CMS-10292 (HIT P-A Model Checklist: HIT Planning-Advance Planning Document

OMB Approval Number: 0938-1088

Draft MODEL cHEcKLIST: Health Information Technology planning – Advance Planning document (hit P-apd) The HIT Planning APD (HIT P-APD) is to be prepared and submitted to your CMS Regional Office for review and approval, prior to initiating HIT activities under the American Recovery and Reinvestment Act of 2009. The HIT P-APD is used to obtain prior approval and to secure ninety percent (90%) Federal financial participation (FFP) for the planning activities that will lead to the State Medicaid HIT Plan (SMHP). The SMHP will be used to plan the implementation activities (to be detailed in a subsequent HIT Implementation APD and future guidance). These activities will include, but not be limited to, administering incentive payments necessary to support the implementation of certified electronic health record (EHR) technology by eligible Medicaid providers, as well as the procedures the State will use to oversee incentive payments made to eligible Medicaid providers. The objective of the HIT P-APD is to describe how the State will develop a high-level management statement of the State’s vision, needs, purposes / objectives, plans, and estimated costs, which will result in an statewide State Medicaid HIT Plan (SMHP), a deliverable resulting from the HIT P-APD. The SMHP will include a Landscape Assessment of the current “As-Is” status of HIT in the State, a future “To-Be” vision of HIT in the State, 5 years into the future, and a State Medicaid HIT Road Map with quantifiable benchmarks tied to timeframes that the State and CMS can use as guideposts along the journey to accomplishing the vision. The focus of the HIT P-APD is on describing how the planning will be accomplished and to demonstrate that the State has established a plan that is reasonable for the level of effort of the project. The HIT P-APD that meets the standards for approval shown below will be approved within 60 days of receipt by the CMS Regional Office, unless there are issues needing considerable clarification. The HIT P-APD has four sections: 1. Statement of Need and Objectives; 2. Project Management Plan for Planning; 3. Proposed Planning Project Budget; and 4. Assurances.
Section	Content	Description of Minimum Requirements
1. Statement of Need and Objectives This section of the HIT P-APD document should clearly state the purpose and objectives of the HIT project to be accomplished.	Statement of Purpose (the purpose statement is pre-filled) Interrelationships with current HIT initiatives and with the Medicaid Management Information System (MMIS) Identify any HIT workgroups and / or collaborative efforts in your State Opportunities for economy or efficiency	Purpose: Create a State Medicaid HIT Plan (SMHP) that serves as your strategic vision to enable the State to achieve its future vision by moving from the current “As-Is” HIT Landscape to the desired “To-Be” HIT Landscape, including a comprehensive HIT Road Map and strategic plan over the next 5 years. Enclosure A of the recently published State Medicaid Director’s Letter contains an overview of the SMHP contents. The attached SMHP document following these HIT P-APD instructions also contains detailed activities that we anticipate States will conduct during planning which will result in the State’s SMHP, a deliverable resulting from the HIT P-APD. It is recommended that the use of MITA concepts, principles, and tools be used to assist in the key planning steps. Follow this link for MITA documents that can be of assistance: http://www.cms.hhs.gov/MedicaidInfoTechArch/
2. Project Management Plan The Project Management Plan summarizes how the State will plan to conduct an assessment of its current and future HIT environment. The State's planning project organization is briefly described. For planning purposes, the State identifies key players in planning, such as the HIT project manager and other key planning staff by name and title. This information can be depicted in an organization chart. The Project Management Plan for HIT planning describes how and when the activities for planning will be conducted with schedules and milestones for completion of key events. This section should include the description of the HIT Project Office or the plans to create one.	Include a detailed description of the nature and scope of activities to be undertaken and the method used to accomplish the project, including products and deliverables. HIT Planning project organization (State and / or contractor resources) – people, responsibilities, and relationships, if an outside procurement is involved, include key dates for the procurement process, including expected dates for submission and approval by CMS of an RFP, proposed evaluation plan, and contract. Include a personnel resource statement indicating key personnel and project manager / director Provide a detailed planning activity schedule	Provide a descriptive one-page chart and one page of accompanying narrative. This section should include the State’s designated HIT contact person for purposes of establishing a single HIT point of contact. This person can be at the Governor’s level or Department level, depending upon the State’s organizational structure and location of the HIT office. This section should include a discussion of the State’s proposed method to conduct the “As-Is” and “To-Be” HIT environmental evaluation.
3. Proposed Project Budget This section succinctly describes in narrative form the resource needs for which funding support during HIT planning may be requested by the State. These needs may relate to State personnel costs, resources, and contractor costs for staff, equipment, facilities, and travel, This section of the HIT P-APD also provides the HIT planning budget and the cost allocation plan to be used during planning.	By categories, cost elements and amounts Cost Allocation Plan In-house staff costs and other costs by outside contractors. These costs should be distinguished from each other.	Estimated costs in this category are for anticipated administrative FFP expenditures at 90 percent for planning purposes only. A cost allocation plan must be included that identifies all participants and their associated cost allocation as specified in Circular A-87 to depict non-Medicaid activities and FTEs participating in this effort. All estimated costs should include activities directly related to the administration of HIT activities as listed in the examples provided in Enclosure D of the State Medicaid Director’s letter. Items not eligible for 90 percent administrative activities should also be included. Include any anticipated State-only costs. Projected costs by fiscal quarter and summarized by fiscal year, including the planning project total for each State Medicaid and non-Medicaid program included in the planning project.
4. Assurances This section includes procurement activities, monitoring and reporting activities, including access to records, licensing, ownership of software, and the safeguarding of information contained within the system. These assurances are required for automated data processing equipment. Indicate by checking “yes” or “no” whether or not you will comply with the Code of Federal Regulations (CFR).	Procurement Standards (Competition / Sole Source) Access to Records Software & Ownership Rights Federal Licenses Information Safeguarding HIPAA Compliance P rogress Reports	45 CFR Part 95.613  Yes  No 45 CFR Part 95.617  Yes  No 42 CFR Part 431.300  Yes  No 45 CFR Part 164  Yes  No Provide an explanation for any “No” answers.

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