Medicaid Vendor Module Precertification Program

Overview

The Centers for Medicare & Medicaid Services (CMS) provides funding to states to develop, upgrade, and maintain the information technology (IT) systems used to administer state Medicaid programs. In the case of Medicaid Management Information Systems (MMIS), CMS certification is required before the state can collect enhanced federal funding for system operations. The certification process, along with the checklists used to ensure systems meet all necessary requirements, is explained in detail in the Medicaid Enterprise Certification Toolkit (MECT).

CMS envisions that modular solutions and architectures for state Medicaid enterprise systems will promote the reuse of technical solutions among states, minimize customization needs, and increase competition in the Medicaid enterprise marketplace. Modular architectures will also improve efficiency and effectiveness of system upgrades, reduce costs, improve system interoperability, and increase adherence to the Medicaid Information Technology Architecture (MITA) and the Standards and Conditions for Medicaid IT. Such open, reusable system architectures help ensure states’ ability to efficiently implement, maintain, and upgrade systems designed to deliver person-centered services and benefits. CMS has thus promoted modularity and reuse through various policies and frameworks.

To accelerate the move toward modularity and reuse, and facilitate lower risk, more cost-effective, and technically successful IT solutions for Medicaid IT, CMS envisions a program that permits vendors to submit modular, reusable Medicaid IT solutions for precertification. Modules that have undergone a state certification process will not be considered “precertified.” Precertification is envisioned as a separate, vendor-facing process with unique criteria. Once a solution is precertified, CMS will add it to a list of CMS-precertified modules that the states can leverage for purchasing decisions for their Medicaid enterprise. Precertification is intended to provide an opportunity for vendors to share the capabilities of their solutions, as well as allow states to see the full range of vendor options available for Medicaid IT.

Key Facts

  • CMS solicited stakeholder feedback on the precertification of modules in a Request for Information released in July 2016.
  • In October 2017, CMS launched a Precertification Pilot for Pharmacy and Provider Screening modules. Please visit the Precertification Pilot Overview page for more information. 
  • In the envisioned program, vendor participation will be voluntary and vendors will not be charged for precertification. The program will not preclude states from choosing outside of the list of precertified modules.

What Kind of IT Solutions Can be Precertified?

  • Only technology that can be certified by CMS for enhanced funding will be considered for precertification.
    • For example, beneficiary eligibility systems, asset verification systems, or provider electronic health record attestation systems are not covered under current certification regulations and would therefore not be eligible for precertification.
    • Underlying architecture such as cloud hosting infrastructure, enterprise service bus, and master data management are not modular solutions per the CMS definition and do not fall under the precertification program. Modular solutions that utilize these technologies and are eligible for certification will also be eligible for precertification. 
  • CMS envisions that precertification vendors will use open application programming interfaces and standards that will allow their solution to be interoperable with other vendor modules once implemented by the state.
  • In July 2017, CMS released updated certification checklists in the MECT. These include criteria reflecting all the federal regulations that may apply to the systems needed by state Medicaid agencies to support their Medicaid enterprise IT needs.
  • The MECT focuses only on the Medicaid systems eligible for CMS certification, which makes the state eligible to receive a 75 percent federal match on the operations and maintenance costs for that module.
  • It is important to refer to the CMS regulatory definition of a module. “Module” means a packaged, functional business process or set of processes implemented through software, data, and interoperable interfaces that are enabled through design principles in which functions of a complex system are partitioned into discrete, scalable, reusable components.

If You Are an IT Solution Vendor Interested in Getting Involved in Medicaid, What Should You Do?

For additional background, refer to the following links:

Additional Background

For additional background, refer to the following links below: