1.Functional Requirements Approach for the Medicaid Management Information System

Template H.1
MMIS Functional System Requirements Approach
Response Template
RFP #03410-143-15
/ Core MMIS
Template H.1 – MMIS Functional Requirements Approach
RFP#: 03410-143-15

Table of Contents

1.1.General Requirements Approach

1.2.Green Mountain Care 2017, Vermont’s Universal, Publicly Financed Health Coverage Model Approach

1.3.Agency of One Requirements Approach

1.4.Member Management Requirements Approach

1.5.Provider Management Requirements Approach...... 9

1.6.Operations Management Requirements Approach

1.7.Financial Management Requirements Approach...... 21

1.8.Data Analytics Requirements Approach...... 30

1.9.Program Integrity Requirements Approach

2.Additional Capabilities Approach

2.1.Interdepartmental Screening Rules Engine Approach

2.2.Consolidated Approval Management System Approach

2.3.Multiple Standards Levels Approach

2.4.Provider Payment Requirements Approach

2.5.Enrollment for Specialty Services Approach

2.6.Budget Reconciliation to Contract Performance Measures Approach

2.7.Holistic AHS and State Information Approach

2.8.Confidential Provider Surveys Approach

2.9.Integrate with Licensing Agencies Approach

2.10.Audit and Process “Incident to” Cases Approach

2.11.Contractor Management Requirements Approach

2.12.IVRS Approach

2.13.Member Benefits Management Approach

3.Statement of Work

3.1.List of Deliverables

3.2.Deliverable Response Template...... 40

4.Functional Requirements Approach Assumptions...... 40

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/ Core MMIS
Template H.1 – MMIS Functional Requirements Approach
RFP#: 03410-143-15

FUNCTIONAL REQUIREMENTS APPROACH FOR THE MEDICAID MANAGEMENT INFORMATION SYSTEM

The Vendor must provide a narrative overview of how the proposed System will meet theMMIS requirements. The following questions pertaining to Functional Requirements are a required portion of the RFP response and will be evaluated by the State of Vermont.

Templates H.2 MMIS Functional Services Requirements and H.3 Contact Center Functional Requirements provide coordinating system and services requirements and should be reviewed and referenced throughout this Template as appropriate.

Instructions: Use these response sections to provide specific details of the proposed approach to meeting the functional requirements in each business process as well as other overarching requested functional capabilities. Responses should, when necessary, reference requirements using the appropriate functional requirement number from Template G.1- Functional System Requirements. Responses in this section must be highly focused on State-specificbusiness processes and requirements and not simply provide generic or marketing descriptions of solution capabilities.

Vendors should indicate how their proposed phased implementation may or may not impact functionality. Additionally, the Vendor should indicate exception handling processes where appropriate and any dependencies on existing systems or components of the new Systemto provide the specified functionality.

1.1.General Requirements Approach

1.1.1.CMS Certification

For any Contact Center portions of the entire Medicaid enterprise that is to be certified, the Vendor is responsible for preparing all documentation and operational examples to demonstrate criteria are met and System and Services address all business functions and performance standards and business model expectations for certification. The Vendor will utilize the MMIS certification electronic document storage solution.

The Vendor must work with the MMIS Vendor as well as any other partner Vendors and subcontractors to achieve CMS certification.

The Vendor must describe its approach to achieving CMS Certification for the system implemented for the State.

1.1.2.Support of Project Objectives and Goals

All systems and services procured with this RFP should be aligned with, and support, the Project Objectives and Goals as described in section 2.5.2 of the RFP.

These Objectives and Goals are:

Contract limitations and cost to maintain / change the system

Support of the State’s vision of an Agency of One, supporting additional programs in the primary benefits management and claiming systems

Improve efficiency and effectiveness of Medicaid Operations by increasing AHS’ MITA 3.0 maturity

Need for more effective cost avoidance and cost recovery through maximizing, fraud, waste and abuse prevention / detection capabilities

Support of Vermont’s transition to Green Mountain Care 2017, assuring access to and coverage for high-quality health care to all Vermont residents

Need to support multiple, evolving payment models

Need to move beyond silos to an integrated enterprise

Mandates to comply with all regulatory reporting and service delivery requirements

The Vendor must describe its support of each of the listed Project Objectives and Goals.

1.2.Green Mountain Care 2017, Vermont’s Universal, Publicly Financed Health Coverage Model Approach

Vermont is on a path to developing and implementing universal coverage for all Vermont residents through a publicly financed model. In May 2011 the Vermont legislature passed Act 48 which recognizes the fiscal and economic imperative for Vermont to undertake fundamental reform of its health care system including the transition to a State-wide universal health care system targeted for 2017.

Green Mountain Care provides universal health care coverage to everyone living in Vermont. Health care benefits will be based on where people live, not where they work. Health coverage will be publicly funded, based on ability to pay. The goal is to save money for Vermonters by creating less hassle and less paperwork. Instead of multiple systems run by multiple insurers, Vermont will use a vendor or vendors – just like a large employer would today – which will create efficiencies and reduce costs.

