MECL 01 - Medicaid Enterprise Certification Life Cycle

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MECT / MECL 2016 Documentation Toolkit
Welcome_to_MECT_2016
MECL_01_-_Medicaid_Enterprise_Certification_Life_Cycle
MECL_02_-_Appendix_A_-_MECL_and_At_a_Glance_Sheets
MECL_03_-_Appendix_B_-_Required_Artifacts_List
MECL_04_-_Appendix_C_-_Std_IV&V_Language
MECL_05_-_Appendix_D_-_Certification_Progress_Report_Template
MECL_06_-_Appendix_E_-_MMIS_Concept_of_Operations_Template
MECL_07_-_Appendix_F_-_MITA_eSelf_Assessment_Scorecard
MECL_08_-_Appendix_G_-_2007_Criteria_to_2016_Checklist_Map
MECL_09_-_Appendix_H_-_Uniform_RFP_Guide
MECL_10_-_Appendix_I_-_MMIS_Certification_Request_Letter_Template
MEDICAID ENTERPRISE
CERTIFICATION LIFE CYCLE
March 2016




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Issued by

Division of State Systems Data and Systems Group
Centers for Medicaid and CHIP Services Centers for Medicare & Medicaid Services


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Contents

MMIS Certification Overview

Introduction

The Medicaid Enterprise Certification Toolkit (“toolkit”) was developed by the Centers for Medicare & Medicaid Services (CMS) Centers for Medicaid and Children’s Health Insurance Program Services (CMCS) to respond to the many changes that have transformed the Medicaid Management Information System (MMIS). This toolkit provides a revised approach to Medicaid enterprise certifications to assist states as they work to modernize and improve MMIS.


The purpose of the toolkit is to provide a consistent, detailed process to certify an MMIS and to help states prepare for the federally required certification review of a state’s MMIS. Use of the toolkit will help ensure that the new MMIS meets all federal requirements and satisfies the objectives described in the state’s Advance Planning Document (APD).


While the MMIS certification process formerly focused on the final, onsite certification visit at the end of a multi-year project, the new certification process described in the toolkit is designed to assist states at every stage of the development process. The new Medicaid Enterprise Certification Life Cycle (MECL) works with the various approaches states may use in MMIS development—modular, agile, waterfall, etc.


The standards and conditions for Medicaid IT require that states use a modular approach to systems development. In the proposed rule change to 45 CFR Part 95, CMS has defined an MMIS module as “a group of MMIS business processes that can be implemented through a collection of IT functionality.” The new Medicaid Enterprise Certification Life Cycle supports modular development. The Federal Funds

Participation (FFP) process (75 FR 66319) allows funding for MMIS in modular increments, and CMS does certify modules.


CMS staff will use the material contained in this document as a standard for review that supersedes all previous certification protocol documents. State personnel and their consultants and contractors working on systems that are subject to CMS review, approval, and/or certification should also use the toolkit to plan their work.


CMS expects to revise this document periodically based on feedback from CMS and the states. This document is the property of CMS. This document may be reproduced, but not modified, sold for profit, or used in commercial documents. Adherence to the protocols, checklists, and other tools contained in this document does not guarantee federal certification of the Medicaid Management Information System.


This document is maintained on Medicaid.gov.


Toolkit Organization

The Medicaid Enterprise Certification Toolkit contains this Medicaid Enterprise Certification Life Cycle (MECL) guidance document, a separate certification life cycle workflow diagram with At-A-Glance sheets, Medicaid Enterprise Certification Checklists, IV&V standard RFP / contract language, a Certification Progress Report template, a list of artifacts required for each type of review, an electronic MITA self-assessment tool, an MMIS Concept of Operations template, an RFP guide created by a cohort of states, a mapping of the 2007 criteria to the new checklists, and a certification request letter template.

Section 1 of this guidance document, MMIS Certification Overview, provides an introduction to MMIS Certification and how it addresses the diversity of development approaches taken by states, such as waterfall and agile methodologies, modular architectures, outsourcing of Medicaid services, and re-use of other states’ MMIS components.

Section 2, Medicaid Enterprise Certification Roles, explains the entities involved in the life cycle and their responsibilities. Section 3, Medicaid Enterprise Certification Life Cycle, describes the process and milestone reviews by which CMS certifies a state’s MMIS. Section 4, Medicaid Enterprise Certification Checklists, explains the CMS checklists used during certification milestone reviews. Section 5 explains the milestone review process and how to prepare. The Toolkit appendices provide a list of artifacts required for each milestone review, an MMIS Concept of Operations template, a Certification Progress Report template, a MITA self-assessment template, and the Medicaid Enterprise Certification Checklists.

A Flexible Medicaid Enterprise Certification Life Cycle

The new certification process contains four life cycle phases and three types of certification milestone reviews. Figure 1 depicts these at a high level. Section 3 provides a detailed life cycle process workflow and in-depth description of each process activity.

Figure 1. Medicaid Enterprise Certification Life Cycle Phases and Milestone Reviews

Figure 1. Medicaid Enterprise Certification Life Cycle Phases and Milestone Reviews

The MECL accommodates various approaches that states employ to update or upgrade their MMIS systems. The flexibility is manifest in four characteristics.

  • MECL fits with a state’s own system development life cycle (SDLC), whether that SDLC is agile-based, waterfall-based, or a hybrid of the two (See Figure 2 for two state examples).
  • MECL accounts for states that choose to outsource some or all of their Medicaid functions.
  • MECL can be used to certify and obtain FFP for MMIS modules (state developed, commercial off-the-shelf (COTS) or reuse modules), even when the modules are developed and deployed at different times.
  • MECL allows the CMS Central Office (CO) and the state to schedule each review to fit within the state SDLC schedule (see Section 1.4).

States’ System Development Life Cycles

System development life cycle (SDLC) refers to the phased approach the state and its contractors use in planning, creating, testing, deploying, and maintaining the MMIS. CMS designed its certification life cycle to fit with waterfall, agile, and hybrid system development methodologies.

CMS certification reviews should not interrupt state SDLC reviews. Certification reviews are planned for key transitions in development efforts and should be an extension of state SDLC practices. CMS is flexible in scheduling MMIS certification reviews, and the state and CMS must work together to set the timing of the certification milestone reviews to be consistent with the state’s own SDLC.

CMS expects that the state will manage its own SDLC, including conducting SDLC gate reviews where “go / no go” decisions are made to move the MMIS system through the state’s SLDC phases. CMS certification reviews serve a different purpose than SDLC gate reviews. SDLC gate reviews focus on development progress, while CMS certification reviews monitor compliance to CMS MMIS system requirements. CMS does not participate in state SDLC reviews.

To avoid confusion between the two types of reviews—state SDLC gate reviews and CMS certification reviews—this toolkit refers to CMS certification reviews as “milestone reviews.”

The toolkit and the MECL do not show state-level SDLC steps or gate reviews performed by the state and its IV&V contractor. Rather, the MECL sits atop the state’s SDLC. The state’s project management plan needs to explain how the state’s SDLC and certification fit together. Figure 2 shows two examples of how actual states’ SDLCs—one using a waterfall SDLC and one using agile—are compatible with the MECL.



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Figure 2. Examples of How MECL Fits Atop States’ SDLCs


Rules for Outsourcing Medicaid Services and / or Using Commercial Off-the-Shelf Products

The MECL is flexible to accommodate a state that contracts with a third party (such as an administrative services organization) to perform Medicaid functions. The state has a choice of which certification checklist set to use for certification and can tailor the checklists to fit its outsourcing strategy. Tailoring of checklists is done in consultation with the CMS Regional Office, which must approve the tailored checklists. This consultation happens in the very first step of the MECL so that together the state and CMS can map the best path through the certification life cycle for the state.


If the state is using a commercial off-the-shelf (COTS) product that has not been certified by CMS, the solution needs to go through the certification process described in this toolkit. If the COTS product (or re-use module developed for another state) has already been certified, then only the integration of that product into the MMIS needs to be reviewed under this certification life cycle. The state must demonstrate that once the COTS or re-use solution is deployed, it will meet all federal Medicaid, security, and privacy requirements.


