CMS-10292 Health Information Technology (HIT) Implementation Advan

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

Health Information Technology (HIT) Implementation Advanced Planning Document (IAPD)
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Name of State____________________________________________________________
Name of State Medicaid Agency:_____________________________________________
Name of Contact(s) at State Medicaid Agency__________________________________
E-Mail Address (es) of Contact(s) at State Medicaid Agency________________________
Telephone Number(s) of Contact(s) at State Medicaid Agency:________________________
Date of Submission to CMS Regional HITECH Point of Contact_________________________
Version #

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.

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Health Information Technology (HIT) Implementation Advanced Planning Document (IAPD)
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TABLE OF CONTENTS
Section I: Executive Summary....................................................................................................... 3
Section II: Results of Activities Included in the Planning Advanced Planning Document (PAPD) and SMHP............................................................................................................................. 3
Section III: Statement of Needs and Objectives ............................................................................ 3
Section IV: Statement of Alternative Considerations .................................................................... 4
Section V: Personnel Resource Statement ..................................................................................... 4
Section VI: Proposed Activity Schedule......................................................................................... 5
Section VII: Proposed Budget ........................................................................................................ 6
Section VIII: Cost Allocation Plan for Implementation Activities ................................................. 7
Section IX: Assurances, Security, Interface Requirements, and Disaster Recovery Procedures .. 8

Appendix A ................................................................................................................................... 10
Appendix B ................................................................................................................................... 10
Appendix C ................................................................................................................................... 10
Appendix D ................................................................................................................................... 10
Appendix E ................................................................................................................................... 11

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Health Information Technology (HIT) Implementation Advanced Planning Document (IAPD)
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INFORMATION REQUIRED FOR THE HIT IAPD
SECTION I: EXECUTIVE SUMMARY
Please draft a brief executive summary describing the intent of this IAPD or IAPD-U.
SECTION II: RESULTS OF ACTIVITIES
Provide a current status of the activities which were included in the P-APD and the State
Medicaid HIT Plan (SMHP). It should also provide the status of the expenditures which were
approved by CMS in the P-APD. Unexpended costs approved under the P-APD must either be
closed out or included as line items within the IAPD budget. If planning activities from the PAPD have been completed, the State should state that all planning activities have been
completed and the planning grant can be closed out.
Sample P-APD Status Table

ACTIVITY TYPE

EHR INCENTIVE PROGRAM: P-APD STATUS
P-APD EXPENDITURES
APPROVED P-APD
TO DATE
State Federal Total State Federal Total

REMAINING P-APD
FUNDING
State Federal Total

PROGRAM TOTAL

SECTION III: STATEMENT OF NEEDS AND OBJECTIVES
Provide a summary of project needs, objectives and the anticipated benefits of the proposed
activities.

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Health Information Technology (HIT) Implementation Advanced Planning Document (IAPD)
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SECTION IV: STATEMENT OF ALTERNATIVE CONSIDERATIONS
Describe any alternatives that the State Medicaid Agency considered regarding implementing
the EHR Incentive Program (such as contract modifications vs. fully competitive procurement,
etc). Where differing alternatives and approaches are possible, a brief description should be
provided of each option, and a justification should be provided for the approach/option that
was ultimately selected.
SECTION V: PERSONNEL RESOURCE STATEMENT
Provide an estimate of total staffing requirements and costs. If any personnel or contractor
resources are to be cost allocated, the total costs and the cost allocation methodology utilized
to arrive at the Medicaid share must be included in the HIT IAPD.
State Staff Title (examples
only)
Personnel - I
Personnel - II
Personnel - III
Personnel - IV
Personnel - V
Personnel - VI
Personnel - VII
Grand Total

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Sample State Personnel Resource Statement
% of
Time

Project
Hours

Cost with
Benefits

20

400

$40,000

100

2000

$140,000

100

2000

$100,000

100

1000

$80,000

20

400

$15,000

100

2000

$75,000

20

400

$15,000

8200

$465,000

Description of Responsibilities

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Health Information Technology (HIT) Implementation Advanced Planning Document (IAPD)
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Contractor Staff Title
(examples only)
Personnel - I
Personnel - II
Personnel - III
Personnel - IV
Personnel - V
Personnel - VI
Personnel - VII
Grand Total

Sample Contractor Personnel Resource Statement
% of
Time

Project
Hours

Cost with
Benefits

20

400

$40,000

100

2000

$140,000

100

2000

$100,000

100

1000

$80,000

20

400

$15,000

100

2000

$75,000

20

400

$15,000

8200

$465,000

Description of Responsibilities

SECTION VI: PROPOSED ACTIVITY SCHEDULE
Present tasks and subtasks required to complete the objectives in the form of a proposed
overall schedule. This section should present a proposed overall schedule of the tasks and
subtasks required to meet the requirements.
Project Schedule

