Form CMS-10385 Expedited Checklist: Medicaid Eligibility & Enrollment I

EXPEDITED CHECKLIST: MEDICAID ELIGIBILITY & ENROLLMENT INFORMATION SYSTEM(S) – ADVANCE PLANNING DOCUMENT (E&E - APD) PURPOSE:  This Expedited Eligibility and Enrollment (E&E) – APD checklist is for States to complete and submit to CMS for review and prior approval in order to receive enhanced federal funding for Medicaid Information Technology (IT) system(s) projects related to eligibility and enrollment functions. This template may be used by any state which is submitting or has submitted an Early Innovator or Establishment grant application. Specifically, this checklist: Guides States in obtaining prior approval to secure ninety percent (90%) Federal financial participation (FFP) for the design, development, implementation (DDI), and/or enhancements of a system(s); and seventy-five percent (75%) FFP for maintenance and operations [42 CFR §433 Subpart C]. Contains Seven Standards & Conditions that the State’s APD must meet. Contains Federal requirements for both PLANNING and IMPLEMENTATION activities of an APD [45 CFR § 95 Subpart F (Revised October 28, 2010)]. (4)   Streamlines the process for States by requiring fewer documents, as well as potentially shortening the review timeframe for CMS, and if applicable, other Agencies, of system projects related to the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act). Although Federal Regulations allow up to sixty days for APD approvals, CMS’ goal is to provide an approval within thirty business days upon receipt. INSTRUCTIONS: The checklist has three columns. Column #1 lists the APD requirements at 45 CFR § 95.605.  Column #2 lists the APD required elements divided into sub-columns listing specific requirements whether the State is engaging in the planning and/or implementation APD activities.  Column #3 is used to capture the declaration and collaboration activities.  CMS will allow the “reuse” of documentation if specific information that is required by this E&E-APD checklist, along with sufficient detailed information to encompass Medicaid functionalities, is provided in a final and approved CCIIO Planning, Early Innovator, and/or Establishment grant application(s), as well as States’ final documents/artifacts that are reviewed, approved by CCIIO’s Exchange Life Cycle Gate Review Process. Where appropriate, please reference the corresponding page number(s) in the CCIIO grant application(s), the sub-section in the APD that fully addresses the Medicaid E&E-APD requirements, and include as an attachment(s). APD Submission to: Mr. Richard H. Friedman,  Director Division of State Systems Centers for Medicaid, CHIP and Survey & Certification Centers for Medicare & Medicaid Services Mail Stop: S2-22-16 7500 Security Boulevard Baltimore, Maryland 21244-1820 Send electronically to “MedicaidE&E_APD@cms.hhs.gov.” Questions should be directed toKirti Patel at kirti.patel@cms.hhs.gov. OVERSIGHT OF OTHER FEDERAL PARTNER AGENCIES: In order for CMS to determine the role of other Federal partners (i.e., USDA FNS, and HHS ACF) in the APD review process, please characterize the vision as most closely resembling one of the following:  Yes  No Our system development will support the full range of Medicaid and Exchange eligibility and enrollment.  Yes  No Our systems development will support Medicaid-only eligibility and enrollment (individuals whose eligibility is based on factors other than modified adjusted gross income).  Yes  No This systems development is part of a broader enterprise architecture plan. Other health and human services partner programs are included in the planning process, and we anticipate that their requirements will be included to the greatest extent possible in the architecture. Their individual program requirements will be addressed in later phases.  Yes  No We are modifying an existing integrated eligibility system (traditionally understood as involving a range of state operated health and human services programs) and anticipate maintaining existing partnerships and linkages. These partner programs are active participants in the planning of this project.  Yes  No We are unable to determine at this time which programs may be included in the project. We are starting work on the requirements of the Affordable Care Act with regard to Medicaid, while continuing to investigate the appropriate role of other programs. An update of this APD will be provided to the appropriate Federal agencies as soon as possible, including the process for inclusion of all program stakeholders, as appropriate. Regarding the State’s Children’s Health Insurance Program (CHIP) please specify: The State CHIP component is part of the systems development approach specified above. Other, please specify _______________________________ State/Territory Name:______________________________________ Date of Submission to CMS: ________________________________ (mm/dd/yyyy) APD Type: Planning APD Implementation APD Both (Planning and Implementation) APD Update (Planning_____ or, Implementation_____) APD Contact: ___ (Name, Title, Department, address, phone, email)
Section	Content Planning APD Implementation APD Activities Activities		Minimum Requirements, Declaration, and Collaboration Activities