Recommendations for Establishing a State Program Management Office

CMS has found that states with well-established project management offices (PMOs) are more likely to produce successful Medicaid systems. CMS expects a state to demonstrate project management planning activities during the planning and initiation phase of the MECL. The state manages the project plan, the budget, risk register, and risk plan, coordinates the work of various MMIS contractors, and ensures that the state’s SDLC gate reviews are being conducted throughout the MMIS project. A PMO can be helpful in serving as a central point for managing these activities. A PMO can also plan the logistics for MMIS certification milestone reviews, such as setting up teleconference lines, developing agendas for review sessions, reserving conference rooms, and facilitating reviews.



Recommendations for Having a Systems Integrator

A good systems integrator, which coordinates the merger of technical solutions, modules, and testing schedules, increases the likelihood that the MMIS will securely achieve state goals and the Medicaid requirements. The integrator could be the state, the development contractor, or a separate contractor. The systems integrator typically:


  • Ensures that all modules work together seamlessly and work securely with external systems
  • Ensures that overall security and privacy remain intact when various modules and components are integrated
  • Negotiates solutions to disagreements that may arise between development contractors who are developing or testing different MMIS components
  • Manages risks that may arise when schedule or technical slippage in one module(s) affects other modules, and
  • Cooperates with a state PMO and the IV&V contractor to give an accurate, honest reporting of project status.


How the Certification Life Cycle Fits with the Advanced Planning Document Process

A detailed description of how the advanced planning document (APD) process works is not within the scope of the MMIS toolkit. This section, however, briefly describes the intersection of APDs and the Medicaid Enterprise Certification Life Cycle.


An APD is a plan of action the state uses to request federal financial participation for the costs of planning and implementing an MMIS. There are specific types of APD documents used during the Medicaid Enterprise Certification Life Cycle:


  • A planning advanced planning document (PAPD), which is optional
  • An implementation advance planning document (IAPD)
  • An implementation advanced planning document update (IAPDU).


The operational advanced planning document (OAPD), used outside of the Medicaid Enterprise Certification Life Cycle, is for systems that have already been certified and are in operation.


APD preparation falls within the planning and initiation phase of the certification life cycle. The state sends it completed IAPD to the CMS Regional Office (RO) to begin the APD approval process. If needed, the CMS office has 60 days to send a letter with questions to the state. Once the state responds, the CMS Regional Office has another 60 days to approve or disapprove the APD.


The MECL does not disrupt the APD process, but has been designed to mesh with it (see Section 3, Figure 3 for the MMIS certification life cycle workflow). Before the state submits its IAPD to the CMS Regional Office (RO), the IV&V contractor reviews the state planning documents, evaluating them against the MECL checklist criteria and critical success factors. The results are compiled into a progress report. The IV&V contractor sends a copy of this certification progress report to the state and the CMS Central Office and to the Regional Office. This gives the state time to remedy gaps or issues before submitting the IAPD. The RO may also find the report helpful when preparing questions for the state.



The Project Initiation Milestone Review is held within 30 days of the IAPD submission. The actual milestone review typically lasts between two to four days, either on site with the state or through teleconferencing, The Project Initiation Milestone Review is not considered officially “closed out” until the RO has rendered its decision whether to approve the IAPD or not. The milestone review does not alter the usual APD approval process; the APD approval process is still followed with CMS and the state exchanging official letters within regulatory timeframes. The Project Initiation Milestone Review provides a forum for the state and CMS to discuss the state’s plans, including the IAPD.


When an IAPD is approved, funds are typically released on a yearly basis, although the RO may decide to approve more or less than a year. This means that the RO usually reviews the IAPD annually to ensure the budget in the original IAPD is still accurate before CMS releases the next round of funds. This annual IAPD review does not trigger any additional project initiation milestone reviews.


Table 1 describes each APD and where it fits within the Medicaid Enterprise Certification Life Cycle.





Table 1. Types of APDs


APD

Type

Name

Description

Overlap with Medicaid Enterprise Certification Life Cycle

PAPD

Planning Advanced Planning Document

Used to request federal funds for planning the MMIS development.

At the beginning of the Planning & Initiation phase, before the state begins most planning. The PADP is optional.

PAPDU

Planning Advanced Planning Document Update

Used to update a previously approved PAPD.

If an update to a PAPD is necessary, Needed PAPD updates usually occur during of the Planning & Initiation phase. The RO reviews and approves, as usual.

IAPD

Implementation Advanced Planning Document

Used to request federal funds for developing and implementing the MMIS system. It should contain the overall development plan, including any staggered module development and a breakout of costs associated with each module by federal fiscal year.

In the Planning & Initiation phase, the IAPD is submitted to the RO after the IV&V contractor has delivered its Certification Progress Report and before the Project Initiation Milestone Review. The IAPD is a required document.


Because funds are typically released on an annual basis, the RO reviews the IAPD each year to ensure the budget is still accurate before the next round of funds is released. The state does not have to repeat the Project Initiation Milestone Review.

IAPDU

Implementation Advanced Planning Document Update

Used to update a previously approved IAPD.

Updates to the IAPDU are most likely to occur during Design, & Development or during the Integration, Test, and Implementation phase of the certification life cycle. IAPDUs are used during a long MMIS development project in which requirements and system designs have evolved. The RO must review and approve any IAPDU, but the state is not required to repeat the first milestone review because of an update.

OAPD

Operations Advanced Planning Document

Used to request funds for operating a certified MMIS.

The state submits OAPDs annually for certified systems that are already in operation. Therefore, OAPDs do not apply to the MECL; they are used after the system is certified.



Transitioning to the New Certification Life Cycle

Some state MMIS improvement projects started prior to the publication of this toolkit and the new certification life cycle. So in some cases, MMIS development projects need to be mapped into an appropriate phase of the new life cycle. States must meet the legislative requirements embodied in the Medicaid Enterprise Certification Checklists, regardless of when the MMIS project began.


Legislation and CMS policies are expected to evolve over time. When legislation or policies change, the CMS CO updates the Medicaid Enterprise Certification checklists and makes them available to states. A grace period to meet any new or changed requirements may be negotiated with the CMS CO.


A state encounters less difficulty adjusting to the new MECL when the MMIS project is at the beginning of its SDLC. To support the new certification process, states need to ensure proper contracts are in place for sufficient time and resources are available to conduct certification activities. The further along a state is in its SDLC, however, the more adjustment may be necessary to ensure compliance with the latest CMS certification requirements. A state that is very far along in its MMIS project may not be required to undergo the new MMIS certification reviews, with the exception of the final certification review.


Table 2 gives example scenarios of states in different SDLC stages and where they would begin in the new MECL. CMS CO and RO work with states that are “in-flight” with their MMIS replacement efforts to ensure minimal disruption in project schedules and system development. A state that does not fit into one of the scenarios below is encouraged to contact its RO to discuss placement within the new MECL.



Table 2. Transitioning States to the New Certification Life Cycle


#

Where State is in its SDLC

Starting Point in Medicaid Enterprise Certification Life Cycle

Actions for the State


1

The state is in planning phase. RO has approved the IAPD, but not the RFP.

The state is expected to go through the Project Initiation Milestone Review (R1). Approval of the IAPD will not be an issue during the review.










The state

  • Reviews the certification requirements in the Medicaid Enterprise Certification Checklists
  • Incorporates necessary changes into project plans
  • Updates the IAPD if necessary, and
  • Updates the IV&V contract, to include standard IV&V wording required by CMS (see toolkit appendices)



2

The state is at the end of the planning phase. It has an approved IAPD and RFP and is about to publicize the RFP.







3

The state is entering the development phase with an approved IAPD and system development contract.

The state undergoes R1 so the CMS certification team can review its project management materials and high level designs. The state must submit an IV&V draft RFP / contract modification for review and approval. The development contract may need to be modified if it doesn’t account for all requirements in the checklists.







4

The state is in the development or testing phases.

The state is not expected to undergo R1, but must submit an IV&V draft RFP

/ contract modification for review and approval and have the IV&V contractor prepare periodic certification progress reports. The development contract may need to be modified if it does not account for all requirements in the checklists. The state would be expected to undergo Operational Milestone Review(s) (R2).










5

The state has deployed its new / updated MMIS.

The state would not be expected to undergo R1 or R2. The state would undergo MMIS Certification Final Review (R3).

