Medicaid Information Technology Architecture (MITA) Where Louisiana Medicaid is Today and Where it Will To Be in the Future April 17, 2012

2 What is MITA (MITA) is an initiative of the Center for Medicaid & State Operations (CMSO). MITA is intended to foster integrated business and IT transformation across the Medicaid enterprise to improve the administration of the Medicaid program. The MITA Initiative is a national framework to support improved systems development and health care management for the Medicaid enterprise.

3 Where MITA can be found  Navigate to:  Click on “Medicaid & CHIP Program Information” tab  Look under “Medicaid Information by Topic”  Click on “Data & Systems”  Go to “Medicaid Information Technology Architecture”  Go to “MITA 3.0 Downloads” Direct Link to MITA

4 Goals of MITA Develop seamless and integrated systems that effectively communicate. Achieve Common Medicaid goals through interoperability and shared standards. Promote an environment that supports flexibility, adaptability, and rapid response to changes in programs and technology. Promote an enterprise view that supports enabling technologies aligned with Medicaid business processes and technologies. Provide data that is timely, accurate, usable, and easily accessible to support analysis and decision making for healthcare management and program administration. Provide performance measurement for accountability and planning. Coordinate with public health and other partners to integrate health outcomes within the Medicaid Community.

5 LA Medicaid Goals The goals of the Bureau of Health Services Financing are to: Improve health outcomes by emphasizing primary care and reducing the number of uninsured persons in Louisiana Expand existing and develop additional community-based services as an alternative to institutional care Ensure cost effectiveness in the delivery of health care services by using efficient management practices and maximizing revenue opportunities Assure the integrity and accountability of the health care delivery system in an effort to promote the health and safety of Louisiana citizens Implement measures that will constrain the growth in Medicaid expenditures while improving services to secure alternative sources of funding for health care in Louisiana Streamline work processes and increase productivity through technology by expanding the utilization of electronic tools for both the providers and the Medicaid Administrative staff

6 Key Concepts of MITA Maturity Model- Describes how Medicaid operations mature over time by defining the characteristics of five levels of improvement. o As-Is= Maturity level of 1, 2-3 years =Maturity level of 2, 5 years =Maturity level of 3, 7-8 years equals maturity level of 4, 10 years = Maturity level of 5 Business Process Model-defines a set of common business processes used across Medicaid. o Eight Business Areas: Member Management, Provider Management, Contractor Management, Operations Management, Program Management, Care Management, Performance Management, Business Relationship Management, Eligibility & Enrollment Management and Plan Management. Business Capability Matrix- Defines the maturation characteristics for individual business processes. o i.e. Changing rates for providers from a manual process to an automated one State Self Assessment (SS-A)-asks states to compare current business operations, technical capabilities and targeted levels of improvement.

7 Current Louisiana Medicaid Operational Structure

8 Vision of Medicaid Operations Aligned Through MITA

9 Business Process Model Business Relationship Management is a collection of business processes that facilitates the coordination of standards of interoperability. Care Management collects information about the needs of the individual member, plan of treatment, targeted outcomes, and the individual’s health status. Contractor Management business area has a common focus on Medicaid contractors (e.g., managed care, at-risk mental health or dental care, primary care physician), is responsible for contractor data store, and uses business process that have a common purpose (e.g., fiscal agent, enrollment broker, Fraud Enforcement Agency, and third-party recovery).

10 Business Process Model … Eligibility and Enrollment Management is a collection of business processes involved in the activity for determination of eligibility and enrollment for new applicants, redetermination of existing members, enrolling new providers, and revalidation of existing providers. Financial Management is a collection of business processes to support the payment of providers, managed care organizations, other agencies, insurers, Medicare premiums and financial participation. Member Management is a collection of business processes involved in communications between the SMA and the prospective or enrolled member and actions that the agency takes on behalf of the member.

11 Business Process Model … Operations Management is a collection of business processes that manage claims and prepare premium payments. Performance Management is a collection of business processes involved in the assessment of program compliance (e.g., auditing and tracking medical necessity and appropriateness of care, quality of care, patient safety, fraud and abuse, erroneous payments, and administrative anomalies). Plan Management includes strategic planning, policymaking, monitoring, and oversight of business process for the agency.

12 Business Process Model … Provider Management is a collection of business processes that focus on terminating providers, communications with providers, dealing with provider grievances and appeals issues, and performing outreach services to providers.

13 Work Plan

14 Work Plan … Conducting a Gap Analysis between our MITA 2.1 SS-A and the MITA 3.0 SS-A Taking our MITA 2.1 SS-A “To Be” Document Assessing The Level We Want “To Be “ For Each Business Process Based On MITA 3.0 Categories Documenting The Difference In Getting To Where We Want “To Be”

15 Work Plan … Converting our 2.1 “To Be” MITA SS-A to both a 3.0 “As Is” MITA SS-A and a 3.0 “To-Be” MITA SS-A

16 Steps/Actions Needed to Move to the “To Be” 1.Devise a plan to determine what steps are necessary to meet our goals. 2.Set benchmarks/timeline to implement plan.

17 Mapping to the 3.0 MITA Business Process Areas

18 Questions ???