Statement of Need and Objectives This section describes the purpose and objectives of the project to be accomplished.	Statement of purpose including vision, needs, objectives and anticipated benefits. Describe the State approach in working and collaborating with the State Exchange entity/component.	Statement of purpose including vision ‘the roadmap', needs, objectives and anticipated benefits. Describe the business need for system(s) development and/or modifications. Indicate which system(s) the State is seeking to modify, if any: [please name and describe these systems] Describe the State approach in working and collaborating with the State Exchange entity/component.	If specific information required in this section was provided in an approved and final CCIIO documentation, please indicate which one by checking the box below, provide the page number(s) of its location, specify which APD sub-section(s) it addresses (i.e. 1.1, 1.2), and include as an attachment(s): Planning Grant App Page (s) ____, APD Section(s) _________ Innovator Grant App Page(s) ____, APD Section(s) _________ Establishment Grant App Page(s) ____, APD Section(s) _________ Gate Review Documents/Artifacts __________, Page(s) _________
Requirements and Alternatives Analysis	n/a	This section provides a summary of the requirements analysis, feasibility study, and alternatives analysis. Cost/Benefit analysis.	If specific information required in this section was provided in an approved and final CCIIO documentation, please indicate which one by checking the box below, provide the page number(s) of its location, specify which APD sub-section(s) it addresses (i.e. 2.1, 2.2), and include as an attachment(s): Planning Grant App Page(s) ____, APD Section(s) _________ Innovator Grant App Page(s) ____, APD Section(s) _________ Establishment Grant App Page(s) ____, APD Section(s) ________ Gate Review Documents/Artifacts__________, Page(s)_________
Project Management Plan The Project Management Plan summarizes the project activities, deliverables, and products; project organization, State and contract resource needs; and anticipated system life.	A detailed description of the nature and scope of the activities to be undertaken and the methods to be used to accomplish the project. The project organization including personnel resources (in house and/or contractor) and responsibilities statement. Project schedule including major milestones, deliverables and key dates. If applicable, procurement and solicitation activities.	A detailed description of the nature and scope of the activities to be undertaken and the methods to be used to accomplish the project. The project organization including personnel resources (in house and/or contractor) and responsibilities statement. Project schedule including major milestones, deliverables and key dates. If applicable, procurement and solicitation activities.	If specific information required in this section was provided in an approved and final CCIIO documentation, please indicate which one by checking the box below, provide the page number(s) of its location, specify which APD sub-section(s) it addresses (i.e. 3.1, 3.2), and include as an attachment(s): Planning Grant App Page(s) ____, APD Section(s) _________ Innovator Grant App Page(s) ____, APD Section(s) _________ Establishment Grant App Page(s) ____, APD Section(s) ________ Gate Review Documents/Artifacts__________, Page(s) ________ Status of State MITA Self-Assessment: Completed (see attachment) Will be conducted and it will be supplied upon completion State wishes to obtain copies of other States’ MITA Self-Assessments State authorizes CMS to share MITA Self-Assessment with other States. Additional information regarding MITA concepts, principles, and tools for key planning and/or implementation steps can be found at http://www.cms.hhs.gov/MedicaidInfoTechArch/. If the APD involves other Federal partners, please seek guidance from the appropriate agency.
Proposed Project Budget and Cost Distribution This section describes the resource needs for planning and/or implementation for which FFP is requested.	Resource needs by categories, cost elements and amounts, including: State and/or contractor staff costs, facility/equipments, travel, outreach and training, etc. (In-house staff costs and other costs by outside contractors. These costs should be distinguished from each other). Estimated total budget with costs broken down by categories (State/federal, and by applicable FFP rates). Cost Allocation Plan and/or Methodology	Resource needs by categories, cost elements and amounts, including: State and/or contractor staff costs, facility/equipments, travel, outreach and training, etc. (In-house staff costs and other costs by outside contractors. These costs should be distinguished from each other). Estimated total budget with costs broken down by categories (State/Federal, and by applicable FFP rates). Cost Allocation Plan and/or Methodology An estimate of prospective cost distribution to the various State and Federal funding sources and proposed procedures for distributing costs. This cost distribution should be broken down into calendar quarters.	If specific information required in this section was provided in an approved and final CCIIO documentation, please indicate which one by checking the box below, provide the page number(s) of its location, specify which APD sub-section(s) it addresses (i.e. 4.1, 4.2), and include as an attachment(s): Planning Grant App Page(s) ____, APD Section(s) _________ Innovator Grant App Page(s) ____, APD Section(s) _________ Establishment Grant App Page(s) ____, APD Section(s) _______ Gate Review Documents/Artifacts__________. Page(s) _______
Statement of Security/ Interface and Disaster Recovery Requirements	n/a	Evidence of declaration by checking the boxes in the next column that the State will meet these requirements.	The State Agency will implement and/or maintain an existing comprehensive ADP security and interface program for ADP systems and installations involved in the administration of the Medicaid program. The State Agency will have disaster recovery plans and procedures available.