During the six or more months of operating the MMIS prior to R3, the state

  • Determines steps to gain compliance with certification requirements in the Medicaid Enterprise Certification Checklists
  • Determines if the IV&V contract needs to be modified

The IV&V contractor

  • Reviews the certification requirements in the Medicaid Enterprise Certification Checklists,
  • Identifies gaps or outstanding new requirements that are not addressed in the MMIS
  • Prepares a certification progress report



Several factors influence the complexity and amount of adjustment necessary to comply with changes in the new MMIS certification requirements. In the planning phase of the certification process, documents and artifacts are prepared to define the development approach and are used to estimate cost, schedule, and acquisition intentions. Most of this initial information is included in the PAPD and are updated and included in the IAPD. The system developers, state PMO, and IV&V contractors must continually monitor compliance to certification requirements to complete milestone reviews successfully.


State PMOs can meet with the RO at any time to discuss concerns about certification requirements. The more flexible or modular the system development approach, the more likely changes to meet certification requirements will incur less time and cost on the part of the state.


System Modularity and MMIS Certification

The standards and conditions for Medicaid IT require that states use a modular approach to systems development. The state may choose to stagger the development of its modules. The MECL supports such a staggered approach. In a case of staggered deployment, during the Initiation & Planning phase, the state explains its overall strategy in its project management plan, MITA documents, MMIS concept of operations, and PAPD and IAPD documents.


The CMS certification team reviews these planning documents during the first certification milestone review (R1), the Project Initiation Milestone Review. Together, these documents should give CMS a clear understanding of the state’s overall approach to modular development. The IAPD should include a breakout of anticipated costs by module and federal fiscal year.


The RO usually releases funds on a yearly basis (although the RO has discretion in this). The state is not required to undergo another Project Initiation Milestone Review with each funding release because CMS has already approved the overarching project and technical plans. Modules that are developed and deployed around the same time constitute a cohort of modules that complete their Operational Milestone Review and Certification Final Review together. FFP grants for operation and maintenance are released for modules that CMS has certified after successful completion of the MMIS certification final review.


Therefore, a state using a staggered approach to modular development will have one Project Initiation Milestone Review, multiple Operational Milestone Reviews, and multiple MMIS Certification Final Reviews. CMS evaluates the overarching strategy at the Project Initiation Milestone Review, and at the subsequent milestone reviews, evaluates each cohort of modules as they are implemented.


Critical Success Factors

The MECL incorporates critical success factors (CSF) into the certification process. There are two types of CSFs—programmatic and MMIS. Programmatic CSFs identify activities the state PMO will need to perform in managing its MMIS project. Compliance to programmatic CSFs are tracked in Certification Progress Reports that are prepared regularly by the IV&V contractor.


MMIS CSFs identify system capabilities required to support Medicaid agency functions. MMIS CSFs are included in the Medicaid Enterprise Certification checklists. Compliance to MMIS CSFs is tracked by the



IV&V contractor using the checklists, which contain built-in mapping between the MMIS CSFs and certification criteria.



Medicaid Enterprise Certification Roles

Four main entities are involved in the MECL: CMS Central Office (CO), CMS Regional Office (RO), the state (including its PMO and contractors), and the IV&V contractor.


CMS Central Office

The CMS CO provides overall supervision for MMIS certifications. The CO attends pre-milestone review calls and certification milestone reviews, as needed. CO approves all IV&V certification milestone review summary reports and issues MMIS / module(s) final certification decisions.


CMS Regional Office

The RO serves as a resource for the state throughout the certification life cycle. At the beginning of the life cycle, the RO reviews and approves draft IV&V RFPs and PAPDs and consults with the state once the MMIS concept of operations (COO) is complete. As part of the CMS certification review team, the RO reviews the IV&V contractor’s certification progress reports and participates in the milestone reviews. The RO approves IAPDs and development contracts and stays abreast of the state’s progress throughout the MMIS project. A state may consult with its RO at any time.


State

The state plans and manages the MMIS project. The state ensures the IV&V contractor has access to evidence needed to prepare its certification progress reports, tracks issues identified by the IV&V contractor, and manages them through resolution. The state plans MMIS certification milestone reviews in coordination with CMS CO.


IV&V Contractor

The IV&V contractor represents the interests of CMS, and as such, provides an independent and unbiased perspective on the progress of MMIS development and the integrity and functionality of the system. CMS expects that the IV&V contractor will participate in state SDLC gate reviews and will inform CMS of significant risks or issues as the module(s) / system is planned, developed, and deployed. To ensure independence, the IV&V contractor must not report to the same agency or department that oversees the Medicaid program. (For example, the IV&V contract may be owned by the state’s auditor’s office or the state’s department of treasury.) The IV&V contractor must not be the contractor performing software testing.


According to 45 CFR § 95.626 (b) and (c),

  1. Independent verification and validation efforts must be conducted by an entity that is independent from the state (unless the state receives an exception from the Department) and the entity selected must:
    1. Develop a project work plan. The plan must be provided directly to the Department at the same time it is given to the state.



  1. Review and make recommendations on both the management of the project, both state and vendor, and the technical aspects of the project. The IV&V provider must give the results of its analysis directly to the federal agencies that required the IV&V at the same time it reports to the state.
  2. Consult with all stakeholders and assess the user involvement and buy-in regarding system functionality and the system's ability to support program business needs.
  3. Conduct an analysis of past project performance sufficient to identify and make recommendations for improvement.
  4. Provide risk management assessment and capacity planning services.
  5. Develop performance metrics which allow tracking project completion against milestones set by the State.
  1. The acquisition document and contract for selecting the IV&V provider (or similar documents if IV&V services are provided by other state agencies) must include requirements regarding the experience and skills of the key personnel proposed for the IV&V analysis. The contract (or similar document if the IV&V services are provided by other state agencies) must specify by name the key personnel who actually will work on the project. The acquisition documents and contract for required IV&V services must be submitted to the Department for prior written approval.


CMS has developed standard IV&V language to be included in the state’s IV&V RFP and contract (or contract modification, if a contract already exists) to ensure that the IV&V contract includes duties CMS expects of the contractor. The standard language can be found in the toolkit appendices.


The IV&V contractor prepares certification progress reports throughout the certification life cycle, but in particular, before certification milestone reviews. The IV&V contractor reviews project and technical progress against the state’s baseline plans and against requirements contained within the Medicaid Enterprise Certification Checklists. The IV&V contractor delivers the certification progress reports, including draft reports, to CMS and to the state simultaneously.



Medicaid Enterprise Certification Life Cycle

The MECL is composed of the following four phases:


  • Initiation and planning
  • Requirements, design, and development
  • Integration, test, and implementation, and
  • Operations and maintenance.


Each phase has distinct activities that a state is expected to perform during MMIS certification. This chapter provides detailed explanations of each activity shown in the workflow diagram (Figure 3). An interactive version of the MECL is included in the toolkit as a separate document. That version also contains quick reference at-a-glance sheets for each activity.


01 MECT Medicaid Enterprise Certification Life Cycle V 1.0

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Figure 3. Medicaid Enterprise Certification Life Cycle





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Initiation and Planning

Figure 4 shows the activities in the initiation and planning phase.


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Figure 4. Initiation and Planning Phase


During the initiation and planning phase, the state


  • Consults with the CMS RO to explain its approach and asks questions about the life cycle
  • Selects a certification checklist set for use throughout the certification life cycle
  • Documents it goals and objectives for the new, upgraded, or replacement MMIS
  • Submits a planning advanced planning document (PAPD), if requesting planning funds from CMS
  • Assesses itself against the Medicaid Information Technology Architecture (MITA) maturity model
  • Contracts with an independent verification and validation (IV&V) provider



  • Prepares the MMIS Concept of Operations (COO) – (A courtesy template is provided in toolkit Appendix E.)
  • Prepares an implementation advanced planning document (IAPD) and draft request(s) for proposals (RFPs)
  • Creates its project management plan, schedule, and risk register
  • Cooperates with IV&V contractor as the contractor prepares a certification progress report prior to the first milestone review
  • Undergoes the first certification milestone review, and
  • Is notified whether the IAPD and RFP(s) have been approved by the CMS RO.


Activity 1: Consultation with CMS

Figure 5 shows the steps within the consultation with CMS activity. This activity includes:


  • Opportunities for the CMS RO to understand the state’s approach to MMIS enhancement / replacement
  • Opportunities for the state to ask questions about the MECL at the onset of the project
  • Advice from the RO on the most appropriate checklists for the state to use
  • Selection of a checklist set, and
  • Mutual agreement between the state and the RO on a preliminary “critical path” for the state’s certification life cycle. This includes a high level timeline for milestone reviews and frequency of certification progress reports that will fit with the state’s project schedule.


