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When it comes to optimizing your exchange, it’s all about data. More importantly, it’s about accurate data. CMS requires states and state Medicaid programs to conduct a heavy amount of reporting, and it isn’t always easy.

360 degrees of reporting

According to the Association of American Medical College, CMS is proposing reducing state reporting requirements for Medicaid FFS (fee-for-service) payment rate changes. Specifically, CMS is proposing the following changes to states with an overall Medicaid managed care penetration rate of 85 percent or greater:

  • Reductions to provider payments of less than four percent in overall service category spending during a state fiscal year
  • When states reduce Medicaid payment rates, they would rely on baseline information regarding access under current payment rates, rather than be required to predict the effects of rate reductions on access to care, which states have found difficult to do

Another current requirement is Medicaid-Medicaid Plan (MMP) reporting. Documents provide guidance, technical specifications, and applicable codes for the core and state-specific measures that MMPs must report. The core and state-specific measures supplement existing Medicare Part C and Part D reporting requirements, as well as measure what MMPs report through other venues, such as Healthcare Effectiveness Data and Information Set (and state Medicaid agencies.

What about Medicaid reporting? One example is generating the Medicaid state’s financial reporting, which displays pertinent results such as the CHIP Program Budget Report (CMS-21B); Medicaid Program Budget Report (CMS-37); Quarterly CHIP Statement of Expenditures (CMS-21); and Quarterly Expense Report (CMS-64). As an example of , the New York’s Medical Assistance Program for prescribed drugs cost $775,219,930, while the state’s share was $339,876,517.


In May, the product owner of Softheon’s Foundry, Vassili Bolotnikov, spoke about our claims processing, reporting, and data wrangling – now, with Foundry BI, there’s a whole lot more! The new Foundry BI solution is an on-demand business intelligence tool that allows states and Medicaid solutions to dive into their data, and displays results in a user-friendly, easy-to-digest format.

Foundry is a real-time reporting platform that allows users to turn data into valuable information across all workstreams whether they are a supervisor, operations analyst, or executive. Reporting comes in two “flavors” – explorative and canned. For example, CMS requires certain state reports to be run and submitted on a schedule – these would be our “canned” reports. The user would simply plug in a parameter, such as current date, and run the report. For requirements that are not this clear-cut, we offer both SQL and non-SQL-based interface to freely explore and visualize all available datasets. Ultimately, we strive to make the necessary data available to allow organizations to work in a proactive – rather than a reactive – manner in order to tackle large-scale problems.

States can create new dashboards which will display the groups of set questions and their corresponding answers, and within each dashboard the user can apply filters. If the user is unable to find the answer they are looking for based on the existing queries in the dashboard, the user has the ability to ask a new custom question; similar to drag and drop. Foundry BI can organize the state or Medicaid program’s complex data from all areas including:

  • Health benefit shopping and account management
  • Secure EDI processing
  • Enrollment and underwriting
  • Bill presentment and payment
  • Enhanced eligibility verification

Data to the rescue

Alistair Tocher, Softheon’s Client Success Manager, communicates with clients by utilizing Foundry BI’s custom reports. Alistair says, “the user interface is very simple and easy to understand. It makes communicating the state’s unique and complex data points effortless, which have been painful at times. Not only can I create new reports anytime, it also saves my queries, reducing repetitive actions and saving time.”

Key benefits highlighted from Softheon’s Foundry BI team are:

  • Generation of de-identified risk adjustment and reinsurance data sets
  • Extract, Transform & Load (ETL) from multiple data sources to create HHS-defined claims & enrollment files
  • Comprehensive reporting for risk adjustments, cost sharing reduction, and profit/loss ratios
  • Compliance with HHS data submission and HIPAA requirements
  • Recovery: Back-up, restore, version, and recover capabilities
  • Service-level agreement (SLA) monitoring tools

States look at our exchange solutions more information about Softheon’s comprehensive suite of cloud-based HIPAA-enabled projects, and state Medicaid programs visit our site to learn more about Softheon’s MITA-aligned solutions.


 The views and opinions expressed by the authors on this blog website and those providing comments are theirs alone, and do not reflect the opinions of Softheon. Please direct any questions or comments to 

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