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Department of Health and Human Services

Centers for Medicare & Medicaid Services

Enhanced Funding Requirements:

Seven Conditions and Standards

Medicaid IT Supplement (IV1ITS-11-01-V1.0)

Version 1.0

April 2011

GwtfeR for Medtoafe & Medteakl Servicee

Table of Contents

1, Introduction ",

1. 1 BiKAground....,

1.2 Purpose fsaS Scope,

2. Conditions and Standard8..,,..,.., i.»,,.,.. <.......,.,......,... »..,..,...,.....................,......... -

2.1 2,3 2,4 2.5 2,6

Modulant^ Slandard MTTA Condition.

Industiy Standards Condition .," Leverage Ccittditloa.

Bnsttoess Resnlts Condition,, Reporting Conditioii.

2.7 IntCTppCTa])iUty CcmdidqA

3. Next Steps.

.,2 ,A ..5 .,5 .,6 ..7 ..7

,8

Acronyms..,....,.,,,...,.,,,,,,,..,,.,,..,,.,.,.,...,,..,,.,.. -"."""..".....,. "".".... ""."".."..""""."".""" 9

Etil)anc%IFundingRequi[erjiCTls:SwenCondilbraan()£aander((s Version 1.0 Apt all;

Contefs for MscJfcare & MecfcqM Services

1. Introduction

1. 1 Background Under sections 1903(a)(3)(A)(i) and 1903(a)(3)(B) of the Soolal Saomity Ast, the CuBteffl for Mddloare <S: Medicaid S wrices (CMS) Iias issued new standaida and condltioias fiiat nmst be met by the states ia ordat for Medioaid tedttiology inveataients (Includfiig traditional diiima ' prooessmg systems, as woU as Biigibilify systems) to be eligiblo far fba aibianoed match ftmdiag.

This final regulatiou Brtabllshiiig fliese standards and conditions was made public on April 14, 2011 at}ifliuZBBW,TB2uii(tfons.Kov/#l8<atohR9Sul1sawalO:po=°70:8<3liIS-2Ql0^5l.

Our purpose in movfag to this atmdaids and conditioiu-based approaoh to Bpprovlag federal funding is intsaded to foator better collaboralioii wifit statM, reduce uniieoessaiy pitiarwoAi and fccas attmtioa on fhe key elements of success for aiodmnsystoinBdsvclopmeatmddeploymeiit.

In^flifsdooumantTwejirOT'ide mare'iietaiTaboutthe swenconaiBonsand'stetuSTBs'BnillEe'Bnis' of idfoiCmation, activities and docBmentation tiie fedatitl govamment will exa.mln? o-rer tho course of a systetas develDpmmt lifeoycle to allow for initial and cmgomg approval oferihmced fending, Moreimportuifly, tese dimensions ofdevelopmaat w.d artifacts are esSBntlgl to hdp states ensure feey am tnaldflg efficient investments and -will iiltimat&ly uqprove the litelihood of suocessftil system miplameDtation and oparation. Thi8docnment, andfhepriliolpleacoitfaineditt ow April 2011 fiBfll rsgnlation, bdld on fea woit: CMB, states ana private iaAutty have done ovsr the last six yesss under (tie Msdicald lafoimation Tedmology Architecture (MTTA) initiative.

MCTA is intended to ftaler integcated busiuass ahd iirformatian tcctoiology (IT) tntBSfonnaUcn across the iSIedicirid en.terprise tn iaipji'ovotho adnmuiStratl(m and bperation oftiie Mediciiiii jiTOgraai. file Medicaid anterpriw is cempriscil of Ac states, the federal govettmiettl, Bnd stakdolderB wlio me directly and iadnectly pm't of fhe admMatration Emd health oare ddivaty ecosystem. ) Tiie MifIA mitiatlye pfovidec a poaunon SsMewatk. for all Medioaid stakeboldffls to focus on opp&rtumties to build common sendces by deKmplmg legacy systems and piwessos, and liberating data previously stored std contained iniliiiccSsaiblB silos, ThcMITA fiameworlt faeflitatea a more modea and a^lc approach, to trailitional systems dwelopaent Ufecycle approaohes that have bsd great difBculty m teepmg up with (he Bite of cllacge demanded by the ch gmg t'usmesa landscape of health care delivary md admimstratioa. By providing a common Frameworis: for (he MeiHcrid Entotprise to plm, architect, Engmeer, nnd ijBiplemant new and ctuagiag business tequirements, Sie effert to aodemfae Mwlicaid rT systams imdprocesseE beeox-nas note stalle, mufcrui, ma lowers Ehe risk of poor implementation. Ovar tima, -this effort will davc ilie states' systeus toward s widesproBd network of sliu-ixl, common teclmology and p.rooessos that fflipport ii-npmved state adinnustratlaa offha Medicaid program. OIB' ililtial empliaeis is on strsaBnlimiig fhe sligib. ility and acrolltaaat ptoceaa, improvmg user e)cpEi'}aic»s, iawcasiflg adininistiattve Bffloieiwieg, and scpportmg widi gi'eatca- affectivenesE the ability to manige care and produce improved heal(h outcoin. es tw difcdioaid banBficiariea.