In this activity, the CMS RO and the state agreed to a frequency for the certification progress reports that the IV&V contractor will prepare throughout the project. At least two such reports much be submitted annually but the state and CMS may choose to require more as appropriate to the project.


Also during this activity, the state, with the approval of CMS RO, selects the checklist set it will use throughout the certification process. The state selects the MITA Business Module Checklist set for module releases around MITA business areas, or the state selects the MMIS Module Checklist Set for releases around traditional modules. The state may use a customized set of checklist criteria (subject to RO approval) for unconventional releases or for funding requests for innovative MMIS approaches. All three checklist sets contain the same criteria; the only difference is the criteria organization. The state cannot switch sets in the middle of development. Section 4 covers the checklists and how to us them.


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Figure 5: Workflow of Activity 1: Consultation with CMS



Activity 2: State Goals and Objectives and PAPD

Figure 6 shows the steps in Activity 2. The state agency considers its vision of the future and sets goals and objectives for the new MMIS. The state should use MITA business areas to guide its planning. The state submits a PAPD to the RO if requesting FFP for MMIS planning. States are not required to submit a PAPD. The output of this activity is a documented set of state goals and objectives and a PAPD, if the state is using one. The state and RO follow established APD processes during this activity. The details of the APD process are beyond the scope of the MECL.


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Figure 6. Workflow of Activity 2: State Goals and Objectives and PAPD


Activity 3: IV&V Draft RFP

The state drafts a RFP for an IV&V contractor, or drafts a modification to an existing contract, if necessary (Figure 7). The inputs to this activity are the state goals and objectives, the Medicaid Enterprise Certification Checklists; the output is a draft IV&V RFP.


CMS expects the state to include certain standard language in the RFP to ensure the contractor


  • Is independent from the state agency that manages the MMIS project
  • Does not perform software testing
  • Reviews project management and technical designs (including security, performance management, claims editing, etc.), and
  • Submits periodic certification progress reports (including drafts) to CMS RO, CO, and the state simultaneously.


Standard language for the state to copy into its IV&V draft RFP / contract can be found in Appendix C of the toolkit. The wording is to be used as written. The standard wording is not intended to provide exhaustive coverage of IV&V contract scope, but stipulates those activities that are the minimum required by CMS during planning, design, development, and implementation through certification. The state may add other duties. If the state is using an agile approach, the state is encouraged to add language requiring the IV&V contractor to participate in sprint burn downs. To maintain true independence, the IV&V contractor must not perform software testing of the system.


The state and CMS RO may need to discuss the frequency of certification progress reports prepared by the IV&V contractor. Reports should be frequent enough to give the RO a solid understanding of MMIS risks and progress, yet not so frequent as to add undue expense and burden on the state and on CMS.


The standard RFP / contract language required by CMS does not cover activities that the state may require of the IV&V contractor during ongoing operations and maintenance (O&M). CMS, however, does expect the state to have an IV&V service provider for O&M. The state may choose to hire a different



IV&V contractor for O&M or retain the one used during development. The IV&V role during O&M is outside the scope of this toolkit.


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Figure 7. Workflow of Activity 3: IV&V Draft RFP


Activity 4: IV&V RFP and PAPD Review

During activity 4 (Figure 8), the RO will review the IV&V and RFP to ensure that CMS’ interests are represented by the contractor and that the scope of IV&V review is comprehensive. If the state is submitting a PAPD, it will send the draft RFP with the PAPD. The CMS RO will review both and suggest modifications, if warranted.


The RO should check the frequency of certification progress reports required in the RFP. Certification progress reports are needed before each milestone review and throughout the project, with a minimum of two per year. (A report prepared for a milestone review counts toward the two-per-year minimum.) Progress certification reports should be frequent enough to give CMS a solid understanding of the risks and progress as the MMIS project proceeds, yet not so frequent as to add undue expense and burden on the state and on CMS. After the state makes any necessary corrections to the PAPD and the IV&V RFP, the RO will decide whether the IV&V RFP and the PAPD have been approved.


The standard IV&V RFP language and certification checklists are inputs to this activity. The outputs are RO decisions of approval or disapproval for the IV&V RFP and the PAPD.



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Figure 8. Workflow of Activity 4: IV&V RFP and PAPD Review


Activity 5: IV&V Contract

The inputs for activity 5 (Figure 9) are the state’s acquisition policies and procedures, the certification checklists, and the IV&V RFP / contract standard language in toolkit Appendix C. The state follows its procurement processes for issuing an IV&V contract, ensuring that the standard language is included in the contract. The state also must ensure that the contractor is qualified to perform reviews of business processes and IT service management processes and technical reviews of design, databases, applications, and security. The state sends the contract to the RO for approval.


Any changes to the IV&V contract that alter the scope of the contract must be reviewed and approved by the CMS RO. Once the state has contracted with an IV&V contractor, the state should conduct a kick- off meeting with the IV&V contractor to explain the state’s goals, SDLC, module release plans, and the checklist set it selected. The output of activity 5 is a contract submitted to the RO for approval.



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Figure 9. Workflow of Activity 5: IV&V Contract


Activity 6: MITA State Self-Assessment

Per MITA 3.0, the state performs a MITA self-assessment (MITA SS-A) and prepares its MITA Concept of Operations. This is activity 6 (Figure 10) in the MECL. The input for this activity is the latest MITA guidance and the output is a set of MITA documents, particularly the MITA concept of operations (COO) and the MITA state self-assessment (SS-A). States may have their IV&V contractor perform the SS-A. CMS encourages states to use the eSS-A scorecard (toolkit Appendix F) for submitting the SS-A to CMS. The state is also encouraged to peruse examples of other states’ self-assessments in the re-use library. (Contact CMS for access to the re-use library.) The state may find it easier and more cost-effective to tailor elements of another state’s SS-A than to start from scratch in preparing its own SS-A. States that use documents from the MES document re-use library can show that use as evidence of compliance to the leverage condition.


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Figure 10. Workflow of Activity 6: MITA State Self-Assessment


Activity 7: MMIS Concept of Operations

The state writes a technical MMIS COO in activity 7 (Figure 11). The input for this activity is the state’s technical concept for the MMIS solution. The output is an MMIS COO. The COO describes, at a high level, the technical solutions the state has selected and how those technical components will integrate internally and with external state and federal IT systems. The concept should explain how the state intends to apply the conditions of reuse and modularity. The state should be able to reuse much of the COO language for its IAPD. The state may choose to use the MMIS COO template provided in Appendix E of the toolkit.


The state is encouraged (not required) to consider examples of other states’ MMIS COOs in the re-use library. (Contact CMS for access to the re-use library.) The state may find it easier and more cost- effective to tailor elements of another state’s MMIS COO than to start from scratch in preparing its COO. States that use documents from the MES document re-use library can show that use as evidence of compliance to the leverage condition.


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Figure 11. Workflow of Activity 7: MMIS Concept of Operations


Activity 8: MITA and MMIS Concept of Operations Consultation

After the MMIS COO is developed, the state sends the document to the RO for review and consultation. The CMS RO discusses the high level design with the state to understand the scope of the work (and later, the funding request for it). CMS also identifies issues with the high level operational design that may pose certification problems. Figure 12 shows the steps in this activity. The input to this activity is the state’s MMIS COO and the MITA COO.


The MMIS COO consultation is informal and usually uncomplicated. The state and RO decide how to conduct the consultation—over the phone, through emails, in-person meeting, etc. The RO is welcome to use other CMS SMEs during the consultation activity. The output of this activity is a revised MMIS COO and revised MITA COO, based on comments, if any, received by the RO.



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Figure 12. Workflow of Activity 8: MITA and MMIS Concept of Operations Consultation


Activity 9: Draft Request for Proposal

The state often contracts with one or more vendors to design, develop, and install its MMIS. The state must ensure that MMIS requirements found in the RFP map to its APD, its MITA roadmap, and its annotated Medicaid Enterprise Certification Checklists. Figure 13 shows the steps in this activity. The inputs are the certification checklists, the MITA documents, and the MMIS COO; the output is one or more draft RFPs for system development.


