The New Hampshire Department of Health and Human Services (DHHS) may have a requirement for Medicaid Enterprise Systems (MES) – Medicaid Management Information System (MMIS) Modular Implementation.

The following information is taken from the Request for Information (RFI) document:

The State of New Hampshire is seeking to revise the MES systems modularity to:

1. Increase the State’s ability to adapt to changing policies, federal compliance requirements, program needs, and user needs.
2. Ensure the State follows industry best practices and approaches to systems development, open interfaces, and industry standards such as FHIR and X12.
3. Increase efficiencies and cost effectiveness.

The State of New Hampshire is embarking on a large initiative to implement a Medicaid Enterprise Systems (MES) that will be built on flexible, adaptable and scalable architecture. As part of the MES implementation, the Department will replace its current Medicaid Management Information System (MMIS), which was built approximately fifteen (15) years ago. The MES implementation will include MMIS modules and other functionality such as the Enrollment & Eligibility system and the Pharmacy Benefits Management system. In New Hampshire, the number of clients enrolled in Medicaid is approximately 187,000, of which:

1. Approximately 131,000 clients are enrolled in standard Medicaid. Of those enrolled, approximately 15,000 are Children’s Health Insurance Program (CHIP) clients.
2. Approximately 56,000 are eligible due to Medicaid expansion population.
3. Approximately 185,000 are enrolled in one (1) of the three (3) Managed Care Organizations, and approximately 2,000 receive all Medicaid services through the Medicaid Fee-for-Service program.

There are approximately 30,600 Medicaid providers enrolled in NH Medicaid. New Hampshire Medicaid services are provided by the three (3) Managed Care Organizations, with a limited number of services covered by the Department’s Division of Medicaid Services through a Fee-for-Service structure. In State Fiscal Year 2019, approximately $654 million in claims were processed by the Managed Care Organizations, and approximately $773 million were processed by the State Medicaid agency for Fee-for-Service.

1. There are a number of services covered through the Managed Care Organizations, including but not limited to:
   1. In-patient hospital care and rehabilitation services.
   2. Physician services.
   3. Prescription drug services.
   4. Physical therapy.
   5. Skilled nursing home health aide.
   6. Physical therapy.
   7. Occupational therapy.
   8. Speech therapy.
   9. Private duty nursing care.
   10. Emergent and non-emergent medical transportation.
   11. Durable medical equipment.
   12. Psychotherapy.
   13. Podiatry.
   14. Advanced Practice Registered Nurse (APRN) services.
   15. Midwife services.
   16. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services.
   17. Laboratory and radiology services.
   18. Hospice care.
2. Additionally, there are carve-out services covered under the Fee-for-Service structure, which include but are not limited to:
   1. Medicaid to School medical services.
   2. Pediatric dentistry services.
   3. Home and Community-based care for the elderly.
   4. Home and Community-based care for developmental services.
   5. Acquired brain disorders.
   6. Children with special needs or disability waivers.
   7. Long-term nursing facility care.

Background information may be updated upon the release of a formal solicitation. 

1. Provide recommendations on the approach to adapting products to state-specific needs, such as policies, standards, and business requirements. Include lessons learned from previous projects.
2. Describe how a successful systems integrator utilizes the following functions:
   1. Ability to integrate multiple MES and non-MES systems using open and published interfaces utilizing industry standards when appropriate.
   2. Ability to support multiple versions of the same interface.
   3. Ability to support synchronous and asynchronous communications.
   4. Ability to check the health of other MES and non-MES systems.
   5. Ability to work with all module vendors to ensure successful end-to-end testing.
   6. Ability to participate in design sessions for other MES modules to ensure proper interface design.
3. Provide recommendations on how technology and service offerings may be used for this type of project. Include the following:
   1. How to build a system using architecturally sound principles to allow for scalability, configurability, modularity, and security.
   2. How a product can adapt to state-specific processes, such as: the use of a configurable rules set and workflow.
   3. Basic information about the use of a solution in other states, such as name of the client organization and contract information, such as value and contract period.
4. Describe how a system supports the following functions:
   1. Provider online application.
   2. Screening and enrollment.
   3. Monthly monitoring.
   4. Provider data management.
   5. Provider revalidation.
   6. Provider communication.
   7. Provider directory
5. Provide recommendations for the following functions:
   1. Ability to determine liabilities of third parties in a timely manner, avoid payments of third parties, and recover reimbursement from third parties.
   2. Ability to reject and return to the provider claims with third party liability.
   3. Ability to handle mandatory pay-and-chase claims.
   4. Timely identification of paid claims that contain diagnosis codes indicative of trauma, injury, poisoning, etc.
   5. Enable states to manage and oversee third-party liability recoveries made by its MCOs.
6. Describe how a system can support the following functions:
   1. Accurate claims adjudication within established time parameters to ensure timely pharmacy claims payments.
   2. Timely processing of manufacturer rebates and tracking of rebates.
   3. Capturing, storing, and transferring data to the payment process system to generate invoices of participating drug manufacturers within 60 days of the end of each quarter.
   4. Managing prior authorizations of prescription benefits.
   5. Identifying patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, or prescribing or billing practices by enabling the collection of data to be used in drug utilization reviews.
7. Describe recommendations for how a system can support the following functions:
   1. Ability to ingest data from multiple sources in different formats.
   2. Ability to process extract, transform, and load (ETL) and map data from multiple sources.
   3. Ability to generate reports and notify interested users.
   4. Ability to have authorized users to perform ad-hoc queries.
   5. Ability to publish both external and internal visualizations in a searchable environment
   6. Ability to support robust data governance model requiring in depth metadata management to classify and authorize access in accordance with multiple business rules associated with federal and state laws.
8. Describe the significant risk factors associated with successful implementation, and how they should be mitigated. Include other suggestions or recommendations you have to ensure the services provided are successful.
9. Please explain any additional concerns or recommendations that are important for the Department to consider with regard to successfully developing and implementing the MMS modular solution.

Requirements may be updated upon the release of a formal solicitation.