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Kansas Medical Eligibility Determination System KMED

Introduction. BackgroundOpportunityBusiness Problem and CausesSolutionSharingQuestions. . 8/16/2011. 2. Background. K-MED started over 2 years ago as a grant request/award.1st year

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Kansas Medical Eligibility Determination System KMED

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    1. Kansas Medical Eligibility Determination System (KMED) Darin D. Bodenhamer, MMIS Director, Medicaid/CHIP Eligibility Kansas Department of Health and Environment Division of Health Care Finance

    2. Introduction Background Opportunity Business Problem and Causes Solution Sharing Questions 8/16/2011 2

    3. Background K-MED started over 2 years ago as a grant request/award. 1st year—built team, completed and released RFP. 2nd year—evaluated responses, awarded contract. 3rd—just getting underway—execution. In the process ACA passed. Administration transition—KHPA rolled into KDHE. Will accommodate other human services. 8/16/2011 3

    4. Opportunity CMS/CMCS enhanced funding regs 90/10 available through 2015 75/25 for ongoing ops Must meet certain conditions, e.g., integration with HIX CMS/CCIIO grants and awards Planning grant Early Innovator Award Establishment grants Late breaking news—SMD letter on cost allocation released 8/10/2011 Temporary waiver of OMB regulations requiring cost allocation across all programs Exchange/CHIP/Medicaid can pay for base system Other federal programs pay for incremental costs to add those programs Federal commitment to quick turnaround 8/16/2011 4

    5. Business Problem It takes too long to process applications. Increase in applications results in backlog and poor customer service. Policy changes take a long time to implement. Information to support policy and process decisions difficult or impossible to obtain. Customers frustrated by cumbersome processes. Customers don’t have ready access to information about their benefits. Error rates too high. Health care delivery for Medicaid/CHIP fragmented. 8/16/2011 5

    6. Business Problem (cont.) Impossible to implement and apply policies consistently. Policy subject to each person’s interpretation and willingness to apply it. Manual processes result in keying errors. Impossible to measure impact of policies and whether desired outcomes are reached. Siloed usage—no reuse potential. No additional capacity for volumes to triple or quadruple by 2014. Large investment in staff training—a long time prior to having a productive employee. 8/16/2011 6

    7. Causes of Problems Manual, antiquated processes. Everything paper based. Business rules must reside in people’s heads. What’s not hard coded is not coded at all. What is hard coded is largely out of date and requires work-arounds. 24 year old eligibility system is coded in antiquated languages. Difficult to change code. Becoming more difficult to find resources who know how to change the system. 8/16/2011 7

    8. Causes of Problems (cont.) Staffing levels have not increased at the rate of program growth. Current eligibility system does not capture the information needed for decision support. Fragmented technology architecture—information resides in multiple systems. 8/16/2011 8

    9. Solution New eligibility system. Web based. Rules engine. Business Process Management tool. Master Data Management. Business Intelligence Services (includes data warehouse). Java based. Relational database (sounds odd, but current system is not). Electronic notification capabilities. Integration with imaging and content management system. Seamless determination of eligibility for all publicly funded or subsidized medical coverage. 8/16/2011 9

    10. Solution (cont.) Online portal. Online application, feeds directly into eligibility and allows for real time adjudication of eligibility. Online presumptive eligibility tool. Customer self-service. Reporting changes. Completing application forms and reviews. Looking up information. Integration with claims and assignment information. 8/16/2011 10

    11. Solution (cont.) Service Oriented Architecture Allows for data sharing and reuse across multiple agencies. Will become the beneficiary component to MMIS. Will house all MEDICAID/CHIP beneficiary information instead of being spread across multiple systems. Potential reuse for HIT/HIE. Integration with HIX process. 8/16/2011 11

    12. Conceptual SOA Platform 8/16/2011 12

    13. Changing Needs 8/16/2011 13

    14. Horizontal and Vertical Integration 8/16/2011 14

    15. Future Possibilities— Sharing Within the State 8/16/2011 15

    16. Sharing With Other States RFP and supporting documents available at: http://www.kdheks.gov/hcf/healthwave/Procurements.html Artifacts will be available by request and other means. Potential transfer solution. Kansas may offer as a Software as a Service (SaaS) solution. 8/16/2011 16

    17. How Would SaaS Work? 8/16/2011 17

    18. Configuration 8/16/2011 18

    19. Pros/Cons to SaaS Pros Quicker implementation Quicker procurement Shared costs More standardized and reusability across states More delivered functionality—focus only on the configurable items More purchasing/negotiating power Cons Less flexible than local ownership More complicated vendor management and governance Potential riskier implementation 8/16/2011 19

    20. Questions 8/16/2011 20

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