CMS has discovered through experience that states that include certain provisions in their RFPs and contracts are more successful in system deployments. Wherever enforceable under state law, a state should include the following provisions:


  • Defined goals and objectives
  • Environment requirements (business, architecture, data), including re-use, interoperability, and modularity requirements
  • Conditions tying compensation to meeting or exceeding defined goals (e.g. service level agreements)
  • Reservation of right for the state to approve and/or remove subcontractors, and
  • Requirement that contractors cooperate with other contractors (including the IV&V contractor) and facilitate progress.


The state should also include language in the RFP and contract that requires contractors to abide by all the state’s security and privacy policies.



According to 45 CFR Part 92, procurement that exceeds a certain threshold dollar amount needs to be approved by CMS. For MMIS, the draft RFP(s) are reviewed by the RO. States using staggered modular development that may require more than one RFP throughout the life cycle need only draft RFPs for the first “cohort” of modules for the Project Initiation Milestone Review. When the state drafts additional RFPs, the state will not need additional Project Initiation Milestone Reviews, but will submit RFPs to the RO for approval. Alternatively, the state also may prepare all RFP drafts at one time.


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Figure 13. Workflow of Activity 9: Draft Request for Proposal


Activity 10: Project Management Plan

The steps in activity 10 are displayed in Figure 14. The input to the project management plan are the MITA and MMIS documentation developed to this point, and the output is a high-level milestone schedule, budget, risk register, project plan, and system development life cycle.


If it has not already established a PMO, the state could do so during this activity. The state


  • Writes or updates the project management plan
  • Develops or updates the budget
  • Develops the project schedule
  • Documents the system development life cycle it will use to develop the MMIS and how the MECL fits atop that SDLC (see Figure 2 for examples)
  • Creates a risk register (waterfall) / exception plan (agile), and
  • Ensures that all necessary artifacts are ready for the Project Initiation Milestone Review. (See toolkit appendices for the list of artifacts).


The first version of the project schedule may only show high level milestones broken out by quarter since often, a project schedule is detailed only after a system’s detailed requirements are determined. The schedule can contain more detail after the system requirements / user stories are defined.


The state is encouraged (not required) to consider examples of other states’ documents in the MES document re-use library. (Contact CMS for access to the re-use library.) The state may find it easier and more cost-effective to tailor elements of another state’s required documents than to start from scratch. States that use documents from the MES document re-use library can show that use as evidence of compliance to the leverage condition.


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Figure 14. Workflow of Activity 10: Project Management Plan



Activity 11: Certification Progress Report

Activity 11 steps are shown in Figure 15. The state fills out all of its Medicaid Enterprise Certification Checklists (see Section 3). Then the IV&V contractor fills out its portion of the all the checklists and uses the checklists to complete a certification progress report. The contractor also fills out Appendix A of the Certification Progress Report Template.


The Certification Progress Report is Appendix D of the toolkit. The IV&V contractor sends both the completed checklists and the certification progress report. The IV&V contractor is not to send drafts of the report to the state unless it is also sending the same draft simultaneously to CMS. CMS uploads the completed checklists to its tracking database.


When preparing the certification progress report required before the Project Initiation Milestone Review, the IV&V contractor evaluates the following state documents for thoroughness, accuracy, and consistency:

  • State goals and objectives
  • MITA self-assessment / MITA roadmap
  • MITA COO
  • MMIS COO
  • Draft RFP(s)
  • Privacy impact analysis
  • State security policies and security plan
  • Project management plan artifacts (budget, schedule, risk register / exception plan)


The progress report details what, if any, issues the state should address before the CMS certification team conducts its Project Initiation Milestone Review. The inputs to this activity are the certification checklists, supporting evidence and documents, including project management artifacts, and the certification progress report template. The outputs are a certification progress report and completed checklists, which are appended to the report.


If the contractor and state have identified particularly good examples of final versions of required documents, the state should consider uploading them as examples to the MES document re-use library. (Contact CMS for access.) Such documents need to be owned by the state and not contain sensitive or proprietary information. States that contribute documents to the MES document re-use library can show that contribution as evidence of compliance to the leverage condition.


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Figure 15. Workflow of Activity 11: Certification Progress Report



Activity 12: Submit Implementation Advanced Planning Document

Activity 12 (Figure 16) represents IAPD submission. The inputs for IAPD submission are all the state’s planning documents prepared to this point. The state follows the Advanced Planning Document process specified in 45 CFR, Part 95.

The IADP includes the:

  • Statement of need and objectives
  • Requirements and alternatives analysis, including considering reuse consideration
  • Project management plan
  • Proposed project budget and cost distribution
  • Statement of security / interface and disaster recovery requirements
  • Assurances
  • Compliance with standards and conditions for Medicaid IT, and
  • MITA self-assessment, as an attachment.


The state sends the IAPD to the RO; the IAPD is the output of this activity. Submission of the IAPD starts the APD approval process, which can last as long as 120 days, but is usually concluded in much less time. The RO evaluates the business case presented in the IAPD, formally submits questions to the state, considers the answers received from the state, and issues a decision on approval. If IAPD is approved, the RO releases FFP funds for design and development.


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Figure 16. Workflow of Activity 12: Submit IAPD


Activities 13a and b: Project Initiation Milestone Review and IAPD Approval

After the state addresses any issues identified in the certification progress report, the state and CMS CO agree on a time to conduct the Project Initiation Milestone Review (Figure 17). The CMS certification team consists of CO and RO representatives. This first milestone review must be conducted within 30 days of the IAPD submission. The inputs to the Project Initiation Milestone Review are the Certification Progress Report, the IAPD, the draft RFP, and all other planning documents. (See the toolkit appendices for a list of artifacts required for each milestone review.) The outputs are an IAPD decision from the RO, an RFP decision from the RO, and the CMS portion of the Certification Progress Report, to include comments, if any, about the state’s status.


The Project Initiation Milestone Review ensures that the state has documented goals and objectives, a solid MITA self-assessment and roadmap and a technical concept of operations. In this review, the CMS certification team evaluates the state’s business case, project management plan, and RFPs. The outcome of the review determines the release of FFP funds to the state for design and development of its MMIS.


At this review, CMS and the state discuss the most appropriate points in the state’s schedule to conduct the remaining certification milestone reviews.



The state generally schedules a few pre-milestone review calls with the CMS certification team. In these meetings, CMS and the state introduce their respective certification teams and the state gives an overview of its MMIS. The state plans the Project Initiation Milestone Review schedule and logistics, such reserving rooms and teleconference lines and granting the certification team access to evidence.


CMS may attend the review on-site or via phone. Reviews typically last between two and four days. After the review meetings, the RO, with assistance from the rest of the CMS certification team, completes the CMS portion of the Certification Progress Report and sends copies to the state and the IV&V contractor.


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Figure 17. Workflow of Activity 13a: Project Initiation Milestone Review


From the time the state submits its IAPD (activity 12) through IAPD approval, the state and CMS RO follow the APD process. (A full description of the APD process is outside the scope of this toolkit.) IAPD approval is shown in the MECL to illustrate how the APD process is conducted concurrently with the MECL milestone review process.


Although the Project Initiation Milestone Review meetings themselves may take only a few days, the milestone review is not considered officially “closed” until the IAPD has been approved and the certification team has issued the updated Certification Progress Report. The state may proceed with the other certification workflow activities so long as the IAPD is approved. (It does not need to wait until CMS updates the Certification Progress Report.)

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Figure 18. Workflow of Activity 13b: IAPD Approval


Requirements, Design, and Development

Figure 19 shows the activities in the requirements, design, and development phase.


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Figure 19. Initiation Design, and Development Phase


During the requirements, design, and development phase, the state:


  • Documents system requirements
  • Designs the system
  • Undergoes an IV&V requirements and design review
  • Documents test / validation plans
  • Cooperates with the IV&V contractor as the periodic certification progress reports is prepared, and
  • Develops the MMIS modules.



States may employ waterfall, agile, or hybrid development methodology. The IV&V contractor reviews requirements and designs and sends periodic reports to CMS RO and CO and the state about the progress of the project.


Activity 14: IAPDU Review and Approval (if Necessary)

A state that has already cleared the Project Initiation Milestone Review and needs to update a previously approved IAPD does not need to go through another Project Initiation Milestone Review. The state would update its IAPD, along with any related RFPs, and send them to the RO to review and approve (Figure 20).


