicaid State Plan, health plan, or health benefit this process sends that information to Maintain State Plan, Manage Health Plan Information or Manage Health Benefit Information business processes to modify the relevant policy or procedure. Disposition could result in legislative change requirements that will be communicated to lawmakers. NOTE: States may define grievance and appeal differently, perhaps because of state laws. *This business process supports grievances and appeals for both prospective and current contractors. A non-enrolled contractor can file a grievance or appeal, for example, when agency does not award a contract to contractor. Protests received from prospective contractors are addressed in the Award Contract business process Statewide or Medicaid Contractor Information Management Requirements Considerations Does the state have documented grievance and appeals procedures in place? Modify the grievance and appeals process to include procedures on how complaints regarding an MCO will Yes No Page 36

37 be handled. Define timeframes for response to consumer, development of corrective action plans, and processing of appeals. None Identified None Identified Page 37

38 3.4. MITA Business Area Eligibility and Enrollment Management (EE) MITA 3.0 Business Area Eligibility and Enrollment Management (EE) Business Category: Member Enrollment (Future Release) EE01 Determine Member Eligibility (Under Development) From MITA 2.01: The Determine Eligibility business process receives eligibility application data set from the receive inbound transaction process; checks for status (e.g., new, resubmission, duplicate); establishes type of eligible (e.g., children and parents, disabled, elderly, or other); screens for required fields; edits required fields; verifies applicant information with external entities; assigns an ID; establishes eligibility categories and hierarchy; associates with benefit packages, and produces notifications. NOTE: A majority of States accept the designation of eligibility from other agencies (SSI, TANF, SCHIP, and other), in which case this business process will not be used by the Medicaid agency for those individuals. In these situations, Medicaid receives and stores the member information sent from other sources in the Member data store. This may require conversion of the data. However, this process will be used by the other States which require the TANF, disabled, elderly applicant to apply for Medicaid, and where the Medicaid agency determines eligibility for State-only programs. Statewide or Medicaid Case Management Requirements Considerations Will the state incorporate member health plan selection during the eligibility application process? How will the state use the HIX to facilitate managed care health plan selection and/or auto enrollment during this process? What type of customer support will they provide to facilitate managed care health Yes No Page 38

39 plan selection during this process? How will the state facilitate eligibility determination and enrollment for newborns? Define requirements for managed care health plan enrollment. Define rules for health plan auto assignment. Enrollment Broker Services: Consider centralized enrollment broker services across all MCOs Operational support services that perform health plan enrollment functions Case Managers: Operational support services that perform health plan enrollment for fragile populations Eligibility Determination System: Ability to apply eligibility determination business rules for Modified Adjusted Gross Income Ability to apply other State business rules for Managed Care Program eligibility determination MITA 3.0 Business Area Eligibility and Enrollment Management (EE) Business Category: Member Enrollment (Future Release) EE02 Enroll Member (Under Development) From MITA 2.01: The Enroll Member business process receives eligibility data from the Determine Eligibility process, determines additional qualifications for enrollment in programs for which the member may be eligible (e.g., managed care, HIPAA, waiver), loads the enrollment outcome data into the Member and Contractor data stores, and produces notifications to the member and the contractor. Either the Agency or enrollment brokers may perform some or all of the steps in this process. NOTE: There is a separate business process for Page 39

40 disenroll member. Statewide or Medicaid Case Management Requirements Considerations How will the state facilitate managed care health plan selection and/or auto assignment during this process? How will the state facilitate eligibility determination and enrollment for newborns? How will the state facilitate enrollment of a Medicare/Medicaid dual eligible in a D- SNP managed care plan. Will the state implement a provision to prohibit MCOs from providing any enticements to members to select their MCO? What requirements will the MCO have to new enrollees? Define requirements for managed care health plan enrollment. Define rules for health plan auto assignment Define rules against providing enticements to members that will encourage them to select their CO. Define MCO requirements for new enrollees. Yes No Eligibility Determination System: Manage Medicaid member initiated Managed Care Organization research and selection Manage Medicaid Managed Care Organization auto assignment Customer Relationship Management: Contact Management Functionality Provide a central repository for capturing and managing member enrollment request contacts and the resolution of those contacts. Page 40