The MTTA iaitiative began in. 2005 wi& (he concept ofmovmg fte deiugn and development of Medicald iBfdunation systssms ftyay fi'om fce siloed, sub-gyrtam ccarpoae.nts fliflt comprise a typical M:ed!caid Mmagem. ent InfoaBationSyStema (MM1S) and mwmf; to B semce oriented architecture (SOA) 6sm.ev/ot1t ofctesigBteg Mectieaid mfoimatioii. Eystems doBg the oarB

Enhaocffift Fimdbfl RsqulrstltenEs; Sewn GondfBons and SlarKJardg Vereloit 1.0 Api 201 If

Cenbn for Mafcaa i Medicald 8«nfcm principle thai 'businesa processes lafonn iicd drive die implementatloa of biisianss services. TIie MTTA initiative prodcced iai arohlteoture fiaa>ewor](-1)uslaess, teohnical, mii iBfomiatloa-dong wifh a buatoess matarity model ferprixieai iinprovemaat, that gtides Uigplannmg of tectoology md infrastTBOtute build-out to meet tlie changmg busmess, needs ofMsdicsid programs. MITA enables all state Medicaid aiterprieea to meet coBimon objectives withm the MTTA ftameworis wlrile BtlU supporting locd needs unique to the .partloulfu- state, AU MTTA flmneworlc doimmaits are available to the public at htto^www. cms. eoWMtdlciddBrfbTechAmh/.

CMS is also Issuing OuidcmoeforEwfumge and 'Medicaid Information Tedinolosy (IT) Sysiems OT &.ttdance) tdwant to Medicaid agencies as it arttouletos e'xpeotadons aid supports development and de.slgti for Medloald and Bxolwngs opetationa. Medlcald and Bxdumge rr Guidance feeuses on those business flmctkmB and sujpportiag TT solutioim needed for succBBafiiI Implfflneotation of expanded coverage flimughprtmium tax crsdlts atidieduced cost aharing, and entoUmant in Medicud md CMIdren's HeaKb. Insm'ance Prograa (CHIP), .

.-. ---CMStEcogmze8that. fcere-lg-nota-"oue8ize-fiO. »lI'^teol). ftology-8ohitiQa-to-cyety-bnailisss_^ oliallenge. Eacli teclmolagy investuieat mwt Ie viewed la Bght of axisting, lalm'elated assets and thetr matarity. Ilei'e sre trade-offs concemirig schedules, costs, riafa, business goals, and ofhat faotars that should be ooamdared when lualdng teclmology ilivestmmta; howevca', CMS must ensure thai enhanced Pedeaal Flnsnoial Participation (FFP) ftmding Is approved only when Medicaid infi-astmcture and uribtWAtion syatsais proj&ots mert Matatary md regulatoiy lequiranents to support efficient and efl'ective opemtion offhe program,

1.2 Purpose and Scope

The purpose of (his docamant ia to assist rtates as they design, develop, implwBect and opefate tectoiologyaadayetuns.ptojeotain support of the Medicud program. Thisdooumsatpiovidea additional insight and conteict to states to allow thorn to meet the conditions and stgndflTda for antunced fedaral matdi for Medxoaid tociaology lnv«8ttaen1a. Putute edttions offhis guidsnce will be dovelopfld with aclditicmal input &oa and oonsnltBtion wifti etates,

