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MEDICAID IT FUNDING OPPORTUNITIES & RESPONSIBILITIES ELIGIBILITY, ENROLLMENT, EDUCATION & ENGAGEMENT - PowerPoint PPT Presentation


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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

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Medicaid it funding opportunities responsibilities eligibility enrollment education engagement

MEDICAID IT FUNDING OPPORTUNITIES & RESPONSIBILITIESELIGIBILITY, 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 MacTaggart

May 19, 12:30 – 1:30


Medicaid opportunities responsibilities concerns context concepts completion
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


Medicaid opportunities responsibilities concerns context concepts completion1
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


Decision Making

Is Even Tougher

& Coverage

Service Delivery

Payment

Eligibility

When the State

Has Little Money


Multiple alabama health it activities framing the need framing the benefit
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


Consumer: Eligibility

MedicaidAgency

Oversight on right care at right time

at appropriate price from appropriate provider

What provider/service delivery

option will provide the care?

Delivery Model

Receive Service

Service Paid

Where Provided

Financial Oversight

Quality Oversight*

Program Mgmt/

Gov’t oversight

  • MCO

  • Partial MCO

  • PCCM

  • Provider within PCCM

  • Care Mgmt

  • PA

  • Pre-cert

  • Authorization for

  • treatment

  • Service Provider

  • Where provided

  • Drug Formulary

  • Rate methodology

  • RBRVS, DRG, etc.

  • Claim Paid

  • Person responsible

  • Pay for Performance

  • Home

  • Institution

    • Hospital

    • NH

    • ICF-MR

    • Group Home

  • Financial Mgmt

  • Transaction

  • Financial Reporting

  • Audits

  • Premium Invoice

  • TPL

  • Consumer Information strategies

  • Provider information strategies

  • F&A/Program integrity

  • Performance measures

  • Information Mgmt

  • Performance Mgmt

  • Grievance and appeals

  • SPA/Waivers

  • Adm. Policies

  • Budget Accounting

  • Reporting

  • Contract Mgmt

  • Feedback

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?

Financial (Hierarchical)

Functional

Categorical*

Coverage

Limitations* (*Individual and Family)

  • Medicaid

  • ¤

  • SCHIP

  • ¤

  • PH Funded

  • ¤

  • MH/SA Grants

  • ¤

  • State only funded programs

  • ¤

  • Not Eligible

  • ADLS

  • Diagnostic/Clinical

  • Pre-Adm NH

  • Screening

  • Programmatic

  • Basic

  • *Temporary

  • SPA Services

  • HCBW Services

  • Basic Services

  • Preventative Services

  • LTC Institution

    • ICF-MR

    • NH

    • Psych-Group

    • Home

  • Home Care

  • Alternative 1115 Waiver

  • EPSDT

  • Administrative

  • Co-pays

  • Cost sharing

  • Caps/Limitations

  • Individual and Family

  • Plan of Care

  • Treatment Plan

Feedback

Consumer Seeks Eligibility

Coverage/Benefits Determined

Feedback

It’s Complicated Even When It’s Automated


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 Times

  • Duplication 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

Design for Future – Not for Today


Eligibility demographics education engagement as component of health information exchange
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


Health information exchange as infrastructure for eligibility
HEALTH INFORMATION EXCHANGE COMPONENT OF HEALTH INFORMATION EXCHANGEAS 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


ELIGIBILITY AS CORE TO EVOLVING HEALTH INSURANCE EXCHANGE COMPONENT OF HEALTH INFORMATION 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


ELIGIBILITY AS CORE TO EVOLVING HEALTH INSURANCE EXCHANGE COMPONENT OF HEALTH INFORMATION EXCHANGE

  • Common systems and High Levels of Integration: No “Gap” in Coverage: Governance and Accounting

  • Non-Dual Disabled May Not Be “Coded” Disabled

Medicaid

138% FPL

Basic Health Plan

139% to 200%

Tax Subsidy

138% to 400%


Mita medicaid information technology architecture framework
MITA: MEDICAID INFORMATION TECHNOLOGY COMPONENT OF HEALTH INFORMATION EXCHANGEArchitecture & 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 & Terminate

Cost Allocation Plan , SMHP


  • Increased Volume

  • Transactions

  • Providers

  • Medicaid/Medicare Changes

  • Provider Rates-Incentives-Penalties

  • Payment Methodologies

  • Service Delivery Innovations

  • New Requirements on States & Providers

  • Administrative Simplification & Program Integrity Provisions

  • Interfaces with HIEs (Information & Insurance)

  • 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)


Implementation concepts transformed into actions
IMPLEMENTATION COMPONENT OF HEALTH INFORMATION EXCHANGEConcepts 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


HIT POTENTIALLY COMPONENT OF HEALTH INFORMATION EXCHANGE ELIGIBLE FOR MEDICAID FUNDING FOR

CROSS INITIATIVE IMPLEMENTATION




State Reform InitiativesHIT Infrastructure Needs Across Health Care Reform Initiatives


OPPORTUNITIES Reform Initiatives& RESPONSIBILITIESConcerns - Context – Concepts - Completion


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