The West Virginia Department of Human Services (DoHS) has been named a 2025 AWS Champions Award winner for successfully transforming its Medicaid Management Information System (MMIS) by implementing Gainwell Technologies’ Claims, Encounters, and Financials (CEF) solution on AWS Cloud. This major modernization effort transitioned the state from an aging, inflexible legacy platform to a modern, scalable, and modular system capable of processing more than $5.7 billion in Medicaid claims annually — all while improving operational agility and supporting enhanced compliance with federal mandates.

With more than 512,000 Medicaid members and over 95,000 enrolled providers, the state’s Medicaid program plays a vital role in the health and well-being of West Virginians. The shift to a cloud-native MMIS represents a foundational investment in long-term sustainability, regulatory readiness, and efficient service delivery.

Project Overview
The West Virginia MMIS modernization project focused on replacing the state’s outdated, monolithic infrastructure with a modular, standards-based system designed for flexibility, scalability, and interoperability. The Gainwell CEF solution, deployed on AWS, now powers the state’s core Medicaid business functions, including:

• Claims processing 
• Member eligibility and enrollment 
• Provider enrollment and management 
• Financial transactions and reporting 

This transformation enables DoHS to manage high volumes of Medicaid fee-for-service and managed care transactions efficiently, while also equipping the agency to respond faster to policy changes, federal requirements, and population health needs.

Challenges Addressed: Legacy Burdens and Operational Limitations
Before modernization, West Virginia’s Medicaid system suffered from the typical constraints of legacy MMIS platforms:

• Rigid architecture: The highly customized monolithic system was difficult to maintain and required significant time and cost to modify, even for minor policy adjustments. 
• Compliance risks: The system struggled to keep pace with evolving federal regulations from the Centers for Medicare & Medicaid Services (CMS), threatening compliance. 
• Lack of modularity: West Virginia couldn’t leverage best practices or modular components from other state implementations due to its bespoke, tightly coupled design. 
• Operational inefficiencies: Manual processes and system fragmentation made it difficult to scale and introduced bottlenecks that impacted providers and members. 

These limitations posed a growing challenge as Medicaid program needs expanded and policy environments shifted rapidly.

Results: Scalable Performance, Fiscal Efficiency, and Provider Satisfaction
The AWS-powered Gainwell CEF solution has delivered remarkable performance and tangible business impact for West Virginia:

• High throughput with reliability: In fiscal year 2024 alone, the system processed more than 36 million individual Medicaid claims, managed $5.7 billion in Medicaid fee-for-service payments, and executed $2 billion in capitation payments — plus an additional $52 million for the Children’s Health Insurance Program (CHIP). 
• Minimal disruption, high stability: Transitioning to the new platform caused minimal disruption for providers, as evidenced by low complaint volumes and consistent payment timelines. 
• Strong return on investment: With an implementation cost of $30 million, the system is already delivering an estimated tenfold return on investment, driven by improved operational efficiency and reduced system maintenance overhead. 
• Future-proofed architecture: The modular design enables DoHS to quickly adopt new functionalities, respond to federal updates, and scale services without the delays and expenses of custom legacy modifications.