2. Conditions and Standards

2.1 Modularity Standard

TJiis ooaditioa requires (heuso of a modular, flexible approaohto systAnu devdopment, ifiClucUag .fheuac ofotisti ititerfBeeai and exposed applieuticinprogrittmmug interfaces (API); the sepamtion ofbusinais rolBS jii-om core progtaniroins and tho avmlability ofbiisinese rules in both hufflan and niachlno-roadable fomaats. The ooimmtmant to foimnl systam developincnt meftodology end open, reusaUe syetam aioluteofiu'c is ciitfemely impottanl m order to enaure tbat slates can more eaaly clianga md. mBmtam syshans, iia well as mtegratB end. interoperatB witli 8 clmicst and aAnimstrative ecosystein deeigad to doBvarpeiEQjn-oentac services and bensflts.

Modularity is breakicg (town Bystetna t'eqult'emenls into component parts. Extremely complex Bystemg can lie developod as pal'l of a satvlcB-orientod atchiteotiire (SOA), Moiiulfiaty aho helps addreas (tie cllBlleuges ofcustoBUzalion, BaseKne Wab aCTmoea iiail eapahiliiies can Ie

Enhanced Fundfis F'tequfremenls; Seven OofflMtons and Sfaitdgrtis Verakn 1.0 AfllMff

Csritars for Madloere & Maloak) Swvices developed ibr and used by anyoas, with exceptions for spectSo buatoess processes hauttlai by a sepmate module that interopemtes with {be baseline modules, Witfa aodulatity, Aanges cm be made kidepemleuflyto fhe baseline oqiabititics wiftiont aSectinfi how (he extamionwatks. By doittg so, £hs desiga aasureB <hat fltture iteratians of software cm be deployed without brsakmg custom fimotionality, A critical elament ofcomplianoe with felfl condition is providiag CMS witfa ec, mida-sticbditig of .whare services and code will be tightly coupled, and wi.a'e (he rtate will pursue a mM& aggrassive deoouplmg strategy.

Use of Syatema Development Llfecycle meihodologles. States alioutd use a system dCTalopmant Ufecyole (SDLC) mefhodology foi uq?roved affieicncy and quaEUy ofptoducts md sandees. The aystam development lifBcycle aethodology should heye distmct, well-defiaed phases for inosptioa through ofcae-out; include plaaaiag that described schaiulea, -target datee, and budgets; sbordd exhibit controls over die life trffhe prqjwt vs .written docamentation, foimal i-eviews, and dgttotC'aaoBptaace by &e system ownat(s); and aSiould liave weU-

-do<mme2it^rqpeatgUe^lo'(^sa-with^leaTnpm-aiid^utput^tCTiff(B^g:T'atifaBts)^ States-- -sltould assess delivmablcs against CMS guiileUiies tudi a8 MTTA md MedicaM artdSSxchcmge TT Guidance.

CMS is implementing a sb'eamliaed systema development life cycle ptoocss for Exnhange Qrante {hat acconuaoifates CMS feedbacfc and direction to fhe states. Ali grantws havcTecaived guidance on this process. We will algo cUsta'bato infoimation on OTO combmBd Bxeliange/ Medicaid govaaiaiice processes to states through a variety of liiffaraat incchatiiams, mcluding Informational butlstim and by posting materials on our GMS wGfcsita. Statos will be required to participate in this pswss for diglbillty fad enrollmaat systeBas needed to iinplemant expuisiflTB under (he AffordEiblB Carn Act Stiites may refer to this SPLC piocess as a model fhey can employ intemaUy for ot&er Medicaid IT projscts. Otheirwiae, the syctem dweIopaBBt tnefhodology {camewwk ealeeted by die state shaidd mit (ha apeclfic Idads ofp'oject, based on varying teclmioal, orgmiaationfll, pro) ect, md team factors. Some mnture methodologiea fcr considwation inclqdc tte tadltl&nal "watedaU" liwdsl; Rttpld Application Dervd&pmont (RAD);

Spiral Approauh; Umfied Frotxsa or Rational Unified Process (RUP), wliich reinfbrceB ttie usage of Unified Modeling LangnagB (UML); and Agile Deyelopmant.

