Integrated Eligibility: From Concept to Reality

What does integrated eligibility (IE) mean to Health and Human Services (HHS) organizations, system integrators (SI), Centers for Medicare and Medicaid Services (CMS), and the Food and Nutrition Service (FNS) agency? It is safe to assume that while the response from these different agencies will have some commonality, it will also have many variations.

To understand the IE concept better, let us consider its key aspects – vision, funding, timeline, operations, collaboration, and systems integration. Each State is at a different level of maturity in its IE implementation. Some States have defined their vision and have made rapid progress towards achieving their goals; some have had limited success. And, there are others who haven’t had any success and are rethinking their strategy.

An ideal end-to-end integrated eligibility system (IES) comprises several components of varying magnitude and complexity, starting from federal expectations to a local SI platform. States that are still in the process of formulating their IES do not need to reinvent the wheel. Careful orchestration of the elements outlined below along with the lessons learned from implementations by other States, successful or otherwise, can help build a powerful IE system and turn the concept into reality.

Integrate health and human services programs

For a State to align its IE goals with federal requirements, it is essential to integrate different health and human services programs. Key factors that facilitate a greater degree of integration include:

The higher the level of integration, the more seamless will be the interaction of multiple programs, from the perspective of both government administrators and program beneciaries.

Flesh out regulatory and policy requirements

CMS, FNS, and all other agencies managing federal, State, and local social programs must straighten out their policy laws and legislations, thus making sure that the regulatory requirements are approved and published on time.

States must engage various stakeholders, including policy and operational subject matter experts; business stakeholders, including project sponsors and steering committee members; end users such as supervising administrators and case workers; IT liaison officers; and industry and technology experts to share knowledge, identify the right requirements, and use the allocated federal funding at the right time.

Select the right implementation approach

The first and foremost step in any IE launch is for the State to select a suitable implementation approach depending on its goals, and then choose the right vendor and product solution. Changing such critical decisions at a later stage will lead to process re-engineering, thus making the entire program not only expensive, but risky as well.

It is essential to execute the pilot implementation in a chosen geographical location based on population demographics. Launching critical programs first, analyzing if all the functional components and program capabilities blend nicely, and then building out the rest of the system is a practical way to look at complex, enterprise-wide system implementations.

States should be able to better leverage the packages / solutions offered by SI organizations for IE. To do so, they must build a detailed project plan with milestones, service level agreements, and deliverables for the complete product, including solution functionalities and interfaces that would be needed to exchange information with other agencies to determine eligibility for State and federal health programs. System integrators and/ or product vendors must showcase the pre- and post-implementation reality of various approaches.

Partner with system integrators for collaborative execution

SI vendors are the right people to show States the different execution paths with varying dimensions and help take difficult decisions with utmost confidence. States and system integrators should join hands and come together to function as one unifying body. Some do’s and don’ts to ensure a successful execution of the integrated eligibility project are:

Do’s:

• Define a collaborative governance model that would ensure the right organizational structure for the project
• Build quality measures into the contract to control ongoing project quality and set expectation standards
• Provide effective leadership with strong decision-making authority
• Set up an efficient communication team to convey project’s progress to federal and State stakeholders, including the media and public
• Commit sufficient resources to the project
• Have a clear and robust scope with defined change control, business process management, knowledge processes, functional capabilities, policy, and operations

Don’ts:

• Avoid overloading the system with complex business components
• Avoid early signs of trouble by identifying gaps that may threaten compliance with federal requirements in the original contract between the vendor and State’s IT sector

Innovate Outside-in

Many States have successfully transformed their legacy systems and adopted the modernized culture of IT systems. They incorporate lessons learned from other States with systems that support IE; build open channels of network with industry leaders, IE enthusiasts, SI vendors, and partners; then communicate and share knowledge.

They also learn from their experience, as well as successes and failures with their implementation strategies, systems integration techniques, architecture platforms and technologies, software tools and packages, hardware requisites, infrastructure, software development life cycle (SDLC) methodology approaches, commercial off-the-shelf (COTS) product suites, and transfer solutions.

Conclusion

Turning IE from a concept to reality requires States to carefully manage a number of different elements including – but not limited to – vision, funding, compliance with regulatory requirements, and IT strategy. System integrators can play a big role in helping States successfully orchestrate their IE implementation program by aligning vision and strategy with the practicality of funding, formulating a strategy to define core vs. peripheral programs and associated timelines, integrating different stakeholders, implementing change management, managing technology, and importantly, adopting insights and industry best practices.