Estimated Start
Date

Estimated
Finish Date

Item I
Item II

10/01/2011
01/03/2012

12/16/2011
12/02/2012

Item II

01/09/2013

06/03/2013

Completion date

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Sample Proposed Activity Schedule

10/31/2013

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Health Information Technology (HIT) Implementation Advanced Planning Document (IAPD)
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SECTION VII: PROPOSED BUDGET
The Proposed Budget presents the total project cost and the overall request for Federal
financial participation (FFP). This would include the total enhanced (90%) FFP, the operational
(75%) FFP if MMIS costs and the total of any general administrative (50%) FFP. It should then
give the requested Federal match amount and the State amount. For example, the total project
cost is $100. The Medicaid allocated share is $50, to which the appropriate FFP rate should be
applied to determine the State share and Federal share. The State should submit a proposed
two year budget, but providing a budget estimate for a longer period of time would be helpful
to CMS.
Example:
State’s total budget is estimated at $465,000 which includes $418,500 (90% Federal share) and
$46,500 (10% State share). The State is requesting $465,000 in new IAPD funding and $0 in new
MMIS IAPD funds for activities for October 2011 - October 2013. The State is carrying over $0
(90% federal funds) in unspent funds for planning activities approved under the State’s HIT
Planning Advance Planning Document (PAPD).
In addition, Section VIII should specify the period over which the FFP will be claimed. This will
correspond to the Proposed Activity Schedule and to the SMHP. Documentation should be
submitted that identifies which IAPD activities were, are being, and will be performed by time
period within these dates and the project costs associated with each of the activities by time
period. A table may be provided to lay out the proposed project budget. Examples in the table
could include:
State Cost
Category
State Personnel
System Hardware
System Software
Training
Supplies
Grand Total

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90% Federal
Share
$418,500
0
0
0
0
$418,500

Sample State Proposed Budget
75% Federal
Share
0
0
0
0
0
0

50% Federal
Share
0
0
0
0
0
0

10% State
Share
$46,500
0
0
0
0
$46,500

Total
$465,000
0
0
0
0
$465,000

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Health Information Technology (HIT) Implementation Advanced Planning Document (IAPD)
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Sample Contract Proposed Budget
Contractor Cost Category

Cost
Contract Personnel
Contract Services
Item - I
Item - II
Item - III
Item - IV
Grand Total

$465,000
0
0
0
0
0
$465,000

SECTION VIII: COST ALLOCATION PLAN FOR IMPLEMENTATION ACTIVITIES
As specified in Office of Management and Budget (OMB) Circular A-87, a cost allocation plan
must be included that identifies all participants and their associated cost allocation to depict
non-Medicaid activities and non-Medicaid FTEs participating in this project, if any.
CMS will work with States on an individual basis to determine the most appropriate cost
allocation methodology.
• HITECH cost allocation formulas should be based on the direct benefit to the Medicaid
EHR incentive program, taking into account State projections of eligible Medicaid
provider participation in the incentive program
• Cost allocation must account for other available Federal funding sources, the division of
resources and activities across relevant payers, and the relative benefit to the State
Medicaid program, among other factors
• Cost allocations should involve the timely and ensured financial participation of all
parties so that Medicaid funds are neither the sole contributor at the onset nor the
primary source of funding. Other payers who stand to benefit must contribute their
share from the beginning. The absence of other payers is not sufficient cause for
Medicaid to be the primary payer.
Federal/State
Program

Medicaid EHR
Incentive
Program

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Medicaid
Share
(%/$)

Sample Cost Allocation Plan

Federal Share
($/%)

State Share
($/%)

TBD Share
(duplicate this
column as many
times as
necessary)
($/%)

Total Program
Cost ($)

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Health Information Technology (HIT) Implementation Advanced Planning Document (IAPD)
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Federal/State
Program

Medicaid
Share
(%/$)

Federal Share
($/%)

State Share
($/%)

TBD Share
(duplicate this
column as many
times as
necessary)
($/%)

TOTAL

Total Program
Cost ($)

The total cost of this HIT IAPD is $xxx.
The total amount of FFP requested is $xxx (details broken out in above table).
EHR Incentive Payment Program Administrative Costs Broken Out by FFY Quarters for Two
Years

Cost Description
HIT Implementation
and Operation In-house
Costs
HIT Implementation
and Operation Private
Contractor Costs
Total Enhanced FFP

