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PL

Maintain Program Policy

Plan Administration

Description

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.

Business Process Template

Trigger events
Environment-based
  • Periodic timetable (e.g., annual) is due for review of program policy.
  • Periodic timetable (e.g., annual) is due to implement new program policy or modification.
  • Ad hoc request for program policy updates.
Interaction-based

None published

Results
  • The State Medicaid Agency (SMA) defines new or modified statement of program policy.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Receive request to add, delete, or change policy.
  • 2. Request information to analyze policy.
  • 3. Assess impact of policy on budget, stakeholders, and other benefits.
  • 4. Formulate and publish policy.
  • 5. Hold public hearings.
  • 6. Revise policy.
  • 7. Seek all federal and state administrative and regulatory approvals.
  • 8. If applicable, assess impact of requested revisions.
  • 9. Determine effective date and date span for policy in coordination with other enterprise considerations.
  • 10. If applicable, develop training plan for new policy.
  • 11. Develop implementation plan for policy.
  • 12. END: Disseminate policy.
Predecessor processes
Successor processes
Shared data
  • Plan data store including Medicaid State Plan, health plan, health benefits, performance measures, and benchmarks information
  • Business Activity data store including performance information (e.g., Consumer
  • Assessment of Healthcare Providers and Systems (CAPHS) and Healthcare
  • Effectiveness Data and Information Set (HEDIS) measures)
Constraints

Economic conditions shift, making less revenue available to fund the approved and planned budget. The SMA will comply with federal and state regulations.

Failures
  • Cost/benefit analysis does not support proposed policy.
  • Inability to obtain necessary approvals.
Performance measures
  • Time to complete the process = within __ days, ___ weeks
  • Achievement of goals and objectives linked to policy implementation

Source: CMS MITA 3.0 Business Process Template, Plan Management BPT.pdf, pages 2-4.

Business Capability Model (12 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. SMA uses tools to gather, record, analyze, formulate, communicate, and distribute information on program policy to SMA leadership and other state agencies.
  3. LEVEL 3SMA automates process by brainstorming and using automatic collaboration tools, which enables statewide input to the policy setting process.
  4. LEVEL 4SMA enables regional input into the policy setting process by automating processes.
  5. LEVEL 5SMA uses automatic collaboration tools to automate processes which enables national input into the policy setting process.
How adaptable is the process to change?
  1. LEVEL 1SMA is unable to adapt easily to changes to the program policy and provide timely information to stakeholders.
  2. LEVEL 2SMA is able to develop and maintained policy with collaboration from other agencies that encourages flexibility.
  3. LEVEL 3SMA develops and maintains policy with collaboration from other intrastate agencies. SMA quickly distributes modifications to policy to stakeholders.
  4. LEVEL 4SMA develops and maintains policy with collaboration from other interstate agencies. SMA distributes in near-real time modifications to policy to stakeholders.
  5. LEVEL 5SMA develops and maintains policy with collaboration from other intrastate agencies. SMA distributes in near-real time modifications to policy to stakeholders.
Are policies traceable throughout the organization?
  1. LEVEL 1SMA is unable to trace operational activities directly to program policy.
  2. LEVEL 2SMA is able to trace some operational activities directly to program policy.
  3. LEVEL 3SMA directly ties all relevant operational activities to program policy within the intrastate. SMA uses business intelligence tools to monitor progress toward benchmarks.
  4. LEVEL 4SMA directly ties all relevant operational activities to program policy across the interstate.
  5. LEVEL 5SMA directly ties all relevant operational activities to program policy 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 nationally recognized 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 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). SMA develops program policy in an ad hoc manner. Time to complete process is indeterminate.
  2. LEVEL 2Process timeliness improves through use of automation. SMA conducts more frequent review and modification to program policy. Timeliness exceeds legal requirements.
  3. LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. SMA develops, modifies, tracks, and report on program policy in less time than at Level 2.
  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 2SMA uses standard transactions to 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. 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. Accuracy rating is at 99% or higher.
  5. LEVEL 5SMA adopts MITA Framework and industry standards for information exchange with national agencies. 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. Program policy is vague and incomplete.
  2. LEVEL 2Program policy is up-to-date and more accurate. SMA stores information in disparate systems, but automation and standards increase accessibility over Level 1.
  3. LEVEL 3SMA obtains information easily and exchanges with intrastate agencies and entities based on MITA Framework and industry standards. Program policy is central, up-to-date and accurate. 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 clinical and 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 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 90% 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, Plan Management BCM.pdf, pages 8-14.

Other Plan Management processes

Develop Agency Goals and ObjectivesMaintain State PlanManage Health Benefit InformationManage Health Plan InformationManage Performance MeasuresManage Rate SettingManage Reference Information