Medicaid Modernization

Medicaid modernization encompasses the entire enterprise — policy, processes, systems, and organization.”

Rob Guenther, Senior Principal, Healthcare and Human Services Practice
Rob Guenther

Medicaid Modernization

A comprehensive approach to program and MMIS modernization is critical to the success and sustainability of the Medicaid enterprise. Drawing on the expertise and experience of CSG can help you maximize the return on your investment in Medicaid modernization.

CSG'S Expertise in Action

 
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Modular MMIS in New Mexico

 
Santa Fe
Santa Fe

The New Mexico Human Services Department (HSD) is implementing a modular MMIS to efficiently administer the State’s Medicaid program to its more than 800,000 recipients. In addition, HSD is maximizing federal funding by aligning its modernization strategy with the new CMS Medicaid Enterprise Certification Life Cycle.

IV&V by CSG SM for MECL

HSD selected CSG to provide comprehensive IV&V services aligned with CMS' MECT v2.2 over the full life cycle of the MMIS replacement, including up to six procurement RFPs and the design, development, certification, and implementation of the new MMIS.

CSG is applying IV&V by CSG℠ to assure the procurements and modular systems are being reviewed both individually, and from an enterprise approach. We are verifying each module meets the RFP system requirements, testing interoperability across modules and services, and guiding the State through the CMS MECL certification process to assure compliance and achieve certification at project completion.

New Mexico has a vision of an improved, person-centric Medicaid Enterprise that reduces costs, improves member health outcomes, and promotes self-sufficiency for the residents who rely on it. CSG is here to help achieve this vision.

Modernizing Vermont’s Medicaid Enterprise

 
Montpelier
Montpelier

The Vermont Agency of Human Services and the Department of Vermont Health Access selected CSG to provide IV&V services for its modular Medicaid Management Information System and Integrated Eligibility and Enrollment system implementation project.

Enterprise IV&V for MECL and MEELC

As Vermont’s Enterprise IV&V partner, CSG provides assessments, observations, and recommendations to support the ongoing implementation and ensure project adherence to federal standards. Our assessments and recommendations span the entire Enterprise, supporting reuse of common components or services across modules and informing State leadership of portfolio and project-specific risks. The CSG team also validates that systems satisfy requirements and reviews evidence that demonstrates that the modules achieves certification compliance. So far, the Pharmacy, Care Management, and Provider Management modules have completed R3 milestone reviews to achieve final certification.

Vermont is committed to improving its health and human services programs by achieving efficiencies through an interoperable enterprise approach. CSG is here to help with this strategic initiative.

Supporting Ohio's Move to Modularity

 
Columbus
Columbus

The Ohio Department of Medicaid (ODM) has a network of more than 83,000 active providers and delivers healthcare coverage to 2.8 million Ohio residents. To assure it provides the most efficient care and leverages technical advancements within the national Medicaid landscape, ODM is launching an initiative to move to a modular Medicaid Enterprise.

Strategic MMIS Planning and Procurement Support

ODM selected CSG to develop a comprehensive strategy and provide procurement support services for modernizing its Medicaid Enterprise. CSG is working with ODM to identify reusable components via the State’s MITA 3.0 SS-A to achieve higher MITA maturity levels and maximize federal funding. CSG is assisting the State in analyzing MMIS operational model options, determining implementation priorities, and sequencing modular components. CSG supports ODM throughout the procurement process to define requirements, develop RFPs, and provide vendor evaluation and selection support.

ODM is committed to achieving the goals of modularity in Ohio. CSG is here to help the State meet its objectives and maximize its return on investment.

MMIS Modernization in Idaho

 
Boise
Boise

The Idaho Department of Health and Welfare’s mission is to promote and protect the health and safety of Idahoans. DHW is replacing its current Medicaid Management Information System (MMIS) with a flexible, modular enterprise system that will quickly adapt to the dynamic, evolving needs of existing programs and support new regulations, policies, and innovations.

PMO by CSG SM

Idaho selected CSG to provide a full-service enterprise Project Management Office to oversee the MMIS procurement planning and modernization project. Engaged early in the project, CSG helps DHW establish and implement effective project management processes, templates, guides, and tools, and supports critical decision-making regarding the scope and sequence of the modular procurements. The CSG team also provides quality assurance, risk management, schedule and resource management, and CMS certification support throughout the modernization effort.

DHW is dedicated to strengthening the health, safety, and independence of Idahoans. CSG is here to help Idaho meet its goals through the implementation of innovative repeatable processes and using best of breed technologies.

