kentucky cabinet for health and family services
division for medicaid services
kentucky mmis procurement 2012
Medicaid information technology architecture
Gap Analysis
Deliverable 8
November 23, 2012
Version 2.0
Prepared by:
7926 Jones Branch Drive, Suite 330
McLean, VA 22102
(480) 423-8184
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/ Kentucky MMIS Procurement 2012MITA SS-A Gap Analysis
Revision History
Version Number / Date / Reviewer / CommentsV1.0 / 7/12/2012 / Fred Hinds / Initial Submission
V1.01 / 11/19/2012 / Fred Hinds / Revisions
V2.0 / 11/23/2012 / Nancy Ferguson / Reviewed and accepted Fred’s changes.
Table of Contents
1 Introduction 5
1.1 Project Overview 5
1.2 Cognosante Methodology 6
1.3 Terminology Clarifications 6
1.4 MITA Framework 2.01 10
2 Kentucky Overview 11
2.1 Kentucky Medicaid Mission 11
2.2 Kentucky Medicaid Vision 11
2.3 Kentucky Medicaid Values 11
2.4 Kentucky Medicaid Guiding Principles 11
2.5 Kentucky Goals and Objectives 11
3 Results of the MITA Business Process Gap Analysis 13
3.1 Overview 13
3.2 Future Capabilities of the Kentucky MITA Business Areas 13
3.2.1 Business Relationship Management 16
3.2.2 Care Management 21
3.2.3 Contractor Management 25
3.2.4 Member Management 33
3.2.5 Operations Management 41
3.2.6 Program Integrity Management 55
3.2.7 Program Management 59
3.2.8 Provider Management 68
4 Conclusion 73
Appendix A: CMS MITA Framework Appendix e (STATE SELF-Assessment Details) 75
List of Figures and Tables
Figure 1: To Be Maturity Level Summary 14
Figure 2: Business Relationship Management 16
Figure 3: Business Relationship Management Maturity Level Summary 17
Figure 4: Care Management 21
Figure 5: Care Management Maturity Level Summary 22
Figure 6: Contractor Management 25
Figure 7: Contractor Management Maturity Level Summary 26
Figure 8: Member Management 33
Figure 9: Member Management Maturity Level Summary 34
Figure 10: Operations Management 41
Figure 11: Operations Management Maturity Level Summary 43
Figure 12: Program Integrity Management 55
Figure 13: Program Integrity Management Maturity Level Summary 55
Figure 14: Program Management 59
Figure 15: Program Management Maturity Level Summary 60
Figure 16: Provider Management 68
Figure 17: Provider Management Maturity Level Summary 69
Table 1: MITA Maturity Model 9
Table 2: Business Relationship Management Business Area 18
Table 3: Care Management Business Area 23
Table 4: Contractor Management Business Area 28
Table 5: Member Management Business Area 36
Table 6: Operations Management Business Area 45
Table 7: Program Integrity Management Business Area 57
Table 8: Program Management Business Area 62
Table 9: Provider Management Business Area 70
List of Acronyms
The following acronyms are used throughout this document:
Acronym / Definition /7C&S / Seven Conditions and Standards
ACA / Affordable Care Act
ARRA / American Recovery and Reinvestment Act of 2009
ASC / Accredited Standards Committee
AVRS / Automated Voice Response System
BCCTP / Breast and Cervical Cancer Treatment Program
BCM / Business Capability Matrix
BP / Business Process
BPM / Business Process Model
CAQH / Council for Affordable Quality Healthcare
CHFS / Cabinet for Health and Family Services
CMS / Centers for Medicare and Medicaid Services
COB / Coordination of Benefits
COTS / Commercial off-the-shelf
DCBS / Department of Community Based Services
DMS / Division for Medicaid Services
DW/DSS / Data Warehouse/Decision Support System
EDI / Electronic Data Interchange
EHR / Electronic Health Record
EOB / Explanation of Benefits
EPSDT / Early and Periodic Screening, Diagnosis, and Treatment
HBE / Health Benefit Exchange
HIE / Health Information Exchange
HIPAA / Health Insurance Portability and Accountability Act
IAPD / Implementation Advanced Planning Document
ICD-10 / International Statistical Classification of Diseases and Related Health Problems, Tenth Revision
ID / Identification
KAMES / Kentucky Automated Management Eligibility System
KenPAC / Kentucky Patient Access and Care
KY / Kentucky
KYME / Kentucky Medicaid Enterprise
MCO / Managed Care Organization
MEMS / Medicaid Enterprise Management System
MITA / Medicaid Information Technology Architecture
MMM / MITA Maturity Model
MOU / Memoranda of Understanding
NCPDP / National Council for Prescription Drug Programs
NPI / National Provider Identifier
OATS / Office of Administrative and Technology Services
PCCM / Primary Care Case Manager
PE / Presumptive Eligibility
RFP / Request for Proposal
SNAP / Supplemental Nutrition Assistance Program
SS-A / State Self-Assessment
SUR / Surveillance and Utilization Review
TANF / Temporary Assistance to Needy Families
TPL / Third Party Liability
UPD / Universal Provider Datasource
USPS / United States Postal Service
/ V 2.0
Page 17
/ Kentucky MMIS Procurement 2012
MITA SS-A Gap Analysis
1 Introduction
1.1 Project Overview
Cognosante is under contract to the Kentucky Cabinet for Health and Family Services (CHFS) to provide consulting services for the Kentucky Medicaid Management Information System (MMIS) Procurement. As part of that work effort, Cognosante is contracted to update the previous Medicaid Information Technology Architecture (MITA) State Self-Assessment (SS-A). Cognosante submits this Gap Analysis deliverable in accordance with Takeover and Replacement Project Amendment 1.
