ATTACHMENT S - MITA SSA 2022 - RFP 758 2500000171 Kentucky Analytics Platform Solution (KAPS).xlsx
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- Kentucky Analytics Platform Solution (KAPS) State and local contract opportunity
- Solicitation number
- RFP-758-2500000171-6
- Issued by
- Kentucky
About this file
This document is a State Self-Assessment (SS-A) for the Kentucky Cabinet for Health and Family Services (CHFS) Department for Medicaid Services, focusing on their 2022 Kentucky Analytics Platform Solution (KAPS). The document comprehensively details Kentucky Medicaid's current technological landscape, business challenges, and strategic roadmap for modernizing their Medicaid Enterprise Systems (MES). The assessment was conducted as a pilot program to streamline the MITA 3.0 process with a business-centered, outcomes-based approach, involving interviews with staff across all divisional departments to document day-to-day activities and identify operational pain points.
The self-assessment identifies numerous technology investment needs across multiple business areas, including Utilization Management, Pharmacy Benefits Management, Claims Processing, Electronic Visit Verification, and Decision Support Systems. Key technological goals include improving data quality, enhancing integration capabilities, implementing modular system architectures, and developing cloud-based solutions. The roadmap includes specific projects like Medicaid Data Warehouse Replacement, Cloud-Based Azure DevOps, Enhanced Integration Hub, and Enterprise Incident Management System. The document reflects Kentucky Medicaid's vision to transform its technological infrastructure, improve operational efficiency, and ultimately enhance healthcare services and outcomes for Kentucky residents through strategic technological investments.
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Introduction Attachment S - RFP 758 2500000171 Kentucky Analytics Platform Solution (KAPS)
2022 State Self-Assessment
Kentucky's 2022 State Self-Assessment was conducted as a pilot program to streamline the MITA 3.0 process with a business centered outcomes based approach. With this in mind and the directives given to us by CMS, we interviewed staff across all divisions within Kentucky Department for Medicaid Services and agency stakeholders that support Medicaid. We documented the day-to-day activities with a focus on their pain points such as: limitations of working with an antiquated system, lack of automated tools, staff shortages, etc. Staff also spoke of the programs and services needed to address the health concerns of Kentucky citizens while expanding and improving the quality of the services Medicaid currently provides. To overcome these challenges and to provide the foundational support to achieve results we leveraged the MITA 3.0 guides and cross-walked the challenges and initiatives to assess the needs within our Four Pillars: System, Data, Integration and Infrastructure. This process shaped our Investment Roadmap and will move us toward a modular transformation to a Medicaid Enterprise Systems.
CMS Directives:
1. Definition of what success looks like in the To-Be state and how it will be measured (outcomes, metrics, goals, and data)
2. Current operational problems and risks, challenges, and limitations of the existing system (As-Is)
3. Medicaid program goals and alignment with resolution of current operational problems
Listing and description of each Tab
| Mission Statement | CHFS and DMS Mission Statements and Goals |
| KY SS-A | State Self-Assessment |
| Approach Sessions | Approach taken to assess Four Pillars of Technology |
| Business Areas | Kentucky's Department for Medicaid Services Divisions and alignment to MES Business Areas |
| Summary | Summary of Business Area needs |
| Diagrams | Kentucky's Medicaid's Current As-Is Diagram and To-Be Diagram and Enterprise System Conceptional Diagram |
| Investment Roadmap | Summary of Investments |
| Org Chart | CHFS Department for Medicaid Organization Chart |
| FEA CRM | Federal Enterprise Architecture Consolidated Reference Model |
| KY leveraged the CMS MES Certification format to outline the state self-assessment. The SS-A consist of the following columns: | |
| • | Kentucky's high-level goals - These may span various Divisions across the Department and encompass several expected outcomes. |
| • | Division or supporting agency - as it relates to the current Challenge/Requirement. |
| • | MES Business Area - The Business Area that most aligns with the DMS Division being assessed. |
| • | Challenge/Requirement - Listing of current challenge or gap facing the Division to reach the goal. |
| • | Outcome - The expected Outcome once the challenge/requirement has been overcome. |
| • | Measurement/Metrics - Defined metrics to verify Outcome has been achieved. |
| • | Resolution - What is required to meet the objective and overcome the challenge |
| • | Solution Name - Name of the solution if it has been assigned. |
| • | Source - Reference to specific state or federal regulation and/or Solution Requirement which addresses challenge/gap. |
| • | Category - type of solution required to address challenge/gap. |
| • | FEA PRM Category - Category assessed to meet challenge and align with goals. |
| • | TA Pillars - Technical Architecture involved in meeting the challenge. |
| ** After the April 2022 submission of this State Self-Assessment, CHFS and the Department for Medicaid underwent a reorganization |
| to better align with the vision and goals as stated on the Mission Statement tab. These new divisions took effect August 2022 |
| and can be found on the Business Areas and Organizational chart tabs. |
Attachment SMITA SSA 2022 KAPS RFP RFP 758 2500000171 Cabinet for Health and Family Services Kentucky Analytics Platform Solution (KAPS)
MITA SSA 2022
Introduction
&P of &N
Mission Statement
VISION FOR THE KENTUCKY MEDICAID ENTERPRISE
The CHFS has developed and described its overall vision, mission, and goals, which lay the foundation for transforming the Kentucky Department for Medicaid Services. The CHFS vision is for a Commonwealth where every Kentuckian reaches their full human potential and all communities thrive. The CHFS mission is to be a diverse and inclusive organization providing programs, services and supports that protect and promote the health and well-being of all Kentuckians and their communities:
• Improve access to quality and affordable healthcare
• Improve consumer access to information about health, health care quality, and the health insurance marketplace
