RD135 - Annual Progress Report on the Replacement of the Medicaid Management Information System – December 1, 2020

Executive Summary:

In 2016, the Virginia Department of Medical Assistance Services (DMAS) embarked on a path to replace its aging Medicaid Management Information System (MMIS) with a modern, modular Medicaid Enterprise Solution (MES), pursuant to new standards set forth by the Centers for Medicare and Medicaid Services (CMS).(*1) The new MES seeks to improve the Commonwealth’s development agility while meeting the rising demand for new services and increased access for its citizens.

Since 2016, substantial progress has been made in the program’s overall trajectory. The MES modular approach has afforded the Commonwealth the ability to implement portions of the overall solution as each satisfies the requirements set forth in the request for proposal (RFP) and are fully tested. Four modules have been successfully implemented in the DMAS production environment to date, further increasing the program’s ability to provide Virginians with access to high-quality health care coverage. Of those four modules, the Encounter Processing System (EPS) module in particular has garnered national attention for its innovation and ability to process mass quantities of data, assisting the program with the management of the Managed Care Plans which help to serve the majority of our Members.

In late 2019, however, the MES program encountered significant challenges with the Operations Services Solution (OPSS) and Plan Management Solution (PLMS). As a result, DMAS executed a contingency plan and switched primary vendors. This transition necessitated a re-baselining of the MES project timeline.

The contingency plan required DMAS to integrate the current MMIS into the planned MES modular framework. This work is referred to as the “Core Contingency." DMAS has worked closely with CMS throughout this change to the MES program to ensure compliance with regulatory requirements and secure the necessary federal funding that had previously been granted. DMAS is also working closely with the Virginia Information Technologies Agency’s (VITA) Project Management Division (PMD) as the program undergoes a process to realign its scope and schedule, and redefine program costs.

Due to the changes described above, the following modules will make up the MES system, along with the Core Contingency: Encounter Processing Solution (EPS); Pharmacy Benefit Management Solution (PBMS); Enterprise Data Warehouse Solution (EDWS); Integration Services Solution (ISS); Provider Services Solution (PRSS); Care Management Solution (CRMS); and Appeals (APLS).
(*1) The standards and conditions for implementing Medicaid information technology (IT) require states to use a modular approach for systems development. Reference: CMS Final Rule, 80 FR 75817 - Medicaid Program; Mechanized Claims Processing and Information Retrieval Systems.