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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

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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 & 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 & 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

  • 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

  • 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 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

  • 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

  • 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 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 & Terminate

Cost Allocation Plan , SMHP


  • ADDITIONAL ACA IMPACTS

  • 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)


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


HIT POTENTIALLY ELIGIBLE FOR MEDICAID FUNDING FOR

CROSS INITIATIVE IMPLEMENTATION


  • HIT POTENTIALLY ELIGIBLE FOR MEDICAID FUNDING FOR

  • CROSS INITIATIVE IMPLEMENTATION


Review: State HIT Infrastructure Needs Across Health Care Reform Initiatives


State HIT Infrastructure Needs Across Health Care Reform Initiatives


OPPORTUNITIES & RESPONSIBILITIESConcerns - Context – Concepts - Completion


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