Situation

• In Illinois, audits found eligibility for Medicaid had not been verified in many years.
• Because the state lacked current information, many ineligible recipients still received benefits. As a result, the state was paying more than it should to managed care plans.
• To address these gaps in integrity and budget, the Illinois Department of Human Services faced the daunting task of verifying 1.4 million Medicaid members.

Challenge

Close gaps in technology to simplify verification, so Illinois could more efficiently determine if members still qualified for Medicaid.

Solution

Since eligibility redeterminations hadn’t been done in so long, the process required matching data from multiple external databases to determine income, residency, and identity.

Through our Enhanced Eligibility Verification (EEV) solution, we were able to aggregate both government and commercial data sources electronically into a single view, significantly improving accuracy and efficiency over traditional methods.

Comparing results to state eligibility rules, our automated process produced recommendations for case workers that were nearly identical to the actual eligibility outcomes reached, underscoring the accuracy of our process.

How we did it

By performing matches across various databases and providing a system for integrating the results, we made it far easier for Illinois to determine consumer status – relocated, deceased, receiving benefits out of state – and make well-informed decisions about benefits.

As a result, more than 250,000 inactive or ineligible recipients were removed from Medicaid (and did not regain eligibility within three months), saving the state more than $200 million in the first year and $70 million the second year.

In addition to closing gaps in technology and budget, Illinois is serving its citizens better by ensuring benefits only go to those who qualify and need them most.

Results

250,000 removed
from Medicaid in one year

$200 million
in savings the first year

$70 million
in savings the second year

10-to-1
return on investment