• Mitigate adverse behavioral health outcomes related to pandemic and historic inequity by preserving and enhancing the behavioral health safety network
• Expand the recovery-oriented system of care to address the opioid crisis and other substance use disorders
• Support and promote the behavioral health and wellness of children and families, especially families involved with or at risk of involvement with child welfare
• Assure a safe and adequate system of care for individuals with intellectual and developmental disabilities
• Enhance the system of supports to serve Kentucky's growing aging population
• Promote the efficient exchange of health information to drive quality health outcomes Kentucky Medicaid’s mission is to be a diverse and inclusive organization that promotes the health and well-being of all Kentuckians and their communities:
• Improve health outcomes and quality of life for our covered population
• Encourage providers to join and be compliant with the program
• Incentivize and hold MCOs accountable
• Be responsible stewards of our funding
• Operate the most responsive and efficient enterprise possible from the perspective of the people we serve
• Collaborate and cooperate with our sister agencies within Kentucky and across the nation
• Improve business processes and utilize automated data processing to support the programmatic outcomes of human services and support programs
Attachment S MITA SSA 2022 KAPS RFP RFP 758 2500000171 Kentucky Analytics Platform Solution (KAPS)
MITA SSA 2022
Mission Statement
KY SS-A
Kentucky Cabinet for Health & Family Services Department for Medicaid Services
275 East Main Street 6WA Frankfort, KY 40621 Lisa D. Lee Commissioner Kentucky Cabinet for Health & Family Services Department for Medicaid Services
275 East Main Street 6WA Frankfort, KY 40621 Lisa D. Lee Commissioner
| Kentucky Medicaid Goals | Department for Medicaid Division or | ||||||||||
| Support Agency | MES Business Areas | Challenge/Initiatives | Outcome | Measurement/Metrics | Resolution | Solution Name | Source | Challenge Category | Category | FEA PRM Category | TA Pillars |
| Improve business processes and utilize automated data processing to support the programmatic outcomes of human services and support programs | Division of Program Integrity | ||||||||||
| (TPL) | Third Party Liability (TPL) | Third Party Casualty Insurance recoveries are labor intensive and time consuming. Ability to streamline the process, securely share supporting documentation with required signatures and track process is needed. | Automation of information collection and workflow using standardized business rules increases accuracy, efficiency and ensures Medicaid is payer of last resort. | - Percentage of TPL cases identified |
- Length of time to complete recovery for a case (in days or hours)
- Error rate for TPL cases
New System Solution MCAFS 42 CFR 433.139(d) Functional Technical Data Data Quality/Data Access Document Management Integration/Interface New Functionality Productivity Cycle Time and Timeliness Information and Data Efficiency Quality Systems Architecture Integration Architecture Case Management tool is needed for TPL Documents to track Service limits from other insurance, co-Insurance, deductible, reason for denial, etc. It should also allow caseworker to keep notes and pull up a case to see a document history including oral correspondence. It should also include what was said and who was on the call.
Staff and external entities need the ability to securely submit TPL supporting documentation online. Kentucky Medicaid utilizes an automated case management tool for tracking and as an information repository to increase efficiency and accuracy. - Number of cases staff handle per period (day, week, other)
- Error rate for cases (number of times initial information must be corrected)
| New System Solution | MCAFS | 42 CFR 433.138(j) | |
| 42 CFR 433.138(h) | Functional |
Technical Data Data Quality/Data Access Document Management Integration/Interface New Functionality Productivity Efficiency Information and Data Systems Architecture Integration Architecture
| Resource | |||||||
| Staff need to be able to track where a reimbursement originated from, e.g. absent parent insurance, commercial insurance | Kentucky Medicaid accurately identifies the source of TPL information to ensure prompt recovery. | - Percentage of cases containing reimbursement origination information | |||||
| - Error rate for TPL sources (how often are sources identified incorrectly) | New System Solution | MCAFS | 42 CFR 435.4 | ||||
| State Plan | Functional | Document Management | |||||
| New Functionality | Productivity | ||||||
| Quality | Systems Architecture |
Integration Architecture
| System should consider Claims Adjustments when calculating the Case Total requiring manual intervention to close remaining billings. | Kentucky Medicaid has reduced errors from manual interventions and expedited recovery of third party claims with its use of a standardized business rules engine. | - Error rate for cases (number of times initial information must be corrected) | New System Solution | MCAFS | 42 CFR 433.14 (c ) | Functional | New Functionality | Quality | |||||
| Efficiency | Systems Architecture | ||||||||||||
| MCOs are not updating TPL information on a timely basis; accurate and real-time data is needed from MCOs | Kentucky Medicaid receives contract-required TPL information within the timeframe stated in the contract to increase efficiency and accuracy | - Time to receive required information from MCOs (Average and Max). | |||||||||||
| - Percentage of MCO updates that exceed contract requirements | New System Solution | MCAFS | 42 CFR 433.139(d) | Functional |
Data Policy or Regulatory Data Quality/Data Access Policy Regs New Functionality Cycle Time and Timeliness Systems Architecture Data Architecture Integration Architecture Incentivize and hold MCOs accountable Policy Directive CAP Penalties COB/TPL Training and Handbook- 2020 (pg. 53-55) Policy or Regulatory Policy Regs Other Be responsible stewards of our funding When doing a match on death certificate, if surviving spouse is identified, system should automatically close Estate recovery case and send a system generated letter. To increase efficiency, Kentucky Medicaid is able to automatically close an Estate Recovery case and generate a notice to the surviving spouse identified when there is a match with a member and a death certificate. - Percentage of claims identified as pay and chase.