The objsctiva of any SDLC process ie to pnnlde stmoture and (iisctptina; and states are to bialtl Becam FT sslutions tiased cm SOA prinolplea. The appS.ca6. oa. of ami adherence to SOA piinoiplas sliould facilitate the dolivary offiffiable, agile, md mteiapo.i'alito MMISs. S-tgtes should employ an open, jsmalile system, architocture that aeparates (he p:esealati(m layei\ 'businoss logic (i,a, serrice laya-), aiid dEta layer far greatai iBexibflity, aecanty, pai&rtaance, and qnatity of design, implementation, maiBtenanoe, and enhancement in the software life cycle, Tfas syBtem areliitectute should utflize a -ueer intErface (UI) ftfiiuework that deploys piesmtatian components to dlow fat coimnunlcittion with disparate pqpulationfi mittg difi'ereut tnfidia foimats snch as web,. amall. mobfle, imd Aort message aervice (i. c,, text mesesgtog), IdcntiAcation and dfssaripticu of open tnterfaces. States should empSiaebs (he flaxMity of open intacfaiseatB. ilcsxposedAPIa as caniponcntslnr the serrice layer. States should identify BU mtafaees in their development plan and diecuss bow those mter&cos will be miiintamed. States must develop and nigiflwii an. exposed API to aby datn Borvices Iwb available for the repartfatg of data, vwrficaticais, and oxohitDfie oi' data among states, garvlce mtetfaoes should tx; documented

Enhanced Fundfng Raqirirentonts: Sevsn Ccndffci ns ay) Starxiards Venlonlj) wmv

Cantera fcr htedloae & MedloQfcj Sarvfw?

m an. lata&ce CcmlTOl Documant (ICD). TUs ICD, lot wUoh CMS oan provide a taBplata, should contidn debdlg gfhaKtWBl'9, opei'almg systems, soSwar&, memory, service packs, pioduet keys, and veisioas, Uae of bliBiness roles engines. States should ecsute (he use of luaineaanilBs engines to septrete business nales fiom core programming, aud afciouldiMovide in&tuatton about fhe change ctmttol proossa that wUI aaaage dsveloptnect Bod implemaitation of business rulea . Statee shouki be able fo acoommodate cliaf^ges to busittess rules OB a regulirized ^cbjedule and OEn ati emeEfganoy

States atiould IdentUy aad dooument the busmess rulss engines used, the mumer ia wSich the bnsfness niles eagine(8) is mtplMnented in {he state's Brolutectiue, the type of business rules engine (e,g., ferwBnI-chalaiDg, backward-cltainiag, drteaixunutic/dorasin epocifio, eveait processing, inferea»9-b£eed, cto. ); the Ucuring and support model associated vtifb. to liuamesa rules mgme(s); and (he approxm.atBnumlia- ofnilea the bcstneaa rules aigine(s) exeouteg foi a given bustoeM process.

Submission of business rules to a HHS-deslgnsted repoiltorf. Stetos ahonld be prepared to submit all fceir budnsss niles ia liutttaa-ieadsble foan to ro HHS n.poaitoty, whidi will be madB available to ote atntea find to the public, to fheirAPD, states must Bpeoity wtien they expect to make ffaoee business rules available, CMB wfll provide addifioiuil detaU md spettfications about how to subcrit flioBe rulea. B (he states -waiit to protect diitribution of any spwiflc li<iatnes3 roles (e.g;, those that protocl against ftaid), states may specify thsir dwire to protact those rules,

2. 2 IVHTA Condition

This conditioa requires states to align to and- advance inoteasmgly in MCTA ni<rturity fei business, aichitectta-e, and data. WS eocpects the stateg to complete and oontlme to mato tusasuiable progteaa hi implen-ienting their MTTA rogdmaps, Already fhe MTTA mvestiaents by federal, state, and private partaaa luve allowed us to make mjportant mcremmtal iiDptovaaeBla to Aare ilata attd ifcnso b-usiness models, applioations, anti oonipoBenta. CMS attivog, boWCTer, to build on stsd acoelstste fhs niodemiiSiilioD of fhe Medlcaid eatatprbo feat has ttius fat leea achieved.

MTTASelfAssessmenb. CMSwitlter<:>viewIt)gandp»ducmgMn'A3. 0in2011, Tbtenext va'eloa ofMETA will t»ke into accotint flie dmages required by the Affordable Care Act md tie availability of new teofumtogies aiich aa cloud comjpnting and bnild out niaturity levels 4 and 5, O.ace coiapleted, CMS sxpects all atatea to update (heir aelfassBSSfflettts wifhill 12 mouflis. If a state lias not yet completed B solf assesemont, it may wait until vonsloa 3,0 is published (acpectcd m2011).

