PL
Maintain State Plan
Plan Administration
Description
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.
Business Process Template
Trigger events
Environment-based
- Periodic timetable (e.g., annual) is due for review of Medicaid State Plan.
- Periodic timetable (e.g., annual) is due to implement new policy or modification.
- Ad hoc request for Medicaid State Plan updates.
Interaction-based
None published
Results
- The State Medicaid Agency (SMA) defines new or modified Medicaid State Plan.
- Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
- 1. START: Receive prompt or notification to review and update Medicaid State Plan.
- 2. Review relevant current Medicaid State Plan documentation.
- 3. Analyze requirements for change to Medicaid State Plan.
- 4. Research information associated with the change.
- 5. Analyze impact of the change and determine whether to move forward with modification based on results of analysis: a. If no modifications to Medicaid State Plan are necessary, END: Business process stops. b. If necessary, request a waiver for submission in accordance with procedures from appropriate authorities.
- 6. Develop Medicaid State Plan modification.
- 7. Disseminate Medicaid State Plan modification for review, comment and approval by internal and external stakeholders.
- 8. Refine Medicaid State Plan modification based on feedback.
- 9. Conduct Medicaid State Plan Amendment (SPA) review process with CMS.
- 10. END: Publish Medicaid State Plan Amendment.
Predecessor processes
Successor processes
- Manage Health Plan Information
- Manage Health Benefit Information
- Manage Performance Measures
- Manage Applicant and Member Communication
- Perform Population and Member Outreach
- Manage Provider Communication
- Perform Provider Outreach
- Manage Contractor Communication
- Perform Contractor Outreach
- Manage Business Relationship Communication
- Manage Compliance Incident Information
- Formulate Budget
- Manage Data
- Establish Business Relationship
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
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
- The SMA is unable to receive approval of Medicaid State Plan from internal or external stakeholders.
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 4-6.
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?
- LEVEL 1The process consists primarily of manual paper-based activity to accomplish tasks.
- 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 Medicaid State Plan to SMA leadership and other state agencies. SMA distributes Medicaid State Plan electronically to stakeholders.
- LEVEL 3SMA automates process to the full extent possible within the intrastate. SMA uses brainstorming and automatic collaboration tools, which enables statewide input to the Medicaid State Plan setting process.
- LEVEL 4SMA automates process to the full extent possible across the interstate.
- LEVEL 5SMA automates process to the full extent possible across the nation.
How adaptable is the process to change?
- LEVEL 1SMA is unable to adapt easily to changes to the Medicaid State Plan and provide timely information to stakeholders.
- LEVEL 2SMA is able to develop and maintained Medicaid State Plan with collaboration from other agencies that encourages flexibility.
- LEVEL 3SMA develops and maintains Medicaid State Plan with collaboration from other intrastate agencies. SMA quickly distributes modifications to policy to stakeholders.
- LEVEL 4SMA develops and maintains Medicaid State Plan with collaboration from other interstate agencies. SMA distributes in near-real time modifications to policy to stakeholders.
- LEVEL 5SMA develops and maintains Medicaid State Plan with collaboration from other intrastate agencies. SMA distributes in near-real time modifications to policy to stakeholders.
Is Medicaid State Plan traceable throughout the organization?
- LEVEL 1SMA is unable to trace operational activities directly to Medicaid State Plan.
- LEVEL 2SMA is able to trace some operational activities directly to Medicaid State Plan.
- LEVEL 3SMA directly ties all relevant operational activities to Medicaid State Plan within the intrastate. SMA uses business intelligence tools to monitor progress toward benchmarks.
- LEVEL 4SMA directly ties all relevant operational activities to Medicaid State Plan across the interstate.
- LEVEL 5SMA directly ties all relevant operational activities to Medicaid State Plan across the nation.
Does the State Medicaid Agency use standards in the process?
- LEVEL 1SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards.
- LEVEL 2SMA applies a mix of nationally recognized and state-specific standards.
- LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards for intrastate exchange of information.
- LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for clinical and interstate information exchange.
- 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?
- LEVEL 1Very little collaboration occurs with other agencies to standardize information exchange or business tasks.
- LEVEL 2SMA collaborates with other agencies and entities to adopt standards and Electronic Data Interchange (EDI) transactions.
- LEVEL 3SMA collaborates with other intrastate agencies and entities to adopt national standards, and to develop and share reusable business services.
- LEVEL 4SMA collaborates with other interstate agencies and entities to adopt national standards, and to develop and share reusable processes including clinical information.
- 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?
- 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 Medicaid State Plan in an ad hoc manner. Time to complete process is indeterminate.
- LEVEL 2Process timeliness improves through use of automation. SMA conducts more frequent review and modification to Medicaid State Plan. Timeliness exceeds legal requirements.
- 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 Medicaid State Plan in less time than at Level 2.
- 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.
- 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?
- 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.
- 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.
- 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.
- 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.
- 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?
- LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually. Medicaid State Plan is vague and incomplete.
- LEVEL 2Medicaid State Plan is up-to-date and more accurate. SMA stores information in disparate systems, but automation and standards increase accessibility over Level 1.
- LEVEL 3SMA obtains information easily and exchanges with intrastate agencies and entities based on MITA Framework and industry standards. Medicaid State Plan is central, up-to-date and accurate. Accessibility is greater than Level 2.
- LEVEL 4SMA obtains information easily and exchanges with interstate agencies and entities. Accessibility is greater than Level 3.
- 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?
- LEVEL 1High relative cost due to low number of automatic, standardized tasks.
- LEVEL 2Automation improves process and allows focus on exception resolution, improving cost effectiveness ratio over Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards further improving cost effectiveness ratio over Level 2.
- 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.
- 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?
- 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.
- LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving efficiency to 95% or higher.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving efficiency to 98% or higher.
- 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?
- LEVEL 1Manual processes result in greater opportunity for human error. Accuracy is low.
- LEVEL 2Automation reduce error and improve accuracy above Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving accuracy to 90% or higher.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving accuracy to 98% or higher.
- 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?
- LEVEL 1Stakeholders lack confidence in information negatively affecting stakeholder satisfaction with the process.
- LEVEL 2Automation and standardization provides clear and useful information. Stakeholder satisfaction is greater than Level 1.
- 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.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving stakeholder satisfaction to 95% or higher.
- 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 14-21.