Wipro’s EMaaS smartly optimizes for modular Medicaid and commercial plans

State health and human services agencies and health plans struggle to enable technologies to address their beneficiaries’ needs. Changing regulations, evolving technology options, and changing beneficiary expectations complicate technology enablement. Wipro’s EMaaS platform (Enterprise Medicaid as a Service) is a solution addressing state and commercial health plans’ current needs while remaining nimble enough to address the evolving regulatory landscape.

Medicaid Management Information Systems (MMIS) is one of the most complex, monolithic, and integrated platforms devised to meet Medicaid needs since the late 1970s. CMS (Centers for Medicare & Medicaid Services) published a broad framework for modularity in 2016 to replace MMIS with modular systems. Modularity mitigates the risks associated with the complexity of MMIS design, costs, and implementation.

With the launch of EMaaS in 2019, Wipro, a diversified global IT and business services company, intends to assist its clients in overcoming challenges related to MMIS design, costs, and implementation. This cloud-based, modular management system tackles Medicaid modularity issues and commercial health insurance opportunities.

Without specifications, the evolving Medicaid landscape remains in flux

Medicaid has been evolving to meet the needs of changing demographics as CMS and states take steps to modernize Medicaid systems. CMS mandated a modular approach, but it did not provide specifications. Instead, it provided states the flexibility to craft solutions to meet the needs of their Medicaid programs. Though each Medicaid program is unique, states provided some common reasons for replacing their MMIS with modular options:

• They must adapt to and implement future compliance requirements, minimizing risks and costs.
• Business rules are hard coded and lack flexibility, making minor upgrades or adding new functionality as complex as an entire system overhaul.
• Increasing complex security vulnerabilities make systems too expensive to maintain.

The transition from MMIS to modular solutions is a challenging and time-consuming process for states. Many states have yet to start this journey, with one-third of US states still not having begun the transition to modular solutions, as shown in Exhibit 1. The complexity and risk associated with such a conversion make it a slow and cautious process for states, and conversion requires careful consideration and planning.

Exhibit 1: Thirty-three states have begun their journey to modularity as of December 2022, while others reflect on their choices

Source: Source: Medicaid.gov, HFS Research

Technology has made Medicaid even more complex, and monolith systems can’t handle it

Transformation and modularity mean new opportunities, complexity, and challenges for service providers.

Medicaid experts say, “If you’ve seen one Medicaid program, you’ve seen one Medicaid program.” All 50 states operate differently, so it’s challenging to have a single solution suitable for all. Exhibit 2 shows generally accepted modules in MITA (Medicaid Information Technology Architecture). Many states have been moving their Medicaid platform to the cloud, allowing artificial intelligence (AI) to analyze the enormous volume of data and optimize delivery. Also, according to CMS, modular and interoperable Medicaid platforms must contain open APIs to communicate with other modules, increasing the possibility of using newer technology to help programs run more efficiently and effectively. Cloud, AI, IoT (internet of things), and chatbots can improve customer service and detect important patterns in member data that can inform patient care.

Wipro’s modular solution is smartly positioned

Wipro’s EMaaS is a cloud-based solution offering designed for Medicaid administration. Wipro EMaaS uses MITA 3.0, the most recent major version of the Medicaid Information Technology Architecture. The MITA 3.0-aligned offering combines COTS (commercial off-the-shelf) and cloud SaaS solutions into a modular solution. It leverages the capabilities of Healthedge’s HealthRules Payer, a platform used by over 50 health plans, making it both flexible and reliable for Wipro’s clients.

Wipro’s EMaaS helps healthcare organizations streamline operations, lower costs, and efficiently manage their data. The modular design enables organizations to select the components that best suit their needs and integrate them with their existing systems, leading to a tailored, adjustable solution. EMaaS is secure, HIPAA-compliant, and uses user-defined terms (UDTs) and a natural language rules engine to capture attributes in the data model, making it highly configurable and scalable.

Exhibit 2: Typical modules to expect with MMIS’ replacement

The Bottom Line: EMaaS’ modular and configurable architecture optimizes and de-risks implementations for Medicaid and commercial plans.

To keep up with changing regulations and evolving beneficiary expectations, states and health plans need to explore partnerships with service providers that can deliver effective modular systems to address the needs of multiple markets. Adopting modular solutions like Wipro’s EMaaS can help healthcare organizations adapt to new compliance requirements and leverage emerging technologies such as AI, IoT, and chatbots to improve customer service and patient care. Overall, embracing modularity enables rationalization across commercial and government markets, while de-risking implementations and optimizing solutions for both Medicaid and commercial plans.