Medicaid Vendor Module Precertification Program

Overview

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 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.

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 MITA 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, the CMS envisions a program that will permit any company to submit its modular, reusable, Medicaid IT solution for precertification. Modules that have undergone a state certification process are not considered “precertified.”  Precertification is envisioned as a separate, vendor-facing process with unique precertification criteria. Once precertified, that solution will be added by CMS to a list on Medicaid.gov that the states can leverage for purchasing decisions for their Medicaid Enterprise.

Key Facts

  • CMS solicited stakeholder feedback on the precertification of modules in a Request for Information released in July 2016.
  • In the envisioned program, vendors will not be charged for precertification. Precertification will be on a voluntary basis for vendors.  It will not preclude states from choosing outside of the precertified list. 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.
  • CMS envisions that precertification will require vendor solutions to use open Application Programming Interfaces (APIs) and standards that will allow their solution to be interoperable with other vendor modules once implemented by the state.

What kind of IT solutions can be precertified?

  • Only technology deployed by state Medicaid agencies that can be certified by CMS for enhanced funding will be eligible 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, 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. 
  • In July 2017, CMS released an updated certification checklist that includes 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 in this context: [“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].
  • Modules that have undergone a state certification are not considered “precertified.”

If you are an IT solution company interested in getting involved in Medicaid, what should you do now?

Precertification Pilot for Pharmacy and Provider Screening Module

CMS will be piloting precertification. In October 2017, CMS will begin accepting vendor submissions for provider screening and pharmacy modules.  Participation in the Pilot gives vendors an opportunity to shape the Precertification process, provide feedback to CMS, refine the criteria used to evaluate each module type, and provide information to help streamline the state certification process. 

The Pilot Overview provides details on:

  • the goals of the Pilot
  • who should participate and why
  • what will be assessed in the Pilot
  • how to participate in the Pilot
  • timeline with key deadlines
  • frequently asked questions

Additional background:

For additional background, refer to the links below: