Change Request:
Medicaid Management Information System
Enhancements Project 2012 - 2014
Presented to
Project Certification Committee
December 19, 2012
Presenters:
Mark Pitcock, Deputy Director, HSD/MAD
Linda Gonzales, Systems Bureau Chief, HSD/MAD
Wayne Pendley, Medicaid IT Project Manager, HSD/ITD
1
Background
• Medicaid State Fiscal Agent:
– Supports payment and operational services for
Medical Assistance Division
– Services range from direct service to hosting OmniCaid
payment application
• State Fiscal Agent contract provides many services
and functions beyond IT operations
– Enroll providers, process claims, enroll Medicaid recipients
in managed care plans, distribute forms and publications,
etc..
2
CMS Approvals for NM Medicaid
• CMS requires HSD to periodically open State Fiscal Agent contract to bid
• CMS approved funds to support Four Phases with federal match rate:
Federal
Match Rate
Purpose
75%
Support costs related to NM staff who will support
procurement.
75%
Support costs related to transition to new contract
operations (incumbent and non-incumbent
bidders were allowed to propose transition
activities and costs).
Enhancement
Phase
90%
Support costs related to remedy current system
issues or to improve functionality related to
upcoming health reform requirements.
Operations Phase
75%
Support costs related to Medicaid operational and
direct services for 7 years.
Category
Procurement
Phase
Transition Phase
3
2010 RFP Objectives
• Open State Fiscal Agent services/professional
services to solicitation
• Organize successful transition to new
State Fiscal Agent contract including:
– Transition of Medicaid Management Information
System (MMIS)
– Transition of MMIS Data Warehouse
– Transition to supporting peripheral
systems/professional services (Pharmacy, etc.)
• Successful implementation of
MMIS enhancements.
4
Procurement/Project Schedule
Period
Event
April 2010
PCC certified Project Initiation phase
July 2010
CMS approved estimated project funding
January 2011
RFP issued
August 2011
PCC certified Planning phase + $1.5M
RFP Evaluation Team selected Contractor
November 2011
HSD submitted APD update and contract to CMS
February 2012
PCC certified Implementation phase + $1.3M
March 2012
Contract signed; Transition and Enhancement work started
July 2012
TARC review of MMIS Enhancements approved
December 2012
Obtain PCC approval of remaining project budget + $10.7M
January 2013
New Contract Operations Begin
October 2014
Enhancement Phase Completed
March 2015
Project Closeout
December 2016
End of Base Contract
5
Procurement/Project Organization
Overall organization based on internal HSD staff with coordinating input from other agencies
Julie Weinberg
Executive Sponsor
PROJECT STEERING COMMITTEE
Mark Pitcock
Business Owner
HSD
Sean Pearson
Technical Sponsor
HSD CIO
Contractor Executive
Account Manager
Wayne Pendley
IT Project Manager
HSD
Roberta Duran
Business Owner
DOH
Robert Stevens
Business Owner
HSD
Contractor
Transition Phase
Manager
6
Medicaid / IT Costs
• CMS approved costs related to Medicaid and IT:
– Medicaid includes administrative and program
– IT includes system enhancements
• CMS approvals for Transition, Enhancements and Operations:
–
–
–
–
Transition Work
Enhancements
IV&V Enhancements
Medicaid Operations
$
623 K
$ 12,062 K
$
792 K
$ 95,404 K
• This PCC Project includes all costs except Operations.
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Enhancements
• Enhancements cover changes to meet federal
mandates, increase efficiency, and improve service to
clients and providers
• Implementation cost of enhancements approved by
CMS is matched with 90 percent federal funds
• RFP included 7 required and 6 optional
enhancements
• Based on contract negotiations, HSD purchased
11 enhancements in the March 2012 contract
• Two CMS-required “HIPAA Operating Rules” plus one
for Centennial Care brings enhancement total to 14.
