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MEDICAID IT FUNDING OPPORTUNITIES & RESPONSIBILITIES
ELIGIBILITY, ENROLLMENT, EDUCATION & ENGAGEMENT
Fully Utilizing Funding Opportunities and Efficiencies through
Leveraging ARRA-HITECH and ACA Options
Maximizing Enrollment 2011 State Meeting Eligibility and Enrollment Systems Transformation:
Building on Lessons and Work in Maximizing Enrollment to Get Ready for 2014
Patricia MacTaggartMay 19, 12:30 – 1:30
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MEDICAID OPPORTUNITIES & RESPONSIBILITIESConcerns – Context – Concepts – Completion
• Concerns: – Multiple Alabama Health IT Activities & Limited Human
and Financial Resources– Challenging Timelines & Fully Utilizing Federal Dollars
• Context:– Medicaid & CHIP Eligibility, Enrollment, Education &
Engagement Policy and Health IT in Service Delivery & Payment Transformation
– Eligibility/Demographics, Education & Engagement as Component of Health Information Exchange
– Eligibility as Core to Evolving Health Insurance Exchange
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MEDICAID OPPORTUNITIES & RESPONSIBILITIESConcerns – Context – Concepts – Completion
• Concepts– MITA: Medicaid Information Technology
Architecture/Framework – ARRA HITECH: Health Information Exchanges (HIEs) , Electronic
Health Record Systems (EHRs) & Meaningful Use (MU)– Patient Protection and Affordable Care Act (ACA): Health Care
Reform, Including Health Insurance Exchanges (HIEs)
• Completion: – Implementation– Next Steps
AdequateProcesses
AdequateExecution
AdequateFinancial &
QualityOversight
Adequate Policy
AdequateInfrastructure
& Co
vera
ge
Paym
ent
Eligibility
Service Delivery
Decision Making Is Even Tougher
When the State Has Little Money
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MULTIPLE ALABAMA HEALTH IT ACTIVITIES Framing The Need – Framing The Benefit
• Interests are the Same Interests are Competing - or Aligned When Not “Horizontal Integration” the Same
• Consumer Centric Only Simplified Eligibility: Medicaid Access Requirements, Enrollment to Medical Homes,
Engagement & Education
• Fully Utilizing Federal Efficiencies Are Not Needed $$ Saves
• Rip and Replace is Not Rip and Replace is Bad Goal Administrative Simplification,
No More Paper & Standardization Private/National
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Oversight on right care at right time at appropriate price from appropriate provider
What provider/service deliveryoption will provide the care?
Health Care Services Delivery Mechanism Determined
Services Provided & Paid
Validation of Services Delivered & EOB
Who is health care purchased for?Eligibility
What Coverage is state willing to purchase?What will an individual’s benefit be?
Consumer Seeks Eligibility Coverage/Benefits Determined
Feedback
Feedback
•MCO•Partial MCO•PCCM•Provider within PCCM•Care Mgmt
Delivery Model
•PA•Pre-cert•Authorization for treatment•Service Provider•Where provided•Drug Formulary
Receive Service
•Rate methodology•RBRVS, DRG, etc.•Claim Paid•Person responsible•Pay for Performance
Service Paid
•Home•Institution• Hospital• NH• ICF-MR• Group Home
Where Provided
•Financial Mgmt•Transaction•Financial Reporting•Audits•Premium Invoice•TPL
Financial Oversight
•SPA/Waivers•Adm. Policies•Budget Accounting•Reporting•Contract Mgmt•Feedback
Program Mgmt/Gov’t oversight
•Consumer Information strategies•Provider information strategies•F&A/Program integrity•Performance measures•Information Mgmt•Performance Mgmt•Grievance and appeals
Quality Oversight*
•Co-pays•Cost sharing•Caps/Limitations•Individual and Family•Plan of Care•Treatment Plan
Limitations* (*Individual and Family)
•SPA Services•HCBW Services•Basic Services•Preventative Services•LTC Institution• ICF-MR• NH• Psych-Group• Home•Home Care•Alternative 1115 Waiver•EPSDT•Administrative
Coverage
•Programmatic•Basic
*Temporary
Categorical*
•ADLS•Diagnostic/Clinical•Pre-Adm NH Screening
Functional
•Medicaid¤•SCHIP¤•PH Funded¤•MH/SA Grants¤•State only funded programs¤•Not Eligible
Financial (Hierarchical)
Consumer: Eligibility Medicaid Agency
It’s Complicated Even When It’s Automated
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MEDICAID & CHIP ELIGIBILITY, ENROLLMENT, EDUCATION & ENGAGEMENT POLICY & HIT
•Eligibility:• Systems Funding: Design, development, installation or
enhancement (DDI) of a state eligibility determination & redetermination and/or enrollment system at 90% federal-10% state for DDI up to 2015 and 75% federal-25% state for ongoing operation.• Move to MAGI (Income and Household) (Modified Adjusted
Gross Income)
•Data on Performance: CHIPRA Quality Measures for Children, MU Measures, ACA Quality Measures for Adults, HCBS Measures for Waivers, PQRI Measures
Get the Data Once & Use It Multiple TimesDuplication of IT Systems Will No Longer Be Funded
MEDICAID & CHIP ELIGIBILITY, ENROLLMENT, EDUCATION & ENGAGEMENT POLICY & HIT: SERVICE DELIVERY & PAYMENT
TRANSFORMATIONTriple Aim: Better Care, Better Health, Lower Costs
• Medical Home Pilots -Accountable Care Plans: how do they link for eligibility and enrollment?
