A Medicaid management information system (MMIS) is the software on which an American state runs Medicaid, its health insurance for people on low incomes. It handles the sign-ups of members and providers, the claims and the payments. Medicaid covers tens of millions of Americans. The federal government and each state pay for it together, and each state runs its own programme with its own rules. A few large companies run these systems for states, and some have large engineering and operations teams in Bengaluru and Chennai.
How is it different from a private health plan's system? The jobs are similar: members, providers, claims and payments. But the scale and the rules are different. One state's programme can cover several million people. Eligibility depends on income, family size and other conditions, and it is checked again regularly. The state must also report in detail to the federal government. The federal government pays a large share of the cost of building and running these systems. To receive that money, a state's system must meet federal standards.
Take, for example, a nursing home in Jackson, Mississippi, in the United States. Most of its residents are on Medicaid, because long stays in a nursing home cost more than most retired people can pay. At the end of each month, the nursing home bills the state for each resident's care. The MMIS checks that each resident is still eligible this month. It checks that the nursing home is enrolled as a Medicaid provider. It applies the state's daily rate for nursing home care. Then claims adjudication decides each claim, and the state pays the nursing home once a week through healthcare payments.
States now replace their old MMIS in separate pieces, called modules. For instance, one company may run claims processing, another the pharmacy claims, and a third the data and reports. Replacing the whole system at once took many years and often failed. A module can be replaced on its own.
In many states, Medicaid members are also enrolled in private managed care plans. The state pays each plan a fixed monthly amount per member, and the plan processes the claims in its own health plan administration system. The MMIS then holds the members and the payments to the plans.
India's closest equivalent is Ayushman Bharat PM-JAY, the scheme that pays for hospital care of poorer families. It is run on a national IT system by the National Health Authority, with hospitals' claims increasingly carried by the National Health Claims Exchange. Both are public systems on a very large scale, like the digital public infrastructure that Indian cities use for public services.