Plan Management

The Develop Agency Goals and Objectives business process periodically assesses and prioritizes the current mission statement, goals, and objectives to determine if changes are necessary. Goals and objectives may warrant change for example, under a new administration, in response to changes in demographics, public opinion or medical industry trends, or in response to regional or national disasters.

The Maintain Program Policy Business Process responds to requests or needs for change in the enterprise’s programs, benefits, or business rules, based on factors such as federal or state regulations, governing board or commission directives, Quality Improvement Organization’s findings, federal or state audits, enterprise decisions, or consumer pressure.

The Maintain State Plan business process responds to the scheduled and unscheduled prompts to update and revise the Medicaid State Plan. The Medicaid State Plan is the officially recognized statement describing the nature and scope of the State Medicaid program as required under Section 1902 of the Social Security Act.

The Manage Health Benefit Information business process includes the activities for development and implementation of health benefit packages to accommodate service delivery to targeted member populations. The health benefit package accommodates information to support current and future health benefit packages for members eligible for programs administered by the State Medicaid Agency (SMA). The SMA determines benefit terms and limitations, and applicable periods for services defined within a health benefit package. Health benefit package administration involves the ability to determine, define and coordinate and modify the following parameters within the SMA, as the Medicaid Enterprise policies, funding and business decisions dictate: • Multiple health benefit package definitions targeted to specific populations. • Service categories to define available covered service. • Federal and state regulations define service limitations to restrict utilization. • Customization of edits and audits relative to SMA policy. • Utilization tracking of limited services at the member level. • Generation of state and federal reporting requirements.

The Manage Rate Setting business process responds to requests to add or modify rates for any service or product covered by the Medicaid Program.

The Manage Reference Information business process is responsible for all operations aspects for the creation, modification, and deletions of reference code information. The Process Claim business process additions or adjustments trigger this business process. Additional triggers for Manage Reference Information business process include the addition of a new health plan or benefit, or the modification to an existing program due to the passage of new state or federal legislation, or budgetary modifications. The business process includes revising code information (e.g., Healthcare Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT), National Drug Code (NDC)), and/or revenue codes. Business process also adds rates associated with those codes and updates existing rates. The business process updates and adds information from the Manage Member Information and Manage Provider Information business processes as well as drug formulary, health plan and health benefit information. Designate Approved Services and Drug Formulary The Designate Approved Services and Drug Formulary activity is responsible for review of new and/or modified service codes (e.g., HCPCS, International Classification of Diseases (ICD) or NDC) for possible inclusion in various Medicaid Benefit programs. The State Medicaid Agency (SMA) may include or exclude certain services and drugs in each benefit package. Internal or external team(s) of medical, policy, and rates staff review service, supply, a inclusion or exclusion of codes to various benefit plans. The review team is responsible for reviewing any legislation to determine scope of care requirements that the SMA will meet. Review includes the identification of any modifications or additions needed for regulations, policies, and or Medicaid State Plan in order to accommodate the inclusion or exclusion of service/drug codes. The review team is also responsible for the defining coverage criteria and establishing any limitations or authorization requirements for approved codes.

The Manage Health Plan Information business process includes evaluation of federal or state regulations, legislative and judicial mandates, federal or state audits governing board or commission directives, Quality Improvement Organization’s findings, enterprise decisions, and consumer pressure to develop or enhance enterprise business rules, benefit plans and services available to members. The State Medicaid Agency (SMA) collaboratively develops Health Plan service offerings with input and review by other agencies and stakeholders. This business process ensures the organization is on track with the goals and objectives of the SMA and is in concert with statewide goals.

The Manage Performance Measures business process involves the design, implementation, and maintenance of mechanisms and measures the State Medicaid Agency (SMA) uses to monitor the business activities and performance of the State Medicaid Enterprise’s business processes and programs. This includes the steps involved in defining the criteria by which the SMA measures activities and programs (e.g., Consumer Assessment of Healthcare Providers and Systems (CAPHS) and Healthcare Effectiveness Data and Information Set (HEDIS) measures). This business process develops the reports and other mechanisms that it uses to track activity and effectiveness at all levels of monitoring. Business Intelligence analysis (i.e., historical, current and predictive views of business operations) occurs within this process. Examples of performance measures and associated reports may be things such as: Goal: The SMA makes prompt and accurate payments to providers. Measurement: Pay or deny 95% of all clean claims within 30 days of receipt. Mechanism: The SMA generates weekly report on claims processing timelines. Goal: Accurately and efficiently, draw and report funds in accordance with the federal Cash Management Improvement Act (CMIA) and general cash management principles and timeframes to maximize non-general fund recovery. Measurement: Draw 98% of funds with the minimum time allowed under CMIA. Mechanism: The SMA generates monthly report on funds drawn. Goal: Improve health care outcomes for Medicaid members. Measurement: Reduce emergency room visits by ten percent by assigning a primary care case manager. Mechanism: The SMA generates monthly report comparing emergency room usage by member for the period prior to and after Primary Care Case Managers (PCCM) assignment.