• Integration:– Physical and Behavioral Health– Integration Public-Private: Premium Based Subsidies– Integration Medicare-Medicaid: Standardized Assessment, Extensive
Data Analysis & Sharing, Financial Incentives for Quality
• Reimbursement Reforms: Primary Care Payments, Access
• Return on Investment Value of Investment 8Design for Future – Not for Today
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ELIGIBILITY/DEMOGRAPHICS, EDUCATION & ENGAGEMENT AS COMPONENT OF HEALTH
INFORMATION EXCHANGE• EHR: Electronic Health Record (across health organizations)
• HIE: Health Information Exchange (across providers, purchasers, regulators) & Health Insurance Exchange (health benefit exchange)
• Health IT: Health Information Technology (EHRs, HIEs, Registries, Tele-health)
• PHR: Personal Health Record
• COWS: Computer on Wheels (hospitals and clinics)• MU: Meaningful Use – Access to personal clinical information
e-Everything: Giving Up the Paper & The Way We Work Paper Based –
Work Arounds Don’t Need to Move Forward
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HEALTH INFORMATION EXCHANGE AS INFRASTRUCTURE FOR ELIGIBILITY
• Identity Management: – Master Patient Index– Provider Directory
• Secure Messaging
• HIE “Gateways”
• Privacy and Security
• National Standards: Terminology & Approach (Medicare, SSA, IRS)
• Project Management: Accountability and Singular/Aligned Structure
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ELIGIBILITY AS CORE TO EVOLVING HEALTH INSURANCE EXCHANGE
•Authority: need to see State Authority
•Implementation is really July 2013• •Single Integrate Pathway • Easy for Individuals to Explore Health Coverage Options• Individuals can Quickly and Accurately Enroll into Coverage
• Financing Plan: matching governance• Exchange: 100% FFP for IT Infrastructure for
Insurance for those components• Medicaid: 90/10 authority have today
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ELIGIBILITY AS CORE TO EVOLVING HEALTH INSURANCE EXCHANGE
•Common systems and High Levels of Integration: No “Gap” in Coverage: Governance and Accounting
• Non-Dual Disabled May Not Be “Coded” Disabled
Medicaid138% FPL
Basic Health Plan139% to 200%
Tax Subsidy138% to 400%
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MITA: MEDICAID INFORMATION TECHNOLOGYArchitecture & Framework
• Member Management: Eligibility, Enrollment & Outreach & Consumer Communication & Information, Grievance/Appeal
• Provider Management: Enrollment, Communication & Information &
Grievance/Appeal
• Operations Management: Authorization, Claims Mgmt & Payment
• Care Management: Individual & Population
• Program Integrity Management: Requirements & Management
• Contractor Management: Health Services & Administration
• Program Management: Drug Formulary, Benefit Package, Goals, Objectives, Policy, Budget, SPAs, FFP, MMIS, I-APD
• Business Relationships Management: Establish, Manage & TerminateCost Allocation Plan , SMHP
ADDITIONAL ACA IMPACTS
New Requirements on States & Providers
•Administrative Simplification & Program Integrity Provisions•Interfaces with HIEs (Information & Insurance)
Medicaid/Medicare Changes• Provider Rates-Incentives-Penalties• Payment Methodologies•Service Delivery Innovations
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Increased Volume • Transactions• Providers
New Aged & Disabled Consumer Benefits & State Opportunities
•Dependent Adults up to 26 on Parent’s Plans even Married (2011)•No Pre-existing Condition Exclusions for Children (2011)• Prohibitions against Lifetime Benefit Caps & Rescissions (2011)•Preventive Care Coverage & No Cost-Sharing Medicare (2011)
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IMPLEMENTATIONConcepts Transformed Into Actions
• Financing Strategies:– Services and State Administration State Strategies– Cost Allocation
• Responsibility to Validate Value - Metrics for Success:– MU Measures for Ambulatory and Hospital– Clinical and Outcomes: Success Rate in Treatment– Productivity: Absenteeism and Presenteeism– Consumer Experience: CAHPS
• Cross Initiative Implementation Strategies:No Current IT Infrastructure Supports the Needs of Tomorrow:
What has to be done 2014 – What Gets Phased In
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Category DescriptionInterface State interfaces of a Health Information Exchange (HIE)--
(e.g., labs, registries, PH databases, emergency preparedness, etc.) needed for providers to reach MU.
