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Integrated Eligibility: Where to Next?

Oct 16, 2019, 13:10 PM by Tristan Louis President and CEO, Casebook PBC
Now that several years have passed since the passage of the Affordable Care Act (ACA) and many efforts have been made to implement an integrated eligibility (IE) system, we asked members of CompTIA's Human Services Information Technology Advisory Group (HSITAG) to explain whether an IE system is working or not.

Since the passage of the Affordable Care Act (ACA), the implementation of an integrated eligibility (IE) system has been a key initiative for many state health and human services agencies.

The widespread goal was particularly attributable to the enticement of the A-87 Cost Allocation Exception, which enabled non-Medicaid programs, to leverage the 90% federal financial participation (FFP) match to share business and technology components. While the funding was time-limited and expired on Dec. 31, 2018, the vision was to link multiple health and human services programs in a streamlined process for citizens applying for benefits, one that aligned program eligibility requirements, modernized IT systems, and put the citizen at the center. 

Now that several years have passed and many efforts have taken hold, we asked members of CompTIA's Human Services Information Technology Advisory Group (HSITAG) to opine on the following topic: 

Has integrated eligibility been achieved and if not, what remains to be done?

Members were cautiously optimistic about the progress but still see a fair amount that needs to be accomplished. 

Galen Bock, of CGI, presents IE as an ever-evolving but ultimately worthy goal:

“The mission of integrated eligibility is to protect the most vulnerable in our communities by giving them a single application for public programs, but at its core is the next step – to effectively and efficiently provide those families with the services they qualify to receive.  While integrated eligibility projects have proved challenging, the effort is worth the goal. With the focus rightly on the recipients of the programs, achieving “integrated eligibility” will be ever-evolving as each state will look to align their current infrastructure, staff, policies, communications, and programs to best meet the unique needs of their state.”

Ravi Jackson, of GovWebWorks, strikes a positive note on progress:

“The vision of an integrated system is getting closer. Program silos are being removed, and technology and operations are becoming more integrated. For users, benefit exploration, application, and service delivery have greatly improved. However, there is room for improvement. On the national stage, policies and standards across programs can be better aligned. At the state level, program success has varied depending on the level of operational and leadership support. Leading states have developed a good rules engine, effective data collection/sharing, and efficient technology. Maintaining a shared vision for holistic system integration will continue to drive progress in this area.“

Denise Winkler, from Microsoft, sees some progress but questions whether the scope of IE programs should be expanded:

“After the passage of the ACA, states envisioned using technology to integrate the delivery of HHS programs focusing on cash, food, and health benefit programs.  The goal was to improve service delivery to citizens and improve agency efficiency. Over the last decade, States have made significant improvements including online client portals; lobby management systems; mobile applications; automated work processes and in some cases complete replacement of aging eligibility systems. Despite these successful innovations, not all States have the resources to modernize technology, so service delivery is inconsistent from state-to-state. In addition, this initial wave of modernization focused on case management functionality, powerful tools such as data analytics and artificial intelligence are just being considered. Ultimately, if the goal is improved service delivery shouldn’t programs such as child support enforcement and child protection be included?”

Vijay Ravichandran, of Infosys Public Services, highlights that while some modernization has happened, there is still a lot of work to get to integration:

“What does ‘Integrated Eligibility’ really mean? Is it a finely architected system, coordinated operations across all programs under the umbrella of ‘integration’ or is it one seamless experience for the citizen? The simple answer is ‘all of the above’, and this vision is still a work in progress in most states. Legacy systems (blue screens and all) were theoretically integrated but couldn’t adapt. Modernization efforts driven by the ACA, involving multi-year procurements and implementations have left most states with a modern but disintegrated stand-alone eligibility system. The next step is to assess the current level of maturity and then use accelerated modular procurement to get to full ‘integration’.”

Karen Rewalt, of IBM Watson Health, keys in on data insight as the next step in improving IE:

“Agencies can build on the progress made with integrated eligibility. Once agencies have a single application to manage multiple health and human service programs, they can improve citizen engagement, and extract insights from the application data collected. Agencies can transform the citizen’s experience by providing personalized, responsive portals to connect them to services and to foster trust and engagement between citizens and agencies. Data insights help caseworkers deliver improved outcomes by giving them a holistic view of clients and the influences on their lives so they can best support them on every step of their journey.”

Teresa Lewis, of Accenture, highlights three key areas requiring improvement:

“On a national basis, most states, unfortunately not all states, have been able to modernize their Eligibility Determination systems to the extent that now they have integrated technology to determine eligibility across most major HHS programs, including Medicaid (both MAGI and non-MAGI Medicaid), SNAP, TANF, Child Care, LIHEAP, etc.  However, even the states who have successfully solved for integrated eligibility determination from a technology perspective will agree that much work remains in several key areas: 1) Data sharing across HHS programs continues to be an issue that must be resolved for agencies to truly care for their constituents in a holistic way; 2) Application of new and innovative technologies like artificial intelligence and robotic process automation should be considered for driving improved customer support and increased caseworker capacity; and 3) Improving workforce skills training, whether that be cross-training workers or improving client engagement skills, will help agencies adapt to the changing needs of the populations they serve.”

Tristan Louis, of Casebook PBC, sees the next step as leveraging technology to make benefits management as easy as accessing the internet:

“The very concept of integrated eligibility as a person-centric answer to protect the most vulnerable members of our society is essential to improving outcomes in human services. But integration across multiple agencies is bound to come with its own sets of challenges. While we have seen great strides in aligning eligibility determination, there is still work to be done in standardizing data sharing agreements and modernizing technology to leverage machine learning and mobile capabilities. Much credit is to be given to all stakeholders in getting us to where we are now but the effort will not be complete until every vulnerable member of society can access and manage benefits as easily as they can access typical consumer offerings.”

Scott Dunn, of Optum Government Solutions, sees the requirements as established but believes a services-first approach is best:

“You could say IE is complete from a RFP requirements or contractual obligations perspective, however, eligibility is an ever-evolving concept and thus requires a solution that is nimble to address changing circumstances.  As a way to do this, state agencies should consider rethinking the way they procure IE capabilities, focusing on “buying services, not systems” to avoid big system builds.  Taking a services-based, modular approach better aligns with federal guidance while leveraging existing COTS technology. This allows Health and Human Services (HHS) agencies to more effectively serve clients, improve outcomes, and help lower the total cost of ownership of their IE systems”

One of the top findings in this year’s HSITAG state-of-the-state survey was that 92% of the states surveyed did not take advantage of the A-87 exemption. This begs the question whether the trend for perpetual transformation has finally replaced the historic large-scale projects envisioned to be “one and done” and sustain the organization for the next 10 to 20 years. 

While the approaches are varied, there is a consensus that there is still much to be done in order to truly achieve an integrated eligibility system that aligns program eligibility requirements, automates processes and puts the citizen at the center. As always, membership in HSITAG is a great way to collaborate with the vendor community on the approaches clients are undertaking to transform their HHS enterprises. Integrated Eligibility will certainly continue being a topic of interest within our community.