Business Rules Management, A Game-Changer For The Affordable Care Act

With the Affordable Care Act, new regulations have gone into effect to provide government funded health benefits as well as more affordable private health insurance. This has created a major shift in the way Health and Human Services Departments on the state level determine eligibility, and as a result they are using cutting edge business rules technology to address the challenge.

The good news is that the eligibility requirements for government-sponsored health insurance like Medicaid have changed to include more people. However, that is bad news for government agencies that struggle to implement the regulated changes within their eligibility systems. While the federal government regulates programs like Medicaid, each state is responsible for administering the program and each has its own additional rules that determine eligibility. To further complicate matters, lawmakers regularly alter both sets of eligibility requirements. It’s a logistical and technical problem but there are very human consequences as delays in benefits can have a devastating effect on those in need of public assistance.

A Little Background

In order to meet the new requirements of the Affordable Care Act, states were charged with modernizing their eligibility systems used for qualifying citizens for Medicaid. This created a trigger to replace legacy systems and manual processes with automated, flexible business rules management systems to ensure that eligibility could be verified accurately and efficiently. In fact, The Affordable Care Act mandated such massive changes, that the federal government offered funding incentives encouraging health and human service agencies to purchase off-the-shelf rules engines, and to reuse rules across states. The best part of these incentives is that they have enabled many states to purchase and implement this technology for a fraction of the cost.  And, many states are starting to use the technology for not only health benefits eligibility, but also for “integrated eligibility” across diverse benefits programs such as cash assistance, food assistance, childcare and more.  These integrated eligibility systems can provide great efficiency both to the states and to their citizens.

Business Rules, Rule

Currently, 20 states are using Progress Corticon as part of eligibility systems. Corticon helps them easily update their systems to reflect the ever-fluctuating eligibility requirements mandated by federal and state governments. Unlike many of the previous systems, Corticon doesn’t require in-depth coding to make changes to complex business rules. Not only does this enable state agencies to make the changes faster, it also saves money by eliminating the need to pay a developer to rewrite the code.

To Medicaid and Beyond

Outside of healthcare initiatives, there is no shortage of government programs that operate at the mercy of ever changing eligibility requirements. Whether those changes are due to budget constraints or public mandates, keeping eligibility systems nimble will be a key driver of public satisfaction and reduced errors. By expanding the use of current systems purchased through the Affordable Care Act incentives, such as Corticon, government agencies will also end up saving money in the long term, as they are able to reduce the need for manual coding across the board.

If there’s one thing that we can be sure of, it’s that the regulations handed down by lawmakers will always be fluctuating. The only difference is that the technology now exists to efficiently facilitate these changes, and agencies are now realizing that the technology will have a drastic impact in simplifying operations and delivering better citizen services.