Form CMS-10536 Medicaid Eligibility and Enrollment (EE) Implementation

OMB Control Number: 0938-1268
(Expires: TBD)

Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document
(IAPD) Template

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 IAPD Submission to CMS: ________________________

Note: A signed transmittal letter to CMS is required with any IAPD Submission.

Version # __________________________

Brief Description of Latest Version Additions/Changes/Deletions: ________________________

PRA Disclosure Statement 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 number for this information collection is 0938-1268.
The time required to complete this information collection is estimated to average 16 hours per response, including the time to
review instructions, searching existing data resources, gather the data needed, and complete and review the information
collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
CMS-10536

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TABLE OF CONTENTS

Section I: Executive Summary....................................................................................................... 3
Section II: Results of Activities Included in the PAPD ................................................................. 3
Section III: Statement of Needs and Objectives of the IAPD ........................................................ 3
Section IV: Requirements analysis, feasibility study, and Alternative Considerations ................. 3
Section V: Cost Benefits Analysis ................................................................................................. 4
Section VI: Nature and Scope of Activities ................................................................................... 4
Section VII: Project Management Planning and Procurement ...................................................... 4
Section VIII: Personnel Resource Statement ................................................................................. 5
Section IX: Proposed Activity Schedule......................................................................................... 6
Section X: Proposed Budget ........................................................................................................... 7
Section XI: Cost Allocation Plan for Implementation Activities ................................................... 9
Section XII: Security, Interface, Disaster Recovery, and Business Continuity Planning ............ 10
Section XIII: Conditions and Standards for Receipt of Enhanced FFP ....................................... 10
Section XIV: IAPD Required Federal Assurances ...................................................................... 11
Appendix A ................................................................................................................................... 12
Appendix B ................................................................................................................................... 15
Appendix C ................................................................................................................................... 16

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SECTION I: EXECUTIVE SUMMARY
The state should provide a brief executive summary describing the intent of this
Implementation Advanced Planning Document (IAPD).

SECTION II: RESULTS OF ACTIVITIES INCLUDED IN THE PAPD
The state should provide a narrative summary of the current status of the activities which were
included in the Planning Advance Planning Document (PAPD). The state should also report the
status of the expenditures which were approved by CMS in the PAPD.
Sample PAPD Status Table (Federal Fiscal Year)
Activity Type

Eligibility and Enrollment: PAPD Status
Approved PAPD
PAPD Expenditures To
Remaining PAPD
Date
Funding
State Federal Total State Federal Total State Federal Total

Program Total

SECTION III: STATEMENT OF NEEDS AND OBJECTIVES OF THE IAPD
The state should provide a summary of project needs, business objectives and the anticipated
benefits of the proposed activities.

SECTION IV: REQUIREMENTS ANALYSIS, FEASIBILITY STUDY, AND
ALTERNATIVE CONSIDERATIONS
If a requirements analysis was conducted for the work to be completed via this funding request,
then the state should provide a summary of the results. If the state did not conduct a
requirements analysis, then it should explain why not. Also, the state should indicate whether
a requirements analysis is waived by law or is not required in regulation.
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Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document
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If a feasibility study was conducted for the work to be completed via this funding request, then
the state shold provide a summary of the results. If the state did not conduct a feasibility study,
then it should explain why not. Also, the state should indicate whether a feasibility study is
waived by law or is not required in regulation. Note that CMS regulations only allow 50 percent
Federal financial participation (FFP) for feasibility studies.
The state should describe any alternatives that the State Medicaid Agency considered regarding
implementing work to be completed via this funding request. Where differing alternatives and
approaches were studied or assessed, the state should provide a brief description of each
option considered, and a justification should be provided for the approach or option that was
ultimately selected.

SECTION V: COST BENEFITS ANALYSIS
The state should provide a cost benefit analysis for the work to be completed, or indicate if
CMS allowed an exemption of this cost benefit analysis.

SECTION VI: NATURE AND SCOPE OF ACTIVITIES
The state should provide a detailed description of the nature and scope of system work and the
methods used to execute the work. In general, this description should match the major task
categories on the project schedule or workplan. Activity examples could include identifying
risks and creating a preliminary mitigation strategy, documenting the As-Is and To-Be
environments, and developing proposal evaluation criteria for procurement proposals.
For eligibility system projects already underway, states should prioritize delivery performance
tuning for Medicaid Modified Adjusted Gross Income (MAGI) determinations (including
accuracy and efficiency, and optimization of real time eligibility determinations); delivery of
additional Medicaid MAGI functionality based upon any new federal or state requirements;
dynamic notices to beneficiaries; and delivery of non-MAGI functionality, in that order.

