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Manage Member Financial Participation

Accounts Payable Management

Description

The Manage Member Financial Participation business process is responsible for all operations aspects of preparing member premium payments. This includes premiums for Medicare, also known as Medicare Buy-in, and other health insurance. The business process begins with the alert to determine if the State Medicaid Agency (SMA) should pay a member’s premium. The SMA will assist low-income Medicare beneficiaries in Medicare cost-sharing, defined as premiums, deductibles, and co-insurance in a process referred to as buy-in. Under the buy-in process the SMA, the Social Security Administration (SSA), and U.S. Department of Health & Human Services (HHS) enter into a contract where States pay the Medicare beneficiary share of premium costs, and, in some instances, deductibles, and co-insurance. An exchange of eligibility information between Medicare and the SMA initiates Medicare premium payments. The service agreement between the SMA and business partner determines the intervals for this business process to execute. The business process receives eligibility information from Medicare, performs a matching process against the State Medicaid Enterprise member data store, generates buy-in files to Centers for Medicare & Medicaid Services (CMS) for verification, receives premium payment information from and generates payments to CMS. The SMA will pay the private health insurance premiums for members who have private health insurance benefits, if it determines the insurance to be cost effective. In these circumstances, the SMA prepares and sends a premium to the member’s private health insurance company. Health insurance premium payment initiates with an application for Medicaid where the applicant indicates they have third-party health coverage or by receiving eligibility information via referrals from Home and Community-Based Services (HCBS) Offices, schools, community services organizations, or phone calls directly from members. The business process checks for internal eligibility status as well as eligibility with other payers, producing a report identifying individuals where paying premiums would be cost effective, and notifying members via Manage Applicant and Member Communication business process. NOTE: This business process does not include sending the premium payments as an Electronic Data Interchange (EDI) transaction.

Business Process Template

Trigger events
Environment-based
  • Periodic timetable is due for receipt of Medicare eligibility information.
  • Periodic timetable (e.g., monthly) is due for insurance premium eligibility redetermination and payments.
  • Receive insurance information either by the member or through a referral.
Interaction-based

None published

Results
  • Modification to Medicare buy-in reporting.
  • Identification of individuals where paying insurance premiums is cost effective.
  • Alert to send notification of premium payment to member via Manage Applicant and Member Communication business process.
  • Alert to send notification of premium payment to Medicaid.
  • Alert to Manage Accounts Payable Information business process for conducting premium payment.
  • If applicable, alert send notification to business partner of member premium payment via Manage Business Relationship Communication business process.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Alert to determine if the State Medicaid Agency (SMA) should pay a member’s premium.
  • 2. Prepare Medicaid Premium Payment. a. Receive State Data Exchange (SDX), Enrollment Data Base (EDB) file, and/or the SSA Beneficiary Data Exchange (BENDEX) eligibility files from the Receive Inbound Transaction. b. Perform a matching process against the Member data store. c. Generate buy-in file, containing both Medicare Part A and Medicare Part B members (includes all requests for action including discrepancies from previous month). d. Send buy-in file to CMS. e. Receive CMS responses to the buy-in file (i.e., the Billing File for both Part A and Part B) including eligibles, responses to errors, and Medicare buy-in file information. f. Process CMS responses to the submitted buy-in file and assess the file for accuracy and completeness. g. Post buy-in modifications to the Member data store. h. Produce buy-in reports reflecting potential Medicare eligibles including any additions or deletions to existing Member data store as well as other discrepancies. i. Staff researches unmatched and discrepancies to determine appropriate eligibility. j. Send problem discrepancy form(s) reflecting potential Medicare eligibles, unmatched, and discrepancies to the Buy-in Administration, and update final Medicare buy-in file for internal use.
  • 3. Prepare Health Insurance Premium Payment (HIPP): a. Receive insurance information either from an applicant or through a referral. b. Check internal and external eligibility information. c. Edit eligibility information. d. Determine cost effectiveness by collecting information such as policy coverage, past usage, and by making a determination of future need - the requirements for determining cost effectiveness will vary among States. e. Produce a report of individuals where paying premiums is cost effective for the SMA.
  • 4. Send alert to conduct premium payment to Manage Accounts Payable Information business process.
  • 5. If applicable, send alert to notify member of premium payment via Manage Applicant and Member Communication business process.
  • 6. If applicable, send alert to notify business partner of member premium payment via Manage Business Relationship Communication business process.
  • 7. END: If applicable, send alert to notify Medicare of member premium payment.
Predecessor processes
Successor processes
Shared data
  • Member data store including demographics, cost share, third-party insurance, and premium information
  • Health Insurance Marketplace data store including applicant eligibility and member enrollment information (i.e., dual-eligibility)
  • Financial data store including accounts payable information
Constraints

The Manage Member Financial Participation business process will adhere to the federal policies and business rules.

Failures
  • State Medicaid dual eligibility information does not match Medicare dual eligibility information - errors in BENDEX, EDB, or SDX files.
Performance measures
  • Time to complete the process: e.g., Real Time response = within ___seconds, Batch Response = within ___ hours
  • Accuracy with which rules are applied =___%
  • Consistency with which rules are applied=___%
  • Error rate =___% or less

Source: CMS MITA 3.0 Business Process Template, Financial Management BPT.pdf, pages 18-21.

Business Capability Model (10 questions)

Each capability question defines five maturity levels, from Level 1 through Level 5.

