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The annual Medicaid Enterprise Systems Conference (MESC) showcased 4 days of interactive sessions discussing health information technology, MMIS implementations, and Medicaid innovations. Set in the picturesque city of Portland, Oregon, the conference welcomed industry experts from all over the country. Day 1 set the tone by asking the audience: “What’s your next big idea in Medicaid?” All sessions to follow explored that overarching question.  

In case you were not able to attend, here is our recap of key topics discussed:

The need for state reusability. With increased interest, States have turned their focus to the concept of ‘state reusability’ in order to provide technology and processes that are flexible, sustainable, and reduce costs. Stemming from an April 18, 2018 CMS letter to State Medicaid Directors, which offered guidance to supplement its “Mechanized Claims Processing and Information Retrieval Systems (90/10), the letter reaffirmed the requirement of reuse: “Over the long run, reuse is expected to lower implementation and operational costs compared to custom or one-off solutions.” To achieve this, a state may elect to incorporate reuse in its design of new capabilities.   According to CMS, this could include: 

  • Hosting software in a cloud, and making it available for other states to use 
  • Developing open source, license-free MES modules that are sharable with other states 
  • Sharing specific customizations or configurations to a commercial off-the-shelf (COTS) software products with other states 
  • Further developing software or systems created for the Health Information Technology for Economic and Clinical Health (HITECH) to support other business processes in the Medicaid Enterprise or connected to the Medicaid Enterprise. 

Innovation is the key to change. As Jeremy Vandehey, Director of Health Policy and Analytics at Oregon Health Authority stated, “states are leaders in innovation.” Today’s opening keynote emphasized not only how state agencies and CMS can drive change that benefits the market, but also examined the need for states to stay abreast of regulatory changes and their potential impact to adapt quickly. Sarah Miller, Senior Director at Audacious Inquiry, emphasized this further, during the CMS Welcome, proclaiming “we are the people we’ve been looking for” and affirming we are among the who’s who in Medicaid and together will bring great change. Her session offered insight into her goals and priorities for 2018 and beyond.  

Significant changes are coming. Sarah Miller also provided an enlightening talk on the role of healthcare payers in State ecosystems. “Given the sheer size of Medicaid – the $565 billion program constitutes 17% of health expenditures nationally – significant changes that we are almost sure to see in 2018 will reverberate in states across the country,” [1] was just one of the quotes included in her keynote presentation to emphasize the magnitude of Medicaid on all stakeholders – including states, government agencies, providers, payers, and consumers.   

Machine Learning for Medicaid Payers and Providers“What is a machine and how is it learning?” Outlining the basics of analytic excellence and how it leads to better decisions. Digging deeper, the session highlighted the differences between Machine Learning and Classic Analytics (BI). 

Strategic Planning for Successful Modular MMIS ImplementationThe Commonwealth of Pennsylvania, who is leading the pack in modularity, is replacing its legacy monolithic MMIS. The new MMIS 2020 Platform will provide a modular enterprise-wide system providing automated support for the department’s programs, supporting almost three million individuals. 

‘What’s the Re-Use? Planning, Considerations for Reuse, and Keys to Success were the three major points of ‘What’s the Re-Use? State and Vendor perspectives on Modularity and the MITA leverage condition. This session was led by Carie Clements of Accenture, Ed Dolly of CMS, and Mary Arcenas of New Jersey. The MITA leverage condition offers agencies the ability to reuse proven technology, practices, and methods while reducing redundancy. 

HIPAA is more than a privacy law. John Allison from CMS stated, “HIPAA is one the most impactful laws in Medicaid Enterprise.” While many consider HIPAA as a privacy law, it contains significantly more that directly impacts the Medicaid Enterprise. HIPAA as we know it today—17 years in the making: 

  • August 1996: HIPAA signed into law  
  • April 2003: HIPAA Privacy Rule Standards for individually identifiable health information  
  • April 2005: HIPAA Security Rule Security Standards to safeguard protected health information  
  • March 2006: HIPAA breach enforcement rule 
  • January 2009: HIPAA 5010 and ICD-10 mandate rules insured  
  • September 2009: HITECH and the breach notification rule—accounting for disclosures  
  • March 2013: Final Omnibus Rule GINA Privacy increased penalties for breaches individual access to electronic records  

States are playing a key role in accelerating interoperability. MITA-Technical Architecture Committee’s (MITA TAC) Chair David Walsh offered an insightful introduction of the committee, which focuses on Medicaid technology, especially standards and interoperability for the past 15 years. During the presentation, he shared that a demo of interoperability was developed here at MESC. The final update to MITA 3.0 is being published by CMS. The 2018 State of the Nation MITA 3.0 presented the results of the 2018 MITA Annual Longitudinal Survey. 2018 marks the 7th year of conducting the survey and is a result of a collaborative effort from state and federal agencies, industry work groups, and the vendor community.  NMEH MITA Co-Chair Jeff Strand  highlighted the modernization strategy and plans to extend the technical capability outside Medicaid. Strand discusses that they are continually updating our system in small portions. In 2017, they implemented a new system, but need to add to the Enterprise due to EVV and more. The system implemented in 2017 provided many updates to maturity. He hopes to have an updated assessment in CY2018. Lastly, he expresses the need to produce a new system which will consist of multiple modules.  

Interest in Community engagement programs grows. A number of states continue to examine the possibility of adding Work Requirements to their Medicaid programs, via 1115 Waivers, despite current some opposition voiced recently. In Arkansas’ session, speakers looked at Arkansas Work’s goals, which included the implementation of an Arkansas Medicaid Work and Community Engagement requirement  and establishing a work requirement as a condition of Arkansas Works Eligibility  among other initiatives including eliminating the employer-sponsored insurance (ESI) premium assistance program .  The Arkansas Works population & work and community engagement requirement would impact beneficiaries aged 19-49. Those aged 50 and over would be not be subjected to the work and community engagement requirement. Other Arkansas Works Exemptions include:

  • Disabled, living in home with dependent minor age 17 or under, pregnancy, caring for an incapacitated person, volunteer, job search, health education class (up to 20 hours per year)  
  • Outreach and education: engaged stakeholders, use an interim period (up to 59 days).   

Addressing Medicaid changes using Social Determinants of Health (SDoH)States are developing initiatives aimed at achieving broader goals not previously emphasized in Medicaid. Key implications on IT and business services; Major changes to Medicaid program business functions and use of IT; consumer empowerment, administration of consumer accounts and link to “healthy behavior”, tracking adherence to work and/ or community engagement requirements, coordination across Medicaid and Marketplace, and technology harmonization. 

Sophisticated data analytic tools are needed to support state initiatives. Presented by Softheon Founder/ CEO Eugene Sayan, Foundry BI is the cloud-based solution’s business intelligence component, featuring configurable, state-of-the-art tools for non-technical users. Providing the ability to “slice and dice” data in near real-time, the reporting and business intelligence suite offers comprehensive analysis of transaction trends and key performance indicators (KPIs), including member demographics, geography, financial data points, and cost comparisons. Benefits:

  • 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 

To learn more about how Softheon is supporting States with Softheon Verify contact Michael Sasko at 

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