In Green Mountain Care, all Vermont residents will be covered with a comprehensive set of health benefits. There will be a single one-stop approach to acquiring the necessary documentation that the state will need in order to cover residents with healthcare services and continue to draw down federal funding to support the healthcare system.

Current plans include the following:

All Vermont residents will be enrolled automatically in Green Mountain Care (GMC).
If individuals have other coverage (e.g., ESI or Medicare), the other coverage would pay first and GMC would supplement as needed (“GMC Secondary”); Medicaid is the payer of last resort.
GMCwill provide comprehensive health care benefits, including at minimum the federal essential health benefits required by the Affordable Care Act, such as:
comprehensive mental health and substance abuse services,
pharmaceuticals,
pediatric dental and vision care, and
care coordination

Vermont will contract with service providers that will manage the relationships with the various funding sources, the full range of accredited providers, and all Vermonters. In addition, the service providers will process claims for the full range of covered services. The future model will manage more funding sources than Medicaid does today (for example, the pass through funding available through an Affordable Care Act waiver under Section 1332), but it will also be simpler because there will be universal coverage and well-defined single responsibilities for all processes.

While the transition to GMC 2017 is not included in this procurement, the State wants assurances that the procured MMIS and Contact Center solutions will be adaptable, extensible and scalable to support the administration of the Green Mountain Care solution in the future.

Figure1.Conceptual View of the Transition to GMC 2017

The Vendor must describe how it is positioned to provide the technology and services defined in the procurement to support Vermont’s health reform plans to transition to a Statewideuniversal, publicly-financed health coverage system by 2017 (GMC 2017). The Vendor should describe its approach to enhance its technologies and ongoing operating services to support the migration to, and ongoing operation of,the future Green Mountain Care 2017 (GMC 2017), that will manage programs that provide health insurance coverage to all Vermonters.

1.3.Agency of One Requirements Approach

AHS has adopted an “Agency of One” vision in regards to the management of services for the Vermonters it serves. This is discussed in AHS’ strategic plan at

The goals of this approach include:

Decrease the lasting impacts of poverty on individuals, children and families in Vermont and create pathways out of poverty

Promote the health, well-being and safety of individuals, families and our communities

Enhance AHS’s focus on program effectiveness, accountability for outcomes, and workforce development and engagement

Ensure that all Vermonters have access to high quality health care

The State understands this requires the following:

Accountability- Results Based Accountability

Emphasizes root causes, prevention & early intervention, not just symptoms

Involves multiple organizations: AHS, State Government, Community Partners

The Vendor must describe its approach to supporting AHS and the State in pursuing this vision.

1.3.1.Partner Vendor Collaboration

The State is in the process of procuring a number of Systems and Vendors to support the Medicaid program and the breadth of health and human services programs in the State. The State is intent on providing a comprehensive and cohesive experience for Members and Providers through all of these programs and this goal has been identified as a fundamental success factor for this project. The Vendor must describe the approach it will take during design, development and implementation to ensure effective coordination and integration of efforts to keep efforts within scope, on budget and in schedule as well as during ongoing operations to ensure a seamless experience for State staff, members, and providers across the continuum of Medicaid services required.

1.4.Member ManagementRequirements Approach

1.4.1.Enroll Member

Significant System capabilities in this area include:

Assign Members to health benefits plan or plans

Maintain a record of Member benefit limitation information

Maintain accurate and current Medicare eligibility information to ensure that, among other things, all dual eligible Members are identified and support proper processing of claims for dually eligibles

Identify and alert the State when Medicare eligibility is terminated for an active Medicaid Member

Generate appropriate notices and alerts due to a Members’ age change

The Vendor must describe its approach to meet the requirements for the business process “Enroll Member”.

1.4.2.Disenroll Member

Significant System capabilities in this area include:

Allow Members to be disenrolled or suspended from a plan or plans

Support the timely disenrollment of Members

Support rules-based exceptions to disenrollment including, but not limited to, a Member moving out of state to receive specialized and pre-approved medical care

Generate notices to all affected programs of a Member’s change in enrollment status

Generate notices to Members of their change in enrollment status for all programs and consolidate this notice with other State notices to the Member to mitigate conflicting notices

The Vendor must describe its approach to meet the requirements for the business process “Disenroll Member”.

1.4.3.Inquire Member Eligibility

Significant System capabilities in this area include:

Search Member records using soundex and fuzzy matching logic to identify all possible matches

Display the current amount of a Member’s cost-sharing (copayments, coinsurance, deductibles), spend-down and patient share, in response to an inquiry from an authorized Provider

Provide Member status in regards to other health plans, e.g. Medicare, Tricare

Support standardized responses containing both program and benefit information, as well as primary care physician or managed care affiliation

Provide notification of program and service restrictions including, but not limited to, lock-in or lock-out

Identify Members active in any health benefits plan or plans

The Vendor must describe its approach to meet the requirements for the business process “Inquire Member Eligibility”.

