PL
Manage Health Plan Information
Health Plan Administration
Description
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.
Business Process Template
Trigger events
Environment-based
- Periodic timetable (e.g., annual) is due for review of policy.
- Periodic timetable (e.g., annual) is due to implement new policy or modification.
- Ad hoc request for program policy updates.
Interaction-based
None published
Results
- The SMA defines new or modified policy.
- Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
- 1. START: Notification of legal or administrative mandates that have potential impact to Health Plan policy.
- 2. Analyze legal or administrative mandates and determine whether to create, revise, or terminate Health Plan policy.
- 3. Assess impact of policy on budget, stakeholders, and other benefits.
- 4. Create, revise, or terminate Health Plan policy and publish new, revised Health Plan policy, or notification of intent to terminate existing Health Plan policy.
- 5. Hold public hearings regarding Health Plan policy.
- 6. Revise Health Plan policy as necessary.
- 7. Submit Health Plan policy to federal and state administrative and regulatory agencies for approval.
- 8. Assess impact of requested revisions, if applicable.
- 9. Determine effective date and duration for Health Plan policy in coordination with other enterprise considerations.
- 10. Develop training plan for new, revised or discontinued Health Plan policy.
- 11. Develop implementation or transition plan for new, revised, or discontinued Health Plan policy.
- 12. Implement Health Plan policy.
- 13. END: Send Health Plan policy to Health Insurance Marketplace for certification.
Predecessor processes
Successor processes
- Manage Health Benefit Information
- Manage Reference Information
- Manage Rate Setting
- 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
- Establish Compliance Incident
- Manage Compliance Incident Information
- Formulate Budget
- Manage Data
Shared data
- Financial data store including budget information
- Member data store including demographic information
- Contractor data store including provider network information
- Provider data store including provider network information
- Plan data store including policy information
- Health Benefit data store including benefit program and benefit information
- Reference data store including code set information
- Authorization data store including authorization and treatment plan 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 6-8.
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?
- 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 plans.
- LEVEL 3SMA automates process to the full extent possible within the intrastate. Health Plan information is shared with Health Insurance Marketplace (HIX).
- LEVEL 4SMA automates process to the full extent possible across the interstate. Health Plan 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. SMA utilizes a Unique Health Plan Identifier.
- LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for clinical and interstate information exchange. SMA utilizes a Unique Health Plan Identifier.
- LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of information. SMA utilizes a Unique Health Plan Identifier.
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 HIPAA 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). The health plan 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 Health Insurance Marketplace (HIX). Timeliness exceeds Level 2.
- LEVEL 4Information is available in near real time. 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 health plan details.
- LEVEL 2SMA stores information in disparate systems, but automation and nationally recognized standards increase accessibility over Level 1. SMA publishes health plans on state’s web site.
- 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 plans are inflexible and lock members into a single plan. 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 21-27.