- Percentage of recovered reimbursement for pay and chase claims.
| - Percentage of cases closed automatically due to death certificate match (based on business rules) | New System Solution | MCAFS | 42 CFR 433.139(f) | Functional | New Functionality | Efficiency | Data Architecture |
| Operate the most responsive and efficient enterprise possible from the perspective of the people we serve | Plan Management | Staff Shortages | Kentucky Medicaid employs an adequate workforce to ensure productivity and efficiency in support of members receiving quality health care. | - Number of cases assigned per staff member (should be below a target) |
- Number of cases resolved per staff member per month (should be above a target)
| - Average length of time to resolve a case | Policy Directive | Being addressed in HB 285 (Governor's Budget Proposal) & HB 1/GA (House Bill Budget) | Resource | Policy Regs | ||
| Other | Productivity | |||||
| Management and Innovation | N/A | |||||
| Third Party Liability (TPL) | KI-HIPP Staff need a holistic view of application status, other insurance, enrollment and correspondence to respond and report effectively. | Kentucky Medicaid can view current status and trends across the KI-HIPP program using the Tableau Dashboard. | -Monthly report on top 10 reasons for denial with percentages |
-Monthly Total of Approved/Denied/Pending -Monthly Report showing Total Issued Amount/Total Issuance Amount
| - Staff satisfaction with ability to reference KI-HIPP data | Enhancement | Tableau Dashboard added to IEES Worker Portal | KRS 205.623 | Functional | New Functionality | Information and Data |
| Effectiveness | N/A | |||||
| Improve business processes and utilize automated data processing to support the programmatic outcomes of human services and support programs | Division of Community Alternatives | |||||
| (EVV) | Electronic Visit Verification | EVV Solution system showed significant downtime in FFY 2021 | The EVV Solution is reliable, accessible and minimally burdensome on providers, beneficiaries and their caregivers. | - Uptime percentage (The EVV Solution shall be available to end users 99% of the time, 24 hours a day, seven days a week, excluding CHFS approved planned downtime.) | ||
| - User satisfaction survey scores | New System Solution | EVV-HCCS | MBP |
42 CR 431.206
45 CFR Part 80
| 36 CFR Part 1194 | Functional | New Functionality |
| Other | Reliability and Availability | |
| Effectiveness | Systems Architecture |
Infrastructure Architecture Successful implementation of EVV for HHCS by January 1, 2023 will require the use of enhanced technology to trace the times, dates, and specific services that are provided Kentucky's EVV Solution technology ensures that recipients receive their approved services. -Report verifying capture of all required data elements
- Number of rejections due to unverified visits
- User satisfaction surveys on how well the EVV system captures data New System Solution EVV-HCCS 21st Century Cures Act: Section 1903(I) Functional Technical Data Data Quality/Data Access Integration/Interface New Functionality Quality Quality and Assurance Effectiveness Systems Architecture Data Architecture Integration Architecture
| Improve Health outcomes and quality of life for our covered population | Division of Community Alternatives | |||
| (Waiver) | 1115 or Waiver Support Systems | There is a need to fill the gap in services for populations with co-occurring disabilities and those with involvement in the criminal justice system. | Kentucky Medicaid decreases hospitalization stays and increased successful return to home and community settings by expanding crisis services, including preventative services, staff, and first responder training for earlier more targeted intervention. | -Number of Emergency Room visits per quarter |
- Number of Crisis Service Calls responded to w/ avg time for response
- Percentage of cases that result in hospital stay
New Initiative Crisis Services KRS 210.365 Functional New Functionality Management and Innovation Customer Benefit Service Quality
| Service Coverage | N/A | ||||||
| Michell P. Waiver services wait list is approximately 5 years before being allocated a slot. Over 50 percent of these individuals are eligible for other services but the lack of proper assessment tools pointing them in the right direction. | Kentucky Medicaid performs comprehensive screenings with knowledgeable staff to ensure individuals who are waitlisted for HCBS waiver services are connected to the state plan or community resources to meet immediate needs. | - Average wait times per period | |||||
| - Number of waitlisted members assigned other services per period | New Initiative | HCBS- Ease of Access | 907 KAR 1:835 Section 12 | Functional | New Functionality | Service Accessibility | |
| Service Quality | N/A | ||||||
| Implement Reporting for CIRS to show usage and trends for critical health related Incidents. | Kentucky Medicaid is proactive in preventing abuse and neglect by reviewing trends and patters from Critical Incident Reporting System (CIRS) reports. | - Avg Incidents reported per month |
- Top Five Critical Incidents reported
- Providers with the highest incident rate New Initiative CIRS Enhancement KRS 209.030 Functional Data
| Data Quality/Data Access | |||||
| New Functionality | Quality and Assurance | N/A | |||
| Encourage providers to join and be compliant with the program | Finding and retaining highly qualified paid caregivers is a challenge for both traditional provider agencies and participants hiring PDS employees. | Kentucky Medicaid invests in recruitment, training and retention of skilled workers improving Waiver participant satisfaction, experience and health outcomes. | - Number of skilled staff per participant |
- Number of training sessions each quarter
| New Initiative | Workforce & Provider Development | KAR 907.1:160 (N,O) | Resource | Other | Service Quality | |||||
| Service Accessibility | N/A | |||||||||
| Division of Program Quality & Outcomes | Lack of Prior Authorization File Share between MCOs for transition of care | Kentucky Medicaid receives monthly Prior Authorization information to aid in the transition of care to its members | - Percentage of Prior Authorization cases received from MCOs per month | MCO Medical/Dental Data Exchange | MMIS CO 33172 | CP3 Prior Authorization |
