Following successful program authorization and creation (or reuse) of an integrated case, program group logic is used on the integrated to determine the set of eligible programs and the clients who will be in receipt of these programs. Rules logic determines whether to create a new product delivery case, or reuse an existing product delivery case, as well as determine the post processing required in various situations. This logic only applies within an insurance affordability integrated case, and not across other integrated cases of this type.
When creating a new product delivery case, a check is performed to determine whether a product delivery of that type already exists on the integrated case. If there is, the existing product delivery can be reused; if not, then a new product delivery is created. If a member is eligible on a product delivery but was previously an eligible member on a different product delivery type, then additional updates must be made to the product delivery case that the member is leaving, before being added as a member on the new product delivery. As the number of Insurance Assistance product deliveries is dependent on the number of tax households within the overall household, this further complicates program group logic.
Changes in circumstances will cause the existing product deliveries to be reassessed. Cases may no longer be relevant for ongoing case management. Federal guidance uses the term 'churn' to describe a situation where household income fluctuates. For example, a Medicaid-eligible household has an increase in income that exceeds the Medicaid standard. The household then qualifies for Insurance Assistance. The HCR solution caters for this churn whereby an Insurance Assistance product delivery would be created. Note that in this scenario the original Medicaid product delivery would not be closed. A future decrease in household income could result in the household being determined eligible for Medicaid again. This may necessitate a separate case closure process which would check for cases where certification periods for all members has ended and automatically closing such cases or notifying a case worker to close them.
To support reasonable opportunity requirements, verifications on the insurance affordability integrated case are mandatory. However, upon creation of the case, waivers are applied to the appropriate evidence items so that outstanding verifications do not prevent activation of the evidence (and hence the case) while the waiver applies. A default value of 90 days is set for a waiver applied to a verification on an integrated case. The duration of these waivers is calculated based on the number of days remaining out of the required 90 since the application case was created.
Milestones are applied to the integrated case for the same duration as the waivers. This allows for work flows to be initiated both on the milestone date (to determine whether the case should be closed or not), and a configurable number of days in advance of the milestone date so that a case worker can be notified that the end of an inconsistency period is approaching.