NHeLP’s Automated Decision-Making Principles in Medicaid Continuous Coverage Unwinding

NHeLP’s Automated Decision-Making Principles in Medicaid Continuous Coverage Unwinding

NHeLP’s Principles for Fairer, More Responsive Automated Decision-Making Systems outline how to realize the benefits of Automated Decision-Making Systems (ADS) while minimizing drawbacks. Many government agencies use ADS for Medicaid eligibility decisions. During the unwinding of the Medicaid continuous coverage period Medicaid eligibility ADS and related processes will be under significant stress due to high workloads, new changes to state policies during the unwinding, and other factors. CMS has suggested several automations for states to incorporate with the purpose of increasing efficiency throughout the redetermination process, such as digital processing of documents and automating processes. As much as these automations may ease workloads for states, they also pose significant risks to Medicaid beneficiaries if they are not designed and implemented fairly and responsibly. Applying NHeLPs ADS principles helps identifying potential issue areas with automations in the continuous coverage unwinding.

Principle 1: Transparency

Transparency across the ADS life cycle phases is critical to preventing harm by allowing issues to be identified earlier, when they are often easier to fix and have not yet impacted people’s benefits. Without stakeholder input throughout the lifecycle, issues with the system will likely only appear after people lose essential benefits.

State Medicaid agencies may feel compelled to quickly launch ADS systems and updates to keep up with the large eligibility workload and timeline of the unwinding period. Even so, they must not forego transparency for efficiency. Stakeholder engagement can inform the state as to how individuals actually interact with an eligibility system and whether planned changes will create barriers. Without meaningful stakeholder involvement and public accountability, states will likely see unnecessary lost benefits due to beneficiary confusion or systems not functioning as intended.

Principle 2: Protect Civil Rights

The use of ADS to determine entitlement benefits programs, such as Medicaid, must adhere to all civil rights and due process requirements.     During the unwinding process, millions of people are expected to receive notices that their Medicaid coverage is being terminated or that their Medicaid coverage is changing, such as changes to premiums or scope of coverage. These notices must explain why benefits are being terminated or reduced so that the affected person can make a decision about whether to appeal and prepare for the appeal if they file.

When an ADS is used in eligibility determinations or notice generation, the benefits decision explanation can be vague or confusing. ADS used during unwinding and beyond must be able to provide a personalized and easy to understand explanation for each eligibility decision. Auto-generated notices, which are used by most Medicaid eligibility ADS, must do the same. ADS that do not properly take into account due process and civil rights requirements, including for people with disabilities and those with limited English proficiency, can cause significant coverage loss and rights violations.

Principle 3: User-focused

ADS must center end users’ experiences through all phases of the ADS life cycle.   Since many individuals and households have not undergone any eligibility determinations since 2020, the eligibility ADS used during unwinding need to be able to accommodate a variety of possible changes to each Medicaid case. Many people will have experienced changes to their contact information, income levels, family structures, and disability status during the COVID-19 public health emergency (PHE). In addition, many state programs have undergone eligibility changes during the PHE. For example, Oklahoma and Missouri adopted Medicaid expansion in 2021, increasing the eligibility possibilities for low-income adults.

ADS must be tested for a representative range and combination of such changes to beneficiary circumstances. Systems must have processes that make it easy to accurately report life changes. Any system changes should be tested to make sure they are reliable usable and operate properly by the relevant users. When an ADS is unable to respond to changes or is not usable all those who need to rely on it, issues must be mitigated before the ADS is used to make additional eligibility determinations.

Principle 4: Validity

Any automation introduced to make benefits decisions needs a clearly defined purpose and must only be used to achieve that purpose. Development must include identifying, explicitly acknowledging, and mitigating any major confounding factors that cannot be avoided.

In preparation for and during unwinding, states may be introducing multiple new automations at a time and working with contractors to incorporate automation throughout the eligibility redetermination process. These automations can make processes more efficient and increase the number of people whose eligibility can be determined ex parte, i.e., without requesting information from individuals. When determining what automations to introduce, state agencies must determine the purpose each automation fulfills, how it will do so, and how it will be tested and monitored and identify any conflicts or complications. Otherwise, the agency runs the risk of failing to meet the automation’s goals while potentially increasing inappropriate coverage reductions and terminations.

Principle 5: Mitigate Bias

ADS should be carefully and regularly reviewed and, as needed, revised to minimize outcomes that exhibit bias against protected communities and prevent ADS access barriers to needed benefits.

At the same time that state agencies are introducing and updating ADS during unwinding, they are also hiring and training many employees and contractors. Many state agencies have experienced increased workforce churn during the pandemic and may have less experienced workers. Eligibility system training before and throughout the unwinding must emphasize the importance of recognizing and mitigating bias. Automations, such as those for call centers and for uploading documents through mobile apps, need to be accessible to all, including those with disabilities and those with limited English proficiency. Agency data systems and collection on unwinding should include reports to help identify disparate results who is using automations and in eligibility redeterminations.

Principle 6: Humility and Redundancy

In full awareness of ADS’s practical and fundamental limitations, agencies and vendors should incorporate human oversight and feedback loops to identify and correct expected errors at the individual and, if needed, systemic level. Creating a beneficiary-centered ADS requires the humility to understand technology’s limits and the awareness of the potentially life-changing and long-lasting consequences of improperly denied or delayed benefits.

During unwinding, state Medicaid agencies and local eligibility office workforces will be strained at all levels. Although it may create more work on the front end, improper denial and delay of benefits can be prevented and workforce strain can be reduced by incorporating human oversight and feedback loops. Catching and correcting mistakes in automated systems early can prevent confusion, such as receiving multiple notices with conflicting information, that leads to increased call center traffic. Human intervention that prevents improper termination of benefits reduces the number of people who need to appeal the agency’s eligibility determination. In turn, this reduces the workload on both informal appeals employees and fair hearing administrative law judges. When humility and redundancy are incorporated throughout the eligibility redetermination process, the process becomes more efficient and accurate. Importantly, such redundancies help prevent and correct inappropriate coverage terminations.

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