CMS-10434 - Summary of & Response to Public Comments

PUBLIC SUBMISSION COMMENT/RESPONSES

CMS-2012-0074-(CMS-10434)

Medicaid and CHIP Program (MACPro) System

Comment Tracking#	State	Public Comment	CMCS Response
8105b027	NE	Thanks for the demo on the new MACPro - this will be so nice to implement. I am familiar with the online process for 1915(c) waivers, so I was glad to see the similarity and feel that it will be user friendly. a) Like the 1915(c) web application, having alpha/number identifiers for sections would be helpful. Not only at the time of completion, but in the printed copy. (This may be in the works and just not ready yet for the demo, but wanted to reinforce that.) b) Copy and pasting from WORD into the narrative boxes is very helpful - hoping that MACPro will accommodate bolding, underline, italics, and bullets. Nice work!!!	N/A
8105e0cc	CO	I have questions/comments: 1. Can email notifications received by the state be based on the applications submitted? Since not all applications involve the same program administrators this would be a nice function. 2. Can the information that wouldn’t change for a state unless legislation is passed be “saved” and auto-populate for each new application? ex. Whether a state is a 209b state	1. Yes. The email notifications that the state receives will be delivered to all users associated with the submission package and will only be relevant to the specific application being amended. 2. The information that a user sees is the most recently approved version of the SPA.
8108114b	NC	I found the MACPro overview session to be informative; thank you. I like the electronic interface for State Plan Amendment (SPA) management in MACPro, and I look forward to using it. Because I work on the SPA for our state's Children's Health Insurance Program, I am familiar with the section prompts in the existing SPA template. My suggestion for improvement in MACPro is to offset any new SCHIP SPA template sections or prompts with bold font or some other indicator, and in those sections, also provide a hypertext link to any new or amended federal statute or regulation that controls that aspect of program administration at the State level. It would actually be helpful to have hypertext links to ALL legal citations in the template. Immediate online access to the legal authority would facilitate State responses to CMS Requests for Additional Information - particularly in offices where staff is not trained in legal research and/or they do not have legal search engine subscriptions.	The current version of MACPro does not support the functionality that is referenced in your comments. CMCS is exploring options for additional enhancements in future releases of MACPro.
810ae579	CA	1. Will CMS transfer all existing approved SPA's into the new MACPro Workflow System? 2. Will MACPro contain the Revised CHIP State Plan Template? Or will the template be changed again to accommodate the new MACPro System. 3. When a SPA is under CMS' review, will CMS show your comments being worked in real time before the official 90 day period starts? Similar to the "hide/unhide" feature for states?	No. CMS will not transfer existing approved SPAs into MACPro. MACPro will be implemented incrementally overtime. During this time states will be able to enter their State plan information into the system. No. MACPro will not contain the revised CHIP state plan template. MACPro will use newly designed applications for the Medicaid and CHIP programs, so it will not look exactly like state plan pre-prints that are currently used. No. Comment will not be viewable before the official 90 day period starts. MACPro is designed to be fully transparent. As such, the system has a comment log that will capture all of the comments from each reviewer assigned to that particular SPA. These comments can then be shared with other users in the system. However, this will not occur before a 90 day period. Users will have the ability to submit a draft submission that can be used to develop a final official SPA. This draft submission is optional.
