Following successful program authorization and creation (or reuse) of an integrated case, program group logic is used on the integrated case 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.
Product delivery cases, one for each of the eligible Insurance Affordability programs that a household is eligible for are created. For each of the PD case, the certification period is set to start on the first day of the coverage period for the first open enrollment period configured in the system (for example,1/1/2014) and ends on the last day of that coverage period (12/31/2014). The product delivery start date is set to the date the case is created and the certification period is set as defined above. The eligibility rules take in to account the certification period and hence decisions within the product delivery case depicting the eligibility duration starting from the PD case creation date, till the end of the certification period are created. So there will typically be two decisions available - one ineligible decision from the case start date till the start of the certification period and another eligible decision covering the duration of the certification period.
Based on the client attested data if the household is eligible for Streamlined Medicaid starting 1st January 2014 till 31st March 2014 and thereafter eligible for Insurance Assistance, both the products would be created during program authorization with the decisions within the product reflecting the eligibility period of coverage on the product.
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.