42 CFR 431.630
42 CFR 431.960
45 CFR 162.1302 Functional Technical Data Data Quality/Data Access Document Management Integration/Interface (?)
New Functionality Information and Data Data Architecture Integration Architecture Challenge assessing the compliance of MCO Reporting
| Kentucky Medicaid receives all contract required reports from MCOs in the timeframe stated in the contract | - Percentage of late or missed mandated reports per period | |||||
| New System Dashboard | MCO Tracking Tool | 42 C.F.R. 438.604 Reporting Requirements | ||||
| Functional | New Functionality | Management and Innovation | Systems Architecture | |||
| Analysis of IPRO External Quality Review reports is backlogged due to increase in volume and understaffing. | IPRO External Quality Review reports are regularly reviewed and analyzed to enable active monitoring of healthcare quality | - Percentage of time IPRO External Quality Review reports are reviewed and analyzed per designated time period |
- aging of reports (time between creation and review)
| - number of reports to review per staff member | New Incentives | |||
| Policy Directive | 42 CFR 438.350 | Functional | ||
| Resource | New Functionality | |||
| Other | Productivity | |||
| Management and Innovation | Systems Architecture | |||
| Provider Management | ||||
| Member Management | Grievance & Appeals process is a manual process of gathering documentation, creating letters, stuffing in envelopes and mailing approx. 400-500 letters each month. There is also not a tracking system to track status of request/response. | Kentucky processes provider & member appeals in an efficient and timely manner. | - Average time (days) to close appeal |
- Aging of cases (time between creation and completion)
- Number of cases completed per staff member Vendor Solution MCAFS 42 CFR 455.422 Functional New Functionality Productivity Cycle Time and Timeliness
| Effectiveness | Systems Architecture | ||||||||
| Member Management | Finding an eligible member EPDT services requires locating an available provider and a facility capable of providing the service. This is a manual process of research and documentation that can create a delay for the member. | Kentucky Medicaid effectively and efficiently provides members needing EPSDT services. | - Average and Max times between members requesting and receiving services | Vendor Solution | MCAFS | 907 KAR 11:034 | Functional | ||
| Technical | Integration/Interface | ||||||||
| New Functionality | Information and Data | ||||||||
| Timeliness and Responsiveness | Systems Architecture |
Integration Architecture Encourage providers to join and be compliant with the program. Encounter Processing System (EPS) & Managed Care System Kentucky last updated our Managed Care Quality Strategy for MCOs and FFS programs in 2019, it needs to be updated to include 2020 amendments provided by CMS. Kentucky Medicaid's Managed Care Quality Strategy for MCOs and FFS programs meets Federal guidelines and ensures our members receive quality care appropriate to their needs. Quality Strategy includes:
- Federal Quality Regulation Brief
- Final Draft for Public comment
| - Final Approved Quality Strategy | Vendor Solution | Northern Kentucky University | 42 CFR 438.340 | Functional |
| Data | Data Quality/Data Access | |||
| New Functionality | Quality | |||
| Management and Innovation | Integration Architecture | |||
| Division of Policy & Operations | ||||
| (Operations Claims & Encounters) | Eligibility and Enrollment | Kentucky has plans to streamline the enrollment process to make it more user friendly for members. Eliminate questions that can't be substantiated such as no income, accept client statement for verification, align eligibility term with other programs, enable OCR, align MCO members with Medicare Part C. | Kentucky Medicaid members experience a user-friendly, dynamic, online application where subsequent questions are based on prior answers. | - Percentage of increased user satisfaction |
| - Percentage of decrease in average time it takes to complete an online application | New Initiative |
Enhancements Policy Directive
| IEES Enhancements | ||
| Policy | 42 CFR 435.907 | |
| Functional | Document Management |
Integration/Interface Policy Regs New Functionality Customer Benefit Timeliness and Responsiveness Systems Architecture Data Architecture Integration Architecture
| Kentucky ranked below State Median of 72.3Percentage for Postpartum Care visits FFY 2020. | Kentucky Medicaid expands coverage to include 12 month eligibility for post-partum services and pregnant women in KCHIP. | - Percentage of increase for expanded coverage in members | ||
| - Percentage of increase in expanded coverage in $ amount | New Initiative |
Policy Directive
| Policy | HB 412 | Functional | |||||
| Policy or Regulatory | Policy Regs | ||||||
| New Functionality | Service Coverage | Systems Architecture | |||||
| Long-Term Services & Supports (LTSS) | Current screening or assessment tools present a barrier that could result in diversion or delay in the need for Long-Term Services and Supports. | Kentucky Medicaid implements new assessment tools which aid in the support of Long-Term services, decreasing the time it takes a member to receive services and the duration on the Long-Term waitlist | - Percentage of decrease in average time it takes to receive Long-Term services | ||||
| - Percentage of decrease in number of persons on Long-Term waitlist | No Wrong Door | Nationally Recognized Assessment Tools | 42 CFR 441.305 | Functional | |||
| Technical | Integration/Interface | ||||||
| New Functionality | Timeliness and Responsiveness | ||||||
| Service Accessibility | Systems Architecture |
Infrastructure Architecture Provider Management PDF version of Fee Schedule posted online for providers is unsustainable. Kentucky Medicaid's interface with the MES offers providers up-to-date fee schedules. - # of hits per month on provider fee schedule
- Response time for provider fee query
| -Provider satisfaction with provider fee schedules | Vendor Solution | MCAFS | KRS 342.035 | Functional |
| Technical | Integration/Interface | |||
| New Functionality | Efficiency | |||
| Information and Data | Systems Architecture |
Integration Architecture Operate the most responsive and efficient enterprise possible from the perspective of the people we serve Member Management Production Support team lacks an incident tracking system to log and track data quality issues Kentucky Medicaid provides for an incident tracking system for data quality issues, improving efficiency and timeliness. - Percentage of Incident Tickets tracked via automation
- Number of incident tickets handled per staff
| - Percentage of decrease in time to complete tickets | SharePoint initiative | Develop SharePoint Tracking System | Functional | New Functionality | Productivity |
| Efficiency | Systems Architecture |
Infrastructure Architecture