810afecd	TX	The webinar presentation indicated that once in the system, information would be retained indefinitely. Stages often have to go back several years to find state plan information for inquires. The state wants to ensure the system will indeed hold all information. Texas currently maintains a paper state plan. The State will require a significant amount of time to complete the initial conversion from the paper plan to the MACPro system. What timeframe will CMS allow for states to enter their initial state plan information? a. Will it be possible to process amendments during the initial data entry period or will states have to suspend the process? b. How will CMS ensure that the Texas plan is the same as the one CMS has on file? How will differences be noted and handled? c. When there is not an easy way to translate current paper state plan pages into the electronic version, how will the transition be adjudicated? If there needs to be significant revision due only to the format change (e.g., narrative to template), will CMS treat this as a “new submission”? d. How will the State’s extant paper state plan pages be mapped to the electronic pages in the new system, which are by their very nature not limited to the size of a piece of paper? How will the State be able to establish a paper trail between fields in the new electronic system and the old paper pages? 3. The system does not include a numbering scheme on the state plan pages. Because the state plan is vast, this could make it difficult for staff to ask and respond to specific questions. Will MACPro have some type of page numbering system? 4. What key fields will be shown on the finder screen? The existing CMS waiver application has a detailed finder screen with effective dates added. Will this detailed finder screen be implemented in MACPro? If so, what fields of data will be available? Will state plan finder screens be sortable? 5. What type of search function will be available for each state’s currently-approved state plan? Texas suggests that a minimal search capability should include the following: a. The ability to find all instances of a keyword or phrase anywhere in the entire state plan; b. The ability to find sections according to service (e.g., all pages covering EPSDT services) c. A table of contents with hyperlinks to individual pages and sections; and d. A “drill-down” index to allow easy navigation and access to embedded screens. 6. Texas is concerned about the 500 character limit considering some state plan pages and 1115 Demonstration pages are comprised entirely of narrative information, rather than checkboxes and template text. How will this be addressed? 7. Users should have the ability to customize certain system preferences. For example, the user could manually set the system timeout or change the font scheme. 8. The webinar provided only a high-level explanation of how the system will work. When does CMS anticipate having a beta version of the MACPro system online and available for states to fully review? Will some states be able to test the system as beta users prior to implementation? 9. The State assumes each state’s full, currently approved state plan will be made available for public viewing through the MACPro system. Can CMS verify this statement? a. What specific information is output to the Healthcare.gov and CMS.gov sites and when does this occur? b. Will the public be able to locate on the CMS site a snapshot of the Texas State Plan at a specific point in time? c. Will the State be able to provide absolute references to various sections or provisions of the plan to stakeholders and other interested parties (e.g., a hyperlink to a specific state plan section)? 10. State plan submissions are currently identified by transmittal numbers (e.g., 12-003). What type of numbering system does CMS anticipate using for state plan amendment submissions in MACPro? 11. System Backup/Recovery/Security: a. Is there a contingency plan for a situation in which a state must submit state plan information by the close of business, but the MACPro system is offline? b. How frequently is the system backed up? Does CMS have a disaster recovery plan to ensure quick data recovery for states? c. If the user and the system have been performing automated and manual saves and the system goes down, will the user be able to fully recover all their input up to the last save? d. Will CMS users be able to make any changes to the State’s data? If so, how will the change be documented in the system? e. What kind of data encryption does CMS plan to use to ensure the privacy of data stored in the MACPro system? f. The webinar did not mention a privacy policy for data stored on the site. Does CMS plan to implement a privacy policy for MACPro? Does it plan to solicit input from the States as to what should be included in such a policy? 12. All data, including drafts that have not yet been submitted or reviewed, reside on CMS’ data servers. Who ultimately owns this data? 13. What will be the “units” of the plan available for editing on the final system? Must the State open an entire section in order to amend a single item? 14. The webinar did not include a demonstration of the commenting system that CMS will use to adjudicate requests for additional information on state plan amendment submissions. Will this system simply show the state a list of comments in text form? It would be more helpful for CMS to build a system to allow for inline commenting, similar the track changes and “comment bubble” feature in most word processors, so that states can easily match comments to specific language in their submissions. Such a comment system could also use the principle of nondestructive editing, so that CMS could suggest specific edits in the actual text without actually overwriting the State’s proposed text. 15. Does the system support attachments, such as the current CMS-179 and standard funding questions? If the system does not support uploads of supporting documentation, part of each state plan amendment submission will still have to be conducted via email. 