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One of the nation’s top 10 largest health insurers and their solutions-based subsidiary, was embarking into state-based Medicaid marketplaces across multiple business lines. They needed to create a pre-enrollment platform that could be customized for state-by-state requirements, as well as tackle the daunting task of handling Medicaid’s notoriously unreliable datasets.

Creating a positive cost impact, their pre-enrollment system is now driven by business rules and can be extended across multiple business lines and easily configured for every state. Most uniquely, they gained new audit capabilities, enabling transaction tracking and reconciliation throughout the process.

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The Challenge

Given the complicated Medicaid marketplace, their platform needed to be adjusted to deliver optimum value and optimize the opportunity to break into the state-based Medicaid marketplace.

This challenge was complicated by three additional factors:

  • First, state data for Medicaid enrollees is considered unreliable; riddled with inaccuracies, incomplete and erroneous information.
  • Second, state programs change their data requirements quite often, making it onerous to maintain pre-enrollment systems.
  • Third, the data needed to be presented to the legacy membership system in a format that they could accept.
The Medicaid Pre-Enrollment System showed a positive cost impact while lowering project risk as the payer entered the state-based Medicaid marketplaces for the first time.
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The Solution

Together, the client and SDLC Partners built the Medicaid Pre-Enrollment System (PES) to deliver value beyond the original requirements. As a business rules-driven system, PES cleanses and interprets incoming Medicaid enrollment data and identifies data errors so that clean and valid enrollment records are sent to the health plan’s membership system.

The power of PES is three-fold:

  • It can be easily configured for any state’s enrollment rules.
  • It can scale across multiple lines of business within a health plan.
  • And, it allows quick resolution and adjustments to the rules when states change their data requirements or enrollment rules.

Other Medicaid Pre-Enrollment System features:

  • Ability to audit, track and reconcile a transaction from when it comes in the door through when it is successfully loaded into the membership system.
  • Accepts and interprets enrollment file(s) for Medicaid.
  • Applies state-specific business rules on enrollment data.
  • Real-time integrations with other health plan applications.
  • Scalable and flexible system can be extended and built out for other enrollment needs.
  • System is agnostic to data file types consumed and produced.
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The Results

The Medicaid Pre-Enrollment System showed a positive cost impact while lowering project risk as the payer entered the state-based Medicaid marketplaces for the first time. Scalability allowed for a lower relative cost for development and support as the health plan looks to expand into multiple states at one time. The system architecture enables shorter development cycles to stand up integrations with new state Medicaid systems. The business rules respond quickly to ever-changing business requirements and improves the overall efficacy of enrollment data going into the member system.

Not only did the system help the client successfully and cost effectively enter state-based Medicaid markets, but it now has a platform that is uniquely positioned to help other payers who want a flexible and scalable enrollment solution.

As more health plans tackle the risk and opportunity within the state-based Medicaid marketplaces, the ability to streamline, scale and improve data quality in pre-enrollment is a wise investment to make once – not every time a health plan decides to enter a new state or line of business.

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