by Stephanie Bell, Medicaid Innovation and Policy Strategist
Automation – ranging from computer algorithms to artificial intelligence – has made a lasting impact on the health insurance eligibility and enrollment journey for federal and state health insurance exchanges and customers alike. Automation has helped improve accuracy, increase efficiency, and provide an easier, more customer-friendly subsidy application and plan shopping experience for millions of Americans. Automation holds a similar promise for the Medicaid and Children’s Health Insurance Program (CHIP) eligibility and enrollment journey, but there’s a long way to go before automation in Medicaid/CHIP is on par with that of federal and state health exchanges.
For example, in January 2025, only 14 states reported automating more than 50% of Medicaid/CHIP determinations at the time of application submission. That number could be much higher – and automation could help the Medicaid/CHIP eligibility and enrollment journey become not only faster, more efficient, and more customer-friendly, but also more accurate, consistent, and compliant.
States are Already Seeing Results
In 2023, Virginia transitioned off the federal exchange platform (HealthCare.gov), opened its own state-based exchange (SBE), and began leveraging multiple forms of carefully curated, thoroughly tested automation for both qualified health plan (QHP) and Medicaid/CHIP eligibility and enrollment. Before this change, Virginia’s Medicaid agency processed roughly 20% of its Modified Adjusted Gross Income (MAGI) Medicaid applications within 24 hours. With the increased automation and autonomy of their new SBE, Virginia now processes and determines approximately 70% of MAGI applications in real time. These are the kinds of results possible with enhanced automation.
How Exactly Does Automation Improve Medicaid/CHIP Outcomes?
Automation has the potential to elevate many aspects of the Medicaid/CHIP eligibility and enrollment journey. Below are three compelling improvements we’ve seen in action.
- Automating Eligibility Determination Processes Improves Speed and Accuracy
Today, one of the most important ways Medicaid/CHIP programs can be improved is by enhancing automated eligibility determination processes. While Medicaid/CHIP eligibility is already automated in many ways, anyone familiar with Medicaid/CHIP eligibility rules knows that they can feel like a bowl full of tangled spaghetti, with overlapping and sometimes competing sets of requirements and thresholds and countless pieces that still require manual workarounds. One path may be automated, but there are always multiple variations to each Medicaid path, and some tend to require worker intervention.
Automation can be leveraged to streamline and simplify how even these variations are handled. For example, coding clear, specific decision logic into an automated decision-making system (ADS) can lead to more consistent and accurate eligibility determinations. With more detailed decision logic, staff are no longer left to navigate the intersections of various requirements and thresholds on their own, which can help reduce variations in how information is prioritized and how eligibility is determined. The more meticulously and thoroughly decision logic is coded, the more consistency and accuracy agencies are likely to see in their determinations.
- Automating Customer Outreach Decreases Coverage Loss
Many Medicaid/CHIP enrollees lose coverage because of avoidable procedural errors, such as incomplete information or unreturned forms. When surveyed, roughly half of Medicaid Managed Care Organizations (MCOs) estimated that procedural errors were responsible for at least 10% of coverage loss during Medicaid unwinding, and a smaller number of MCOs predicted that procedural errors caused more than 50% of coverage loss within their organizations during this time. This leaves many Americans to navigate unnecessary disruptions in care coverage that a better system could have avoided.
Automation can help agencies reach out to customers who need to submit more information or return forms, provide reminders and instructions on how to send in information or forms, and perform verifications and redeterminations once material has been received, providing an easy way to correct bureaucratic errors without staff intervention. Automation can also help with another hurdle: returned mail. Sorting through piles of returned mail and tracking down updated addresses isn’t the best use of staff time. Automation can help complete these tasks, and even better – health and human services systems can be configured to automatically share address updates across systems, eliminating the need for customers to submit updates in multiple places.