16. The initial rollout of the MACPro system is scheduled to require the submission of state plan eligibility information, which will encompass the Medicaid expansion included in the ACA. The recent Supreme Court ruling on the ACA, however, makes this expansion optional for states. Will there be a way to submit eligibility material under the new system without opting into the new expansion? 17. How will states input existing 1115 Demonstration waivers into the new portal if the web portal does not match the states paper format? How will changes to the existing waiver and the template be handled? 18. Can amendments to an 1115 waiver be submitted prior to approval of the version of the 1115 that is input in the web portal? If not how will amendments be made and approved? 19. Will states use the 1115 portal to submit the Special Terms and Conditions (STCs) set forth by CMS? If not, how will the STCs be submitted and approved?	1. Yes. Records will be stored indefinitely. 2. MACPro will be implemented overtime in phases. States can use this time to convert their paper based state plans into the system. States will be able to begin adjudicating SPAs once the system goes live. Additionally, states may be required to maintain dual processes until they are fully loaded into the system. Additional guidance on converting paper to system is forthcoming. States will be required to attest to the accuracy of their submission. CMS has conducted extensive interviews and joint application development (JAD) sessions with business owners to ensure that the paper based workflow is captured in MACPro. Please note that the state plan has been completely redesigned and the look and feel of the process will not be the same. CMS has conducted extensive interviews and joint application development (JAD) sessions with business owners to ensure that the paper based workflow is captured in MACPro. Additional guidance regarding converting paper to the electronic process is forthcoming. Yes. MACPro will have a unique ID. A unique ID is assigned by MACPro at package creation. After the submission of the Initial Application form, MACPro generates the next logical unique ID for the package. The unique ID is designed to include information that will identify the state that submitted the package, the year it was submitted, the package type and authority, and a serial number. MACPro will have similar functionality to the finder screen. MACPro allows users to do a search within a package as well as an on screen search. Reports/queries exist in the system which allow for other search capabilities. This functionality exists within the application. This functionality exists within the application. This is allowable. This functionality exists. The character limit has been increased from 500 to 2,000. Uses will be able to set various preferences. However, the ability to manually set the system timeout or changing the font is not an option within the system. However, MACPro is 508 compliant. The 30 day comment period recordings will provide walkthrough of the content and functionality of the complete system. CMS has identified several states who will participate in User Acceptance Testing (UAT). Additionally, CMS will do a rollout of the system that will include training for state users. Confirmed. Approved state plans will be viewable in MACPro. States can choose a. CMS will publish approved state plans as well as state specific information to Medicaid.gov. Additional information may be shared at later points of time. b. No. A state will only be able to see an approved state plan. c. The current version of MACPro does not support the functionality that is referenced in your comments. CMCS is exploring options for additional enhancements in future releases of MACPro. - A unique ID is assigned by MACPro at package creation. After the submission of the Initial Application form, MACPro generates the next logical unique ID for the package. The unique ID is designed to include information that will identify the state that submitted the package, the year it was submitted, the package type and authority, and a serial number. a. No b. The system is backed up daily. c. There is no auto save function at this time. Users have to manually save their work. d. No. CMS cannot edit user’s data or information. Personally identifiable information does not exist in any of the program. Also, MACPro is not a public facing system. See above. The state owns the data until it becomes an official submission. Yes the State must open an entire section to amend a single item. However, CMS is exploring options for additional enhancements in future releases of MACPro. The information in the comment log supports what goes into a RAI. CMS is exploring options for additional enhancements in future releases of MACPro. Uploads of attachments are only allowed in certain sections of the State Plan and must be in a pdf format. State plan eligibility is no longer a part of the initial release of MACPro. 1115 Demonstration waivers are no longer part of the initial release of MACPro. 1115 Demonstration waivers are no longer part of the initial release of MACPro. 1115 Demonstration waivers are no longer part of the initial release of MACPro. 1115 Demonstration waivers are no longer part of the initial release of MACPro.