This activity also covers the case where the RO plans to release funds annually and needs to review a previously approved IAPD before releasing funds. Again, in such a routine annual IAPD review by the RO, the state will not undergo another Project Initiation Milestone Review.


The input to this activity is the updated IAPD (or a previously approved IAPD). The output is a decision from the RO regarding approval and a release of funds.


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Figure 20. Workflow of Activity 14: IAPDU Review and Approval (If Necessary)


Activity 15: State Procurement Process

The state follows its own procurement processes to enter into contracts with developers, testers, system integrators, etc. The state sends the contracts to the RO for approval (Figure 21). The inputs are the state’s procurement policies and procedures and the RFP. The output is a contract(s) submitted to the RO for approval.


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Figure 21. Workflow of Activity 15: State Procurement Process


Activity 16: Requirements and Preliminary Design

If the state is developing a system (as opposed to purchasing a COTS product or outsourcing services), the state documents system requirements, system design, and test plans (Figure 22). If the state is purchasing a COTS product, the state must produce an interface design document including a description of application programming interfaces (APIs). The state also must develop a test plan to verify that the system / module meets all CMS requirements and will operate seamlessly within the MMIS (e.g., host identity management, data updates, etc.). The toolkit Appendix B contains a list of artifacts required for each milestone review.



In an agile development, requirements may take the form of epics and user stories on note cards or in a software suite. Each user story is mapped to a test case for validating the code produced during sprints. Use case testing is developed in parallel with product development. Integration testing is crucial for MMIS success and must be included in test plans.


In traditional waterfall development, mapping between requirements and test cases is called a requirements traceability matrix (RTM). Agile approaches may not have a formal RTM, but regardless of the methodology used, mapping must contain requirements traceability and must detail requirements for the following categories:


  • Business
  • Data
  • Capacity / performance
  • Security / privacy / HIPAA compliance
  • Usability
  • Maintainability
  • Interface, and
  • 508 compliance.


The inputs for this activity are the MITA technical strategies, MITA COO, MMIS COO, and the certification checklists, including critical success factors. The output is a set of technical designs and requirements / use cases or user stories.


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Figure 22. Workflow of Activity 16: Requirements & Preliminary Design

All applicable criteria found in the Medicaid Enterprise Certification checklists must be covered in the requirements along with any state-specific requirements. Requirements and design typically change over the course of a large development and must be kept current.



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Activity 17: Requirements and Design Review(s) / Sprint Retrospective

Activity 18: Certification Progress Report

Activity 19: Review Certification Progress Report

Activity 20: Periodic Certification Progress Report

Activities 17, 18, 19 and 20 are covered together because they are closely related. Regarding activity 17, the success of the MMIS project depends on the inclusion of all federal and state Medicaid systems requirements in the technical designs. CMS does not perform a formal milestone review of the detailed requirements and designs because states develop detailed designs at different times and in different ways, depending on their SDLC. CMS does require that the IV&V contractor use the Medicaid Enterprise Certification Checklists to review requirements and design as they are developed. The IV&V contractor also needs to report to CMS any risks and gaps using the periodic certification progress reports. The inputs for activity 17 (Figure 23) are the COO documents and preliminary designs, requirements, and test plans. The output of activity 17 and 18 together are a Certification Progress Report.


The IV&V contractor prepares progress reports periodically (activities 18 and 20) throughout the MECL on a schedule agreed on by the state and CMS during activity 1. Each year, a minimum of two progress reports must be prepared. (The state and CMS may have agreed upon a more frequent schedule of reporting during the Consult with CMS activity.) For each progress report, the state updates all it checklists. Then the IV&V contractor reviews artifacts and evidence and updates the reviewer columns in the checklists, and appends the checklists to the completed progress report.


Special occurrences of the Certification Progress Reports can count toward the minimum of twice annually. These are prepared immediately before a milestone review (activities 12, 23, and 26) and after the preliminary requirements and designs have been created (activity 18). The report generated after preliminary design development gives the CMS RO a chance to review designs and notify the state of any issues early in development, when it is least costly and less time-consuming for the state to correct them.


The state should schedule the IV&V certification progress report after preliminary requirement and design to fit its SDLC phase gates. For example, a state following a waterfall development may have a single design phase gate. That would be the most appropriate time for the IV&V contractor to perform its requirements and design review.


A state employing an agile approach will not likely have a design gate review. It may instead perform a series of sprint retrospectives, where the backlog is prioritized and designs modified at the conclusion of each sprint. In such a case, the IV&V contractor may perform a requirements and design review at each sprint retrospective, during every other sprint retrospective, or at some other pre-agreed schedule. The requirements and design must have been thoroughly reviewed at least once by the IV&V contractor.


For the periodic certification progress reports, the IV&V contractor will review the following:


  • Project plans and progress



  • System design document, or, if the state is purchasing a COTS system, an interface design document
  • Information system security assessment
  • Test plan
  • Test report / validated product reports
  • Interface control document
  • Database design
  • Data conversion / data management plan
  • Implementation plan
  • Contingency / recovery plan
  • Data use / exchange interconnection security agreement
  • Project progress against plans, and
  • MITA progress.


The IV&V contractor delivers the report simultaneously to CMS RO and CO and to the state. The IV&V contractor is not to send drafts of the report to the state unless it is also sending the same draft simultaneously to CMS. The state may respond to issues identified in the certification progress report. State comments are appended to the report, but the report is not altered. CMS can insert comments in the appropriate section of the report. CMS will pay particular attention to how the state is designing security and privacy into the modules / system.



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Figure 23. Workflow of Activity 17: Requirements & Design Review

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Figure 24. Workflow of Activities 18 and 20: Certification Progress Report

Once the CMS RO reviews the certification progress report, it may add comments and suggestions to the CMS section of the report and return the updated report to the state and to the IV&V contractor. The state should incorporate CMS suggestions into project plans, as appropriate. The final version of the certification progress report, with state and CMS comments, is sent to the state and to the IV&V contractor and is stored in a CMS repository. Figure 25 shows the steps of activity 19. The input is the



IV&V Certification Progress Report; the output is comments in the CMS section of the report, if CMS has comments.


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Figure 25. Workflow of Activity 19: Review Certification Progress Report

Activity 21: Develop

The state and its contractors develop the MMIS / modules according to their own SDLC processes.


Integration, Test, and Implementation

Figure 26 shows the activities in the integration, test, and implementation phase.


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Figure 26. Integration, Test, and Implementation Phase


During the Integration, Test, & Implementation phase, the state



  • Integrates modules
  • Tests the integrated system
  • Cooperates with IV&V contractor as periodic certification progress reports are prepared
  • Undergoes Operational Milestone Review(s), and
  • Deploys the system / newly developed modules into production.


Activity 22: Test and Evaluate

The state and its contractors employ their own testing procedures to evaluate the functionality of the MMIS / modules against documented requirements or user stories (Figure 27). Testing includes generating reports of how documented requirements or user stories were tested, along with the test results or evidence of product acceptance by users. For agile approaches, use case testing is developed in parallel with product development. If the state is using an automated test suite, the entire set of test cases could be run on the production environment before the Operational Milestone Review(s). CMS encourages the use of automated testing and continuous integration, when possible.

The inputs for activity 22 are working code and test plans / test cases. The output is documented test results, or in the case of agile development, product acceptance by the customer.




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Figure 27. Workflow of Activity 22: Test & Evaluate


Activity 23: Certification Progress Report

During this activity (Figure 28), the IV&V contractor reviews the working modules / system and all the artifacts required for the Operational Milestone Review (see the list of required artifacts in the toolkit appendices) and evaluates whether the modules / system are ready for the Operational Milestone Review.


If a state is releasing several modules at the same time, the IV&V contractor need only produce one certification progress report. The state and IV&V contractor will need to update all the checklists for all the modules (even those not undergoing a milestone review) for the report, however, only those modules undergoing the milestone review will be examined during the milestone review.


After the state has updated all the checklists, the IV&V contractor completes the reviewer comment sections of the checklists. The IV&V contractor uses these to prepare the certification progress report and delivers the report simultaneously to the CMS RO and CO and to the state. The IV&V contractor is not to send drafts of the report to the state unless it is also sending the same draft simultaneously to CMS. The progress report details what, if any, issues the state should address before the CMS certification team performs the Operational Milestone Review. As with all certification progress reports, the state may respond and those responses will be appended to the report.




