AHCA RFI 014-2425_FX Core-FMMIS Final.pdf

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

REQUEST FOR INFORMATION

AHCA RFI 014-24/25, Page 1 of 11

AHCA RFI 014-24/25 FLORIDA MEDICAID MANAGEMENT INFORMATION

SYSTEM TAKEOVER AND MODERNIZATION

RFI RELEASE DATE: April 1, 2025

TABLE OF CONTENTS

I. GENERAL INFORMATION

A. Request for Information Process

B. Background

C. Purpose

II. RFI RESPONSE INSTRUCTIONS

III. PUBLIC RECORDS EXEMPTIONS, TRADE SECRET OR PROPRIETARY

INFORMATION

IV. RESPONSE SUBMISSION

V. COSTS

VI. QUESTIONS

VII. CALENDAR

VIII. CHANGES TO THE RFI

IX. AGENCY FOR HEALTH CARE ADMINISTRATION WEBSITE

X. SPECIAL ACCOMODATIONS

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I. GENERAL INFORMATION

A. Request for Information Process

This is a Request for Information (RFI) as defined in Section 287.012(22), Florida Statutes (F.S.), for planning purposes. This RFI is issued by the State of Florida, Agency for Health Care Administration (Agency), to solicit information regarding available providers for the services described herein.

An RFI is not a method of procurement. Responses to an RFI are not offers and shall not be accepted by the Agency to form a binding Contract. This RFI and Responses to it shall not result in the execution of a contract with the Agency. By submitting a Response to this RFI, a Vendor is not prohibited from responding to any related subsequent solicitation. This RFI may be used for purposes of researching general, special, and/or technical specifications for a solicitation. The Agency reserves the right to utilize the information gathered through the RFI process to develop a scope of services, which may be incorporated into a contract using a statutorily approved method of procurement.

B. Background

The Agency is adapting to the changing landscape of healthcare administration and increased use of the Centers for Medicare and Medicaid Services’ (CMS) Medicaid Information Technology Architecture (MITA) to improve the administration and operation of the Florida Medicaid Enterprise. The current Florida Medicaid Enterprise is complex; it includes services, business processes, data management and processes, technical processes within the Agency, and interconnections and touchpoints with systems necessary for administration of the Florida Medicaid program that reside outside the Agency. The future of the Florida Medicaid Enterprise integration is to allow the Agency to secure services that can interoperate and communicate without relying on a common platform or technology.

The Florida Medicaid Management Information System (FMMIS) has historically been the central system within the Florida Medicaid Enterprise, functioning as the single, integrated system for claims processing and information retrieval. As the Medicaid program has grown more complex, the systems needed to support the Florida Medicaid Enterprise have grown in number and complexity.

Florida Health Care Connections (FX) is a multi-year transformation to modernize the current Medicaid technology using a modular approach, while simultaneously improving overall Agency service delivery and building better connections to other data sources and programs, resulting in the ability to provide better health care for all Floridians.

FX is the transformation of the business, data, services, technical processes, and technology necessary for the administration of the Florida Medicaid program. The FX transformation is guided by the FX Vision to Transform the Florida Medicaid Enterprise to provide the greatest quality, the best experience, and the highest value in health care.

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The largest system in the Florida Medicaid Enterprise is FMMIS, currently operated by Gainwell Technologies, LLC (the Agency’s Fiscal Agent vendor). The FMMIS components of the system are comprised primarily of a collection of custom-built software applications used for processing Medicaid claims and encounter transactions. This processing includes the adjudication of claims and encounter transactions via batch processes and online submissions, the processing of financial transactions, producing and distributing payments (including managed care capitation payments), the storing and utilization of provider and recipient enrollment and demographic data, and the implementation of business rules and supporting reference data.

The technologies utilized in FMMIS include Windows and Linux operating systems, Oracle and SQL Server databases; COTS products such as SPSS, and;

programming languages include C, C#, VB.NET, JavaScript, Perl, VBScript, R, and

SAS.

The Interchange User Interface (UI) is a web-based solution, used in multiple states, developed with Microsoft.NET technologies. The UI allows access to all Claims, Provider, Recipient, Financial, and Reference data stored in the FMMIS. Authorized users also have access to update relevant data.