810b87d0	MI	The MACPro System is similar to the online waiver application system for §1915(c)/(b) waivers, which has some flaws. If staff inadvertently created a SPA or §1115 demonstration application by mistake, the State should have the option to delete this error and not have it displayed on the list page of the online application. Currently we have several blank waiver and amendment applications by staff who were unsure as to how to use the online application process for §1915(c). Hence it will be helpful if a tutorial webinar on the use of the online application process is posted on the MACPro website. The tutorial should include step-by step instructions on the creation of a new or revised SPA along with the creation of new, or amended or renewal of a §1115 Demonstration. The PowerPoint for the §1915(c) online application is not that helpful when it comes to initiating a new, amendment or renewal. Michigan recommends a help desk or online chat to address any and all questions concerning the online application. Michigan also recommends that frequently asked questions be posted to the MACPro website as well. The FAQs should include questions that are received and answered by the CMS MACPro technical support. Michigan recommends that like the §1915(c) online application website, resource materials be posted on the MACPro website. Michigan recommends that the online application have the ability to be saved as a legibly readable Word or pdf document that is vastly different than the online application for the §1915(c). This allows States to post the draft and final versions on their respective websites. This also allows the ease in readability for those who are visually challenged. Michigan recommends that the online application have text boxes that have at least 2000 characters or above to allow for better descriptions of the question or clarification being asked. Michigan recommends that CMS allow the States retain the right to determine who has read, write or read & write capabilities to the MACPro system. This includes being flexible in allowing those who have both read and write capability for the SPA to be excluded from having this same function under the §1115 Demonstration .Michigan would like to know if States will have the ability to view other States drafts and final SPAs and §1115 Demonstrations. State staff would like to have the ability to view another State’s draft SPA or demonstration to have an idea on what is feasible. Michigan would like to know how charts, tables and spreadsheets will be incorporated into the MACPro System. We suggest that the new system is capable of incorporating charts, tables and spreadsheets. For example our §1115 Demonstrations required worksheets with and without waiver costs. Under the old system the worksheets were e-mailed to the regional office, but under the new system will there be a place for attachments or an online worksheet template? Michigan would like to know the retention policy for retaining online documents in the MACPro System. Michigan would like to know who has account management. Michigan would like to know what information from the MACPro System will be shared with the www.medicaid.gov and wwww.healthcare.gov websites. Michigan would like to know that if multiple SPAs are submitted, does this open up other areas of the State Plan for review and questions by CMS. Michigan would like to know how new SPAs will or should be incorporated into the current State Plan if a new numbering system is employed. Most States post their State Plan online for public view. Will CMS provide guidance on incorporating the new into the old or will States be required to keep two versions? Michigan would like to know how CMS plans to incorporate the existing pages of the State Plan into the MACPro template configuration and if this will be done without requiring States to submit a State Plan Amendment that would open pages for CMS review. Michigan would like to know what CMS plans for a new numbering system. The State is concerned that the historical tracking of SPAs now available using the current TN identification will be lost unless there is a conscious effort to develop something that will preserve it. Michigan supports the proposed changes and appreciates CMS interest in working with States to resolve issues through a range of corrective actions.	This functionality currently exists in the MACPro system. All MACPro trainings and webinars will be recorded posted on Medicaid.gov for viewers to access at any time. Resource materials exist within the system and additional information including FAQs and other available resources is will be posted on Medicaid.gov. A dedicated helpdesk and resource mailbox have been established to address any and all questions concerning the online application. This functionality currently exists within the system. The character limit has been increased from 500 to 2,000. This functionality currently exists within the system. Yes, there is a question within MACPro that asks if you would like to share the drafts and final SPAs with other States. There are sections throughout the application that supports uploading of attachment. Additionally, text field exist in the application that allows users to provide additional information or clarification. MACPro will be the system of record. All actions will be maintained indefinitely. State Medicaid Directors will identify users of the system and what roles they will have within the system. Approved SPA would be the information that is shared on Medicaid.gov. Additional information may be published as the process progresses. Yes. A unique ID is assigned by MACPro at package creation. After the submission of the Initial Application form, MACPro generates the next logical unique ID for the package. The unique ID is designed to include information that will identify the state that submitted the package, the year it was submitted, the package type and authority, and a serial number. CMS will provide guidance and training on how to convert their paper based SPAs to MACPro. Until this process is fully completed states will be required to maintain two versions. States will be required to convert their paper based plan information into the system Doing this will not open the pages for review. A unique ID is assigned by MACPro at package creation. After the submission of the Initial Application form, MACPro generates the next logical unique ID for the package. The unique ID is designed to include information that will identify the state that submitted the package, the year it was submitted, the package type and authority, and a serial number.