Data Mgmt
Creation/enhancement of a Data Warehouse/Repository (cost allocated), for evaluation and data analysis for federal and state reporting, as well as external and internal management that complies with HIPPA Privacy and Security requirements related to authorization to data, access to data types and functions, role permissions, ability to further designate third parties, and security to prevent breaches.
Identity Mgmt
Development of a Master Patient Index (cost allocated).
HIT POTENTIALLY ELIGIBLE FOR MEDICAID FUNDING FOR CROSS INITIATIVE IMPLEMENTATION
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Category DescriptionProvider
MgmtProvider Help-Line/Dedicated E-mail Address/Call Center (hardware, software, staffing)
Operations Mgmt
System associated with the collection and verification of MU data from providers’ EHRs and Data Analysis, Oversight and Auditing and Reporting on EHR Adoption and MU as well as regular Medicaid oversight activities
Program Integrity
System and resource costs to develop, capture, and audit provider attestations for MU, including e-signature. Systems related to fraud and abuse prevention activities, such as interfaces with the Board of Medical Quality Assurance (BMQA) for licensing status.
HIT POTENTIALLY ELIGIBLE FOR MEDICAID FUNDING FOR CROSS INITIATIVE IMPLEMENTATION
Initiative HIE (Information)
HIE (Insurance) Meaningful Use
Other HC Reform (adjustments to
private insurance changes/Medicare-
accountable plans/payment
reform)
Medicaid Eligibility
Expansions
e-signature Provider & consumer
Consumer, provider, insurer
provider Consumer, provider, consumer
Secure single-entry web portal / external “face
Provider & consumer
Consumer, provider, insurer
Provider ???? Provider & consumer
Security to meet National Requirements
(authorization, authentication, access, auditing, encryption
clinical and administrative
data
Administrative data
Clinical and administrati
ve data
Administrative, potentially clinical data
(payment reform both)
Administrative
Privacy (HIPAA/Medicaid) clinical and administrative
data
Administrative data
Clinical and administrati
ve data
Administrative, potentially clinical data
(payment reform both)
Administrative
Identify Mgmt (patient, provider, entity)
Provider/entity Consumer, provider, entity
provider Variable consumer
Data Repository Metadata Actual data
Potentially yes Eventually Potentially Potentially
Intake yes yesReporting (federal & state for
financial & quality, Yes yes yes Potentially yes
Review: State HIT Infrastructure Needs Across Health Care Reform Initiatives
State HIT Infrastructure Needs Across Health Care Reform Initiatives
Initiative HIE (Information) HIE (Insurance) Meaningful Use
Other HC Reform
Medicaid Eligibility
Expansions
Rules Engine & Business Intelligence
Potentially yes yes Depends on initiative
yes
Interfaces with federal agencies
Eventually – VA facilities, DoD
facilities
Yes – eligibility verifications IRS,
etc.
NLR Depends on initiative
Yes –income IRS, citizenship
SSA, etc.
Interfaces with other state
agencies
State as provider (PH, MH, State
hospitals), State as Regulator,
State as Purchaser (State
Employees/ Medicaid)
Exchange – Medicaid
TBD Exchange/Medicaid
Aligning with National Standards
Yes- opportunity Yes – mandate
Yes-mandate
TBD Yes-mandate
ICD-10 and 5010 yes Overlaps/yes
TBD
SOA Yes Yes yes yes yes
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OPPORTUNITIES & RESPONSIBILITIESConcerns - Context – Concepts - Completion