Systems And Documentation
What Changes In Eligibility Systems
- Eligibility Rules - New logic sorts members into subject and exempt and decides which months count. It has to run at application, at renewal and at every extra check a state adds.
- Data Matching - Automated checks against payroll, claims and agency data. A member who already complies should never see a request.
- Notices - Templates for advance outreach, noncompliance, hardship exceptions and coverage loss, with each timing rule built into the template itself.
- Caseworker Task Queues - Cases the data can't settle go to a queue sorted by deadline, where a 30-day window can't lapse without someone seeing it.
- Reporting And Audit Trail - Every check, notice and decision gets logged, because any of them can come up at a fair hearing.
Documentation Checklist
- Member Notices - Plain language, with the action, the deadline and the method stated before anything else.
- Caseworker Procedures - Step-by-step guides for exemptions, hardship requests and the cases data can't settle.
- System Release Notes - Staff get a short note with every system change, covering what moved and what they now do differently.
- Version History - Keep a record of when each notice and procedure changed. At a fair hearing, one of the first questions will be which version the member was sent.
- Review Sign-Off - Policy, legal and QA should all read a notice before it goes out. If one of them hasn't, it isn't ready to send.
Release Notes Template
| Field | What To Write |
|---|---|
| What's Changing | One sentence on the change. |
| Who It Affects | Members, caseworkers or both. |
| Effective Date | The date the change applies. |
| What You Do Now | The new steps, numbered. |
| Where To Get Help | The contact or resource for questions. |
Rewriting A Member Notice
An illustrative example. It isn't taken from any state's notice.
Before
Pursuant to federal requirements, your continued eligibility for medical assistance is contingent upon verification of compliance with community engagement requirements. Failure to furnish acceptable documentation within the prescribed period may result in termination of benefits.
After
Action needed by [date]: Tell us about your work, school or volunteering
To keep your Medicaid, we need to know you spent at least 80 hours in [month] working, studying, volunteering or in a job program. We couldn't confirm this from the records we have. You can upload pay slips or a school letter at [website], call [number], or return the enclosed form. If something stops you from meeting this requirement, such as a health condition or caring for a child, tell us. You may not need to meet it at all.