810c2ef2	MN	To Whom It May Concern: Thank you for the opportunity to provide input in the development of the system, designed as a web-based mechanism for the submission and approval of Medicaid and Children's Health Insurance Program (CHIP) Programs (MACPro) state plan amendments and waiver requests. We have a number of comments. First, as CMS states in the Federal Register notice of June 8, 2012, it would not have been useful to collect public comment on a paper-based version of the MACPro data collection instrument. For that reason, CMS conducted four webinars from June 13 to July 11, so that interested parties could see the MACPro system in operation. Unfortunately, the part of the MACPro system related to waivers is not yet complete, and therefore not shown at all in the webinar. Also, \because the webinar did not show all of the elements of the state plan data collection instrument, and because the webinar was not interactive, this webinar was not effective in gathering the input of affected parties, especially state Medicaid agencies. We think it would be extremely useful for CMS to conduct a second round of public comment, including an interactive webinar, when MACPro is better developed. We are very supportive of an electronic state plan submission and approval process that will eliminate some of the administrative burden involved with the submission and review of waivers and state plan amendments, improve transparency, and hopefully improve the timeliness of the process. We have some concerns, however, based on the recent webinar and on our experience with the web-based portal developed for home and community-based waivers. First, it was unclear from the webinar whether MACPro will be able to identify for CMS and state staff, through highlighting, strikeouts and underlines, or other means, the specific amendments being added or deleted. This is important for the review process and for purposes of tracking the history of the state plan and waivers. The current portal for home and community-based waivers do not highlight or otherwise track the specific amendments. Consequently, when we file an amendment through the portal, we are inevitably asked by CMS reviewing staff to produce another document, outside the portal, showing the same amendments in strike-out and underline form, so that CMS staff does not have to compare two 250-page waivers, before and after the amendment, in order to find the changes. In addition, although we understand from the webinar that the MACPro system will allow us to track history by producing a full copy of our waiver or state plan as it existed at any point in time in its history, it is not clear that MACPro will allow us to track to the date in history on which we proposed or CMS approved a particular change. This information is extremely important to states, because issues in Medicaid are revisited often. Being able to trace an amendment by transmittal number back to a corresponding file with related background information, correspondence, etc., is an important way to achieve a number of goals, including consistency both at the state and CMS levels. If MACPro is not built with this functionality, the result is effectively more work for states, not less, because they would then have to reproduce the waiver or state plan amendment in separate software program in order to track the actual changes they are making. It appears that MACPro includes an element called "change log," and another called "change report," but the description of those elements leads us to believe that they will track when amendments are submitted, and by whom, but not necessarily the identifiable language changes to the state plan and waivers. My next concern is about character limits on the text boxes that states are required to use. In our experience with the CMS Waiver Applications Portal, these character limits are unnecessarily restrictive. As we converted our home and community-based waivers from their paper format to the portal, we found ourselves moving important and relevant information to less relevant sections of the template (where there was more room), abbreviating words, removing verbs, etc. to a point that the document becomes difficult to understand. Our description of payment rates for nursing homes is about 180 pages long. It is hard to imagine how a limit on the # of characters is going to be manageable. On a related note, in the CMS Waiver Applications Portal, the text boxes will not accept any type of formatting-no indents, no outline numbering, etc. If the MACPro system repeats this mistake, it will be impossible to provide CMS with the kind of detailed payment methodology that it has demanded of our state plan over the years. Also, it has been our experience that the CMS Waiver Applications Portal does not accept files that originated from spreadsheet software such as Excel. In Minnesota, the personnel who are developing estimates of cost, utilization and enrollment are analyzing data compiled from multiple sources. The HCBS waiver portal will accept only one number at a time, so each time we amend our estimates, state personnel then have to cut and paste each number from our spreadsheets into the CMS portal. This is painstaking, and prone to error. We hope that MACPro is developed to accept an entire file that contains the correct elements. We have numerous questions about the related changes to the substance of the state plan and waivers by virtue of revised or new templates, as well as the approval process, especially about the conversion of the current state plans and waivers into the portal. However, but we have limited our comments here to the MACPro system as presented during the webinars. Thank you for the opportunity to comment, and we look forward to further interaction on this topic.	CMS will be conducting additional webinars that show all of the elements of the state plan data collection instrument. Additionally, CMS will be conducting interactive trainings for state on MACPro. CMS is exploring implementing functionality that will identify specific sections that have been changed. The current version of MACPro does not support the functionality that is referenced in your comments. CMCS is exploring options for additional enhancements in future releases of MACPro. Correct. However, CMS is exploring implementing functionality that will identify specific sections that have been changed. The character limit has been increased from 500 to 2,000. MACPro has text boxes that allows for additional explanation or clarification of information. CMS is exploring implementing functionality that will allow for detailed formatting. Various sections within the system allow for uploading pdf documents only. CMS is exploring implementing functionality that will support uploading non-pdf documents.