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Figure 28. Workflow of Activity 23: Certification Progress Report


Activity 24: Operational Milestone Review(s)

After the state addresses issues the IV&V contractor identified in the certification progress report, CMS conducts the Operational Milestone Review (see Figure 29 for the steps involved). The inputs to this review are working module(s) and the Certification Progress Report. The outputs are CMS certification team comments, if any, in the CMS portion of the Certification Progress Report.


Milestone reviews are scheduled by mutual agreement between the state and CMS CO to accommodate the state’s deployment schedule and CMS subject matter expert (SME) availability. During this review CMS validates the functionality and security of the MMIS / modules ready before deployment.


Generally, a few pre-certification calls are scheduled with the CMS CO. In these meetings, CMS and the state introduce their respective certification teams and the state gives an updated overview briefing of the MMIS / module to be released. The state plans the review schedule and logistics, such reserving rooms and teleconference lines and granting the certification team access to evidence.


CMS may attend the review on-site or via phone. Reviews typically last two to four days. The CMS RO, with assistance from the rest of the certification team, fills out the CMS portion of the certification progress report. In the CMS portion of the report, CMS outlines any corrective actions the state needs to take before the final certification review.


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Figure 29. Workflow of Activity 24: Operational Milestone Review(s)


Operations and Maintenance

Figure 30 shows the activities in the operations and maintenance phase.



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Figure 30. Operations and Maintenance Phase


During the operations and maintenance phase, the state


  • Operates the MMIS according to the state’s processes and procedures
  • Requests certification formally, and
  • Undergoes the final certification review.


Activity 25: Certification Request

The final certification milestone review cannot take place until the MMIS / module(s) has been operating in production for at least six months. At some time before (or after) the six month operational point, the state’s Medicaid director or comparable state official sends a letter to the CO requesting certification of its MMIS / module(s) (Figure 31). Appendix I_MMIS Certification Request Letter Template is a form that a state can use to prepare its letter to CMS.


The letter must include:


  • The date the system / module(s) became fully operational
  • A copy of the state’s letter to the MMIS contractor or state development team accepting the system / modules(s)
  • A proposed time frame for the review
  • A declaration that the state’s MMIS meets all of the requirements of law and regulation
    • Meets the requirements of 42 CFR 433.117 for all periods for which the 75-percent FFP is being claimed



  • Issues Explanation of Benefits (EOBs) on a regular basis for all periods for which 75 percent FFP is being claimed, in accordance with the provisions of Section 10 of P.L. 95142, which amends section 1903(a)(3) of the Social Security Act.
  • Is ready for CMS certification, based on the state’s evaluation using the checklists in the Toolkit
  • Adjudicates claims and information required for payment of services in accordance with all provisions of 42 CFR 447 and the approved state Medicaid plan
  • Generates up-to-date and accurate T-MSIS (Transformed Medicaid Statistical Information System) data
  • Routinely generates back-ups containing up-to-date and accurate T-MSIS data
  • Exercises appropriate privacy and security controls over the system in accordance with 45 CFR Part 164, P.L. 104-191, the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and 1902(a)(7) of the Social Security Act as further interpreted in regulations at 42 CFR 431.300 to 307.


CSM will respond with an official letter. Together CMS and the state will set dates for the MMIS Certification Final Review.


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Figure 31. Workflow of Activity 25: Certification Request


Activity 26: Certification Progress Report

During this activity, the IV&V contractor reviews the working modules / system and all the artifacts required for the Certification Final Review (see toolkit appendices) and evaluates whether the modules / system are ready for the MMIS Certification Final Review (Figure 32). The IV&V contractor completes the reviewer comment sections of the checklists and prepares a certification progress report, delivering the report to both CMS RO and CO and to the state simultaneously. The progress report details what, if any, issues the state should address before the CMS certification team performs the MMIS Certification Final Review. The output of this activity is a Certification Progress Report.


If a state requests certification for several modules at the same time, the IV&V contractor need only produce one certification progress report for that certification milestone review. If later, another cohort of modules is ready to be certified, the IV&V contractor prepares a certification progress report for that cohort before it undergoes its MMIS Certification Final Review.


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Figure 32. Workflow of Activity 26: Certification Progress Report


Activity 27: MMIS Certification Final Review

During activity 27 (Figure 33), the CMS certification team evaluates the modules / system against CMS guidelines and federal regulations after the modules / system have operated for at least six months. The inputs to this activity are one or more working MMIS modules, the Certification Progress Report, the certification request letter, and supporting evidence and documentation (see toolkit Appendix B for a list of artifacts required at each milestone review). Based on the results of this review, CMS decides whether to certify the modules / system and release FFP funds to the state for MMIS maintenance and operation.


The state arranges logistics for the MMIS Certification Final Review, such as scheduling rooms, granting the members of the certification team access to evidence, and setting up teleconference lines.


During the review, the CMS certification team will verify that the criteria based on federal and state requirements are satisfied by reviewing functionality of the modules / system in production. CMS will perform the verification by actual system interaction, review of documents, and interviews with state and, potentially, contractor staff. The visit will conclude with an exit conference in which CMS summarizes the activities and observations made during the review. The decision to certify or not certify the state’s system is deferred until the CMS certification team can analyze all information gathered during the review or submitted subsequently by the state.


The CMS RO, with assistance from the rest of the certification team, fills out the CMS portion of the certification progress report and issues a decision letter stating whether the MMIS or module(s) has been certified and any conditions to the certification.


If certification and funding has been granted for a module or group of modules, but additional MMIS modules are still under development, the remaining MMIS modules must also go through final certification review to be funded.


Once all the MMIS modules have been certified (either through a series of staggered final certification reviews or all at one time), the capabilities of the certified system will be used as the baseline for future MMIS updates.


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Figure 33. Workflow of Activity 27: MMIS Final Certification Reviews(s)



Medicaid Enterprise Certification Checklists

The Medicaid Enterprise Certification checklists have been updated to reflect current regulations, MITA architectures (business architecture, information, and technical), and the standards and conditions for Medicaid IT. Checklists are used throughout the certification life cycle and support a variety of state development approaches—modular, phased, agile, waterfall, etc.


Selecting a Checklist Set

Together, the state and CMS RO select a set of checklists that the state will use throughout the MECL during the first activity of the certification life cycle. The state can choose one of three checklist set options. All three checklist sets contain the same criteria; the only difference is the organization of those criteria.


The first option is the MITA Business Module set. This set is for states developing MMIS modules organized according to the MITA business areas. The second checklist set option is the MMIS Module set, for states with MMIS system-centric modules. The third option is a tailored set of checklists arranged by the state for exceptional cases in which a state takes an innovative approach to MMIS or in which the state is requesting funds for a non-traditional function that cannot be covered under one of the first two checklist sets. The customized approach requires approval from CMS CO. Table 3 lists the checklists that make up each of three options. Note that the technical architecture, information architecture, and the Standards and Conditions for Medicaid IT checklists are included in all checklist sets.


Table 3. Checklist Sets


MITA Business Module Checklist Set


MMIS Module Checklist Set


Customized Checklist Set

  • Business Relationship Management
  • Care Management
  • Contractor Management
  • Eligibility & Enrollment
  • Financial Management
  • Member Management
  • Operations Management
  • Performance Management
  • Plan Management
  • Provider Management
  • Information Architecture
  • Technical Architecture
  • Standards and Conditions for Medicaid IT
  • Member Enrollment
  • FFS Claims & Adjudication
  • Pharmacy
  • Third Party Liability
  • Care Management
  • Program Integrity
  • Decision Support System
  • Reference Data Management
  • Provider Management
  • Registries
  • Information Architecture
  • Technical Architecture
  • Standards and Conditions for Medicaid IT
  • Checklist determined by state and approved by CMS RO
  • Information Architecture
  • Technical Architecture
  • Standards and Conditions for Medicaid IT


Before each milestone review, the state downloads the zip file of its checklist set, along with the technical architecture, information architecture, and the Standards and Conditions for Medicaid IT checklists (which are required every time, regardless of the modules being developed). The state fills out



the checklists and the IV&V contractor uses the checklists to complete its certification progress report. The IV&V contractor completes the reviewer section of the checklists, appends them to the certification progress report, and send copies of the report simultaneously to CMS RO and CO and to the state. The checklists are then uploaded to a tracking database maintained by CMS. This allows CMS to keep a running record of MMIS certification progress throughout the certification life cycle. CMS runs a report from the database that shows which CSFs have not been met.