8
Disposition of RFP-Required Enhancements
Enhancement
ICD-10
Remediation
Disposition
Purchased
Purpose
Meet national deadline to convert to new ICD-10 diagnosis
and surgical procedure codes
MARS Replacement Deleted
Replace the legacy Management and Administrative
Reporting System with a data warehouse-based system
HIPAA 270/271
Purchased
Implement eligibility verification inquiry and response
transactions to comply with HIPAA standards
HIPAA 276/277
Purchased
Implement claim status inquiry and response transactions to
comply with HIPAA standards
HIPAA 820
Purchased
HIPAA 834
Purchased
Client Eligibility
Span Dates on the
Web Portal
Incorporated into
new replacement
Web Portal
enhancement
Implement premium payment transactions for Managed
Care Organizations to comply with HIPAA standards
Implement benefit enrollment and maintenance
transactions for Managed Care Organizations to comply with
HIPAA standards
Allow providers to inquire on a span of dates when checking
client eligibility instead of a single date of service
9
Disposition of RFP-Defined
Optional Enhancements
Enhancement
Web-based Direct Data
Entry
Web-based Provider
Enrollment
Client Web Portal
Electronic Billing of Other
Carriers
Disposition
Incorporated in new
Web portal
enhancement
Incorporated in new
Web portal
enhancement
Incorporated in new
Web portal
enhancement
Purpose
Allow providers to submit claims electronically via
the Web portal
Allow providers to submit enrollment applications
via the Web portal
Give clients new self-service options via a Web
portal
Purchased
Replace current paper billing of other insurance
carriers with electronic billing
Automated Processing and
Posting of Third Party
Liability Payments
Deleted
Accept electronic payment transactions from
insurance carriers and use the information to post
payments and adjust claims
NCPDP 3.0
Optional
Implement the new National Council of
Prescription Drug Programs (NCPDP) subrogation
10
Additional Enhancements
Enhancement
Disposition
Purpose
New Web Portal
Purchased
Replace the current Web portal with a new portal that
meets the RFP’s enhancement requirements (client
eligibility span dates, client-facing capabilities, webbased provider enrollment, and direct data entry of
claims)
New Fraud and Abuse
Detection System (FADS)
Purchased
Replace the current FADS with a new system with
enhanced case management and tracking capability
New Pharmacy Benefits
Management System (PBMS)
Purchased
Replace the current PBMS with a new system platform
for ease of maintenance and reduced ongoing costs
Add Workflow Component
to Electronic Document
Management System
(EDMS)
Purchased
The Workflow component will automate many
document handling processes, improve the timeliness
and quality of services, and provide enhanced tracking
and reporting for fiscal agent activities
HIPAA Operating Rules
(HOpR)
ACA / CMS-required
The Affordable Care Act of 2010 (ACA) requires
operating rules to increase electronic transaction
efficiency
• For eligibility and claim status by 1/1/2013
• For EFT, payment & remittance advice by 1/1/2014
ACA/Centennial Care
CMS Waiver now
under review
Address ACA eligibility requirements and simplify the
Medicaid program with a single CMS waiver that
contracts managed care for the full range of health care.
11
Changes Since Last PCC Certification
• CMS delayed the mandated ICD-10 deadline by one year –
until October 1, 2014
• HIPAA Operating Rules required for eligibility and claim status
by January 1, 2013
– Penalties of up to $1.5 million for non-compliance
• HIPAA Operating Rules required for Electronic Funds Transfer
and Electronic Remittance Advice (EFT/ERA) by January 1,
2014
– Requires an assessment of current MMIS and translator capabilities
• Centennial Care DDI work estimated at $ 997 K
• PPACA and Centennial Care require major changes
in the MMIS
• Today’s funding request accounts for these changes
12
Final Enhancement List
•
•
•
•
•
•
•
•
•
ICD-10 Remediation
HIPAA 270/271, 276/277, 820, & 834 (four enhancements)
Electronic Billing of Other Carriers
New Web Portal
New Fraud and Abuse Detection System
New Pharmacy Benefits Management System
Add Workflow Component to EDMS
NCPDP 3.0 Subrogation (optional)
HIPAA Operating Rules (Phase 1 + Phase 2 Assessment)
• Centennial Care DDI
13
Key Deliverables for Each Enhancement
•
•
•
•
Requirements Analysis Document
Detailed Design Document
Acceptance Test Results
Implementation
These Deliverables also represent payment
milestones for most of the 14 enhancements.
14
Procurement/Project Funding
•
•
•
•
11 MMIS Enhancements in March 2012 contract
2 added for CMS-required HIPPA Operating Rules
1 added for Centennial Care
These 3 new enhancements require a 3.3% increase in APDU budget ($3.5M over $106.6M approved)
Area
Activity
Initiation
o Acquire state and
federal approvals.
o Issue RFP.
o Review Proposals.
Planning
o Select Winning
Proposal.
o Initiate Contracting
Process.
o Obtain State and
Federal Approvals.
Implementation and Closeout
o
o
o
o
o
Sign contract.
Initiate transition activities.
Initiate project activities.
Perform IV&V on projects.
Finalize transition to new contract.
Contracted
Services
$0
$0
$1.5 M approved @ Planning Phase
$1.3 M approved @ Impl. Phase
$10,677,226 (current request)
HSD
Personnel
$0
$0
$0
15
Summary
• HSD requests renaming of this HSD project from
“MMIS Re-Bid RFP” to “MMIS Enhancements”
to better communicate the remaining work
• Current baseline costs for Contract Transition + MMIS
Enhancements + IV&V total: $13,477,226
• PCC has previously certified $2.8 M for requirements
analysis, IV&V and contract transition work.
• HSD requests certification of remaining
$10,677,226 to complete DDI work on these
14 MMIS Enhancements.
16