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Systems for Eligibility Determination:
How to Get 30 Million New Enrollees as
Defined by the Affordable Care Act by 2014
Medicaid Innovations Forum
February 2012
Eligibility Determination
Who is impacted?
Stakeholders - Medicaid applicants
and beneficiaries, Tax Payers and
State Human Services managers.
One size does not fit all!
Key Challenges:
Business
Shrinking budgets and Limited Staff
Shifting paradigms – Innovation in Business Process
Traditional vs. Current System
Data Sharing – Exchanges and Interoperability
Increased capacity
Health literacy
Changing Laws
States are "...forced to recognize but not prepared to manage.
"
HITECH & PPACA Issues:
Standards and certifications – EHR
Meaningful Use
Privacy and Security
Electronic Eligibility and Enrollment
Clinical Reporting
"Information-driven healthcare"
"Plenty of data but no information"
Eligibility Determination
“It is easy to build systems that are
hard to use, but much harder to build
systems that are easy to use!”
Bruce Whitehead, MariChris, LLC., VP/CTO
MariChris, LLC
the Company
M A R I C H R IS
H A S P A R T I C U L AR
TECHNICAL EXPERIENCE WITH
M EDICAID APPLICATIONS AND
RELATED HEALTHCARE PROCESSES.
MariChris, LLC
the Company
WE
HAVE APPLIED OUR TECHNOLOGY,
BUSINESS PROCESSES AND CONTROL
SYSTEMS TO A WIDE RANGE OF
GOVERNMENT, INSURANCE CARRIER AND
PROVIDER SYSTEMS.
MariChris, LLC
the Company
WE
BRING A PERSPECTIVE FROM ALL
SIDES OF THE BUSINESS WITH
G R O U N D B R E AK I N G T R A C E I T S O F T W A R E
THAT INTEGRATES COMPREHENSIVE
T R A C K I N G , T R A C E A B I L IT Y A N D
REPORTING.
MariChris, LLC the Company
At MariChris, we
understand the
complexity of the
Medicaid/MMIS
development
environment.
We understand that
there are
50 States
and
50 individual
MMIS solutions!
Our Products
TraceIT and UnivERS
PROVIDE STRONG SUPPORT FOR
E LIGIBILITY
D ETERMINATION MARKETS .
THE
MMIS
AND
TraceIT
 CMS Checklist
Certification
Traceability
Login
Project / Account
CMS Certification
MITA BA
CK LIST
Business Area or
Subsystem
Business
Requirements
MITA BP
Process
[GSD Object]
MITA SBP
Use Cases
[DSD Object]
Data Elements
Pages / Screens /
Reports
Business Rules
System Integration
Testing
Change Logs
Error Messages
Test Case
[Unit/Sys
Testing]
Ops Readiness
Testing
Legend:
MITA 3.0 XREF
Test Script
Certification
REQ Validation
DESIGN
TESTING
TRACKING
Defect Logs
Test Result
Simplify Eligibility
Program Processes
The sheer number and complexity of
f i n a n c i al a n d m e d i c a l a s s i s t an c e b e n e f i t
programs that exist today often make it
d i f f ic u l t f o r a d m i n i st r a t o r s t o
determine eligibility, and for providers
to initiate needed care to their patients
in a timely manner.
UnivERS
Is a comprehensive eligibility technology solution
that solves this problem and works with any financial or
medical assistance program,
including all programs supported through the
Medicaid Management Information Systems (MMIS)
and Public Health programs.
UnivERS
Allows program administrators to easily build and
maintain eligibility rules and conditions for any
program, with the process of preliminary eligibility
determination and final eligibility determination being
fully automated.
UnivERS
Now eligibility, for “ever changing” financial and medical
assistance programs, can be determined in real time and
without delay, as the application process is being conducted.
