Medicaid identifies Recipients – NM residents who Applicants submit individuals, based on apply for or who receive applications either by standardized criteria, who Medicaid Enterprise benefits phone, fax, mail, or qualify for cost-sharing entered directly through reductions, Medicaid or CHIP, YES-NM and other insurance Recipients submit affordability programs eligibility verifications in Medicaid conducts near-real electronic and paper time verification of application format information and, where Recipients receive possible, enrolls the individual multiple notices regarding into coverage real-time and eligibility from the notifies the issuer of new Medicaid Enterprise and enrollment the MCO CMS systems exchange Centers for Medicare & Medicaid Enterprise information with Medicaid Medicaid Services (CMS) - A submits invoices and agencies and the Health branch of the U.S. Department Medicaid Statistical Information Exchange (HIE) to of Health and Human Services Information System populate MSIS and derive (HHS). CMS is the federal (MSIS) reports via email other budget information in agency that administers Medicaid Enterprise real-time Medicare, Medicaid, and the electronically submits For administrative reporting, Children’s Health Insurance CMS budget reports using CMS systems interface with Program (CHIP). CMS provides MBES/CBES the State Medicaid Enterprise information for health to derive records needed for professionals, regional reports governments, and consumers. Other Payers – Other benefit Benefit information is Other benefit programs share programs with liability to cover exchanged prospectively benefit coverage with medical costs for Medicaid Medicaid recipients. Includes private Automated business rules insurers perform coordination of benefits, preferably utilizing data exchanges focused on a cost avoidance mode, rather than pay and chase
Recipients – NM residents who apply for or who receive Medicaid Enterprise benefits Applicants submit applications either by phone, fax, mail, or entered directly through YES-NM Recipients submit eligibility verifications in electronic and paper format Recipients receive multiple notices regarding eligibility from the Medicaid Enterprise and the MCO Medicaid identifies individuals, based on standardized criteria, who qualify for cost-sharing reductions, Medicaid or CHIP, and other insurance affordability programs Medicaid conducts near-real time verification of application information and, where possible, enrolls the individual into coverage real-time and notifies the issuer of new enrollment Centers for Medicare & Medicaid Services (CMS) - A branch of the U.S. Department of Health and Human Services (HHS). CMS is the federal agency that administers Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). CMS provides information for health professionals, regional governments, and consumers. Medicaid Enterprise submits invoices and Medicaid Statistical Information System (MSIS) reports via email Medicaid Enterprise electronically submits CMS budget reports using MBES/CBES CMS systems exchange information with Medicaid agencies and the Health Information Exchange (HIE) to populate MSIS and derive other budget information in real-time For administrative reporting, CMS systems interface with the State Medicaid Enterprise to derive records needed for reports Other Payers – Other benefit programs with liability to cover medical costs for Medicaid recipients. Includes private insurers Benefit information is exchanged prospectively Other benefit programs share benefit coverage with Medicaid Automated business rules perform coordination of benefits, preferably utilizing data exchanges focused on a cost avoidance mode, rather than pay and chase