Manage Health Benefit Information

Health Benefit Administration

Description

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.

Business Process Template

Trigger events

Environment-based

None published

Interaction-based

Receive inquiry for health benefit information from enterprise business processes.
Receive an inquiry from authorized external parties (e.g., a legislator requests outcome measures for a particular program). Environmental Trigger Events:
Periodic or near real-time transmission of program information to authorized external parties or systems, (e.g., Centers for Medicare & Medicaid Services (CMS) or Medicaid Statistical Information System (MSIS)).

Results

Response to inquiries from authorized requestors and/or applications.
Provision to all other Health Plan Management business processes with program information as needed (i.e., to develop benefit packages and drug formularies, set rates, analyze and project budgets, perform accounting functions, manage federal financial participation (FFP), measure quality, outcomes and performance, and develop policies and strategic initiatives, etc.).
Provision to all MITA business processes with program information needed (e.g., to manage communications, manage business relationships, perform outreach and education, and manage contracts).
Delivery of information to external parties or systems for reporting (e.g., CMS Medicaid Statistical Information System (MSIS) and public health for population health studies).
Delivery of modification to health benefits to Health Insurance Marketplace for certification.
Tracking information as needed for measuring performance and business activity monitoring.

Business process steps

1. START: The modification of health plan policy determines the health plan benefit packages that require definition or modifications to comply with the policy.
2. Create and modify health plan benefit packages that support definition of services available for various SMA programs.
3. Define the effective date and duration of the health plan benefit packages.
4. Define the health plan benefit package coverage narrative.
5. Define services specific to unique health plan benefit packages.
6. Specify limitations at both the service and monetary levels relative to health plan benefit packages and service categories.
7. Define any applicable member monetary constraints that include co-pay, co-insurance, deductible, and share of cost amounts, limits, and lifetime maximums.
8. END: Send health plan benefit services to Health Insurance Marketplace for certification.

Predecessor processes

Successor processes

Shared data

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)
Plan data store including policy and health benefit information
Health Benefit data store including benefit package and benefits information
Provider data store including provider network and contract information
Contractor data store including provider network and contract information
Member data store including applicant or member demographics, enrollment, financial, social, functional and clinical information
Claims data store including payment history

Constraints

Policies and procedures will differ by state, especially those relating to information standards, record keeping, and privacy.

Failures

Inability or failure to load initial records, properly analyze, update, or locate existing records in the Business Activity data store.

Performance measures

Time to store information = within __ minutes
Time to access information = within __ minutes
Error rate = __% or less

Source: CMS MITA 3.0 Business Process Template, Plan Management BPT.pdf, pages 10-13.

Business Capability Model (11 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 business intelligence tools to analyze data to support maintenance of the health benefit packages.
LEVEL 3SMA automates process to the full extent possible within the intrastate. Health Benefit information is shared with Health Insurance Marketplace (HIX).
LEVEL 4SMA automates process to the full extent possible across the interstate. Health Benefit information is shared with Health Insurance Marketplace (HIX).
LEVEL 5SMA automates process to the full extent possible 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 flexible are the contents of the health benefit package?

LEVEL 1Health benefit packages have pre-set services and provider types.
LEVEL 2SMA structures waiver programs to permit more flexibility around selection of services and providers within a health benefit package.
LEVEL 3The process is fully flexible to the extent possible across the intrastate All programs introduce flexibility within health benefit packages, enabling consumer driven health care with more choices among services and provider types.
LEVEL 4The process is fully flexible to the extent possible across the interstate.
LEVEL 5The process is fully flexible to the extent possible across the nation.

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 nationally recognized standards and Electronic Data Interchange (EDI) transactions. SMA collaborates with Waiver programs, other agencies, Managed Care Organizations (MCOs) through a Memoranda of Understanding (MOU) to define shared services.
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). The health benefit changes take a significant amount of time to complete, depending on the complexity and cost of coverage affected.
LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements.
LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. Timeliness exceeds 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 2HIPAA standard transactions 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. Decision-making is automatic using standardized business rules definitions. 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. Decision-making is automatic using regional standardized business rules definitions. Accuracy rating is at 99% or higher.
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?

LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually. SMA does not publish or widely distribute the health benefit package.
LEVEL 2SMA stores information in disparate systems, but automation and nationally recognized standards increase accessibility. SMA publishes the health benefit packages on state’s web site. Accessibility is greater than Level 1.
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.
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 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. Health benefit packages are inflexible and lock members into a single package. Accuracy is low.
LEVEL 2Automation and standardized business rules definitions 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 34-40.

Other Plan Management processes

Develop Agency Goals and Objectives Maintain Program Policy Maintain State Plan Manage Health Plan Information Manage Performance Measures Manage Rate Setting Manage Reference Information