Assurances This section includes procurement activities, monitoring and reporting activities, including access to records, licensing, ownership of software, and the safeguarding of information contained within the system. These assurances are required for automated data processing equipment. If the APD involves other Federal partners, please certify your compliance with assurances associated with all Federal stakeholders.	Procurement Standards (Competition / Sole Source) Access to Records Software & Ownership Rights/Federal Licenses/Information Safeguarding/HIPAA Compliance/Progress Reports Indicate by checking “yes” or “no” whether or not you will comply with the Code of Federal Regulations (CFR).	Procurement Standards (Competition / Sole Source) Access to Records Software & Ownership Rights/Federal Licenses/Information Safeguarding/HIPAA Compliance/Progress Reports Independent Verification &Validation (IV&V) – optional where considered a high-risk project. Indicate by checking “yes” or “no” whether or not you will comply with the Code of Federal Regulations (CFR).	Procurement Standards (Competition / Sole Source) : SMM Section 11267  Yes  No 45 CFR Part 95 Subpart F §95.615  Yes  No 45 CFR Part 95 §92.36  Yes  No Access to Records: 42 CFR Part 433.112(b)(5) – (9)  Yes  No 45 CFR Part 95 Subpart F §95.615  Yes  No SMM Section 11267  Yes  No Software & Ownership Rights, Federal Licenses, Information Safeguarding, HIPAA Compliance, and Progress Reports: 45 CFR Part 95 Subpart F §95.617  Yes  No 42 CFR Part 431.300  Yes  No 42 CFR Part 164  Yes  No IV&V: 45 CFR Part 95.626  Yes  No If no, provide a detailed explanation in your APD under the appropriate section.
Addressed or Not Addressed This section ensures that the State will come into compliance with the standards and conditions pursuant to 42 CFR §433 Subpart C.	For planning activities only, addressed or not addressed is required by checking the boxes in the next column.	For implementation activities, addressed or not addressed is required by checking the boxes in the next column and by providing where in the APD section(s) the supporting information for each of the seven standards and conditions. For example – APD section(s) : 1, 2, and 3 (where sections 1, 2, and 3 of the APD provided the information that addressed the requirements regarding the S&C #1)	1.  Yes  No Modularity Condition. Use of a modular, flexible approach to systems development, including the use of open interfaces and exposed application programming interfaces; the separation of business rules from core programming; and the availability of business rules in both human and machine readable formats. APD section(s): ________ 2.  Yes  No MITA Condition. Align to and advance increasingly in MITA maturity for business, architecture, and data. APD section(s): ________ 3.  Yes  No Industry Standards Condition. Ensure alignment with, and incorporation of, industry standards: the Health Insurance Portability and Accountability Act of 1996 security, privacy and transaction standards; accessibility standards established under section 508 of the Rehabilitation Act, or standards that provide greater accessibility for individuals with disabilities, and compliance with Federal civil rights laws; standards adopted by the Secretary under section 1104 of the Affordable Care Act; and standards and protocols adopted by the Secretary under section 1561 of the Affordable Care Act. APD section(s): ________ 4.  Yes  No Leverage Condition. Promote sharing, leverage, and reuse of Medicaid technologies and systems within and among States. APD section(s): ________ 5.  Yes  No Business Results Condition. Support accurate and timely processing of claims (including claims of eligibility), adjudications, and effective communications with providers, beneficiaries, and the public. APD section(s): ________ 6.  Yes  No Reporting Condition. Produce transaction data, reports, and performance information that would contribute to program evaluation, continuous improvement in business operations, and transparency and accountability. APD section(s): ________ 7.  Yes  No Interoperability Condition. Ensure seamless coordination and integration with the Exchange (whether run by the State or Federal government), and allow interoperability with health information exchanges, public health agencies, human services programs, and community organizations providing outreach and enrollment assistance services. APD section(s): ________
State Certification	The Department (name) for the State of (name) by signing below, agrees that the APD requirements, indicated above in column 3, are included in the indicated approved and awarded CCIIO grant application and approve use of this information to fulfill the regulatory requirements required by submitting this APD. _______________________________________________________ (Signature) Name __________________________________________________ Title____________________________________________________ State Department Name____________________________________

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