Medicaid Promoting Interoperability Program Document Templates

CMS-10292 (OMB 0938-1088; Expires: TBD)

DRAFT MODEL CHECKLIST: HEALTH INFORMATION
TECHNOLOGY PLANNING – ADVANCE PLANNING
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
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.

Content


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

Description of Minimum
Requirements
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 PAPD 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:

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PRA Disclosure Statement As described in 42 CFR part 495, subpart D, States must submit to CMS a State Medicaid Health IT Plan (SMHP) outlining
various aspects of how they will operate their Medicaid Promoting Interoperability Program. Further, for States to receive the FFP described above for the
incentive payments as well as expenditures relating to their Medicaid Promoting Interoperability Program, they are required to submit for approval Advance
Planning Documents that include specific information to support the state’s funding request. Under the Privacy Act of 1974 any personally identifying
information obtained will be kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-1088. The time required to complete this information collection is estimated
to average 16 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

CMS-10292 (OMB 0938-1088; Expires: TBD)

Section
2. Project Management Plan

Content


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.

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.



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



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.

Description of Minimum
Requirements
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.

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

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CMS-10292 (OMB 0938-1088; Expires: TBD)

Section

Content

Description of Minimum
Requirements
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
Progress Reports






45 CFR Part 95.613

45 CFR Part 95.617
42 CFR Part 431.300
45 CFR Part 164

ο

Yes

ο
ο
ο

Yes
Yes
Yes

ο

No

ο
ο
ο

No
No
No

Provide an explanation for any “No” answers.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09381088. The time required to complete this information collection is estimated to average 1 hour per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop
C4-26-05, Baltimore, Maryland 21244-1850.

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