MEDICAID IT FUNDING OPPORTUNITIES & RESPONSIBILITIES ELIGIBILITY, ENROLLMENT, EDUCATION & ENGAGEMENT

1. 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

2. 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

3. 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

4. Decision Making Is Even Tougher & Coverage Service Delivery Payment Eligibility When the State Has Little Money

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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%

13. 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

14. 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)

15. 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

16. HIT POTENTIALLY ELIGIBLE FOR MEDICAID FUNDING FOR CROSS INITIATIVE IMPLEMENTATION

17. HIT POTENTIALLY ELIGIBLE FOR MEDICAID FUNDING FOR • CROSS INITIATIVE IMPLEMENTATION

18. Review: State HIT Infrastructure Needs Across Health Care Reform Initiatives

19. State HIT Infrastructure Needs Across Health Care Reform Initiatives

20. OPPORTUNITIES & RESPONSIBILITIESConcerns - Context – Concepts - Completion