Policy & Regulation News

Mechanized Claims Processing the Future of Medicaid?

By Jacqueline DiChiara

- The Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS) present a proposed rule to extend enhanced federal financial participation for Medicaid eligibility and enrollment systems beyond the present regulatory deadline of December 31, 2015.

90/10 federal funding Medicaid eligibility systems

Under the proposed rule, there will be permanent recognition of Medicaid and the Children’s Health Insurance Program (CHIP) as a pivotal aspect regarding Medicaid mechanized claims processing and information retrieval systems.

The proposed rule additionally plans to update current Medicaid Management Information Systems (MMIS) conditions and standards.

The combination of supplemental funding and a time extension will enable states to switch out outdated systems for those that are up-to-date and modernized.

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  • “These changes will promote an integrated, enterprise approach to Medicaid information technology,” confirm CMS and HHS, who anticipate this approach will help decrease potentially redundant health information technology costs.

    Additionally, the proposed rule will support the collective dynamics of Medicaid eligibility, Medicaid enrollment, and delivery system needs. The enhanced funding is specifically available for state projects observing various updated standards and conditions.

    Changes via the proposed rule will result in a variety of new changes, says CMS and HHS, including allowing states to improve customer service and support the vigorous nature of Medicaid eligibility, enrollment, and delivery systems.

    Proposed regulatory changes from CMS and HHS will permanently recognize Medicaid and CHIP eligibility and enrollment systems as an integral part of Medicaid mechanized claims processing and information retrieval systems, and would remove the time limits on the availability of enhanced rates of Federal Financial Participation (FFP) for qualifying systems.

    “With the proposed on-going access to enhanced funding for eligibility systems, and in recognition of refinements needed to the standards and conditions that pertain to [Medicaid Management Information System] MMIS and eligibility and enrollment systems,” CMS and HHS state within the proposed rule, “we are proposing new criteria and modifying the existing standards and conditions required for the states to access the enhanced funding and provide greater accountability for the system investment.”

    As CMS and HHS additionally confirm, the implementation of the Affordable Care Act (ACA) has demonstrated Medicaid eligibility policies and business processes only benefit and thrive from continued pushes for updates and advancements.

    Additionally, there will be active revision of the regulatory definition of Medicaid mechanized claims processing and information retrieval systems to include Medicaid eligibility and enrollment (E&E) systems, which will make available for E&E systems the enhanced federal financial participation (FFP) under the Social Security Act.

    FFP will be available under certain circumstances, for costs of such systems at a 90 percent federal matching rate for design and development activities, and at a 75 percent federal matching rate for maintenance and operations activities, confirms the proposed rule.

    Upcoming public commentary, due June 15, 2015, will be considered regarding the extension of 90/10 federal funding for Medicaid eligibility systems.