The claims processing system in FMMIS is rules driven and has been configured to monitor and manage the execution of Medicaid policy. Edits, audits, and various configurations of rules are applied to submitted Fee-for-Service (FFS) claims to process Florida Medicaid related business processes. The current management and application of rules does not happen in a single component, but through multiple components which work together to comprise the business process workflow.

The Agency is taking an iterative approach to transformation where key functions supported by FMMIS and the Fiscal Agent are to be replaced by new modules and integrated as they are developed. The transformation timeline is reflected in the FX Strategic Roadmap which can be found on the Agency’s website at FX Strategic Roadmap | Florida Agency for Health Care Administration.

The Agency has successfully procured and implemented the base technology required to support the individual modules, including the integration services, platform, and an enterprise data warehouse. Additionally, key business operations, such as contact centers and print and mail services, are in the process of being consolidated into a Unified Operations Center (UOC). With the support of other module vendors, the Agency is currently working on the implementation of the Provider Services Module (PSM), which will manage Medicaid provider enrollment, re-enrollment, credentialing, and maintenance. Upon completion of the PSM and UOC implementations the remaining FMMIS services will be focused on claims and encounter processing, Electronic Data Interchange (EDI), financial management, and recipient data management (including intake and maintenance).

This RFI is requesting input and recommendations from vendors on the approach and information needed to transition and modernize the remaining limited scope within FMMIS, following the full implementation of the PSM and UOC modules, into a standalone module.

https://ahca.myflorida.com/medicaid/florida-health-care-connections-fx/fx-strategic-roadmap https://ahca.myflorida.com/medicaid/florida-health-care-connections-fx/fx-strategic-roadmap

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The standalone module represents the most fundamental functionality required for Medicaid processing and the most complex functionality within the current system.

The standalone module will:

• Adjudicate FFS claims for Medicaid reimbursement

• Process managed care encounter claims

• Support all Medicaid financial activity (including managed care capitation payments).

• Manage the receipt, adjudication, editing, pricing/shadow pricing, disbursement of funds, and reporting of claims and encounters including, but not limited to, physician, hospital, outpatient, nursing home, dental, vision, transportation, disability services, behavioral health, and waiver services.

• Adjudicate FFS claims in real-time and produce X12 transaction remittance advices.

• Support a diverse set of reimbursement methodologies for FFS and managed care organizations, and apply those reimbursements based on the appropriate criteria.

• Track, display, and report on all claims and encounters processing activity throughout the adjudication process, including reimbursement.

• Be configurable and flexible to support claims and encounters processing to ensure accurate and timely processing and adjudication determinations based on benefit criteria, reimbursement rules, and associated standard reference data.

• Generate capitation payments to the health plans based on the number of recipients assigned to the plan and the correct capitation rate based on the rate cell within which the recipient resides.

• Be responsible for the file maintenance, reconciliation, storage, and retrieval of reference data including that of recipients and providers received from external partners or other module vendors to generate enrollments, process claims, encounters, and capitation payments.

• Maintain recipient eligibility, benefit plan assignment, and plan enrollment

• Process MCO enrollments and auto enrollments.

• Process and maintain CMS Buy-in functions and reference data.

• EDI transactions using the X12 format with enhanced validation processing to share data with trading partners

Exhibit 1: Modular Journey Graphic depicts the future state vision.

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In the summer of 2024, an Agency team conducted a comprehensive assessment to evaluate the viability, operability, scalability, and sustainability of the FMMIS applications and infrastructure. This assessment encompassed a thorough review of various aspects, including the infrastructure and technical architecture, applications, hardware, software configurations, audit logging, system monitoring, disaster recovery, and security information and event management.

The team reviewed and analyzed the retrieved documentation, synthesizing the findings into a list of forty-one (41) areas identified as potential opportunities for modernization or modularization.