810c2ef6	CO	I am writing to you on behalf of Colorado's single state Medicaid agency, the Department of Health Care Policy and Financing to provide comment related to CMS-1 0434 Agency Information Collection; Comment Request; Webinars: MACPro to seek clarification on system function. Colorado appreciates and applauds CMS' efforts to develop more streamlined submission and approval processes for Medicaid and CHIP State Plans and Information systems Advanced Planning Documents, and other State submissions for federal review and approval. Based on the functionality demonstrated via the webinar(s) and our own experience with such processes, Colorado has specific questions as follows: Please clarify the timeline for migration of current State Plan content into MACPro and whether there is expectation that the entirety of each State's Medicaid and CHIP State Plans will be fully migrated by some yet-to-be-specified date certain. Colorado notes that migration of 1915(c) home and community based services (HCBS) waiver content into the Waiver Management System was phased to match waiver renewal timelines. Please clarify the process around uploading current State Plan content, specifically: Will uploaded content be treated as new SPA submission with potentially new effective dates? Will such uploads be "auto-approved" by CMS or will there be an active re-review by CMS? Will it be possible for some current SPA content to be handled differently if a State wishes to amend or is in the process of amending? Please clarify how attachments to current SPA submissions will be treated. Specifically, proof of Tribal consultation, responses to the five (5) standard funding questions or client access questions. Will there be an electronic equivalent of Form CMS 179, including the budget impact information? Please clarify how informal and formal Requests for Additional Information (RAI) and other correspondence will be handled, including whether that information will be available for viewing by the public or other interested parties. IF RAIs and State responses will be available for public view, will it be during negotiation with CMS or only after CMS has made an approval/denial decision? Please clarify issues of user access. Will States have a limited number of “licenses?” Is it possible to have multiple drafters but limited official submitters? Will submitters be allowed to have delegated administrative staff? What system capacity safeguards have been contemplated to ensure that multiple States can be drafting multiple SPAs at the same time without function compromise? In Colorado’s experience there were considerable capacity issues for HCBS waiver electronic submissions. Who decides what “role” a state user will have (read only, create/edit, or submitter)? Will the decision be left with the State Medicaid Director, or designee, or will CMS decide? What will be the protocol for adding or deleting users? Will someone at the State have “permission over-ride” capability against some unanticipated event where a staff person leaves and is the only one with change access for a submission? Please clarify whether State access to a submitted SPA will be locked during the period of CMS review. Please clarify how a minor correction (typographical or otherwise) will be handled; will the submission date/time reset? Please clarify whether there will be public access to MACPro, available to other States as well as the general public. If so, will that access include: Approved SPAs CMS Denials (with or without access to the submitted SPA) How will the MACPro system handle the traditional State Plan naming conventions of “section, attachment and supplement?” It appears that the system recognizes those relationships in how the links work but will there be some kind of labeling or explicit crosswalk? Colorado strongly suggests either retaining the label or publishing a crosswalk; it will make uploading current State Plan content much easier to validate. Will each State be responsible for uploading its own State Plan content or will CMS/CMS contractor perform this duty?	Additional information is forthcoming on the time frame for migrating paper based information into the system. a. No uploaded content will not be treated as a new SPA. b. N/A c. N/A These will be uploaded as pdf documents. Alternative Benchmark Plan (ABP) screens have a budget section. Only approved SPAs will be made available for viewing my the public, a. No b. Yes C. No. d. Multiple drafts can be in progress. However, two people cannot access the same data at the same time. State Medicaid Directors will identify users of the system and what roles they will have within the system. Yes, users can be reassigned. The SPA will be locked during CMS review. The general public will not have access to MACPro. Only approved State users responsible for adjudicating action will have access. Approved SPAs will be made public. Crosswalks have been developed for each Medicaid authority that shows MACPro users how the existing State Plan preprints or other forms relate to the forms in MACPro States will be responsible for uploading its own State Plan content.