| Eligibility and Enrollment | MMIS has limitation to store only 3 locations for a provider. CLIA providers have been asked to enroll each location as a different unique provider with unique ID per their CLIA location. | The Kentucky MES has the capability of storing X amount of locations for a provider in order to accommodate requirements of CLIA providers. | - Percentage of CLIA providers with unique IDs per CLIA location | Vendor Solution | MCAFS | KRS 205.532 | ||||
| 42 CFR 493.19 | Functional | New Functionality | Efficiency | |||||||
| Information and Data | Systems Architecture |
Infrastructure Architecture
| IEES triggers eligibility transactions in Real Time to MMIS. MMIS processes them every 10 minutes to KY Healthnet with a nightly batch file to MCOs causing a lag for providers and MCOs. | The Kentucky MES provides eligibility transactions to providers and MCOs in real-time in order to provide them with current information. | - Percentage of eligibility files sent to providers and MCOs per designated time period | New System Solution | MCAFS | |||
| SDH | EE11 Enrollment | ||||||
| MCAFS 6.2 | Functional | New Functionality | |||||
| Other | Information and Data |
Quality and Assurance Efficiency Systems Architecture Data Architecture Integration Architecture Claims Processing Currently Claims attachments are scanned into KY Healthnet portal or come in as paper claims and scanned into MMIS by Gainwell staff as PDF documents. PDF documents are not machine readable therefore information has to be manually keyed in. The Kentucky MES process X12 275 electronic claim attachments to decrease paper claims which improves timeliness and accuracy. -Percentage of claim attachments received electronically vs paper System Solution MCAFS MCAFS 1.2 (G.OM24) Functional Technical Data Data Quality/Data Access Integration/Interface
| New Functionality | Information and Data |
| Quality and Assurance | Systems Architecture |
Data Architecture Integration Architecture
| Encounter Processing System (EPS) & Managed Care System | MMIS 834 file sends a three byte qualifier for Medicare Part A and Part B but not for Medicare Part C which causes confusion among providers and has increased the number of Encounter rejections. | Kentucky Medicaid correctly identifies Members with Medicaid Part C, improving accuracy and timeliness. | -Percentage of Encounter rejected due to incorrect or missing qualifier | New System Solution | MCAFS | G.EI27 | ||
| G.EI28 | Functional |
Technical Data Data Quality/Data Access Integration/Interface New Functionality Information and Data Systems Architecture Data Architecture Integration Architecture
| Eligibility and Enrollment | Audit Finding on multiple Medicaid IDs - Linking logic with MCI requires 5 point verification for exact match (SS#, DOB, FName, LName, address). Without an exact match, partial match selection is at the discretion of the Case Worker who may choose a pseudo Medicaid ID instead. | Kentucky Medicaid implements new matching policy for Case Workers, which improves accuracy | - Percentage of decrease in number of duplicate IDs | |||
| - Percentage of matches not based on exact match (i.e., case worker discretion) | System Enhancements | |||||
| Training | G.OM43 |
G.OM85
G.OM183 Functional Technical Data Data Quality/Data Access Integration/Interface
| New Functionality | Management and Innovation |
| Quality and Assurance | Systems Architecture |
Data Architecture Integration Architecture
| IEES Member Case file updates may not trigger a file transaction for MMIS which creates a dire need issue for members when systems aren't in sync especially at Pharmacy POS. | Kentucky MMIS accepts real-time IEES member case file updates, improving member experience by providing accurate information | - Percentage of decrease in number of member case files out of sync | ||||
| - Aging between when updates are made in IEES and corresponding update is made in MMIS | New System Solution | MCAFS | Section 1927(g)(3)(D) of the SSA |
42 CFR 456.712
Section 1944€(1) of the SSA Functional Technical Data Data Quality/Data Access Integration/Interface
| New Functionality | Quality and Assurance |
| Efficiency | Systems Architecture |
Data Architecture Integration Architecture
| Division of Fiscal Management | ||||
| (Financial Management) | Financial Management | The State accounting system, eMARS, is not integrated with the MMIS resulting in duplicate effort and opportunity for errors. | Kentucky Medicaid is interfaced with eMARS, improving timeliness and accuracy | - Percentage of decrease in errors |
| - Percentage of eMARS information manually entered in MMIS | Vendor Solution | MCAFS | G.FM177 | Functional |
Technical Data Data Quality/Data Access Integration/Interface New Functionality Quality Efficiency Systems Architecture Data Architecture Integration Architecture
| Managing FFP for MMIS is a process that uses inputs from automated systems but the interfaces are manual and time consuming. Information from eMARS and MMIS and other sources must be manually compiled. The process is open to inaccuracy because of the manual interface between systems. | Kentucky Medicaid utilizes automated tools to calculate and manage state share vs federal share for services and programs, improving timeliness and accuracy | - Average time to calculate State share vs Federal share | ||||
| - Error rate in calculating State share vs Federal share | Vendor Solution | MCAFS | 42 CFR 433.10 |
42 CFR 435.1002
42 CFR 438
42 CFR 447.56(d) Functional Technical Data Data Quality/Data Access Integration/Interface
| New Functionality | Quality |
| Cycle Time and Timeliness | Systems Architecture |
Data Architecture Integration Architecture
| Be responsible stewards of our funding | MMIS report options are only available in PDF format requiring staff to manually key data into excel spreadsheets to reconcile Account Receivables. | Kentucky MES offers multiple format options for reporting to improve timeliness and accuracy | - Time to complete reconciliation of ARs | |||
| - Error rate in reconciliations of ARs | New System Solution | MCAFS | G.RM39 | |||
| G.RM102 | Functional |
Technical Data Data Quality/Data Access Integration/Interface
| New Functionality | Quality |
| Cycle Time and Timeliness | Systems Architecture |
Integration Architecture
| MMIS annual balance of ARs will show some negative balances due to disposition codes being used. Moving forward it would be nice to have checks and balances to prevent negative ARs. | Kentucky Medicaid ensures correct disposition codes are being used to improve accuracy of accounts receivables. | - Percentage of negative accounts receivables | ||||
| - Percentage of incorrect disposition codes | New System Solution | MCAFS | G.FM291 | |||
| G.FM316 | Functional | |||||
| Data | Data Quality/Data Access | |||||
| New Functionality | Quality | |||||
| Management and Innovation | Systems Architecture |