MITA Ruudinaps. States wUlpwwKte to CMS a WTA Maturity Model S.oildmap that addteeses goals and objeotiveg, as wall as ksy sctivitlas and milestonaa, covaring a^-year oudoolc for ftieir proposed MMIS whitian, as part of the A?D process, This doeumnit will ba updated on an aanual biuis. Stales slionld demoDBttate how Aey plm to iinprovB in MTTA maturity over fhe S-yearpariod aud tlidi' mticfpaied tlmtng fiiT fall MTTA matm-tty. StaKA should, eusura that ttiey have a tequmcmg plan that cons.ldsrs ooEt, beiiefit, schodiile, and risk.

Concept of OperutionB (COO) and Business yrocess Models (BPM). StatBs should dcyeTop a oonoept ofopea-atlona and business woik: flows for (ha difiemit bnsineBS fimotioBfl ot'&» \etate to

Entiancsd FuncBng Requ'rem&nls; Sown CciKStions and Slawtar* Versioit 1,0 AplllZOII;

Cenlnrefo; Medfsains & Msdoakl Servtesa advance fee aligciueat offha state's oapability maturity with fee MTTA Maturity Model (MMM).

These COO end buaitiesa wnA flows shm)ld aBgtL to imy provided by CMS ijn support of Medioaid and BxchmgB buslnesa oporatioiis' and re<t(dral>aats' statM aliodd woric to atreamthiB and standmdize fhsge oparatloaal appraaclias and hulness work: flowa to minitnme cuetomizatiim damands on teolmology eolutions and optiuize business oatccmea. CMS will provide more direction in fatwe guidance about the fona and format for the COO aid BPMs.

2.3 Industry Standards Condition

States must eaews alignmant with, and inoorporatiau of, Industiy standards; (he Healfii Insntaaee Fortalility and Accountability Act of 199S (HIPAA) secimty, privacy and trangaotioa stmdaris;

BCceasibj.Uly etaadatds rttaWatied utider aeotlon 508 offha Rehabilitation Act, or staadat-dt ttat provide greats' aoosssibility for mdlviiiua.ls with disabilities, uid oarqilianse wiBi ftderd dril rights lawa; standards adopted bytlie Secretary mdw sedion 1104ofttiaAffBrdaUe Care Aot;

and standards and protocols adopted by flie Seeretary wndCT sedion 1561 of the AffordaUs Care Act.

CMS muat enewe tiist Meiiieaid mftBatructm-e and infmmatioa system iBvesunmta ate made with the assuranoe that dmdy and relialile adoption ofindusby standmds and productive us« of those rtandaids are psct offlis investtBents. liidustiy stanlards pTnmote icusc, data exohange, and reduction of admimstmth'o burden on.patienfs, provida'a, md qiplicants, Ideutlflcntion of iailustty standiu-ds. GMS will coniaitinlcate applloshle stmdards fo states.

Standards would be updated periodically to eaisuie confnEmance wi£h changes in fba miiusby.

States will t&reqtdred to updale systena andpiaotioes to adllei'e to Svolyiug fadustry staDdards in Older to reman Bllgible for erihaaoed PEP fimding.

The state cnmt identify all uuiushy staadardi wlevait to (he aooipe aadpu.tpose ofttiefa-pTO]ect and produce development and testmg plans to ensure fall compliance. States must Bko have risk and mitigation iftratagies in place to address potaatial .tiuhres to comply, iBcorpoyation of Industry standards in requirements, develupmenf, and tBsttng phasea.

Slates must implement practices and prooechnw for (he systatn diwelopment plusea svch as igquiraiaants analyais, tystacu testing, alid user Bcceptance lestmg (UAT). States' plans mvst ensure &st all syisteins comply felly saS on-time with all ittdustiy statKl&rds adopted by fhe Seorctuy ofHHS.

To wmpl-ywlfh to the S.ehabiUtation Act's seetioa SOS(c) for iicceca'lrility ofuear mterfa<SBs for disabled persons, stales must pwduce a Section 508 Prodiwt A^Besstaent Package as part of their SDLC. Tbc state should parfona regulariy scheduleii (i. e., aictomstic) seals' and aamial testwg &i Seetkm 508(t>) compliamie for dl types ofusor mterface acreeas (riatic, dymanic, Web, clleat-servsr, mobile, ete. ) to meet (be standacda for flill coapUanoe. Softwiiw is avaflable that eaaist with Section 508((. ) complimoe tftating.