Maximizing the Value of Modularity for Kentucky’s Medicaid Enterprise

 
Frankfort
Frankfort

The Kentucky Cabinet for Health and Family Services (CHFS) is responsible for overseeing the Commonwealth's Medicaid program. In order to more efficiently administer services to its 1.2 million recipients, CHFS is modernizing its Medicaid Enterprise Management System (MEMS) using a modular procurement strategy.

Modular Procurement Support and IV&V Services for MECL Certification

To help assure successful implementation, CHFS selected CSG to provide IV&V Services from procurement support through the system development life cycle until final system certification. CSG reviewed and provided feedback on the MEMS RFP, developed a Procurement Integrity Plan, and updated the Commonwealth's MITA SS-A to align with the new RFP and Concept of Operations. CSG also assisted CHFS in understanding CMS’ Medicaid Enterprise Certification Life Cycle (MECL), providing critical feedback and support for Milestone Reviews and Implementation Advance Planning Document development.

The CSG team uses our knowledge of CMS processes to assure evidence addresses CMS certification and funding requirements, including the Standards and Conditions for Medicaid IT, Programmatic Critical Success Factors, and other directives. To date, the CSG team has provided IV&V oversight for the Commonwealth’s MEMS project, Partner Portal Project, KY HEALTH 1115 Waiver project, and Waiver Case Management system.

Together, CHFS and CSG are working to meet the agency’s goals and provide superior Medicaid services to Kentuckians.

Georgia’s Modular Medicaid Enterprise System Implementation

 
Atlanta
Atlanta

The Georgia Department of Community Health provides Medicaid coverage for more than 2 million Georgians. The agency is executing a Medicaid Enterprise System Transformation program that includes the multi-year agile implementation of a modular Medicaid system that will improve the customer experience; provide flexibility for changes in technology, program, and policy; and enable data-driven decision making.

IV&V by CSG SM

DCH contracted with CSG to provide proactive, full life-cycle IV&V services across the enterprise and for individual modules including Provider Services, Claims and Financial Management, Pharmacy Benefits Management, and Third Party Liability. The CSG team observes meetings, reviews deliverables and documentation at both the enterprise and modular levels, and conducts interviews to inform monthly dashboard reports evaluating project health. We assess aspects of the project including project progress, operational readiness, organizational change management, vendor and resource management, and governance to identify risks and recommend mitigation strategies.

Georgia is modernizing its Medicaid technology to enhance health care quality and outcomes for its citizens. CSG is here to ensure the state achieves its goals.

Pharmacy Benefit Management System Modernization in Massachusetts

 
Boston
Boston

The Massachusetts Executive Office of Health and Human Services (EOHHS) is comprised of 12 agencies focused on the health, resilience, and independence for the 1.6 million residents it serves. EOHHS has launched an initiative to modernize its legacy Pharmacy Benefit Management System with an adaptable, flexible, and interoperable solution that increases automation and enhances customer experience. The new Pharmacy On-Line Processing System will support the Commonwealth’s advancement toward a modern Medicaid business and technical environment.

IV&V by CSG SM

EOHHS selected CSG to provide comprehensive IV&V services for the implementation. CSG is conducting ongoing assessments of project performance and progress, analysis of project risks and issues, reviews of vendor deliverables, and evaluations of requirements traceability and defect tracking. Our team also assures that the solution achieves MITA compliance and supports CMS certification activities.

The Pharmacy On-Line Processing System modernization project is a complex effort with strategic objectives focused on improved customer service and health outcomes for Commonwealth residents. CSG is here to help EOHHS achieve its goals on this strategic initiative.

Strengthening Program Integrity in South Dakota

 
Pierre
Pierre

The South Dakota Department of Social Services is implementing corrective action plans resulting from Payment Error Measurement (PERM) and Program Integrity (PI) reviews conducted by CMS. By completing these plans, the State is strengthening the program and ensuring it meets all federal requirements.

Strategy by CSG SM

CSG was contracted by DSS to bring Program Integrity expertise and provide project management, gap analysis, policy review, and guidance to navigate CMS corrective action plans. CSG also assisted DSS staff with preparing claims data and documentation for submission to CMS and federal contractors as part of the PERM and PI reviews. Additionally, CSG supported Organizational Change Management activities including building additional capacity across agency operational units and developing stakeholder training.

DSS is working to ensure its Program Integrity unit complies with CMS requirements and protects the Medicaid program against fraud, waste, and abuse. CSG is here to support the State in reaching those goals.