Data Architecture Integration Architecture
| Implement Direct Deposit for Drug rebates which average out to $800 million annually. Currently checks come into state via mail, mail has to be opened/processed and checks sent to Magellan. | Drug Rebate payments are directly deposited to improve timeliness and effort | - Percentage of Drug Rebate payments not directly deposited | |||||
| - Number of Drug Rebates processed per period (e.g., day, week, month) | New System Solution | 42 CFR 447.509 | Functional | New Functionality | Productivity | ||
| Management and Innovation | Systems Architecture | ||||||
| Improve business processes and utilize automated data processing to support the programmatic outcomes of human services and support programs | OATS DSS/DW | Decision Support System & Data Warehouse | Currently data resides in disparate systems resulting in data quality issues. | Kentucky Medicaid supports data driven policy decisions through seamless integration of data from multiple sources. | - Percentage of decrease in duplicate data stores |
- Percentage of decrease in number of data quality issues
- Decrease in number of Independent data stores
- Percentage of data stores fully compliant with data standards Vendor Solution Medicaid DSS/DW Replacement 42 CFR 433.112 Functional Technical Data Data Quality/Data Access Integration/Interface
| New Functionality | Management and Information |
| Information and Data | Systems Architecture |
Data Architecture Integration Architecture Lack of an enterprise decision support system prevents Kentucky from utilizing the volume of data that is available in a useful manner. Kentucky Medicaid utilizes an enterprise decision support system which analyzes the volume of Medicaid data to aid better decision making. - Percentage of decision making processes that do not utilize the DSS
- Percentage of data stores not connected with the DSS
- Percentage of decision topics that find no data in the DSS Vendor Solution Medicaid DSS/DW Replacement 42 CFR 433.112 Functional Technical Data Data Quality/Data Access Integration/Interface
| New Functionality | Management and Innovation |
| Quality and Assurance | Systems Architecture |
Data Architecture
| Kentucky requires a FFS Utilization Management vendor that offers modularity and flexibility to keep up with evolving healthcare trends and solutions | ||
| Kentucky Medicaid ensures Medicaid spending supports requirements for medically necessary and clinically appropriate care, improved patient safety, improve patient health outcomes and quality care through a combination of prior authorization, pre-payment and post-payment review, audits and trend analysis. | - Number of Retrospective reviews > ten days |
- Number of determinations referred to physicians
- Conduct yearly desk top utilization audit reviews and report within forty-five calendar days to DMS Vendor Solution UM 907 KAR 9:005
907 KAR 11:034
907 KAR 3:130
907 KAR 1:330 Functional Technical Data Data Quality/Data Access Integration/Interface New Functionality Management and Innovation Systems Architecture Data Architecture Integration Architecture
| Division of Policy & Operations | ||||
| (Benefit Policy) | Provider Management | Travel reimbursements for clinic staff is time consuming and burdensome. Policy directive to return original receipts requires scanning of originals, documenting, time stamping and approvals before they can be turned in. Currently tracking on Excel spreadsheets and storing in shared drive. | The process for clinic staff travel reimbursements is automated to improve timeliness and reduce manual effort. | - Average time to process staff travel reimbursement |
| - Staff satisfaction surveys for the automated travel reimbursement process | Policy Directive | |||
| SaaS | N/A | 200 KAR 2:006. | Policy or Regulatory | Policy Regs |
| Other | Productivity |
Cycle Time and Timeliness
| Effectiveness | N/A | |||
| Retain Certified Nursing Assistants for Nursing Facilities | Certified Nursing Assistants remain working in nursing facilities for a minimum of X months to ensure adequate and continuous patient care | - Track number of Certified Nursing Assistants in each Nursing Facility |
- Average length of employment for each Certified Nursing Assistant
| Grant Solution | 42 CFR 83.35 | Resource | Other | Management and Innovation | N/A | ||
| Phase Pilot Telehealth Virtual Project for Nursing Facilities into permanent solution. | Virtual Telehealth is implemented permanently into each Nursing Facility for more efficient patient care. | - Percentage of increase in telehealth appointments | |||||
| - Percentage of increase in Nursing Facilities participating in Telehealth | New Initiative | KRS 205.632 | |||||
| KRS 211.334 | Organizational | Other | Management and Innovation | ||||
| Service Coverage | N/A | ||||||
| Collaborate and cooperate with our sister agencies within Kentucky and across the nation | |||||||
| OHDA KHIE | |||||||
| Care Management - Registries | Health Information Exchange (HIE) | Increase Outreach: Increase # of organizations utilizing services; Increase Organizations feeding the services and Increase outreach to inform end users of the availability of data and how to access. | Kentucky Medicaid increases the number of organizations utilizing HIE services. | - Percentage of increase in number of organizations utilizing services | |||
| - Percentage increase in the number of users accessing the data | New Incentives | Townhalls | |||||
| Training Seminars | KRS 194A.101 | Organizational | Other | Management and Innovation | |||
| Service Coverage | N/A | ||||||
| Decision Support System & Data Warehouse | Growing amount of data and the cost of storage. | Kentucky Medicaid performs a cost analysis to determine the best solutions for the growing amount of data and its associated costs. | - Cost of storage per amount of data (e.g., per GB, per TB) overall and for each storage provider |
- Percentage of data stored with each storage provider
| - Percentage of data stored in duplicate locations | New Solution | Medicaid DSS/DW Replacement | KRS 194A.101 | Functional | |||||||
| Data | Data Quality/Data Access | ||||||||||
| New Functionality | Financial | ||||||||||
| Technology Costs | Data Architecture | ||||||||||
| Health Information Exchange (HIE) | Adding standards for future connections and revisit previous feeds to increase quality of data. | Kentucky Medicaid develops and implements information exchange standards for the use of future and past data connections, improving data quality. | Percentage of data connections/interfaces not complying with data standards | Enhancement | Medicaid DSS/DW Replacement | KRS 194A.101 | Functional |