2,4 Leverage Condition State solutions Ehould prcunote shflrmg, leverage, and reuse ofMedtoald technologies find .

systems wlfhin and (ttnong rtates.

States (an benefit substffintiaDy floni flu) experience and inveBfa&eails vi'otbet -states tiu'ougbi Bie 1'ciiae of oompoiiaita and taoliBologiasBlroBdy developed, consisteut with B Ba-rice-oriB Btad

Enharad Funding Rafiulfemwlt; $av8n Condllloiia and Standailt Vwskin 10 wwv

C&nteffi.for Medtoafa 5 Msdkiajd'Senicw andutectare, from publicly availaUe 01 cammcroiaily sold components and products, and flCBl the uae of cloud tecliaologiea to sliare inftasteuctere »nd applteatioas. CMS ccmtnits to woA aesartively wUb fbe states to idanttfypramising stato eysteme that oaa be leveragEa3 and used ly othn gtattg. PurBier, CMS would stroiigly ettwniage the states to move to regional or uultt-state solutions wbai cost effective, aad will seBk to support mfl feciUtate suofa solutions, h addition, CMS ml] axpedite APD apptovala for states that me partioipafag m shaied developaeat aothdties widi other strtes, md (hBt an devdopiag components and solutlMia sxpresBlymtaauied fei BBWesafu! reuse by other states, CMS wifl also 1'eview oarefally Bny proposed tnveiitmeats iu aA-state Eystema whea (he fedeiral govermfieat is asked to share ia the costs of updating or mamtaiiBag multiple systems parfocming esseiitially the same fiinctlcna wiiUn &e same Etste.

MuM-stofc efforts, States diogld Identtfy my componrofs snd soliitions that vs bring developed with £he participation oforcontributionliy otfaer statea.

Availabfllty for reuse. States should identify my componenta and solutious that hsvs high applicability fer other reuseby oliier states, how otto stalas will participate m advismg and reviewing ttxese artifacts, and the development and testing path for teae solutions and componentB will pramofe reu8e, As fhn capability becomes aniUble, states should suBplykcy arti&otg to a ootnmon, nadoiml clouil-based repoeitoiy aoceBaible by aU states and CMS, ?ur(har definition of tlieae artifacts (SLDC deliverableB, bnsinssB requn'ements and process flows, and oomeptiial and logical data models) and how to provide them to (he national repoaltary will foflowjia subsequettt gmds. nce.

Idenfificatioii of open scnrce, doud-bascd aud couunercial proilncts. States ahoukl pui'sae a eervic&'baeed nnd oIond-Blst stiategy for system development. States will identtiy and (flscuss bow (hey will identify, evalnate, and inooipoi'dte commereially or publicly available off-ttic-ahelf or open source wlutioM, sad discuss ixnBiderations aid plans for cloud oomputmg. States ahoulti identify any ground-np devalopiaent activity wiftiin {heir (iwelopamt apiwoaclies md explain why tiiis ground-ap activity luia teen selectod.

Customization, gtateg will identi'fylhe degiee and aaonnt of cnstomtzation needed for my temda' solutiocs, m.d how Bu.eh cuetotnlzatlon will be mmjmized.

Tranaitiou and returement plans. States shouldidec. tify eriatmg dnplicativo system dCTvfaes' within the state aud asek to oluninato dapEcative system seivioos. ifftte work is cost effectlTe eaoh a8 IOWCT total cost of ownersUt) over (bie .long tenn.

2. 5 Business Results Condition

Systems stuiutd aypport nconrate and timely processing ofclainis (including claims of etigflrilily), adjudicatlons, aid eftfective comuiimlcBdohB wlfliprcwidera, benefica'aries, aadffis public, Ultimately, the test of m effeofiva find eiHdcat systam id whaflier it supports and enables au effentha and efBcjcnt Irosiness proceeei protluomg and coinmmucatmg (he intended c'pa'atioinal resiiltstrftha high degree of ttliabUity and aoourBcy. ItwouldbeinappropriatotopT ovido aahaticcd fcdoi'd fundiag fer systonis tliat Wte nnable to mpport desii'ed linsbieag outcnnies.