Modernization focuses on transforming legacy systems or processes to improve operational efficiencies during system operations and maintenance. For example, a recent key modernization initiative by the Fiscal Agent involved migrating from the HP-UX operating system to Linux on both database and application servers. This upgrade was designed to address performance challenges by leveraging more powerful hardware and increasing processing capacity. The successful completion of this Linux migration has significantly enhanced hardware processing capabilities by adding more central processing units (CPUs), thereby improving FMMIS processing and alleviating constraints on Enterprise Data Warehouse (EDW) data replication sessions.

Modularization involves restructuring legacy systems, functions, or processes to align with other module vendors or integrate them with enterprise-wide tools and products. Consolidating operations under enterprise tools across all modules not only streamlines operations but also reduces costs. Additionally, as responsibilities shift from legacy contracts to other vendors, the scope of future FMMIS functions will be narrowed. A prime example of modularization currently in Design, Development, and Implementation (DDI) is the integration of the enterprise tool ForgeRock for user authentication and single sign-on (SSO) within FMMIS. This integration will facilitate the retirement of the legacy Medicaid Enterprise User Provisioning System

(MEUPS).

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The legacy vendor is currently involved in DDI activities for two key modernization and modularization tasks identified as potential opportunities. In addition to transitioning MEUPS to ForgeRock, the legacy vendor will implement GainwellConnect Lite, enabling FMMIS API service capabilities. This will allow other module vendors or external sources, such as PSM, to communicate with the legacy system.

Furthermore, two discovery and planning activities are in progress. These include the migration of FMMIS to the cloud from the existing on-premises Orlando Data Center and the alignment of disaster recovery processes with the standards set by FX Enterprise.

The full list of proposed modernization and modularization task can be found in Attachment A.

C. Purpose

The Agency is seeking information from entities and stakeholders with direct experience with Medicaid fiscal agent systems and operations regarding best practices and innovations in modular transition, operations and maintenance, and modernization of existing legacy Medicaid Management Information Systems (MMIS). The Agency is issuing this RFI to the vendor community to obtain information on the takeover and modernization/modularization of the FMMIS solution and associated Fiscal Agent business processes into a standalone module. The current contract for the operations and maintenance of FMMIS expires on December 31, 2027.

The Agency is seeking innovative ideas, best practices, and proven experience in the transition and takeover of state MMIS systems, specifically in the following areas:

i. Vendor experience in taking over existing FMMIS systems and business operations.

ii. Approach and strategy to transition the takeover of FMMIS systems and business operations.

iii. Processes and risk mitigation strategies to ensure a smooth, timely, and successful takeover.

iv. Vendor’s methodology and approach to continue business operations and supporting technology for functions that may not have transitioned from the existing legacy operations in accordance with the FX Strategic Roadmap.

v. Business continuity strategies to maintain operations seamlessly upon takeover.

vi. Strategies for continuous monitoring of the system’s performance post-takeover to identify and address issues quickly, ensuring that goals are being met.

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vii. Recommended implementation roadmap or timeline for the transition.

viii. Strategies for retaining current fiscal agent staff during and after the transition.

The Agency is seeking innovative ideas, best practices, and proven experience in modernizing legacy state MMIS systems into a modular environment.

i. Insights gained from experience in other states related to modernizing claims/encounter and financial management processes.

ii. Strategies for ensuring seamless integration with other modules or infrastructure within the Medicaid Enterprise.

iii. Knowledge of obstacles to modernization of legacy MMIS systems and tactics to offset or avoid.

iv. Recommendations for business functions within a standalone module, including whether the module should be comprehensive or if functions such as EDI, Encounter Processing, or Recipient Management should be separate modules or procurements.

v. Guidance on prioritizing or inclusion of modernization and modularization opportunities outlined in Attachment A.

vi. Proposed roadmap or timeline for conducting DDI activities related to the identified modernization and modularization opportunities.

vii. Refactor to a scalable system to support interoperability and future innovations.

viii. Help reduce the total cost of operations, improve availability and increase data accessibility.

Respondents who reply to this RFI may be invited to present their ideas in person to Agency leadership. An invitation to present in person does not prohibit an entity from responding to any related subsequent solicitation.