Technical Data Data Quality/Data Access Integration/Interface New Functionality Information and Data Systems Architecture Data Architecture Integration Architecture Collecting social determinants of health to aid Medicaid in the aggregation of data for data analytics. Social determinants of health details are captured for Kentucky Medicaid members to aid in promoting healthier outcomes. Percentage of Medicaid members without or with incomplete social determinants of health in member file Enhancement Medicaid DSS/DW Replacement KRS 194A.103 Functional Technical Data Data Quality/Data Access Integration/Interface New Functionality Management and Innovation Systems Architecture Data Architecture Integration Architecture
| Seeking to have clinical document exchange with skilled nursing and Long Term Care facilities. | Kentucky Medicaid exchanges clinical information with skilled nursing facilities and Long-Term Care facilities, improving program efficiency. | - Percentage of skilled nursing and Long Term Care facilities exchanging clinical data and electronically integrated with KY Medicaid | DPH Grant Solution | Quality Health Initiative | KRS 194A.101 | Functional | ||
| Technical | Document Management |
Integration/Interface
| New Functionality | Management and Innovation |
| Information and Data | Systems Architecture |
Integration Architecture
| Division of Program Integrity | |||||||
| (Provider Management/Enrollment) | Provider Management | Kentucky would like to receive updated licensure data from sister agency Office of Inspector General. | Kentucky Medicaid receives a weekly data feed providing licensure data from the Office of Inspector General to improve accuracy and efficiency. | Percentage of time a data feed is received per designated time frame | Vendor Solution | KYMPPA Enhancement | KRS 194A.101 |
| 42 CFR 455.412 | Functional | ||||||
| Technical | Document Management |
Integration/Interface New Functionality Information and Data Efficiency Systems Architecture Integration Architecture
| N/A | Staffing Shortages | Adequate numbers of staff are employed to perform activities within Kentucky Medicaid | Percentage of staff openings per department or division | Legislative (State Budget to include incentives) | HB1 | Resource | Other | Management and Innovation | N/A | ||||
| Eligibility and Enrollment | Surrounding states do not always notify KY when a provider has been disenrolled or suspended. A feed from surrounding state licensure boards would remedy this. | Kentucky Medicaid receives a weekly data feed from licensure boards of surrounding states providing provider disenrolled or suspended information, improving efficiency and accuracy. | - Percentage of out-of-state licensure boards participating in data feed | Outreach | |||||||||
| Interface | N/A | 42 CFR 455.416( c ) | Functional | ||||||||||
| Technical | Integration/Interface | ||||||||||||
| New Functionality | Management and Innovation | ||||||||||||
| Information and Data | System Architecture |
Integration Architecture
| Provider Management | Currently an ad-hoc report has to be requested to view provider network adequacy. | Kentucky Medicaid provides a dashboard report displaying provider network adequacy, improving efficiency | - Average refresh rate on provider network adequacy | ||||
| - User satisfaction surveys for the automated reporting process | Vendor Solution | MCAFS | 42 CFR 438.68 | Functional | |||
| Data | Data Quality/Data Access | ||||||
| New Functionality | Management and Innovation |
Efficiency
| Effectiveness | Systems Architecture | |||
| Be responsible stewards of our funding | ||||
| Division of Program Integrity | ||||
| (Compliance) | Decision Support System & Data Warehouse | Review of the Claims Top 200 report comparison with the MCO Lock-in Report requires comparing the report with each of the six MCO reports. Would be beneficial to have MCO lock-ins in same database. | Kentucky Medicaid provides an automated method for comparing the Claims Top 200 with each MCO lock-ins, improving efficiency and timeliness. | - Total number of enrollees who have been admitted and discharged into the Lock-In Program per quarter |
| - User satisfaction survey regarding new reporting format | Vendor Solution | MCAFS | 907 KAR 1:677 | Functional |
Technical Data Data Quality/Data Access Integration/Interface New Functionality Management and Innovation Effectiveness Quality and Assurance Systems Architecture Data Architecture Integration Architecture
| Provider Management | Review & Identify potential fraud, waste and abuse in genetic testing. | Kentucky Medicaid reviews genetic testing services for the identification of potential fraud, waste and abuse. | - Percentage of cases identified with fraud, waste, and abuse | ||||
| - Error rate in identifying fraud, waste, and abuse (i.e., cases missed during review that are identified later) | New Initiative | Healthcare Fraud Prevention Partnership Genetic Testing Audit | 907 KAR 1:671 | Functional | |||
| Technical | Integration/Interface | ||||||
| New Functionality | Management and Innovation | ||||||
| Quality | Systems Architecture | ||||||
| Provider Management | Review and Identify potential fraud, waste and abuse with Sober Living Residential treatment services. | Kentucky Medicaid reviews and identifies potential fraud, waste and abuse in Sober Living Residential treatment services. | - Percentage of cases identified with fraud, waste, and abuse | ||||
| - Error rate in identifying fraud, waste, and abuse (i.e., cases missed during review that are identified later) | New Initiative | Sober Living Residential Treatment Services Audit Review | 907 KAR 1:671 | ||||
| KRS 205.6318 | Functional | ||||||
| Technical | Integration/Interface | ||||||
| New Functionality | Management and Innovation | ||||||
| Quality | Systems Architecture | ||||||
| Member Management | Tax Interceptions Project to recoup monies from members convicted of fraud. | Kentucky Medicaid recoups monies from members convicted of fraud via the Tax Interceptions Project. | - Percentage of fraud cases pursued under the Tax Interception Project | ||||
| - Percentage of fraud cases successfully concluded in collection of monies owed | New Initiative | Tax Interceptions Project | 907 KAR 1:675 | ||||
| KRS 205.598 | Policy or Regulatory | Other | Financial | ||||
| Management and Innovation | N/A | ||||||
| Plan Management | Lack of a case tracking management system requires tracking status of suspected fraud/abuse incidents on Excel Spreadsheets prior to turning over to investigations. | A case tracking system has improved efficiency and ability to track status of pending cases. | - Percentage of compliance incidents managed within case tracking system |
-Average time from receiving case to closure
- Staff satisfaction with case tracking system Vendor Solution MCAFS KRS 205.6318
42 CFR 455.17
| 42 CFR 455.23 | Functional |
| Data | Data Quality/Data Access |
| New Functionality | Productivity |
Management and Innovation Efficiency Effectiveness Systems Architecture Data Architecture
| Improve Health outcomes and quality of life for our covered population | Office of Commissioner | ||
