Authorization of each program on an application case is required in order to process the application case to completion. The authorization process varies depending on the nature of the programs that are being applied for. An authorization strategy can be configured for an application case. For HCR, this is a strategy of type 'Application' meaning that a rule set can be associated with an application case which determines the set of eligible programs and the clients entitled to receive the programs.
A submitted application does not require caseworker intervention when all client-attested information has been e-verified. In that scenario, straight-through processing ensures that the case worker is notified about the application case when it is authorized, however as the name suggests, there is no need for the caseworker to get involved.
Any evidence items which haven't been verified by an external system as part of the application process or accepted based on client self-attestation, require manual verification by a case worker. Straight-through processing is halted and a caseworker is assigned the task of resolving the outstanding evidence verifications with a client. Evidence with outstanding verifications is mapped to the application case in an 'in edit' state. Federal requirements for reasonable opportunity or inconsistency periods allow states to continue with the delivery of a program during this period. This is detailed below.
Following the authorization of program(s) on an application case, an integrated case is created and the application case evidence is brokered onto the integrated case. Integrated cases allow for the typical case management tasks of resolving verifications and capturing updates to evidence for ongoing eligibility. Integrated cases can be used to manage any number of application cases which may exist for the members in a family. For example, an employee application for employer-sponsored coverage will result in an application case for that employee. If other household members were to apply for assistance in the individual exchange this would result in an insurance affordability application case. When verifications are resolved and the programs associated with these applications are authorized, they will result in one integrated case for the household. The Evidence Broker configuration used in HCR allows evidence to be automatically accepted and activated on the integrated case.
Ongoing case management requires both an integrated case and a product delivery in order to complete the delivery of services and benefits to clients. Integrated cases are not necessarily created for every program authorization, however. An existing integrated case can be used to host newly created product delivery cases. This is controlled via a configuration setting for application cases. For HCR, If integrated cases exist of the appropriate type for which any of the application case clients is a member, the case worker is presented with the option to use one of these cases or to create a new integrated case.
Federal rules require that states allow a period of 90 days to resolve inconsistencies between the information an applicant provides and information available from other trusted sources, during which the applicant can still receive benefits based on the information they have provided. The inconsistency period starts five days from the date the potential eligibility notification is sent. In order to support the reasonable opportunity requirement, the verification requirements have been configured to be optional for the application case, allowing the program to be authorized with outstanding verifications. The verifications are mandatory for the IC. But in order to activate the PD cases to ensure benefit delivery during the inconsistency period, the system automatically bypasses any mandatory outstanding verification by creating 'Verification Waivers'. The waiver period is set to the duration of the inconsistency period plus the 5 days from the date the notification was sent. This would allow activation of evidences and product delivery cases with outstanding verifications thereby allowing applicants to have access to benefits during this period.
If the inconsistencies are not resolved by the end of the reasonable opportunity period, follow-up actions such as redetermination of eligibility using information available are required. In order to trigger these actions, Case Milestones are created, with the expected start and end dates set to be the same as the inconsistency period. The actual start date of the milestone is set to the date the notification was sent and the 95-day period countdown begins. When the business date passes the 95-day period, the milestone overdue event is raised which can be used to perform the follow-up actions.