II. RFI RESPONSE INSTRUCTIONS

Respondents to this RFI are asked to be thorough, but concise. Respondents should minimize the focus on their background and prioritize addressing the four objectives outlined in Subsection B below. The RFI Response should include the following:

A. The Respondent’s name; place of business address(s); web site address, if applicable; and contact information, including representative name and alternate, with telephone number(s) and e-mail address(es).

B. A description of how the Respondent's approach will 1. offer advantages or improvements over existing processes of the FMMIS operations and maintenance,

2. ability to seamlessly takeover operations without a degradation in services, 3.

tactical approach for expedited implementation of modernization and

AHCA RFI 014-24/25, Page 8 of 11 modularization activities, and 4. recommendations for scope of services to be included in a single or multiple procurements. The description should also identify known or potential concerns or risks with the approach.

III. PUBLIC RECORDS EXEMPTIONS, TRADE SECRET OR PROPRIETARY

INFORMATION

Any portion of the submitted Response which is asserted to be exempt from disclosure under Chapter 119, Florida Statutes, shall be provided in PDF format; shall be clearly marked “exempt”, “confidential”, or “trade secret” (as applicable); and shall also contain the statutory basis for such claim on every page. Pages containing trade secret shall be marked “trade secret as defined in Section 812.081, Florida Statutes.” Failure to segregate and identify such portions shall constitute a waiver of any claimed exemption and the Agency will provide such records in response to public records requests without notifying the Respondent. Designating material simply as “proprietary” will not necessarily protect it from disclosure under Chapter 119, F.S. An entire Response should not be considered trade secret. Respondents who fail to identify trade secret as directed herein acknowledge and agree that they waive any right or cause of action, civil or criminal, against the Agency for Health Care Administration, its employees, and its representatives, for the release or disclosure of trade secret information not so identified.

IV. RESPONSE SUBMISSION

Respondents to this RFI shall submit one (1) electronic copy of its Response. The Response shall not exceed twenty (20), single-sided pages in length. The electronic format shall be submitted via e-mail. The software used to produce the electronic files must be Microsoft Word 2013 and/or Excel 2013 or newer. The electronic files must be appropriately named.

The Respondent shall also submit via e-mail one (1) electronic redacted copy of the Response suitable for release to the public. Any confidential or trade secret information covered under Section 812.081, Florida Statutes, should be either redacted or completely removed. The redacted Response shall be marked as the “redacted” copy and contain a transmittal letter authorizing release of the redacted version of the Response in the event the Agency receives a public records request.

Responses to this RFI shall be provided no later than 5:00 PM, Eastern Standard Time

(EST), May 1, 2025. Responses shall be e-mailed to:

solicitation.questions@ahca.myflorida.com.

Responses shall be addressed to:

Brooke Coulliette

Procurement Officer

Email: solicitation.questions@ahca.myflorida.com

V. COSTS

Respondents are responsible for all costs associated with preparing a Response to this mailto:solicitation.questions@ahca.myflorida.com

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RFI. The Agency will not be responsible for any Respondent costs associated with preparing a Response to this RFI.

VI. QUESTIONS

Questions concerning this RFI shall be submitted in writing by no later than 5:00 PM, EST, April 8, 2025, via email to: solicitation.questions@ahca.myflorida.com.

All Agency responses to questions received by the deadline for questions will be posted with this RFI in the Vendor Information Portal. The Agency anticipates responding to questions by April 17, 2025.

VII. CALENDAR

Listed below are important dates and times when actions should be taken or completed. If the Agency finds it necessary to update any of the dates and/or times noted, it will be accomplished by an addendum to the RFI. All times listed below are in Eastern Standard Time (EST).

VIII. CHANGES TO THE RFI

The Agency will post the RFI and any addenda to the RFI on the Florida Vendor Information Portal (VIP) at MyFloridaMarketPlace Vendor Information Portal. Each vendor is responsible for monitoring the VIP for new or changing information.

IX. AGENCY FOR HEALTH CARE ADMINISTRATION WEBSITE

Additional information about the Florida Agency for Health Care Administration can be found on the Agency’s website at: http://ahca.myflorida.com.