| Currently mobile crisis services are being underutilized where only 15% of behavioral health services are mobile crisis services. | |||
| Structured multi-disciplinary mobile crisis teams that includes practitioners and providers trained in diverse response approaches, provides Kentuckians experiencing a behavioral health crisis the right care at the right time. | - Percentage of behavioral health incidents eligible for mobile services | ||
| - Member satisfaction surveys where mobile crisis services are used | Grant Solution | Mobile Crisis Intervention (MCI) | 907 KAR 3:170 |
| 907 KAR 15:020 | Functionality |
Data
| Organizational | Data Quality/Data Access |
| New Functionality | Service Coverage |
Customer Benefit Systems Architecture Data Architecture Member Management Expand provisions, services and outreach for behavioral health services. Expansions in behavioral health services include outreach, suicide and overdose prevention, as well as follow-up appointment communications - Percentage of deaths by suicide
- Percentage of overdose deaths among all adult Medicaid beneficiaries in a geographic area
| - Percentage of suicide/overdose cases where follow-up appointments are made/kept | Demonstration Project | Certified Community Behavioral Health Centers (CCBHC) | EDW-SUD-019 | Functional | ||||||
| Organizational | New Functionality | |||||||||
| Other | Service Coverage | |||||||||
| Service Accessibility | Systems Architecture | |||||||||
| Expand the use of community health workers across the state. | The use of community health workers is expanded across the state to increase member access | - Ratio of community health workers to member population per geographical region | Grant Solution | EDW-SUD-020 | Functional | |||||
| Resource | New Functionality | |||||||||
| Other | Service Coverage | Systems Architecture | ||||||||
| Expand Telehealth to include remote patient monitoring tools. | Expansion of Telehealth to include patient monitoring tools has improved Kentucky's health outcomes for our rural members and reduced the number of emergency room visits. | - Percentage of reduced emergency room visits |
-Percentage of decrease in hospitalizations
| TBD | KRS 205.632 | ||||||||||
| KRS 211.334 | Functional | New Functionality | |||||||||
| Other | Financial | Systems Architecture | |||||||||
| Improve business processes and utilize automated data processing to support the programmatic outcomes of human services and support programs | |||||||||||
| OHDA Data Governance | Decision Support System & Data Warehouse | Communication can be a challenge with so many moving parts between agencies sharing data there is a need to develop standardization of terms and defining expectations and understandings to ensure everyone is in alignment. | Kentucky Medicaid develops a data governance plan to be used across the Cabinet | -Percentage of Divisions participating in or complying with the data governance plan | New Solution | Medicaid DSS/DW Replacement | KRS 194A.101 | Functional | |||
| Organizational | New Functionality | ||||||||||
| Other | Management and Innovation | Systems Architecture | |||||||||
| Need for a single process across cabinet for data sharing request that would trigger any other processes needed to get data sharing agreements in place. | Kentucky Medicaid implements a single process across the Cabinet for data share requests | - Percentage of Divisions participating in or complying with the data request process | New Solution | Medicaid DSS/DW Replacement | KRS 194A.101 | Functional |
Technical Data Data Quality/Data Access Documentation Management Integration/Interface New Functionality Management and Innovation Systems Architecture Data Architecture Integration Architecture
Attachment S MITA SSA 2022 KAPS RFP 758 2500000171 Kentucky Analytics Platform Solution (KAPS)
KY SS-A
TA Planning
Attachment S MITA SSA 2022 KAPS RFP RFP 758 2500000171 Kentucky Analytics Platform Solution (KAPS)
TA Planning
&P of &N
MITA Components for Pilot SS-A
Conduct Technical SS-A with a focus on business challenge common themes and for each New MES Business Area Steps for Technical SS-A
1. Begin Technical SS-A with review of business goals to determine gaps in technology support and investment needs
a. Review desired business outcomes and challenges identified in the business sessions
b. Identify common or overarching challenge themes
2. Review TA Pillars for foundational technical needs in the new MES modular approach (SaaS, PaaS, etc.)
3. Document technical needs, identifying leverage opportunities and consolidate for an investment list to be prioritized
4. Submit to KY Medicaid Commissioner to prioritize identified investment needs for roadmap
KY MITA Pilot Approach – Technical SS-A Focus on CMS’s 3 pilot overarching goals and approved KY approach
1. Definition of what success looks like in the To-Be state and how it will be measured (outcomes, metrics, goals, and data)
2. Current operational problems and risks, challenges, and limitations of the existing system (As-Is)
3. Medicaid program goals and alignment with resolution of current operational problems
Approach Sessions
| Assessment Categories and Questions with a Focus on the Modular MES Approach | Needs Met? | ||
| Yes/No/Partial | If No/Partial - | ||
| Gap Resolution Strategy | If No/Partial - |
Identified Technical Investments (Foundational/
| Technical Business Enablers) | If Yes or Partial - | |||||
| Validation Notes for items currently being met | Reuse/Leverage Opportunity - | |||||
| System Architecture | ||||||
| Step 1 | Understand Business Agenda - Categorize and review challenges identified in the business sessions to determine common or overarching themes to be discussed during the Technical SS-A | |||||
| Step 2 | Review TA Pillars for Foundational Technical needs in the new MES Modular Approach (SaaS, PaaS, etc. cloud based environment) | |||||
| Step 3 | Modular Readiness Assessment - Conduct series of questions to determine gaps that require investments | |||||
| System Architecture | Business Results | •Automation | ||||
| Q - Has KY Medicaid reviewed the challenges, overarching limitation themes, desired outcomes and resolution targets identified in the business SS-A sessions so plans for IT support requirements can be addressed during the Technical SS-A? | Yes | N/A | Automation and module resolution targets currently identified by the business include (* in procurement): |
• *MCAFS - claims, financial, portals,
• *PBM - Pharmacy
• *UM - Utilization Management
• *EVV HHCS - Electronic Visit verification
• Medicaid DSS/DW Replacement
| Q - Are key business processes fully documented to ensure repeatable tasks and other requirements can be identified for process automation initiatives? | Partial | Desktop level guides and SOP for some task but not all. |
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