- Automating Customer Service Increases Access to Issue Resolution
With automated customer service systems, such as chatbots, interactive virtual response systems, and interactive virtual agents, customers can access support 24/7/365. This is especially important for individuals and families who work or have other responsibilities during contact center hours. Automation can also offer customer support in text or voice chat and in multiple languages, and can provide easy escalation to a translation service, teletype service, or human representative during available hours if needed, ensuring customers with a wide range of communication needs and preferences can receive support when they need it, without delay.
Automating common self-service tasks, including password resets, account lookups, and application status checks, also means that customers don’t have to wait for live support to resolve common inquiries. This not only empowers customers; it also unlocks agency capacity by freeing up staff time for complex customer issues.
Addressing Common Concerns about Automation
Concern: Ensuring Accuracy with High Levels of Program Complexity
While the process of formalizing and coding decision logic tends to enhance the transparency, consistency, and accuracy of determinations, because the decision logic for Medicaid is complex, it can be exceeding difficult to test out every circumstance and confidently ensure accurate determinations across applicants. There have been several recent stories of automated decision-making failures, including one ADS for Medicaid services that consistently incorrectly found individuals with cerebral palsy ineligible because coding instructions weren’t fully aligned with eligibility rules. This left many eligible individuals wrongly without coverage.
With stories like this, maintaining accurate results in automated Medicaid eligibility programs has become a common concern. As such, coding the decision logic for a Medicaid/CHIP ADS – or for any automated Medicaid feature – requires extensive knowledge of Medicaid/CHIP program rules and policies, how they tend to play out in practice, and when they might lead to complicated outcomes.
Related Tip: When selecting a Medicaid/CHIP technology provider or modernization partner, ask about how accuracy in automated processes is tested and consider the value of a partner who has expertise not only in automation, coding, and ADS development, but also in Medicaid/CHIP eligibility rules, decision logic, and program policies.
Concern: Quickly Adjusting to Evolving Policies
If ensuring accuracy in automated Medicaid/CHIP determinations is difficult, it becomes exponentially more difficult when factoring in all the policy changes programs must quickly adapt to over time. For many agencies, simple policy changes may already be queued for six months to a year before being implemented, and many changes wind up being more complex to implement than anticipated because of interconnected processes and dependencies. For many agencies, the idea of adding a technology partner to the mix only makes program and policy updates seem more daunting.
However, while agencies may worry about scrambling to keep an ADS current with program and policy updates, the process of changing eligibility rules and decision logic in an automated system doesn’t have to require much time or effort. Today, with the right technology provider, it can be as simple as adjusting a setting.
Related Tip: When it comes to technology providers, pay attention to policies around system changes, configurations, and compliance. Some providers offer easy system configurations and guarantee compliance with most changing policies free of charge, while others may not.
Concern: Customers Respond Better to Humans
Agencies may also be worried about customers preferring human support over automated support – or about automated support missing important context and adding to customer frustration. For example, if a family experiencing housing instability goes through many address changes over a certain period, will automated outreach be sensitive to that? If a customer is upset, will a virtual agent respond appropriately? Thankfully, natural language processing and sentiment analysis are increasingly being used for virtual customer support, offering an experience that better mirrors human interaction. Additionally, a recent study reveals that while people generally prefer human support, many prefer a chatbot if they believe their inquiry to be somehow embarrassing, indicating that automated support may have its own advantages in certain contexts.
Related Tip: When determining a partner for automated customer service assistance, ask about natural language processing, sentiment analysis, and what is being done to ensure automated customer service is continually assessed, updated, and improved.
Leveraging the Untapped Potential of Automation in Medicaid/CHIP
For Medicaid/CHIP, automation presents an incredible amount of potential, but it requires very careful planning, testing, and an intentional approach that keeps the people we serve at the center of all our endeavors. While automation can do many things, it’s best to think of it as an enhancement to human support, rather than a replacement. Automation can take care of many of the more basic, simple tasks, but a big part of why that matters is that it frees up staff time to focus on the tasks and customer situations that aren’t so simple and require human support – which makes it especially promising for Medicaid/CHIP programs.
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