SECTION VII: PROJECT MANAGEMENT PLANNING AND PROCUREMENT
The state should describe the organization, including state and contractor responsibilities as it
pertains to the work to be completed via this funding request. Who are the key state staff that
will be involved in the work? The state must provide additional documentation about
governance, including project roles and responsibilities of different agencies and contractors,
how coordination and decision-making occurs between the key stakeholders, and how the
single state agency responsible for Medicaid is overseeing and monitoring project performance
if undertaken by a sister state agency.
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Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document
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The state should have a project management office (PMO) either in-house or via contract.
Does the state have a PMO associated with the work to be completed? If yes, then briefly
describe. If not, then provide justification.
The state should also include a Project Schedule showing major milestones and deliverables
and a Project Management Plan.
Will there be any procurements associated with the work to be completed? If yes, then briefly
describe. Note that CMS, in accordance with 45 CFR 95.611, may grant an exemption from
prior approval for an acquisition document based on a state’s favorable responses to the
checklist in Appendix C.
Will the procurements be competitive? If yes, then briefly describe. If not, then provide the
rationale for an “alternative procurement methodology” that is consistent with 45 CFR
92.36(a).
Will the contracts be deliverables-based? If yes, then briefly describe the deliverables, when
they will be delivered, and the consequences of failing to deliver. If not, then provide
justification.
The state should provide a brief description of the vendor selection approach.
Will Commercial Off The Shelf (COTS) software or other items of reuse be used for the work to
be completed? If yes, then briefly describe.
Note that acquisition documents must be submitted to the appropriate Federal Agency or
Agencies in accordance with 45 CFR 95.611.

SECTION VIII: PERSONNEL RESOURCE STATEMENT
The state should provide an estimate of total staffing requirements and personnel costs. If any
personnel or contractor resources are to be cost allocated, then the state must include the total
costs and the cost allocation methodology utilized to arrive at the Medicaid share.
In addition to a description of responsibilities, the state should indicate all proposed
personnel’s hourly rate, official job title, and other relevant information that will assist CMS in
evaluating the state's project staffing.
Sample State Personnel Resource Statement (Federal Fiscal Year)
State Staff Title
% of
Project
Cost with
Description of Responsibilities
(examples only)
Time
Hours
Benefits
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Personnel - I

20

400

$40,000

Personnel - II

100

2000

$140,000

Personnel - III

100

2000

$100,000

Personnel - IV

100

1000

$80,000

Personnel - V

20

400

$15,000

Personnel - VI

100

2000

$75,000

Personnel - VII

20

400

$15,000

8200

$465,000

Grand Total

Sample Contractor Personnel Resource Statement (Federal Fiscal Year)
Contractor Staff Title
% of
Project
Cost with
Description of Responsibilities
(examples only)
Time
Hours
Benefits
Personnel - I
20
400
$40,000
Personnel - II

100

2000

$140,000

Personnel - III

100

2000

$100,000

Personnel - IV

100

1000

$80,000

Personnel - V

20

400

$15,000

Personnel - VI

100

2000

$75,000

Personnel - VII

20

400

$15,000

8200

$465,000

Grand Total

SECTION IX: PROPOSED ACTIVITY SCHEDULE
The state should describe tasks and subtasks required to complete the objectives in the form of
a proposed overall schedule. The state should provide a proposed overall schedule with start
and end dates of the tasks and subtasks required to meet the requirements.
Sample Proposed Activity Schedule (Federal Fiscal Year)

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Project Schedule

Estimated Start
Date

Estimated
Finish Date

Item I
Item II
Item II
Completion Date

SECTION X: PROPOSED BUDGET
The state should provide the proposed budget, with the total project cost and the overall
request for FFP. The budget should include the total enhanced (90% and/or 75%) FFP, the
operational (75% and/or 50%) FFP, and the total of any general administrative (50%) FFP. The
state should also provide the requested Federal match amount and the state match 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 budget for a single Federal fiscal year, but providing a budget estimate for
additional Federal fiscal years would be helpful.
In addition, the state should specify the period over which the FFP will be claimed,
corresponding to the Proposed Activity Schedule in Section IX. The state should submit
documentation that identifies which IAPD activities were, are being, and will be performed
within the specified time periods and the project costs associated with each of the activities.
When submitting IAPD Annual Updates, the state should include a project expenditures report
detailing actual costs by Federal fiscal year.
Sample State Proposed Budget – Budget Totals
State Cost
Category
Category I
Category II
Category III
Category IV
Category V
Grand Total

FFY 20xx
Projected

FFY 20xx
Projected

FFY 20xx
Projected

FFY 20xx
Projected

Total

For each Federal fiscal year listed in the State Proposed Budget table above, the state should
outline each cost category by FFP rate below.