Business Capability Descriptions

Is the process primarily manual or automatic?
  1. LEVEL 1The process consists primarily of manual paper-based activity to accomplish tasks.
  2. LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks.
  3. LEVEL 3SMA automates process to the full extent possible within the intrastate.
  4. LEVEL 4SMA automates process to the full extent possible across the interstate.
  5. LEVEL 5SMA automates process to the full extent possible across the nation.
Does the State Medicaid Agency use standards in the process?
  1. LEVEL 1SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards.
  2. LEVEL 2SMA applies a mix of HIPAA and state-specific standards.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards for intrastate exchange of information.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for clinical and interstate information exchange.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of information.
How does the State Medicaid Agency collaborate with other agencies or entities in performing the process?
  1. LEVEL 1Very little collaboration occurs with other agencies to standardize information exchange or business tasks.
  2. LEVEL 2SMA collaborates with other agencies and entities to adopt HIPAA standards and Electronic Data Interchange (EDI) transactions.
  3. LEVEL 3SMA collaborates with other intrastate agencies and entities to adopt national standards, and to develop and share reusable business services.
  4. LEVEL 4SMA collaborates with other interstate agencies and entities to adopt national standards, and to develop and share reusable processes including clinical information.
  5. LEVEL 5SMA collaborates with agencies and entities for national (and international) interoperability improvements that maximize automation of routine operations.

Business Capability Quality: Timeliness of Process

How timely is the end-to-end process?
  1. LEVEL 1Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation).The process is complete in one (1) month.
  2. LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements. The process is complete in ten (10) or fewer business days.
  3. LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. The process is complete in 24 hours or less.
  4. LEVEL 4Information is available in near real time. Processes that use clinical information result in immediate action, response, and results. SMA has interstate interoperability, which further improves timeliness over Level 3.
  5. LEVEL 5Information is available in real time. Processes improve further through connectivity with other States and with federal agencies. Most processes execute at the point of service. Results are almost immediate.

Business Capability Quality: Data Access and Accuracy

How accurate is the information in the process?
  1. LEVEL 1Use of direct data entry for information collection is manually intensive and susceptible to inconsistent or incorrect information. Stakeholders are unable to rely on information for decision-making.
  2. LEVEL 2HIPAA standard transactions improve accuracy of information but the decision-making process may be erroneous or misleading. Accuracy is higher than at Level 1.
  3. LEVEL 3Automation of information collection increases the reliability of SMA’s internal information. External sources of information use MITA Framework and industry standards for information exchange. Decision-making is automatic using standardized business rules definitions. Accuracy rating is at 99% or higher.
  4. LEVEL 4Automation of information collection increases the reliability of SMA’s internal and external sources of information. SMA adopts MITA Framework and industry standards for information exchange with interstate agencies. Decision-making is automatic using regional standardized business rules definitions. Accuracy rating is at 99% or higher.
  5. LEVEL 5SMA adopts MITA Framework and industry standards for information exchange with national agencies. Decision-making is automatic using national standardized business rules definitions. Accuracy rating is at 99% or higher.
How accessible is the information in the process?
  1. LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually. Data access may take one (1) or more business day.
  2. LEVEL 2SMA stores information in disparate systems, but automation and HIPAA standards increase accessibility over Level 1. Data access may take up to four (4) hours.
  3. LEVEL 3SMA obtains information easily and exchanges with intrastate agencies and entities based on MITA Framework and industry standards. Accessibility is greater than Level 2.
  4. LEVEL 4SMA obtains information easily and exchanges with interstate agencies and entities. Accessibility is greater than Level 3.
  5. LEVEL 5SMA obtains information easily and exchanges with national agencies and entities. Accessibility is greater than Level 4.

Business Capability Quality: Cost Effectiveness

What is the cost of the process compared to the benefits of its results?
  1. LEVEL 1High relative cost due to low number of automatic, standardized tasks.
  2. LEVEL 2Automation improves process and allows focus on exception resolution, improving cost effectiveness ratio over Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards further improving cost effectiveness ratio over Level 2.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for interstate information exchange. SMA increases cost effectiveness ratio over Level 3.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national (and international) information exchange. SMA increases cost effectiveness ratio over level 4.

Business Capability Quality: Effort to Perform; Efficiency

How efficient is the process?
  1. LEVEL 1Process is labor intensive. There is wasted effort or expense to accomplish tasks. Process meets minimum state process guidelines and SMA performance standards. Efficiency is low.
  2. LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving efficiency to 95% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving efficiency to 98% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving efficiency to 98% or higher.

Business Capability Quality: Accuracy of Process Results

How accurate are the results of the process?
  1. LEVEL 1Manual processes result in greater opportunity for human error. Accuracy is low.
  2. LEVEL 2Automation and standardized business rules definitions reduce error and improve accuracy above Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving accuracy to 98% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving accuracy to 98% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving accuracy to 98% or higher.

Business Capability Quality: Utility or Value to Stakeholders

Does the business process satisfy stakeholders?
  1. LEVEL 1Stakeholders lack confidence in information negatively affecting stakeholder satisfaction with the process.
  2. LEVEL 2Automation and standardization provides clear and useful information. Stakeholder satisfaction is greater than Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving stakeholder satisfaction to 90% or higher. SMA uses survey or questionnaire for information collection.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving stakeholder satisfaction to 95% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving stakeholder satisfaction to 98% or higher.

Source: CMS MITA 3.0 Business Capability Model, Financial Management BCM.pdf, pages 58-63.

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