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Department of Human Services Division of Medical Services Eugene Gessow Director.

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Presentation on theme: "Department of Human Services Division of Medical Services Eugene Gessow Director."— Presentation transcript:

1 Department of Human Services Division of Medical Services Eugene Gessow Director

2 ARKANSAS MEDICAID ENTERPRISE PAGE 1 The Arkansas Medicaid Enterprise (AME) will be: all of the people, processes, hardware, software, policies and procedures that are necessary to run a nimble, effective, efficient, disciplined Medicaid program in a time of change and with limited resources. Arkansas must change the way it manages the Medicaid program, and Medicaid, as the state’s largest payer, must be a leader in “bending the curve” in reducing health care costs. The business processes will be designed to accommodate the information needs and business methods of today and tomorrow, will be fully electronic, and will be able to obtain, process, and exchange information in real time.

3 ARKANSAS MEDICAID ENTERPRISE PAGE 2 The Medicaid Management Information System (MMIS) will be replaced with an array of commercial-off-the-shelf (COTS) products that are selected as the “best of breed” to meet the information management requirements for both the transactional processing, to make payments and support eligibility, and the analytical needs for program management, outcomes analysis, predictive modeling, and detecting fraud and abuse. The MMIS Replacement will be designed to interoperate and exchange both administrative and clinical data through the Arkansas Health Information Exchange (HIE). Where practical, HIE and MMIS will adopt a common infrastructure and technical governance.

4 ARKANSAS MEDICAID ENTERPRISE PAGE 3 Providers will have greater access to current and historical information about members to improve quality, efficiency, and effectiveness of care, coordinate care, and perform targeted case management. Providers will be expected to use information to effectively manage care and will be able to obtain information as necessary to facilitate care management. Members will have greater access to information, which will help them find providers, improve individual health practices, and become engaged in their health care.

5 ARKANSAS MEDICAID ENTERPRISE PAGE 4 The AME will enable DMS to establish enterprise-wide goals and objectives with the means to measure Medicaid program performance metrics and contractor performance requirements. The AME will strengthen direct lines of authority and accountability by Medicaid staff for the operation and direction of the Medicaid Program.

6 CMS PROPOSED RULE FOR ENHANCED FFP CMS-2346-P PAGE 5 CMS has recently issued a proposed rule for Medicaid enterprises “We are proposing to define MITA at §433.111(c) in this rule and we propose to build on the work of MITA by codifying that enhanced FFP (either at the 90 percent rate for design, development, installation or enhancement; or at the 75 percent rate for maintenance and operations) is only available when certain standards and conditions are met. Specifically, we articulate a set of standards and conditions that States must commit to in order to receive enhanced FFP:”

7 CMS PROPOSED RULE FOR MEDICAID ENTERPRISE PAGE 6 1.Use of a modular, flexible approach to systems development, including the use of open interfaces and exposed application programming interfaces; the separation of business rules from core programming; and the availability of business rules in both human and machine readable formats. 2.Align to and advance increasingly in Medicaid Information Technology Architecture (MITA) maturity for business, architecture, and data. 3.Ensure alignment with, and incorporation of, industry standards 4.Promote sharing, leverage, and reuse of Medicaid technologies and systems within and among States.

8 CMS PROPOSED RULE FOR MEDICAID ENTERPRISE PAGE 7 5.Support accurate and timely processing of claims (including claims of eligibility), adjudications, and effective communications with providers, beneficiaries, and the public. 6. Produce transaction data, reports, and performance information that would contribute to program evaluation, continuous improvement in business operations, and transparency and accountability. 7.Ensure seamless coordination and integration with the Exchange (whether run by the State or Federal government), and allow interoperability with health information exchanges, public health agencies, human services programs, and community organizations providing outreach and enrollment assistance services.

9 Functional Overview of System and Business Services System Integrator Contract Management Dashboard Enterprise Data Model Enterprise Service Bus / Technical Services / Workflow Management / Document Management/ Rules Engine Business Offices Member Management Provider Management Rates and Costs Financial Management Program Integrity Audits Revenue Collection & TPL Operations System Support Claims Receipt, Adjudication, Payment & Adjustments Medical Management Authorize Service Care Management; State Data Center Telephone System Local LAN PC / Desktop Support Health Information Exchange (HIE) MMIS Operations System Modules MemberProvider Authorize Services and Treatment Plan Core Claims; Other Payments Pharmacy POS and PBM Program Integrity Fraud & Abuse Detection Master Client Index TPL / COB Provider Services Web Portal DSS / Data Warehouse Case/Diag. Mgm’t Registry Shared Services Accounting Services

10 HOUSE AND SENATE INTERIM COMMITTEES ON PUBLIC HEALTH Report on the Medicaid Management Information System (MMIS) PAGE 9 Questions

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