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Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document
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Sample State Proposed Budget (Federal Fiscal Year) – Design, Development, and
Implementation Activities
State Cost
Category
Category I
Category II
Category III
Category IV
Category V
Grand Total

90% Federal
Share

10% State
Share

75% Federal
Share (DDI)

25% State
Share (DDI)

Total

Sample State Proposed Budget (Federal Fiscal Year) – Maintenance and Operations Activities
State Cost
Category
Category I
Category II
Category III
Category IV
Category V

75% Federal
Share (M&O)

25% State
Share (M&O)

50% Federal
Share (M&O)

50% State
Share (M&O)

Total

Grand Total

Sample State Proposed Budget (Federal Fiscal Year) – General Administration Activities
State Cost
Category
Category I
Category II
Category III
Category IV
Category V

50% Federal
Share (General)

50% State
Share (General)

Total

Grand Total

The state should also provide budget information for contract activities that will be funded
through this IAPD.
Sample Contract Proposed Budget (Federal Fiscal Year)
Contractor Cost Category

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

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Grand Total

In addition to the budget information provided, the state should complete the Medicaid
Detailed Budget Tables in Appendix A.

SECTION XI: COST ALLOCATION PLAN FOR IMPLEMENTATION ACTIVITIES
The state should provide a summary of the allocation of costs by funding source, as specified in
Office of Management and Budget (OMB) Circular A-87. The cost allocation plan must identify
all participants directly benefitting from the work to be completed and their associated cost
allocations. CMS will review the allocation of the costs associated with the work to be
completed, including design, development, and implementation activities as well as
maintenance and operations activities.
Also, the state should make clear whether they are invoking the exception to the OMB Circular
A-87 regarding shared services that was outlined in the Tri-Agency Letters. The letters can be
found at http://www.medicaid.gov/AffordableCareAct/Provisions/Information-TechnologySystems-and-Data.html.
Does the state intend to invoke the OMB Circular A-87 exception?  Yes

 No

If “Yes,” then the state should provide a detailed narrative as to how the cost allocations were
arrived at for each of the other human service programs and a description of how these other
programs are benefitting from the work to be completed.
Does the state intend to share the costs of the system work related to this funding request with
Section 1311 Exchange establishment grant funding?  Yes
 No
The state should provide a detailed narrative outlining its methodologies used to determine the
cost allocation for each participant in the work to be completed, identifying shared services as
well as items that benefit certain programs exclusively.
Cost allocation formulas should be based on the direct benefit to the Medicaid program, taking
into account the following:
 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’s
Medicaid program, among other factors.
 Cost allocations should reflect the timely and ensured financial participation of all
relevant parties so that Medicaid funds are neither the sole contributor at the onset nor
the primary source of funding. Examples of other participating programs are Health

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Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document
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Insurance Exchange, Supplemental Nutrition Assistance Program (SNAP), and Title IV-D
Child Support.
Sample Cost Allocation Plan (Federal Fiscal Year)
Federal/State
Program

Allocation %

Federal Share

State Share

Total Program Cost

Medicaid
CHIP
Other Human
Service Programs
(add a row for each
program as needed)
Exchange Grant
TOTAL

SECTION XII: SECURITY, INTERFACE, DISASTER RECOVERY, AND BUSINESS
CONTINUITY PLANNING
The state should implement or maintain a comprehensive Security and Interface Plan for IT
systems and installations involved in the administration of the Medicaid Program. The state
should describe what is included in this Plan. Examples include site and facility security,
security of data communications equipment, and security of personal health information (PHI)
as required by Health Information Patient Access Act (HIPAA).
The state should maintain a Business Continuity and Disaster Recovery Plan throughout the
work to be completed. The state should describe what is included in this Plan. Examples
include a contingency plan, a list of key personnel to be contacted in the event of an
emergency, and maintenance of a complete set of backup programs and related system
documentation that will be stored off-site to be used in an emergency.

SECTION XIII: CONDITIONS AND STANDARDS FOR RECEIPT OF ENHANCED
FFP
The state should provide a brief descrption about how the system plans supported under this
IAPD are aligned with the Conditions and Standards in 42 CFR Part 433. The state should
develop a chart that describes how its proposed IT solutions will meet each of the Conditions
and Standards and how it will ensure that the systems are integrated within the total Medicaid
IT enterprise, as appropriate, rather than being stand-alone systems.