After reviewing the periodic progress report or after performing a certification milestone review, the CMS RO fills out the CMS section of the certification progress report with the assistance of the rest of the certification team. CMS stores a copy of the report in its repository and sends copies of the updated certification progress report to the IV&V contractor and to the state.


This process is repeated every time a certification progress report is prepared by the IV&V contractor. Figure 34 shows the checklists through the certification life cycle.


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Figure 34. The Life of Checklists


Anatomy of a Checklist

Each checklists is an Excel workbook with three tabs. One tab is a set of instructions (Figure 35), one tab is the checklist (Figure 36), and the third tab (Figure 37) is a list of CSFs or MITA business areas. (The MITA module checklist set has CSFs and the MMIS module set has MITA business areas.)




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Figure 35. Instructions Tab



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Figure 36. Example MITA Certification Checklist


The header across the top of the checklist tab shows the name of the checklist and checklist set in parentheses. Below that are the MMIS milestone review checkboxes. When a box is checked in the review selection section, the sheet will automatically display the columns that apply to that period of the certification life cycle and will hide information that does not apply. The state checks the box of the next pending milestone review.


Individual criteria are listed in rows, with a mapping of their sources and criteria number. Appendix G maps the 2007 certification criteria to the 2016 checklists.


The evidence columns are of two types: columns for the state to complete and columns for the IV&V contractor to complete. The state fills out the Yes / No column and the evidence column. For those criteria which lists the MITA level in the Source column, the state must enter compliance evidence when the To-Be MITA maturity level is equal to or greater than the level stated in the Source column. The IV&V contractor fills in the review date, reviewer name, reviewer assessment and review comments columns.


The spreadsheets are imported into the CMS tracking database, so the structure of the checklists must not change (i.e. label names, merged columns, etc.), and many cells are locked. Checklist names for the canned checklist sets, tab names, and reference numbers should not be changed; however, column widths and row heights can be adjusted to suit user needs. Numbers are color-coded to indicate the nature of the criteria. The checklist can be filtered by column and by the pre-set filter dropdowns in each column header. The filter function in the data menu bar will not work with the pre-set filters set.


Checklists also contain the factors considered critical to the success of an MMIS system. These are called “functional critical success factors” or CSFs. CSFs are listed in the checklist instructions tab and are also shown as green rows in the checklist tab.




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Figure 37. Example Critical Success Factors Mapping Tab



The CSF or MITA business area tab is for reference so that the state and IV&V contractor can easily determine which CSF / MITA business area maps to which criteria.


Certification Milestone Reviews

Certification milestone reviews follow a pattern (Figure 38). Several weeks prior to a milestone review, the IV&V contractor submits the Certification Progress Report with completed checklists. CMS CO uploads the completed checklists to its central repository.


After submission of the Certification Progress Report and at least two weeks before the milestone review, the state and the CMS certification team will have one or more pre-certification calls to plan the logistics and agenda of the review meetings. The CMS certification team consists of CO and RO representatives. The state will give the certification team access to the evidence and documentation. A milestone review kickoff meeting will be held for the state and CMS to introduce their respective team members.


The review meetings generally last from two to four days and are broken into sessions based on system functionality and/or checklist areas. CMS team members will be assigned to sessions based on their subject matter expertise. CMS may conduct the reviews entirely by web conferencing or may send a few members of the team to the state site while the remaining members join via phone.


After the review meetings, the CMS RO, with the help of the other CMS certification team members, fills out the CMS portion of the Certification Progress Report and send copies to the state and to the IV&V contractor.


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Figure 38. The Milestone Review


Preparing for a Milestone Review or a Progress Report

Before the IV&V contractor prepares a certification progress report (whether it is prior to a milestone review or as periodic, routine report), the state selects those checklists that pertain to the modules under development, including the information architecture, technical architecture, and standards and conditions for Medicaid IT checklists. The state then fills out the yes / no and evidence column for each criterion and includes a hyperlink that points to evidence in the state’s repository. Only one hyperlink can be added to any one cell. If a state needs to point to more than one artifact for a criterion, the state can point the reviewer to a document which lists all relevant hyperlinks if the state needs to provide more than one artifact for a criterion.

Clear, simple linkage between the criterion and the evidence is very important. In one early case, a state mapped criteria to a complicated mapping matrix outside of the original checklist. The complexity of the mappings within mappings and the repeated logins required every time a document was opened in the evidence repository resulted in a reviewer having to perform 109,056 operations to complete review of a single checklist. Such complexity is unnecessary and costly. The state needs to maintain a simple mapping from checklist criteria in the checklist to the supporting evidence. The state will also need to ensure that the IV&V contractor and all members of the CMS certification review team have access to the evidence repositories.




In the checklists, the state must clearly map each checklist criterion directly to the evidence that supports it.

Only one hyperlink can be added to any one checklist cell. So if the state needs to link to more than one artifact for a criterion, it may provide a link to a separate document that lists all the relevant hyperlinks.


5.1.1 An Example

State X is taking a MITA aligned approach to its modules and is using the MITA module set of checklists. State X is currently developing a cohort of three MITA aligned modules—care management, contractor management, and eligibility & enrollment. The IV&V contractor needs to write a certification progress report, so the state downloads the zip file for the MITA checklist set and extracts the care management, contractor management, and eligibility & enrollment as well as the technical architecture, information architecture and the Standards and Conditions for Medicaid IT checklists.


State X first checks the phase box in the upper left hand corner of the checklist tab. As a routine progress report occurring after the Project Initiation Milestone Review but before the Operational Milestone Review, the state selects the “operational” box. This report will give CMS an idea of the state’s progress toward the Operational Milestone Review.


The state then reads through each criteria in the checklists and indicates in the yes / no columns if each criterion applies to its modules. If a criterion does not apply, State X explains in the evidence column.



Then, State X fills out the evidence column for each criterion and explains how that criterion is met. It also gives a hyperlink to the artifact that supports that criterion. For one of the criterion, State X has three artifacts as evidence, but because a cell can contain only one hyperlink, the state mentions the three artifacts in the evidence column and adds a hyperlink to a Word document. The Word document lists hyperlinks to the three evidence artifacts.


The state ensures that the IV&V contractor staff have access to the artifact repository and sends the checklists to the IV&V contractor. The IV&V contractor reviews the state entries in the checklists, along with the evidence. The contractor may request interviews or ask for additional information. The IV&V contractor fills out the reviewer comment columns, uses the progress report template to complete its report, and appends the completed checklists to the certification progress report before sending copies to the state and to CMS simultaneously.


In the next certification progress report for these three modules, State X uses the last version of the checklists from the last certification progress report, updates the evidence columns, sends the updated checklists to the IV&V contract, and the process repeats.


When State X starts developing its next set of modules, performance management and plan management, it downloads the zip file for the MITA checklist set and extracts the performance management and plan management checklists along with clean technical architecture, information architecture and Standards and Conditions for Medicaid IT checklists. The state will use those checklists to shepherd the next cohort of modules through certification.


Artifacts Required for Each Review

Toolkit Appendix B has a list of the artifacts required for each of the milestone reviews. Minimum requirements for each document are given. The requirements are not an exhaustive list of what typically is included in each artifact, and states are encouraged to add elements as appropriate.


Document names used in agile methodologies often differ from those used in traditional waterfall methods, so wherever possible, the corresponding agile term is used alongside the traditional name. Because of agile methods’ lighter approach to documentation, a couple of artifacts are not required for agile implementations until the final milestone review. In general, CMS expects designs created during the initiation and planning phase to be at a high level. As part of its periodic certification progress reports, the IV&V contractor will review detailed designs as they are developed during the Requirements, Design & Development phase of the certification life cycle. For the purpose of certification reviews, CMS does not expect detailed designs until the Operational Milestone Review.


With the exception of APD forms, MITA templates, MMIS Concept of Operations, privacy impact assessments, and Medicaid Enterprise Certification Checklists, CMS expects that the state and its contractors will use their own SDLC artifact templates that contain the minimum content.


At time of certification milestone reviews, CMS will supply the location for the state to upload its major artifacts (for example, MITA documents). States will still maintain their own document repositories. In its certification checklists, a state will include hyperlinks that point to evidence residing in the state’s repository.

Notes

This content is verboten displayed from the original PDF documents found on https://medicaid.gov