 Ability to create and manage
 Application data collected can be
any number of active programs
 No technical skills or support
are required to create and
manage benefit program rules
 Rule sets can be added,
modified, end dated, or
inactivated at anytime
applied to any eligibility program
or benefit plan
 System can seamlessly match
applicants to all available
programs
 System supports comprehensive
patient inputs, workflow
management and caseload
management capability
Eligibility Determination Solutions
must accomplish:
 Reduction of redundant data entry across eligibility





programs
Decreased processing time for changes and
redeterminations
Minimization of the need for technical assistance
Increased level in employee productivity
Lower participants' reliance on face-to-face agency contact
Provide convenient access to policy and procedural guides
UnivERS
Accomplishes all of these MUST HAVES!
BuiltUnivERS
for Future Needs
U NIV ERS LEVERAGES PROVEN
FUNCTIONAL COMPONENTS IN A
FRAMEWORK DESIGNED AROUND YOUR
OBJECTIVES .
UnivERS
Built for Future Needs
Implementation involves application design,
development, operations and maintenance, as well
as integration services. We tailor the Eligibility
Solution to your needs and integrate reusable
portions of your legacy applications.
UnivERS
Built for Future Needs
Characteristics of the UnivERS Eligibility Determination Solution
that make it easily adaptable to changing needs and conditions:
 Modular architecture –
 Rules-based applications –
based on a collection of open
systems components that
offer both flexibility and
expandability
 Flexible design –
integrates services across
agency and program
boundaries, inviting
implementation of new
access channels
provide an adaptable framework of
functional components that permit
rapid deployment of new service
delivery models and implementation
of new policy requirements
 Web-based or Client Server user
interface – enhances user
experience and requires minimum
training
 Tailored components – ensure
system is aligned with your goals and
processes
Our commitment to
the State Medicaid Agencies
Healthcare reform as defined by PPACA
 Online eligibility applications and renewals must use




simplified rules
The decision must be rules based
Use electronic databases to validate or verify
customer of household financial statements
Use electronic signatures
Interface with the HIE and HIX’s with a seamless
transition between programs
Our commitment to
the State Medicaid Agencies
Innovatively provide:
 An integrated solution that includes Medicaid, S-Chip,
SNAP, TANF, WIC, etc.
 An integrated solution which will focus on bringing
Medicaid and Public Health under one umbrella when
Determining Eligibility.
 An integrated UnivERS for all of the citizens of the
State Enterprise.
UnivERS
MariChris Goals for Design and Implementation
 Reduce redundant data entry across benefit programs
 Decrease processing time for changes and redeterminations
 Minimize the need for technical assistance
 Raise employee productivity
 Lowers participants' reliance on face-to-face agency contact
 Give convenient access to policy and procedural guides
 Save on cost through operational efficiency and reduced
labor/contractor staff
 MariChris, today’s newest provider of Eligibility
Your Partner
for:
_________
A successful
change for
the next
generation of
Eligibility
Systems!
Determination Systems designed and built by
eligibility professionals
 4Thought, two decades of professional service to the
Medicaid community guiding Medicaid information
system modernization through to successful
implementations
 STC, twenty years of integrated health information
systems to improve population health outcomes and
positively impact the economic benefits of
communities
 Polygot, using innovative social media resources to
reach and engage the high risk and uninsured
 The Experts, the largest provider of Medicaid
professionals in the last decade
UnivERS
“Universal Eligibility
Response System”
MariChris and the AIM Alliance
are an Innovative
Eligibility Determination Solutions Team.
READY NOW, FOR 2014
and Beyond!
____________________
Take
on your
Eligibility Determination System!
MariChris, LLC 116 Grand Oaks Drive St. Augustine FL (919)325-6679
www.MariChrisLLC.com
[email protected]
SOA and Interoperability Concepts applied to UnivERS
UnivERS@Home
Data Collection
(Intake)
Data Integrity
Eligibility
Determination
Data Verification
Rule Management
WebServices
UnivERS
Online &
Realtime
UnivERS
RulesXpress
HIX
RulesXpress
Batch
Data
Integrity
Rules Engine
Elig Rules
Engine
System
Interfaces
Elig Rules
Engine