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The relevant information can be found at: http://www.medicaid.gov/

SECTION XIV: IAPD REQUIRED FEDERAL ASSURANCES
The state should indicate by checking “Yes” or “No” whether or not it will comply with the Code
of Federal Regulations (CFR) and the State Medicaid Manual (SMM) citations.
The state should provide an explanation for any “No” responses.
Procurement Standards (Competition / Sole Source)
SMM, Part 11

 Yes

 No

45 CFR Part 95.615

 Yes

 No

45 CFR Part 92.36

 Yes

 No

Access to Records, Reporting and Agency Attestations
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
45 CFR Part 95.617

 Yes

 No

42 CFR Part 431.300

 Yes

 No

45 CFR Part 164

 Yes

 No

Independent Verification and Validation (IV&V)
45 CFR Part 95.626

 Yes

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 No

Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template
APPENDIX A Medicaid Detailed Budget Table
Medicaid/CHIP Detailed Budget Table
Covers Federal Fiscal Years 20XX-20XX (ending September 30, 20XX)
These tables include all previously approved funds covering these Federal fiscal years for Medicaid/CHIP eligibility and enrollment funding
Medicaid
Share
(90% FFP)
DDI

State
Share
(10%)

28A & 28B†

--

Medicaid Share
(75% FFP) DDI
(COTS)
28A & 28B†

State
Share
(25%)
--

Medicaid Share
(75% FFP) M&O

State
Share
(25%)

Medicaid Share
(75% FFP) M&O
E&E Staff

State
Share
(25%)

28C & 28D†

--

28E & 28F†

--

Medicaid
ENHANCED
FUNDING
FFP Total

Medicaid
ENHANCED
State Share
FUNDING
Total
(TOTAL
COMPUTABLE)

FFY
20XX
FFY
20XX
FFY
20XX
Total
FFY
20XX20XX

Medicaid Share
(50% FFP)
M&O
E&E Staff

State Share
(50%)

Medicaid Share
(50% FFP)
General

State Share
(50%)

28G & 28H†

--

49†

--

FFY 20XX
FFY 20XX
FFY 20XX
Total FFY
20XX-20XX

12

Medicaid
NOT
ENHANCED
FUNDING
FFP Total

State Share
Total

Medicaid NOT
ENHANCED
FUNDING
(TOTAL
COMPUTABLE)

Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template
CHIP FFP %

STATE %

CHIP FFP
Share

State Share

33†

--

CHIP
Total

FFY 20XX
FFY 20XX
FFY 20XX
Total FFY
20XX-20XX
Medicaid
ENHANCED
FUNDING
FFP Total

Medicaid
NOT ENHANCED
FUNDING
FFP Total

CHIP
FFP Total

TOTAL FFP

STATE SHARE TOTAL

APD TOTAL (TOTAL
COMPUTABLE)

FFY 20XX
FFY 20XX
FFY 20XX
Total FFY
20XX-20XX
Project
Total*

Medicaid/CHIP
Allocation
Amount

Medicaid
Allocation
Percentage

Medicaid
Allocation
Amount

CHIP
Allocation
Percentage

CHIP
Allocation
Amount

Exchange Grant
Share*

FFY 20XX
FFY 20XX
FFY 20XX
Total FFY 20XX20XX
* Please note that total project costs, human services, and exchange-allocated costs are for informational purposes only. Please put N/A if this does not apply.

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Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template
†MBES Line Item
28A E&E - Title 19 (Medicaid) DDI- In-house Activities
28B E&E - Title 19 (Medicaid) DDI- Contractors
28C E&E - Title 19 (Medicaid) Software/Services/Ops- In-house Activities
28D E&E - Title 19 (Medicaid) Software/Services/Ops- Contractors
28E E&E – Title 19 (Medicaid) Eligibility Staff- Cost of In-house Activities (staff who makes eligibility determinations)
28F E&E – Title 19 (Medicaid) Eligibility Staff- Cost of Private Sector (staff who makes eligibility determinations)
28G E&E – Title 19 (Medicaid) Eligibility Staff- Cost of In-house Activities (staff whose duties are related to eligibility, such as outreach, plan enrollment, etc.)
28H E&E – Title 19 (Medicaid) Eligibility Staff- Cost of Private Sector (staff whose duties are related to eligibility, such as outreach, plan enrollment, etc.)
33
E&E - Title 21 (CHIP) Administration
49
E&E - Title 19 (Medicaid) Other Financial Participation
FFP rates for specific activities and costs can be found at 76 FR 21949, available at https://federalregister.gov/a/2011-9340

