CMS Streamlined Modular Certification

Modernizing and Simplifying the Certification Process

The Centers for Medicare and Medicaid Services (CMS) provides regulatory oversight of Medicaid Enterprise System (MES) modernization projects that are implemented by State Medicaid

Agencies (SMAs).

Federal certification activities are currently organized using a CMS framework known as Streamlined Modular Certification (SMC). SMC was developed to simplify the certification process for system modernization projects. A similar process, Outcomes Based Certification (OBC), is utilized exclusively to certify Electronic Visit

Verification (EVV) systems.

The SMC process replaces an earlier CMS approach that consisted of the Medicaid Enterprise Certification Life Cycle (MECL) and the Medicaid Enterprise Certification Toolkit (MECT).

The SMC approach is based on the following basic concepts:

The SMA must coordinate with its CMS State Officer to select and organize certification activities
The SMA must coordinate closely with its CMS State Officer to write and receive approval for any state-specific certification outcomes
The software solution must implement the expectations that are set forth in the State’s Advanced Planning Documents (APDs) that support the project
The performance of the software solution must be measured using Key Performance Indicator (KPI) reporting
SMA’s and solution vendors must establish and execute a robust set of quality assurance testing activities throughout the Design, Development, and Implementation (DDI) phase, as well as during the Operations phase of the project. This topic is discussed in the CMS Medicaid Enterprise Systems (MES) Testing Guidance Framework.

The SMC process is structured around three specific elements that support certification: Conditions for Enhanced Funding, Outcomes, and Metrics Reporting.

Conditions for Enhanced Funding

States are required to ensure that the modernized systems that they develop meet and comply with all the requirements described in the US Code of Federal Regulations: 42 C.F.R. §433.112 FFP. The system must also remain in compliance with these requirements once it is in production.

CMS requires that SMAs submit a Conditions for Advanced Funding Intake Form for SMC projects.
This form is not required for EVV implementations, which are certified using the OBC process.

Outcomes

Business outcomes define the expected system results that are needed to meet federal, and the SMA's pre-defined business expectations. The software solution is expected t provide a measurable improvement to the state’s current Medicaid program.

The CMS certification process provides for two types of outcomes:

CMS-required outcomes
State-specific outcomes

A state’s certification team will manage the development and use of outcomes as follows:

Identify pre-defined CMS outcomes for a given system
Provide CMS-defined outcomes to the State Medicaid Agency for inclusion in ADP and RFP documentation
CMS requires that SMAs submit an Outcomes intake Form for both SMC and OBC projects.

Metrics

An SMA must provide evidence to demonstrate that its CMS-approved outcomes for a given module are implemented in the software solution.

The SMA must produce performance measures that verify the system’s compliance with pre-defined business requirements, security requirements, and quality standards.
To qualify for Federal Financial Participation (FFP), a state must submit periodic key performance indicator (KPI) reports to CMS.
Each KPI report demonstrates the system’s compliance with the performance goals for a specific
outcome (KPI reports are not required for certain outcomes).

The following Medicaid Modules are in-scope for Certification:

1115 or Waiver Support Systems
Asset Verification System
Claims Processing
Decision Support System / Data Warehouse
Electronic Visit Verification (EVV)
Eligibility and Enrollment
Encounter Processing System (EPS) / Managed Care System
Financial Management
Health Information Exchange (HIE)
Long Term Services & Supports (LTSS)
Member Management
Pharmacy Benefit Management (PBM) / Point of Sale (POS)
Prescription Drug Monitoring Program (PDMP)
Program Integrity
Provider Management
Third Party Liability (TPL)

A Certification Process Overview

Evidence demonstrating that the delivered system has met state and CMS business, functional and performance requirements is documented by the SMA and its vendors.
Subject matter experts then present this information during two certification review events. CMS presents its questions, and the SMA provides answers.
CMS evaluates the system and determines whether the system merits certification.
Certification activities begin in the planning phase (prior to the start of the DDI project) and continue for more than six months after the system’s go-live (Operations Phase start).
The SMC process focuses on the delivery of a specific set of required artifacts and related evidence.
During a system’s implementation, state and vendor’s certification team will be responsible for coordinating the work that is needed to define, develop, validate, and deliver this set of artifacts to CMS.
Documented evidence of the success of a system implementation project is presented to CMS during
the Operational Readiness Review (ORR), held before the system goes live, and during the Final Certification Review (CR), held at-least six months after the go-live date.
A successful CR presentation to CMS leads to formal certification of the system, and to the approval of FFP.

Charles has extensive experience in managing and executing on all SMC activities. He is knowledgeable regarding both the vendor and SMA aspects of the process.

Charles provides the following services to MMIS initiatives:

See the following links for additional information:

Policy and Regulatory Requirements Integration