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Degree c{ airtomatton. T&e stnto should be highly automated in systematic prooesmng of claims (inoluding olritns ofeligibltlty) and steps to aocept, process, and matatatn all adjudiosted cldms/temsactioDa.

Custonier service. States ghoiilddoomneatliowAey-will p'oduoe. a 21 -centmyoiistoinia-iiBd pmtnESF experience for all individuals (sppUcsats, lianefidarieg, plans, imd provldars). This 21 -oentey custonsr a>g>admce ehould inoluds fiia ability to submit sad manage fatemctlons mlii Madloaid througfi the web and to sdf-mfflnago and fflcdtot acoounta acd hiatory elwtronlcaBy.

fi should also outline how customar prefereaces for ooaummioatiocs by eiaail, text, mobile dsvicfls, or phones will Its accommodated. States staild also conttttit to tBsting fmd evahiation plans to ensute ptovidersi applicmts, and otiisra intaraoting with and uamg (heir systems will

. liavetiigopportcmitytoprovidsjfTOdbaokaadasaassmectofaccBadlrilily, easeofuae, md appropriatmess ofdeclalom, Performance standards and testing. CMS intends to provide additmnal guidance cOBcemmg performance staadftKb-botti ftmctloual aitd non-flinctioaal, md vria laspwst to aervice level agieamecta (SLA) aDdkeyperfbrmenoe iadlcatois (KPI), We expect to consult with atatea and stakaholders aa we develop and refine fa<ao measures and aaiiociated titfgets. As thia list of measures wffl be fcouseil onvuy oors elameats/iiidicatora ofsucceaB, statss should also consida-adding stirte-speoifio measims to this list.

Foi the implementation of IT system anIiancementB, states will execute tests BgBinst test casee intended to veatiy iaad vdKdate the aystem'e adharaice to its functional and non-ftmctional reqmremenU.

For opCTBtioiud IT systtttxis, states will pa'iodieaUy evaluate systBDa pgrfomiance against sstabUsIied SLAs, Wheu SLAs are not met, atetes will create and Bfccute a Plan of Action with Milestones (POAM). CMS resBrvea fee rigtit to iiepB ct 3 state's perfoiaiimce assosameut outcoraos andPOAMs. States will periodically evaluato'oparattonalboaineasprooegses agaiiist csttibliahcd KPft. WIicnKPIs are not met, gfates mil create arul execute a POAM. CMS reserves (he right to mspect a state's periomimoe Bssesmieatoiifcomes and POAMs.

2,6 Reporting Condition Solutions shonld tffoduec tratKiafition data, Teporta, ahd pnrfonwicft informatioii that would

. oontribule to program eviilnation, continnous iinprovammt tn busmsss operatioiis, and transparency End flCGountiibiltty, Systfans ahould be alle toptoduce and to expose electmaioaUythe aecuttde data. dist ate neceaaszy for cn'arsight, Bdminietratiou, waluation, integrity, aad trausparebcy. Tissa lepoi-te should be automatically generated ttirougli open urterfaces to dtesignatcd feda(al repositori'es at data Iiuba, with Bppmpriato audit trails, MITA 3.0 will provide additional ctetidl alont reportug requiremtiuis and -needs ttuit arieB froa file Affordabie Care Act. Additloasl details about data defimtioas, speeifioutiotia, tiaatug, aad. I'outing ofiitfonnatioa wiU Ie suppUed later tint ywr.

2.7 Interoperability Condition

Systems must ansure sowtess ooordinatlon and lutegnfion with the Bxchange (wheflier Tim by fba state or federal govamnaat), and allow iateroperayiity wifti healfli mfcamation sxdiangea, Enhanced FuncUtio RoqulrantefTb; Seven Condltfoits arxi iltaiirfarcfa Vefsion 1.0 <|il20111 public healttl agencies, hnmaa seivioes piogriius, ani comnnmity organizations provldiag outreadl and earollmart aaaistmce aavices.

CMS expects that a toy outcome of the government's technology mvestoents wffl 'be a mucll Mgher degree oficteractioa and intaroperabllity in order to nucdnaze valus and tBiatmize birden and costs onprovidetE, beiiBfidaries, and otiiar stakdioldaiis. CMS is emphasizing m (Us standard and condition an expectation (hat Medicaid agendw WoA ll> wnowt with BxchrogTO (wliether state or fed.aially adiiualateired} to share busmesa aavices nad teolmology InvesfmsBte in ordfr to produce seamless and. dfiaolccnt customw oxperieoces. Systeius tnnat also b» built wifit the appropriate aroluteoture and natogstmdaniizKl messaging and coatmimioation protocols in order to ptwssve (he ability to efBciaitIy, effeotively, and SRpropriately exohmge data wifli oiher participants in tile liealth ami hinnrti aarvlees entafpriae.

As atated toMITAFnmwwoxic 2,0, esofa atote Is "I'BSpBBsiMe ftirknowliig md unda-standuig its mriroiunent (data, applioatioos tmd mftgBfracture) in order to map ito data to infoffliatlon-shamig reqoTanenta. The data-sharing afoliitecture also addresses die conoeptoal and logioal meflhaiusma wed for dat&sharing (i.a,, data hubs, lepositddes, andiegistries). The data-aharing arclulectuio will abo address <iafa semanticiS, data tuu'aonizstioc suategles, shared-data ownersliii), wottrity aad ptivaoy anpUcations of shared data, and the qnaUty of Ehared dfrta.

Interacttons with the Bxchange. Stgtes should eaevte that open interfacw ani establjsbed md aaurtamed with nay federal data ssrvieas hub and {hat 1'eqnests to fhe 1mb ai'e prepared and available for submisEioii immediately after suocesEfuI completion of the application fcj-eligibiUty. Statea must enaure and test commuiricstians betweEm Bxohauge ami Medioaid systems so that dotennmstions and referrals cm be cflsctpfssly frfmnltted flwn the Exchange.

States stould desoabe how ahsiea. eei-vioea will support botii fho Bxchimge and Medioiiid, Interacflcna with other entities. States ahoiild consult with aud discuas llow tha proposed systains developmant pafli wiB sqsport 'IntBropa'abillty wifli healfli infommtion exchaBgee, public health agencfoa, and hntnaa EeryieEis ptognuns to promote effeotivo- cuatomer servicB and 'bett«r oliridal miuutgement itnd health gendces to beneficiaries. Slates should also consult wifii and diaaisa how eligibility systems wfll allow oommunlty seni joe orgaiiizatloiu to assist spplicants aeekmg healfh care coverage to complete fcnms and to submit fhose forms oleotronioally, 3, Next Steps

CMS will coatiaue to fafine, update, and expand this guidance in the ftrfuxe, based on iutial and coutinumg fecdbacJc tfom statas, omeflciiB'iea, pro-ridera, md mdurtry; taid witk esfiwiwc over time. We intend to actively aoBdtfeaitbaak and well as to imdte if. Our experience wife rtatae that are early m iniplementiag new eligibility systuns m support ofBxcbiwges, Medieaid, and CBIP, »s wall as statas flut are beginning of in oariy atlges of dovelopmcnt rfnew ohllT ilystems, will be matrumontal in telpmg us to fiirtfwr lefine and ahape this guidaaoe.

Enhmced Fnrrihg Reqiiimnienfe: Sswn Condilions and StaiKlaris Verstoj i 1.0 AllMIV

Centm ftr Medicare i MedkiAfSsnilcas

Acronyms

API Application Prograunalng Interface BPM Business Process Model

CHIP Ctaldren's Health Insuraaca Progfam CMS Cantera for Medicare & Medioaid Sarricas

COO Concept of Operations

CTTP RxlaraiPinandairarticipation

EES U. S. Dopartment of Health and Hnuian ServioeB

BBPAA Health tosunance PortabUity and Aocountabillty Act of 1996 IT Infnnnation Technology

KPI Key Patfonnance Indloator

MITA McdioaidlD&i'mationTeciinologyArcbitBctou'B

MMIS Medicaid Management Erfonnatioa System MMM MTTA Maturity Modd FOAM Plan of Action md Milesfeines

RAB Rapid Application Development Am? Rational Unified Piwesa

SVLC System DCTelopinaat Life Cycle

SLA Sem'ce Level Aglcement

SOA Serricc-OnaatedArcUteetiOT

UAT User Accqrtance Testing UI . Usa Interisce

TOIL Unifoim Modelifig Language fahaical Funilne Requtenianls' Savai Condltbtis and Etaiidariis Vaglon 1.0

Apt ai v