Department of Human ServicesDivision of Medical Services

Eugene GessowDirector

ARKANSAS MEDICAID ENTERPRISE PAGE 1

• The Arkansas Medicaid Enterprise (AME) will be: all of the people, processes, hardware, software, policies and procedures that are necessary to run a nimble, effective, efficient, disciplined Medicaid program in a time of change and with limited resources.

• Arkansas must change the way it manages the Medicaid program, and

Medicaid, as the state’s largest payer, must be a leader in “bending the curve” in reducing health care costs.

• The business processes will be designed to accommodate the information

needs and business methods of today and tomorrow, will be fully electronic, and will be able to obtain, process, and exchange information in real time.

ARKANSAS MEDICAID ENTERPRISE PAGE 2

• The Medicaid Management Information System (MMIS) will be replaced with an array of commercial-off-the-shelf (COTS) products that are selected as the “best of breed” to meet the information management requirements for both the transactional processing, to make payments and support eligibility, and the analytical needs for program management, outcomes analysis, predictive modeling, and detecting fraud and abuse.

• The MMIS Replacement will be designed to interoperate and exchange

both administrative and clinical data through the Arkansas Health Information Exchange (HIE). Where practical, HIE and MMIS will adopt a common infrastructure and technical governance.

ARKANSAS MEDICAID ENTERPRISE PAGE 3

• Providers will have greater access to current and historical information about members to improve quality, efficiency, and effectiveness of care, coordinate care, and perform targeted case management.

• Providers will be expected to use information to effectively manage care

and will be able to obtain information as necessary to facilitate care management.

• Members will have greater access to information, which will help them

find providers, improve individual health practices, and become engaged in their health care.

ARKANSAS MEDICAID ENTERPRISE PAGE 4

• The AME will enable DMS to establish enterprise-wide goals and objectives with the means to measure Medicaid program performance metrics and contractor performance requirements.

• The AME will strengthen direct lines of authority and accountability by

Medicaid staff for the operation and direction of the Medicaid Program.

CMS PROPOSED RULE FOR ENHANCED FFPCMS-2346-P

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CMS has recently issued a proposed rule for Medicaid enterprises

“We are proposing to define MITA at §433.111(c) in this rule and we propose to build on the work of MITA by codifying that enhanced FFP (either at the 90 percent rate for design, development, installation or enhancement; or at the 75 percent rate for maintenance and operations) is only available when certain standards and conditions are met.

Specifically, we articulate a set of standards and conditions that States must commit to in order to receive enhanced FFP:”

CMS PROPOSED RULE FOR MEDICAID ENTERPRISE PAGE 6

1. Use of a modular, flexible approach to systems development, including the use of open interfaces and exposed application programming interfaces; the separation of business rules from core programming; and the availability of business rules in both human and machine readable formats.

2. Align to and advance increasingly in Medicaid Information Technology Architecture (MITA) maturity for business, architecture, and data.

3. Ensure alignment with, and incorporation of, industry standards

4. Promote sharing, leverage, and reuse of Medicaid technologies and systems within and among States.

CMS PROPOSED RULE FOR MEDICAID ENTERPRISE PAGE 7

5. Support accurate and timely processing of claims (including claims of eligibility), adjudications, and effective communications with providers, beneficiaries, and the public.

6. Produce transaction data, reports, and performance information that

would contribute to program evaluation, continuous improvement in business operations, and transparency and accountability.

7. Ensure seamless coordination and integration with the Exchange

(whether run by the State or Federal government), and allow interoperability with health information exchanges, public health agencies, human services programs, and community organizations providing outreach and enrollment assistance services.

Functional Overview of System and Business Services

System Integrator Contract Management Dashboard

Enterprise Data Model

Enterprise Service Bus / Technical Services / Workflow Management / Document Management/ Rules Engine

Business Offices

Member Management

Provider Management

Rates and Costs

Financial Management

Program IntegrityAudits

Revenue Collection

& TPL Operations

System Support

ClaimsReceipt,

Adjudication, Payment &

Adjustments

Medical

Management Authorize Service

Care Management;

State Data Center

Telephone System

Local LANPC / Desktop Support

Health InformationExchange (HIE)

MMIS Operations

SystemModules Member Provider

Authorize Services and

Treatment Plan

Core Claims; Other Payments

Pharmacy POS and PBM

Program Integrity Fraud & Abuse

Detection

Master Client Index

TPL / COB

Provider Services

Web Portal

DSS / Data Warehouse

Case/Diag. Mgm’t

Registry

Shared Services

Accounting Services

HOUSE AND SENATE INTERIM COMMITTEES ON PUBLIC HEALTHReport on the Medicaid Management Information System (MMIS)

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Questions