The four key deliverable documents for the Kentucky MITA SS-A update are as follows:
- Kentucky MITA SS-A As Is update – This deliverable outlines the current capabilities and maturity levels for the various MITA business process (BP) areas.
- Kentucky MITA SS-A To Be update – The amendment required an examination of the previously produced MITA SS-A document and a determination regarding the impact of the recent Kentucky enhancements to the As Is maturity levels and a review of the impacts that the Affordable Care Act (ACA) and Centers for Medicare and Medicaid Services (CMS) Enhanced Funding Requirements, Seven Conditions and Standards (7C&S) will have on the To Be MITA maturity level goals. This document presents the results of the examination of the To Be assessment of future goals, objectives, opportunities, and challenges.
- Gap Analysis – This deliverable will identify the gaps between the As Is and the To Be, encompassing the Kentucky Medicaid program’s needs for business process improvements. This deliverable will also include the MITA Framework 2.01 Appendix E, which provides the justification documentation required by CMS for Implementation Advance Planning Document (IAPD)-planned improvement funding requests for the MMIS.
- Transition Plan – The Transition Plan will highlight a plan to transition from the current MMIS architecture to future business and technology needs and services.
This document represents Deliverable 8: Gap Analysis and will present CHFS with a description and maturity level for the To Be business processes provided by the MITA Framework Version 2.01, Business Process Model (BPM) Version 2.01. This deliverable will describe the capabilities and maturity the Commonwealth wants to achieve (To Be) and provide the supporting detail for maturity level determination.
Section 2 presents Kentucky Medicaid’s goals and objectives as they relate to MITA.
Section 3 provides details on the current and future levels of maturity of each Division for Medicaid Services (DMS) business process. This section provides a summary overview of the MITA management area within the Kentucky Medicaid Enterprise (KYME). Each subsection includes bulleted capability recommendations for maturity development and a detailed table for each business process. The tables provide the As Is and To Be maturity levels for each process. The tables also provide a description of maturity gaps that need to be met in order to achieve the desired To Be goals.
1.2 Cognosante Methodology
Because the schedule for this engagement was aggressive, Cognosante used the original Kentucky MITA Framework 2.01 material as a foundation with its eight business areas and 79 business processes, as the baseline. The original material was reviewed and placed in standardized templates. A review of recent changes to the MMIS, legislation such as the ACA, and CMS requirements was conducted and any updates and new findings were added to the templates. The detailed templates were used as the basis for the final deliverables. These completed templates will be delivered in a soft copy form because of the size and the need to be able to search the documents electronically. This process assured that all MITA business areas and processes would be addressed.
As a result of the review, the MITA To Be goals of certain business process capabilities were revised in order to meet the new requirements. The gap between the current As Is capabilities and the desired future To Be capabilities is the focus of this document.
1.3 Terminology Clarifications
Several concepts and entities are used in specific sense throughout this document, and the following definitions serve to clarify the in-depth discussions they precede.
1. Enterprise
The term enterprise is used throughout this document. It is preceded by an adjective to describe the processes and systems that make up the Medicaid solution. In this document, the term enterprise means:
§ A group of organizations (e.g., CHFS operating agencies)
§ Staff, systems, and interfaces that have a common purpose (e.g., Medicaid)
The following enterprise definitions are used to help the reader understand the context of terms used throughout this document.