X. SPECIAL ACCOMODATIONS

Any person with a disability requiring special accommodations to participate in the RFI shall contact the Agency contact person at the phone number above at least five working days prior to the submission deadline for Questions and/or Responses. If you are hearing or speech impaired, please contact this office by using the Florida Relay Services which can be reached at 1 (800) 955-8771 (TDD).

Date Time Description

April 1, 2025 N/A RFI Release.

April 8, 2025 5:00 p.m. Questions due to the email address in Section VI.

April 17, 2025 N/A Anticipated Answers to questions posted.

May 1, 2025 5:00 p.m. Responses are due to the email address in Section

IV.

http://ahca.myflorida.com/

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ATTACHMENT A

MODERNIZATION ITEMS

# Recommendation Type Value Effort

Modernizing our EDI offering (SNIP Level 4 to 7)/modern software framework Operations Efficiency High High

Configurable business rules and use BRE instead of embedded code Operations Efficiency Medium High

Improving database normalization along with data cleansing Operations Efficiency Medium Medium

Modernizing our front end/GUI. Enhanced user experience with advance search capability and other embedded researching tools

Operations Efficiency Medium Medium

5 Deidentifying data, even in lower environments Security Compliance Low Medium 6 Bank checks to EFT Operations Efficiency High Medium 7 Tracking user PHI access Operations Efficiency High Medium

Revisit SFTP server re-login attempts to adhere to Agency Security Standards Operations Efficiency Medium Low

Update Security Documentation (SSP) to be in compliance with FX standards Security Compliance Medium Medium

Implement a PAM based on recommendations from SSA Security Compliance Low Low

11 Revisit infra redundancy and high-availability Operations Efficiency High Medium

Integrate with the FX Enterprise Disaster Recovery process Operations Efficiency High Low

Revisit and implement a Disaster Recovery process that align with the current needs (RPO/RTO) for the enterprise.

Compliance High High

Revisit System Monitoring process and introduce efficiency to manage competing resources Operations Efficiency High Low

15 Support FX Replication without any interruptions Operations Efficiency High Low 16 Implement an interim CMDB and capacity plan Operations Efficiency Low Low

Identify processes that can leverage real-time data vs batch processes by implementing a Service Oriented Architecture

Operations Efficiency High Medium

Leverage modern ETL tools for data ingestion and migration Operations Efficiency High High

Align the testing and environments with the TCOE processes. Operations Efficiency High Low

Align FMMIS Change Control to Agency's Change Control Operations Efficiency High Low

Sunset SAP BO and replace with the EDW tools or other modern DA tools Modernization Low Medium

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22 Modernizing the platform and hosting in the Cloud Operations Efficiency High High

MODULARIZATION ITEMS

# Recommendation Type Value Effort

Sunset iTrace, using FX Service tools (Jira, KMS, LMS) ITCO High Medium

2 Integration with Gainwell Connect Modularization High Medium 3 SFTP to ISIP Managed File Transfer Modularization High Medium 4 Document and align with MITA business processes Modularization Medium High

Sunset Onbase, migrate content and integrate with

ECM

Modularization High High

6 Sunset MEUPS and integrate with ForgeRock SSO Modularization High Medium 7 Integrate and leverage FX Helpdesk (ServiceNow) Modularization High Low 8 Integrate InterChange with FX Portal Modularization High Medium 9 Integrate with the EDW Reporting portal Modularization High Low

Use the Enterprise Address verification, formatting and validation (AddressDoctor)

Modularization Low Low

Leverage the Enterprise Job Scheduler (ActiveBatch) Modularization High Medium

12 Log shipping to the Enterprise SEIM (Splunk) tool Modularization High Low

Leverage MDM for the Recipient Intake (DCF, SDX, FHKC etc.)

Modularization High High

Revisit the Recipient Management/Maintenance Process and the implementation owner

Modularization High High

15 Monthly/Quarterly File Reconciliation Modularization Low Medium 16 Monthly Plan Enrollment File Modularization Low Medium 17 Move EDI Helpdesk to UOC Modularization High Low 18 Leverage CobbleStone for SLA monitoring Modularization High Low 19 Participate in ARB, EDG and ERG Modularization High Low