Transitioning to a Managed Care Model

 
Des Moines
Des Moines

The Iowa Medicaid Enterprise (IME) administers the State’s Medicaid program for over 560,000 Iowans. IME is transitioning from a traditional Fee-For-Service (FFS) claims payment model to a Managed Care Organization (MCO) reimbursement model. To better serve the members of its community, IME has contracted with several professional and systems services providers to support the operations of the Medicaid program.

Research, Planning, and Procurement Support by CSG

IME selected CSG to develop a holistic approach to help the State define and build a foundation for its Medicaid enterprise and affiliated professional and system services that aligns with the operational needs of the new MCO model. We provided research and planning support to help IME navigate the changing Medicaid landscape and obtain enhanced federal funding in accordance with MITA and the new CMS guidance for certification criteria and modular system standards. CSG also defined RFP-ready requirements that are mapped to the MECT 2.0 checklist, developed RFPs and Advance Planning Documents (APDs), and assisted in the evaluation of bids and contract negotiations to procure qualified vendors to support IME operations moving forward.

IME is working to advance the State’s vision of improved quality and access to health care services, accountability for outcomes, and a more predictable and sustainable Medicaid budget. CSG is here to help.

Virginia's Modular, Interoperable MMIS

 
Richmond
Richmond

The Virginia Department of Medical Assistance Services (DMAS) administers the Commonwealth’s Medicaid program for over 950,000 Virginians. In order to provide high quality and cost effective services, DMAS is transitioning from a legacy mainframe MMIS to a modular, interoperable solution that encompasses the entire Medicaid Enterprise.

Requirements Definition and Procurement Support Aligned With MECL

DMAS engaged CSG to provide procurement support services, including assistance for incorporating the new CMS modularity standards and aligning the new Medicaid Enterprise system plans with the Commonwealth’s MITA 3.0 SS-A. We helped define RFP requirements across each of the modular components, develop the RFP documents, and support federal funding by developing the Implementation Advance Planning Documents and federal budget tables for CMS.

DMAS is committed to transitioning to a holistic Medicaid Enterprise model which provides a system of high quality and cost effective healthcare services for Virginians and their families. CSG is here to help navigate the changing Medicaid landscape to assure Virginia meets its goals.

Developing the Strategy to Modernize Missouri’s MMIS

 
Jefferson City
Jefferson City

The Missouri Department of Social Services’ MO HealthNet Division (MHD) has been operating its current MMIS for over 30 years, processing over 99 million claims from over 49,000 providers per year.  In order to provide the most effective support to the people they serve, MHD launched a major initiative to improve the administration of the Medicaid program across the entire Medicaid enterprise.

Strategic MMIS Planning and Procurement by CSG

MHD selected CSG to develop a comprehensive strategy and provide procurement support for this strategic initiative. The CSG team assessed the alignment of MHD’s business functions and systems with the CMS’ Seven Conditions and Standards and MITA 3.0 Framework, led visioning sessions with project stakeholders, and produced a MITA SS-A to determine key enhancement efforts. CSG also worked closely with the State to assess the availability of modular solutions, analyze the current vendor landscape, and leverage our experience with CMS and other states to assist MHD in defining an enterprise wide modernization strategy. We then provided requirements definition and procurement support for the RFP process to procure the most efficient and cost effective MMIS.

The people of Missouri are making a strategic investment in Medicaid modernization. MHD and CSG are working together to assure that the State’s MMIS meets the needs of the people who depend on it.

Medicaid Contract Management in Texas

 
Austin
Austin

The Texas Health and Human Services Commission (HHSC) coordinates the planning and delivery of health and human services programs in the State, including its Medicaid program. In order to provide Texans with enhanced service and performance of their Medicaid program, HHSC is transitioning to performance-based contracting to more efficiently achieve program objectives.

Developing a Performance-Based Contracting Plan

HHSC selected CSG to help transition the State’s current Medicaid fiscal agent contract monitoring methodology to a performance-based contract management process. CSG assisted the State in establishing an overall vision, defining goals and objectives, developing a performance-based contracting plan, and implementing contract monitoring and reporting methods. CSG also completed a gap analysis of HHSC’s current contract management system to identify potential modifications, reviewed HHSC’s standard contract management-related RFP requirements and provided recommendations for change, and identified new reporting methods to align with the updated monitoring approach. The CSG team also addressed contract monitoring governance, provided recommendations for organizational alignment, and facilitated training sessions to help State staff transition to the new performance-based contracting methodology.

HHSC is committed to modernizing its Medicaid program to enhance services for Texans. CSG is here to assure its objectives are met.