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Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document
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APPENDIX B Eligibility and Enrollment Staff
If the State is requesting funding for Eligibility Determination Staff, then the State should
include information to satisfy requirements listed in guidance on Medicaid.gov:
http://www.medicaid.gov/state-resource-center/FAQ-medicaid-and-chip-affordable-care-actimplementation/downloads/Affordable-Care-Act-FAQ-enhanced-funding-for-medicaid.pdf

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Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document
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APPENDIX C Acquisition Checklist
The Department of Agriculture, Food and Nutrition Service (FNS) and the Department of Health
and Human Services (HHS) have developed the following optional checklist for States and
Territories to use to provide assurances that an acquisition of automated data processing
equipment and/or services complies with all Federal regulations and policies. The Federal
Department(s), in accordance with the regulations at 45 CFR 95.611, may grant an exemption
from prior approval for an acquisition document based on a State’s favorable responses to this
checklist.
This checklist may be used for certain Requests for Proposal, Requests for Quote, Invitations to
Bid, contracts, contract amendments, or similar State and Territory acquisition documents;
however it may not be submitted for contracts or Advance Planning Documents that require
Federal prior approval (unless specifically exempted by the Department). Please include the
following information:
Project name:
Acquisition name:
Acquisition and/or reference number:
Date the acquisition document will be released to vendors:
Number of Days vendors will have to respond to the proposal or invitation to bid:
Estimated Cost of acquisition (including all option years):
A brief paragraph describing the acquisition activity should be included in the cover letter
submitted with this request. The submission should identify (1) the state or territorial agency(s)
and stakeholders involved, (2) basic system characteristics, project scope, life span, benefits and
all pertinent details, (3) the type of contract or agreement that is expected to result from the
acquisition. For each “No” response to the checklist, a full narrative explanation must be
provided either directly following the checklist or on a separate sheet of paper.
The checklist should be submitted to the applicable Federal program office(s).

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Description

Checkbox

1. Will the acquisition be conducted in a manner that provides, to the maximum
extent practicable, open and free competition? (Note 1)

Yes
No

2. Does the acquisition, if funded in whole or part by FNS and/or HHS meet the
standards and functional requirements set forth in the Federal program
regulations?

Yes
No

3. Does the acquisition comply with all applicable Federal , State and Territorial
acquisition standards, laws, policies and procedures?

Yes
No

4. Does the acquisition document contain a clause that provides the United States
Departments of Agriculture and Health and Human Services and/or their
representatives access to State or Territorial agency documents papers, or other
records pertinent to the procurement in order to make audits, examinations,
excerpts and transcripts?

Yes
No

5. Does the acquisition comply with Federal rules relative to State or Territorial
ownership rights to all software products, documentation and intellectual property
created under this acquisition?

Yes
No

6. Does the acquisition document contain a clause that grants the Federal
Government a royalty-free, nonexclusive, and irrevocable license to reproduce,
publish, or otherwise use and to authorize others to use for Federal Government
purposes, software, modifications, and documentation developed and/or obtained
through this acquisition?

Yes
No

7. Does the Statement of Work in the acquisition document convey expectations to
be met by the successful contractor including items such as required tasks,
deliverables and their schedule of delivery, technical requirements, security,
privacy and confidentiality requirements, roles and responsibilities, and project
reporting requirements?

Yes
No

8. Does the acquisition document include clauses covering mandatory contract terms
and conditions, order of precedence, compliance with laws, liability, period of
performance, Force Majeure, availability of funds, notices, disputes, failure of
performance, damages and termination?

Yes
No

9. Does the acquisition document include information about the evaluation and
selection process such as technical and cost scoring and weighting, and proposal
ranking and selection?

Yes
No

10. Has the evaluation and selection process been finalized relative to technical and

Yes

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Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document
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Description

Checkbox

cost scoring prior to the release of the acquisition document?
11. Does the acquisition document delineate responsibilities relative to key staff, the
change order process, and documentation requirements?

No
Yes
No

Note 1: The acquisition document must be submitted to the appropriate Federal Agency or
Agencies if the acquisition is a sole source solicitation and the cost exceeds the thresholds
established in the Federal regulations.
This form must be signed by either the appropriate State or Territorial official authorized to
submit acquisition documentation to the Federal Department(s) or the State or Territorial director
of purchasing.
Signature: ______________________

Printed Name: ______________________

Title: ___________________________

Date: _______________________

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