What is Medicaid Enterprise System?

A Medicaid Management Information System (MMIS) is an automated system that manages Medicaid claims processing and information retrieval. These systems are required to meet certain standards set out by the Centers for Medicare & Medicaid Services (CMS) to receive federal funds. However, in 2015, the CMS presented incentives to state governments to accelerate their adoption of modular Medicaid Enterprise Systems (MES).

Medicaid Enterprise System reassembles Medicaid management into a modular, flexible, and upgradable system that offers significant control for agency users and seamless access to members, providers, and third-party agencies. MES provides a system focused on data-driven decision-making, advanced reporting and fraud detection, beneficiary eligibility, care management, and provider electronic health record incentive payments.

To deliver quality care, State Medicaid Agencies must consider a range of tools, ideas, and constraints such as:

  • Fast Healthcare Interoperability Resources (FHIR) Standards
  • Social Determinants and Population Health Data
  • Value Based Payments (VBP)
  • Health Information Exchanges
  • Block Grant Funding Models; and more.

To successfully respond to these developments, Medicaid Enterprise System (MES) strategies must mirror long-term planning that includes both conventional and new solutions.

Building your Medicaid Enterprise System

While each agency has the flexibility to choose how to define, procure and implement MES modules, an ideal modular system must include cloud-based or COTS-based components that:

  • Can independently support the key functions or processes
  • Are interoperable with other internal and external modules and systems
  • Meet existing requirements and can easily pivot to address future requirements
  • Comply with the MITA and 7 Conditions and Standards
  • Can be quickly implemented at lower cost and risk
  • Are less expensive to maintain and operate
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