810c67	CA	The California Department of Health Care Services (DHCS) supports the Centers for Medicare and Medicaid's (CMS) efforts to improve the efficiency and ease of the State Plan Amendment and Waiver submission and review process through a user-friendly online tool. We appreciate CMS's thorough informational webinars on MACPro and the opportunity to comment. DHCS submits the following technical questions and comments about how the MACPro system. will function for your consideration in response to the request for public comment notice in the June 08, 2012 Federal Register Which of the documents and information submitted through MAC Pro will be made public? At what point in the application process will public posting of submitted documents occur? In the current state process, a transmittal number is assigned and required for each State Plan Amendment submission. The transmittal number is used to track previous amendments and is incorporated into the State Plan approved pages. According to the webinar, the MAC Pro system is designed to navigate through the State Plan by major subject titles, sections and subsections. There is no mention of the use of transmittal numbers or attachment numbers. Will CMS require transmittal numbers for State Plan Amendment submissions under the new MAC Pro system? Will the format of the State Plan pages change or will it stay the same? The webinars mention that once submitted, an application becomes "locked" but can be reopened if something needs to be modified or changed. Does "locked" indicate that the submitted information becomes public? Will the state need special authorization or justification to unlock a submitted application and make changes? DHCS currently has Waivers in place that have been approved by CMS. Will there be an interim period during which amendments to existing Waivers that have been submitted and are pending will continue to be processed through current means? The Federal Register notice indicates that MACPro will be operationalized in phases. How long does CMS plan to allow for an interim process to operate outside of MAC Pro before full transition to the MACPro system is made? The webinars indicate that only the state Medicaid director has access to officially submit a package of information to CMS. Would the MAC Pro system allow for delegates of the Medicaid director to handle submission of internally approved documents and be the designee to receive comments and correspondence back from CMS? The webinars also showed a function to limit document editing access for each state staffer who has a Jog-in to MAC Pro-who will have the authority to control this access? Often, when submitting applications or amendments to CMS, DHCS attaches back-up documentation and attachments that further explain our proposals. How will DHCS be able to submit additional attachments or back-up documentation in the MAC Pro system? Word limits on written fields may prove constricting for the state and the space provided may not be sufficient for the state to provide all the information necessary. CMS staff has a "comment" feature on submissions by the state. How can state staff respond to these comments? A comment feature for the state would also be helpful especially if the goal is to keep as much of the conversation on-line as possible. The webinar presenter described a notification feature which alerts CMS any time a major change has been made to an application. The State currently has working relationships with key CMS contacts specializing in specific areas such as managed care, financial management, and rates development. Will we be able to target these notification alerts to specific individuals at CMS or will there be one point of contact at CMS who would distribute states' submissions to appropriate staff? DHCS appreciates the opportunity to provide comments on the MACPro System.	Approved State Plans will be made public. The format of the state plan pages will change. An official package can be unlocked by the system if CMS request additional information. Additional information is forthcoming on the time frame for migrating paper based information into the system. At this time only the Medicaid Director may certify the document. MACPro has a document upload function in certain sections of the SPA or waiver. Additionally, there are text fields that allows for further explanation. The character limit has been increased from 500 to 2,000. There is a correspondence log associated with each package. The email notification feature in MACPro that the states will receive and will be delivered to all users associated with the submission package and is only relevant to the specific application being amended.

Page 1 of 23

December 7, 2012

MACPro 30-Day