Modernizing Florida's MMIS

 
Tallahassee
Tallahassee

The Florida Agency for Health Care Administration (AHCA) oversees the State’s Medicaid program providing healthcare coverage to nearly 3.8 million Floridians. To enhance and integrate its MMIS and Decision Support System (DSS) capabilities, the State has launched a major initiative to modernize its Medicaid enterprise.

MMIS Modernization Strategy, Requirements Development, and Procurement Support by CSG

AHCA selected CSG to facilitate development of the modernization strategy, conduct requirements development, and provide vendor solicitation, evaluation, and selection support throughout the MMIS/DSS procurement process. CSG conducted a gap analysis of the State’s MITA SS-A and MMIS/DSS to identify areas for system improvements, and conducted sessions to update Florida’s MITA 3.0 SS-A. We utilized our MMIS Landscape tool to assist AHCA in identifying states with similar MMIS modernization plans and leveraged our MMIS Alternatives Assessment Matrix and Cost Benefit Analysis tools to compare solutions and make recommendations that best fit their modernization needs.

CSG is also applying our set of MMIS baseline requirements to assist the State in creating custom requirements for the technical and operational aspects of its solicitation, and supporting the development of Fiscal Agent requirements, solicitation evaluation criteria, and vendor evaluation training for State staff.

AHCA is dedicated to providing better healthcare for all Floridians. CSG is helping the State achieve this vision.

Successful MMIS Implementation in Ohio

 
Columbus
Columbus

Ohio’s Medicaid program provides healthcare coverage for 2.8 million residents at a cost of $15 billion per year. The Ohio Department of Medicaid (ODM) has reached a major milestone in Medicaid program modernization with the successful implementation of the Ohio Medicaid Information Technology System (MITS). MITS is built on robust business and technical architectures and leverages innovative technology to increase productivity, enhance customer service and ease of use, provide flexibility for complying with dynamic federal mandates and statutory rules, and support MITA goals today and in the future.

Proactive MMIS Modernization Services

CSG provided comprehensive proactive MMIS modernization services throughout the project. Our services encompassed all aspects of the MITS modernization effort, including project management and governance, technical architecture and design, business transformation and training, requirements management, data conversion, technical and operational readiness, and MMIS certification.

The people of Ohio are making a large investment in Medicaid modernization. ODM and CSG are working together to assure that the State’s efforts meet the needs of Ohio’s Medicaid Enterprise and the people who depend on it.

Modernizing Medicaid in Iowa’s Best of Breed Model 

 
Des Moines
Des Moines

The Iowa Department of Human Services, through the Iowa Medicaid Enterprise (IME), provides healthcare coverage for 684,000 residents at an annual cost of nearly $4 billion and depends on its MMIS to manage this critical responsibility. IME has undertaken a large and highly visible effort to modernize both the core MMIS and the Pharmacy Point-of-Sale (POS) systems to support dynamic Medicaid policies and address current and future MITA goals. The technology and business rules are complex. But the opportunities are great.

PMO by CSG SM

One of IME’s strategies for overseeing the project is the adoption of a Project Oversight, Management, and Integration services program. CSG was IME’s partner in fulfilling this critical management function. Our oversight and management of the implementation contractors and project team assured that all aspects of the project – including requirements management, adherence to the schedule and budget, project governance, technical architectures, and organizational changes – were effectively achieved.

Together, Iowa and CSG are working to ensure that the MMIS/POS modernization meets the needs of the IME and the people who depend on it.

Medicaid Modernization in Minnesota

 
St. Paul
St. Paul

The Minnesota Department of Human Services (DHS) had been operating its current MMIS for over 20 years. In order to improve interoperability between systems and agencies, DHS launched a major initiative to modernize its MMIS within a common framework Service Oriented Architecture.

MMIS Strategy and Planning by CSG

Minnesota selected CSG to provide strategy and planning services for its MMIS modernization effort, including conducting their MITA 3.0 State Self-Assessment. CSG completed an alternatives assessment, feasibility study, and cost-benefit analysis to identify requirements and support buy/build decision making. CSG also developed an MMIS Modernization Roadmap for aligning the MMIS modernization effort with other State systems and technologies. The roadmap is built on a collaborative approach to integrate MMIS, Health Insurance Marketplace, and integrated eligibility systems. CSG also produced an Implementation Advance Planning Document (IAPD) to obtain federal funding for the project.

Minnesota DHS is committed to excellence in service delivery and efficient government. CSG is there to help the State achieve its objectives.