Migration and Modernization Strategy for Integrated Eligibility Systems - Migration and Modernization Strategy for Integrated Eligibility Systems
Introduction

Migration and Modernization Strategy for Integrated Eligibility Systems

Transforming benefits and eligibility systems using cloud computing

Publication date: November 10, 2021 (Document history)

Introduction

In the fiscal year 2019, the US federal, state, and local government agencies spent approximately $2.5 trillion on various social and safety net programs, which included Social Security, Medicare, Medicaid, Supplemental Nutrition Assistance Program (SNAP), and others, that assist low-income families. (Source: https://www.cbpp.org/research/federal-budget/where-do-our-federal-tax-dollars-go) Tens of millions of customers apply for these benefits every year. (Source: https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html) The enrollment can include complex eligibility determination and adjudication processes. In most cases, beneficiaries have to wait several weeks before their cases are adjudicated due to the high volume of applications. Additionally, it takes a large work force to review and process these applications which are submitted multiple ways (for example, web, mail-in, or contact center communications).

Integrated eligibility systems (IES) provide the enabling technology for some of these health and human services programs. They provide multiple channels for application and recertification intake—complex rules engines that use data to calculate benefit amounts. Additionally, IES includes reporting, appeals, and investigations modules that monitor program integrity and federal compliance. After the passage of the Affordable Care Act (ACA) in 2010, state agencies took advantage of enhanced matching funds to modernize their IES.

IES have traditionally been monolithic and tightly coupled systems that are difficult to customize for specific state needs. As a result, these systems often lack the flexibility to adapt to program and policy changes. Additionally, benefits administrators face a number of challenges with IES. These include:

  • Increasing application backlogs and delayed benefits to citizens

  • Complex case review and adjudication processes

  • The inability to handle increasing call volumes for follow-up activities, including interviews, application status, and appeals

  • The inability to provide deep insights into program operations, such as incidents of fraud, waste, and abuse, and the means to drive improvements

The benefits of IES cloud migration include improving business and mission agility, lowering the total cost of ownership (TCO), and improving system resiliency. IES modernization results in better beneficiary experience, improved case worker productivity, high visibility into program operations, and reduced fraud, waste, and abuse.