§ CHFS Enterprise – The staff, systems, and interfaces that make up the Kentucky CHFS organization
o Program Agencies
§ Department for Aging and Independent Living
§ Commission for Children with Special Health Care Needs
§ Department for Community Based Services
§ Department for Family Resource Centers and Volunteer Services
§ Office of Health Policy
§ Department for Income Support
§ Department for Medicaid Services (DMS)
§ Department for Behavioral Health, Developmental and Intellectual Disabilities
§ Department for Public Health
o Program Support Agencies
§ Governor’s Office for Electronic Health Information
§ Office of Administrative and Technology Services (OATS)
§ Office of Health Policy
§ Office of Communication and Administrative Review
§ Office of Human Resource Management
§ Office of the Inspector General
§ Office of Legal Services
§ Office of Ombudsman
§ Office of Policy and Budget
o Divisions
§ Administrative Hearings
§ Child Care
§ Child Support
§ Disability Determination Services
§ Family Resource and Youth Services Centers
§ Family Support
§ Prevention Violence Resources
§ Protection and Permanency
§ Women’s Physical and Mental Health
o Advisory Commissions, Councils and Boards
§ Institutional Review Board
§ Kentucky Commission on Community Volunteerism and Service
§ Commonwealth Council on Developmental Disabilities
§ Kentucky e-Health Network Board
§ Kentucky Health Information Exchange Coordinating Council
§ Medicaid Enterprise – The staff, systems, and interfaces that are used to process, hold, or distribute Kentucky Medicaid information across the operating agencies
2. Silo
Silo is another term used throughout this document. Along with the term “compartmentalized,” silo is used to describe the lack of system interoperability, communication, and common goals across two or more business areas. For most of the CHFS enterprise management systems, the focus is inward and information communication is vertical. In general, staff members serve as information gatekeepers, making timely coordination and communication among departments difficult to achieve. Information gatekeepers also make seamless interoperability with external parties impractical. In general, silos tend to limit productivity in practically all organizations and provide greater risk for security lapses and privacy breaches.
3. MITA Maturity Model, Maturity Level, and Capability
The MITA Framework is grounded in several significant terms. Among the most significant terms are MITA Maturity Model (MMM), Maturity Level, and Capability.
MMM – A maturity model serves to measure and guide the performance of a specific business area (e.g., a long-term care waiver program) or business function (e.g., enrolling members) across time. The MMM provides each state’s Medicaid Enterprise with a structured timeline for realizing certain performance standards (e.g., within five years, enrolling members occurs online and information is automatically transferred from the application to systems for enrollment).
Maturity Level – Within the MMM there are five maturity levels for the each business process. These maturity levels are the summation of a set of performance standards and represent steps along the MMM. The maturity levels for individual processes are described in the tables beginning with Section 4. Each business process is assessed at one of its five maturity levels. This will be described as a certain business process having been assessed at a “MITA Maturity Level.”
Table 1: MITA Maturity Model
Definition of State Medicaid Levels of MaturityLevel 1 / Level 2 / Level 3 / Level 4 / Level 5
Agency focuses on meeting compliance thresholds for State and Federal regulations, primarily targeting accurate enrollment of program eligibles and timely and accurate payment of claims for appropriate services. / Agency focuses on cost management and improving quality of and access to care within structures designed to manage costs (e.g., managed care, catastrophic care management, and disease management). Focus on managing costs leads to program innovations. / Agency focuses on adopting national standards, collaborating with other agencies in developing reusable business processes, and promoting one-stop-shop solutions for providers and consumers. Agency encourages intrastate data exchange. / Agency benefits from widespread and secure access to clinical data and focuses on improvement of healthcare outcomes, empowering beneficiaries and provider stakeholders, measuring objectives quantitatively, and ensuring overall program improvement. / Agency focuses on fine tuning and optimizing program management, planning and evaluation since it has benefited from national (and international) interoperability and previously noted improvements that maximize automation of routine operations.
Capability – The “performance standards” referred to in the two definitions above, are commonly referred to in the MITA Framework as capabilities. Each of the 79 business processes discussed in these deliverables has a set of capabilities associated with them. For each business process, the sum of capabilities is known as a Business Capability Matrix (BCM). The KY MITA SS-A update was completed using the BCM from MITA Framework 2.01. As noted by CMS, below are the main types of capabilities:[1]
§ Timeliness of Business Process – Time lapse between the agency’s initiation of a business process and attaining the desired result (e.g., length of time to enroll a provider, assign a member, pay for a service, respond to an inquiry, make a change, or report on outcomes)
§ Data Accuracy and Accessibility – Ease of access to data that the business process requires and the timeliness and accuracy of data used by the business process
§ Efficiency; Ease of Performance – Level of effort necessary to perform the business process given current resources