South Dakota Medicaid

1
South Dakota Medicaid Medicaid Management
Information System (MMIS) Project Larry Iversen,
Medicaid Director August 23, 2007
2
Background of Medicaid In South Dakota

• Larger healthcare insurer in South Dakota with
  125,000 unduplicated individuals participating in
  the program during FY06 and average monthly
  enrollment of over 101,000.
• Program adjudicates over 5 million claims per
  year.
• In FY06, the state expended 640.1 million in
  total on healthcare services and administration
  of the Medicaid program. The 208.9 in general
  funds match represented 20.7 of the entire state
  budget.
• Complex program involving federal and state
  laws, rules, and policies.
• Numerous funding sources to draw funds from,
  depending upon the services rendered or who is
  providing the services.
• Very comprehensive program that pays for a wide
  variety of services.

1
3
South Dakota Medicaid Covered Services

• Inpatient and outpatient hospital
• Physician services
• Prescription drugs
• Nursing facility services for individuals age
  21 or older
• Medical and surgical dental services
• Home health care
• Rural health clinic services
• Laboratory and radiology services
• Medical transportation services
• Adult optometric services and eyeglasses
• Durable medical equipment and prosthetic
  devices
• Hospice care
• Personal care services
• Chiropractic services
• Mental health and chemical dependency services

2
4
Medicaid Management Information System (MMIS)

• Current MMIS is a 1978 legacy mainframe system
  programmed in Cobol.
• Base system was transferred from another state
  and modified to work with South Dakotas rules.
• The MMIS has numerous other systems that feed
  into it, including systems from other state
  agencies and various eligibility systems within
  DSS.
• The current system processes claims efficiently
  however, it lacks flexibility, ease of use by
  administrative staff, and will be unable to meet
  future federal mandates.

3
5
Benefits of a New MMIS

• Improve payment accuracy
• Improve customer service
• Increase cost avoidance and fraud recoveries
• Increase third party liability payments
• Incorporate Federal National Provider
  Identification requirements
• Meet Federal Medicaid Information Technology
  Architecture requirements
• Provide improve budgeting and forecasting
  analysis
• Use technology to identify individuals needing
  focused case management
• Improve interoperability and interfaces with
  other systems and agencies
• Increase administrative efficiency

4
6
Return on Investment

• Federal funding of MMIS projects, with approval
  from the Centers for Medicare and Medicaid
  Services (CMS), is 90 percent.
• Cost avoidance ability to better pursue third
  party liability and the use of clinical edit
  software to insure correct procedure codes are
  billed in conjunction with each other.
• Cost recovery overall claims payment error
  rate in current system is 1.91. New MMIS will
  improve accuracy and increase ability to detect
  fraud and abuse. Nationally, states are
  recovering 8 11 for every 1 spent on recovery
  efforts.
• Administrative Opportunities real-time,
  on-line adjudication the use of web interfaces
  data warehouse and cessation of current data
  matching expenses.

5
7
Progress to Date

• Replacement process began in October 2005
• Assessment of current MMIS and documentation of
  all business processes.
• Development of requirements for new MMIS.
• Draft and submission of Implementation Advance
  Planning Document to CMS to secure 90 Federal
  funding.
• Development of Requests for Proposal for the
  Project Management Independent Validation and
  Verification and Design, Development, and
  Implementation contracts.
• Review and scoring of all contract proposals.
• Started on-site visits to other state Medicaid
  agencies to evaluate operation of their MMIS.

6
8
Project Completion Timeline

• September 2007 Oral presentations by Design,
  Development, and Implementation bidders.
• December 2007 Targeted contract start date for
  Design, Development, and Implementation vendor
• December 2009 - Implementation of new MMIS
• December 2010 Certification approval by the
  Centers for Medicare and Medicaid Services
• The projected timeline is aggressive, given the
  complexity of the system. Testing of the new
  system will be extensive and we will run
  concurrent systems until we are confident the new
  MMIS is operating appropriately.

7
9
(No Transcript)