Analysis Item 13: Oregon Health Authority Medicaid Management Information System Workgroup

Transcription

1 Analysis Item 13: Oregon Health Authority Medicaid Management Information System Workgroup Analyst: Linda Ames Request: Acknowledge receipt of a report on recommendations regarding the Medicaid Management Information System (MMIS) and related systems and interfaces. Recommendation: Acknowledge receipt of the report. Analysis: The budget report for SB 5526, the budget bill for the Oregon Health Authority (OHA), included the following budget note: The Oregon Health Authority shall put together a work group to compile a list of the current issues of concern in regards to the functioning of the Medicaid Management Information System (MMIS) as it relates to other systems and interfaces, and to make recommendations on resolving those issues. The group shall include staff from the agency, three coordinated care organizations, three health care providers, and the Legislative Fiscal Office. By November 2015, the agency will report the findings of the group, and the resolution or expected resolution of the issues, to the Interim Joint Committee on Ways and Means. MMIS is the system used to enroll OHA and Department of Human Services (DHS) Medicaid clients, process Medicaid claims, and manage information about Medicaid beneficiaries and services. Information about Oregon Health Plan clients is sent to MMIS from the new Oregon eligibility (ONE) system and certain older DHS systems, and MMIS then transmits eligibility and enrollment information to providers and coordinated care organizations. The agency provided its first report to the Interim Joint Committee on Ways and Means in November 2015, with a general work plan. Since then, the group has met four times and generated this final report. The report includes a list of the 15 perceived MMIS issues that were identified by the group, as well as potential solutions. Many of the concerns raised through the workgroup discussion are data integrity issues resulting from the use of multiple eligibility systems, including manual processes, put in place after the failed Cover Oregon solution. These systems sometimes lacked needed functionality and did not always include necessary edits. This resulted in erroneous and sometimes conflicting data being fed to MMIS. While users of the system perceive these as MMIS issues, they are actually problems with the eligibility systems. Now that the new ONE eligibility system has been implemented, many of the data issues will be cleaned up by February 2017, as data is reviewed during the redetermination process for each client. The report groups the 15 issues into the following three categories: Improved with ONE implementation: Seven issues fall within this category, as described above. These include such issues as missing or incorrect redetermination dates, members enrolled but coordinated care organizations (CCOs) not receiving capitation payments, incorrect addresses Legislative Fiscal Office Emergency Board May 2016

2 and demographic data, and family members not assigned to the same case. This data will gradually improve until all cases have been redetermined by February Resolved/action planned: These four issues are either resolved or a plan is in place. One issue was a MMIS defect resulting in CCOs not always receiving records for members who were disenrolled. The system was modified in April 2016 to correct this issue. Referred for further discussion: Two of these issues relate to HIPAA/privacy concerns. OHA will review with the Information Security and Privacy Office and then report back to the on-going advisory committee for MMIS issues. The other two other issues will be referred to this same advisory committee for further discussion. One of these is the issue of MMIS assigning members to a health care plan, but not to a primary care provider. There are policy arguments on both sides, and not all CCOs agree which is best. The work of this specific workgroup has concluded. However, as a part of this workgroup a number of on-going forums were identified dealing with either communications or MMIS governance. This includes the All Plan Systems Technical Workgroup, an advisory committee that collects input and issues of a technical nature related to MMIS and its associated systems, which will continue to meet monthly to identify and make recommendations related to the system. OHA intends to work with this group to identify a wish list for future functionality for MMIS to be considered for future upgrades. The Legislative Fiscal Office recommends acknowledging receipt of the report. Legislative Fiscal Office Emergency Board May 2016

3 13 Oregon Health Authority MacDonald Request: Report on the findings and recommendations of the Medicaid Management Information System (MMIS) workgroup by the Oregon Health Authority (OHA). Recommendation: Acknowledge receipt of the report. Discussion: The budget report for Senate Bill 5526 (2015) includes the following budget note requiring OHA to form a workgroup and report on issues of concern related to MMIS: The Oregon Health Authority shall put together a work group to compile a list of the current issues of concern in regards to the functioning of the Medicaid Management Information System (MMIS) as it relates to other systems and interfaces, and to make recommendations on resolving those issues. The group shall include staff from the agency, three coordinated care organizations, three health care providers, and the Legislative Fiscal Office. By November 2015, the agency will report the findings of the group, and the resolution or expected resolution of the issues, to the Joint Interim Committee on Ways and Means. MMIS is the system of record Oregon uses to process and manage Medicaid claims, beneficiary, and service data. The system interfaces with Medicaid eligibility and enrollment systems in OHA and the Department of Human Services and exchanges data with coordinated care organizations (CCOs) and health care providers. Challenges with the reliability of Medicaid eligibility data have existed in the past due to the reliance on the multiple systems. OHA is in the process of implementing a new Medicaid eligibility system, called ONE. This new system will provide Medicaid eligibility determinations consistent with the Modified Adjusted Gross Income (MAGI) eligibility requirements under the federal Affordable Care Act. The eligibility portal of ONE went online in December 2015 and a phased-in implementation of the applicant portal began in February A core purpose of the MMIS workgroup was to address the MMIS data challenges to ensure resolution of the issues upon OHA s transition to ONE. OHA submitted a high-level report on the status of the MMIS workgroup to the Joint Interim Committee on Ways and Means in November The workgroup subsequently met four times and completed its assessment of MMIS in April OHA now submits a final, more detailed report to the legislature identifying the issues of concerns and planned action items. The workgroup s recommendations identify 15 issues of concern that fall within one of the following three disposition categories: Referred for further discussion (four issues): These represent issues that are both systemrelated and dependent on policy decisions that require additional review and discussion for a final determination to be made. Improved with the implementation of ONE (seven issues): These represent five system and two policy issues that are being resolved through the implementation of ONE and the decommission of legacy systems and processes. Department of Administrative Services 13-i May 25, 2016

4 Resolved or action planned (four issues): These represent three policy issues and one system issue that have either been resolved or have a resolution plan in place. OHA intends to address those issues that still require a system or policy change by leveraging two existing CCO advisory forums and two existing MMIS governance forums. OHA will also provide a single point of contact to CCOs and health care providers to assist with future MMIS issues; create an internal OHA workgroup to identify process improvements; brief the CCO advisory forums twice annually regarding MMIS system changes; and identify potential future MMIS functionality to take user needs into account when system upgrades occur. The report indicates data cleanup issues will continue through February 2017 as MAGI Medicaid beneficiaries reapply for coverage and are entered into ONE. Department of Administrative Services 13-ii May 25, 2016

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