OctDec

FFY 2011
JanAprMar
Jun

JulSep

OctDec

FFY 2012
JanAprMar
Jun

JulSep

Total

$1

$1

$1

$1

$1

$1

$1

$1

$8

$2

$2

$2

$2

$2

$2

$2

$2

$16

$3

$3

$3

$3

$3

$3

$3

$3

$24

SECTION IX: ASSURANCES, SECURITY, INTERFACE REQUIREMENTS, AND
DISASTER RECOVERY PROCEDURES
Please indicate by checking “yes” or “no” whether or not the State will comply with the Code of
Federal Regulations (CFR) and the State Medicaid Manual (SMM) citations.
Please provide an explanation for any “No” responses.
Procurement Standards (Competition / Sole Source)

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42 CFR Part 495.348

∆ Yes

∆ No

SMM Section 11267

∆ Yes

∆ No

45 CFR Part 95.615

∆ Yes

∆ No

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Health Information Technology (HIT) Implementation Advanced Planning Document (IAPD)
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45 CFR Part 92.36

∆ Yes

∆ No

Access to Records, Reporting and Agency Attestations
42 CFR Part 495.350

∆ Yes

∆ No

42 CFR Part 495.352

∆ Yes

∆ No

42 CFR Part 495.346

∆ Yes

∆ No

42 CFR Part 433.112(b)(5) – (9)

∆ Yes

∆ No

45 CFR Part 95.615

∆ Yes

∆ No

SMM Section 11267

∆ Yes

∆ No

Software & Ownership Rights, Federal Licenses, Information Safeguarding, HIPAA Compliance,
and Progress Reports
42 CFR Part 495.360

∆ Yes

∆ No

45 CFR Part 95.617

∆ Yes

∆ No

42 CFR Part 431.300

∆ Yes

∆ No

42 CFR Part 433.112

∆ Yes

∆ No

Security and interface requirements to be employed for all State HIT systems.
45 CFR 164 Securities and Privacy

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∆ Yes

∆ No

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Health Information Technology (HIT) Implementation Advanced Planning Document (IAPD)
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Appendices:
APPENDIX A should contain breakout of allowable expenditures for MMIS FFP, if any, and
how they will be integrated in the project. See State Medicaid Director Letter 10-016 for
examples and other guidance regarding appropriate MMIS expenditures.
APPENDIX B should contain estimates of provider incentive payments broken out by FFY
quarter. Note: This is not a requirement of the regulation but the information provided by the
States would be helpful to CMS.
APPENDIX C should contain information about any grants, State or local funds, or other
funding sources that are available to the State and that will contribute to the costs of activities
for which the State is requesting HITECH matching funds. See State Medicaid Director Letter 10016 for examples and other guidance.
APPENDIX D should contain information required per State Medicaid Director Letter 11-004
to support requests for FFP for activities related to health information exchange. The letter
requires States to provide justification for their HIE approach, details regarding other payer and
provider contributions and cost allocation.
Appendix D Checklist: Please ensure that all of the questions below are addressed in Appendix
D if seeking FFP for HIE – related expenditures
Question/Issue
Y/N
Description of the HIE approach (statewide, sub-state HIOs, etc) ; discussion of
anticipated risks and mitigation strategies; linkages to meaningful use of certified EHR
technology; plans for collection of clinical quality measures and/or public health
interfaces as appropriate; the short and long-term value-proposition to providers; role of
State government in governance and policy-setting and a description of the exchange
standards and policies and how they align with Federal guidance
Description of proportional investments by other payers/providers than Medicaid;
including market share and projected transactional volume
Annual benchmarks and performance goals (Year 1, Year 2 of funding, etc)
Description of (including copies) of legal agreements with other payers/providers
regarding their contributions to HIE costs and governance (including scope, timing and
budget)
Discussion of how the State will handle early investor benefits and reallocation of costs as
other payers/providers join
Description of the transition from HIE infrastructure development for core services to ongoing operations (including timeline, benchmarks and proposed sustainability strategy for
on-going operations)
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Description of the cost allocation methodology and data sources by activity and by
funding stream (e.g. MMIS vs. HITECH)

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Health Information Technology (HIT) Implementation Advanced Planning Document (IAPD)
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Question/Issue
Break-out of funding request by MMIS or HITECH, as appropriate (and with varying cost
allocation methodologies, as appropriate)

Y/N

APPENDIX E should contain information about how the system plans supported under this
HIT IAPD are aligned with the 7 standards and conditions in 42 CFR Part 433. States should
develop a chart that describes how their proposed IT solutions will meet each of the 7
standards and conditions and how they will ensure that the HIT-related systems are integrated
within the total Medicaid IT enterprise, as appropriate, rather than being a stand-alone system.
The relevant information can be found at: http://www.cms.gov/Medicaid-InformationTechnology-MIT/Downloads/Enhanced-Funding-Requirement-Seven-Conditions-andStandards.pdf

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