1.4.4.Manage Member Information

Significant System capabilities in this area include:

Maintain information on each Member’s health benefits plan or plans to support claims payment and other financial processes

Accept valid electronic updates of Member data from external systems

Support inquiry and display information related to third party payer notifications

Maintain Member TPL information and allow authorized users to update the information

The Vendor must describe its approach to meet the requirements for the business process “Manage Member Information”.

1.4.5.Manage Member Communication

Significant System capabilities in this area include:

Communicate with Members via a number of channels including, but not limited to:

Secure e-mail
Automated phone notification
Traditional mail
Fax
Social Media

Generate Member communications in multiple languages, as defined by the State

Bundle communications to a single Member

Log and maintain electronic copies of all Member correspondence as well as maintain full audit trail details including, but not limited to:

Date sent
Sender
Format correspondence was sent (e.g., email, mail, fax)

Generate automated schedule notices for Member follow-up and required actions

The Vendor must describe its approach to meet the requirements for the business process “Manage Member Communication”. The response must include the Vendor’s approach to managing and consolidating multiple notices, coming from multiple systems, in order to minimize Member confusion.

1.4.6.Perform Population and Member Outreach

Significant System capabilities in this area include:

Aggregate claims data to discover the prevalence of specific population health issues, and notify interested parties of results

Support the identification of health promotion and incentive opportunities based on claims data for all Members, including those currently enrolled, past participants, and potential enrollees

Identify and conduct data cleansing prior to sending any outreach communication

Support the generation of educational materials and surveys tailored to the Member, family, or population by, at a minimum, disease and/or care level

Generate surveys and collect the data, in a variety of formats, as required by the State

The Vendor must describe its approach to meet the requirements for the business process “Perform Population and Member Outreach”.

1.4.7.Manage Member Grievance and Appeal

Significant System capabilities in this area include:

Support the submission and tracking of Member fair hearings, grievances and appeals online through but not limited to the Member portal, the Member Service Center, and interfaces with other systems

Provide the ability to log and track Member fair hearings, grievances and appeals including, but not limited to:

Issue being appealed
Date of filing
Audit trail information of user entering information
Worker assigned

Triage the fair hearing, grievance or appeal to appropriate personnel for review

Provide a workflow to support the various types and categorizations of fair hearings, grievances and appeals

Allow staff to log disposition of the fair hearing, grievance or appeal

Automatically generate fair hearing, grievance and appeals correspondence to all appropriate recipients, per State policy

The Vendor must describe its approach meet the requirements for the business process “Manage Member Grievance and Appeal”.

1.5.Provider Management Requirements Approach

1.5.1.General

Significant System capabilities in this area include:

Set triggers and/or alerts as needed for follow-up actions

Provide a Provider portal that supports Provider submissions, notifications, and information sharing

The Vendor must describe its approach to meet the general requirements “Provider Management“.

1.5.2.Determine Provider Eligibility

Significant System capabilities in this area include:

Allow Providers to submit and complete enrollment requests through a number of channels including, but not limited to: Provider portal, email, traditional mail, telephone

Support Provider enrollment eSignatures

Provide workflow tools to automate, standardize and support the Provider eligibility and enrollment process

Support the Provider eligibility and enrollment process based on 42 CFR 455 Subpart E

Produce an electronic checklist to assist in site-visits, accessible through a mobile device and will support uploading pictures and geotagging

Provide the ability to enroll non-traditional Medicaid Providers to support payment of services in the MMIS including, but not limited to: taxi/transportation and respite

Utilize the National Provider Identifier (NPI) confirmed through data exchange with the National Plan & Provider Enumeration System (NPPES)

Maintain a Provider review schedule to ensure Providers continue to meet eligibility requirements

Facilitate efficient re-enrollment of all Providers to prevent service and payment disruptions

The Vendor must describe its approach to meet the requirements for the business process “Determine Provider Eligibility”.

1.5.3.Enroll Provider

Significant System capabilities in this area include:

Automate background and credential checks of Providers, group managers, controlling interests, owners and non-clinical management staff through electronic information exchange with verification agencies including, but not limited to, licensing and credentialing boards", Should add "and excluded parties list located at "Provide the ability for currently enrolled Providers to enroll in additional services with the minimum amount of additional information required for that specific service

Maintain historical enrollment information on all Providers, including Providers denied enrollment

Provide the ability to provide forms online and in downloadable format. Specific forms to be defined by the State include, but are not limited to:

Applications based on Provider type
Addendums
Provider agreements
W-9 form
EFT
Change of address

Provide the ability to aggregate Providers in flexible groupings for evolving payment strategies (including ACO, Shared Savings, etc.)