Timely, Automated Data Helps Improve Decision Confidence and Protect Program Integrity for State Health & Human Services Agencies

Improving program integrity remains a top priority for state Medicaid agencies, especially since it’s the second-largest state budget driver. As discussed in a roundtable session co-hosted by Equifax and the Arizona Health Care Cost Containment System (AHCCCS), state agencies are continually assessing their process efficiencies as well as the data used to make benefit determinations.  

During the joint panel, discussion zeroed in on the CMS (Centers for Medicare & Medicaid Services) Data Services Hub (CMS Hub), which offers state agencies a connection to common federal and commercial data sources needed to verify eligibility for Medicaid. Equifax is the trusted data source used by the CMS Hub for certain income and employment verifications via The Work Number® database.

Access to the Hub is free for state agencies, and AHCCCS has been leveraging it since its inception in 2013. In an effort to continuously improve application processing, AHCCCS often refines and enhances how they use data to make benefit determinations. As a first step in the eligibility verification process, AHCCCS queries the CMS Hub. When they aren’t able to verify all employers using records returned by the Hub, AHCCCS then queries The Work Number directly to retrieve additional verifications as required. 

“We have a customer-facing portal for Medicaid applications, where customers can fill out the application, and if everything checks out, they can get a same-day answer,” explained Lori Boyd-Draper, Deputy Assistant Director of Operations at AHCCCS. “When there is no response required, our system can auto-adjudicate the application. In fact, over 70% of our renewal applications are auto adjudicated, and this is made possible thanks to our waterfall of Hub verification sources and The Work Number.” 

Having trusted data resources in place and having them integrated into both processes and systems can help state agencies make determinations with more confidence and protect the integrity of their programs. The Work Number database is updated every payroll cycle. The availability of real-time data helps with both auto and manual adjudication for agencies looking to deliver efficient responses to applicants in need. 

While the CMS Hub provides state agencies with specific data at no cost, as noted by AHCCCS during the discussion, there can be instances in which state Medicaid agencies may need supplemental data in order to improve decision accuracy. 

As the discussion with AHCCCS showed, verification policies can require more information than what is provided by an initial call to the CMS Hub. System integration of additional data provides state agencies with a more robust capability to auto-adjudicate and deliver faster, more confident determinations. For example, when a Federal Employer Information Number (FEIN) is not associated with an employer record, the CMS Hub does not return the record. Such records may be available when a state queries The Work Number directly.

Equifax offers a service called ACA Total Income to help make it easier for state Medicaid agencies that use the Hub to quickly retrieve additional income and employment data they need to better protect program integrity. Designed to match the CMS Hub experience, it’s easy to implement and familiar to use for Medicaid caseworkers, allowing for additional data fulfillment which helps improve efficiency and more informed decision-making.

The panelists also discussed strategies for automating renewals. Income variability and seasonal employment can make it challenging to automate some redetermination decisions, even though Medicaid rules allow states to account for “reasonably predictable income changes.” This is where detailed employment and income data, such as that delivered by the CMS Hub, or directly from The Work Number, can make the difference. Current, per pay period data provides a more complete picture that can be used to verify and explain income variability, something annual or quarterly income totals generally can’t do.

To learn more about how Equifax supports social service agencies, visit our web page.