Excellence in Action
Cutting Through the Clutter
of Member Eligibility Data
Evolent Health Services helps Medicaid members get the home- and
community-based services they need, without unnecessary delay.
THE CHALLENGE
The home- and community-based services (HCBS) Medicaid waiver
program allows enrollees to receive services they need without leaving
their familiar surroundings or loved ones. For example, the HCBS
program can provide for in-home nursing care or household help for
people to stay at home instead of going into a nursing facility. Eligibility
for these wide-ranging services is often determined by a variety
of state agencies, making it difficult for Medicaid plans to identify
which members are eligible for what services, and for what period.
Recently, Evolent Health Services collaborated with a Medicaid
plan partner and the health departments in one state to establish
clear-cut eligibility data for waiver members. As in many states,
sources of data were housed at different agencies, with information
sometimes conflicting and no clear hierarchy dictating which agency
took precedence. Further complicating things, data formats and
delivery mechanisms varied wildly from agency to agency, from flat
files to individual emails, requiring time-intensive workarounds
OUR APPROACH
Evolent worked with its Medicaid plan partner to streamline eligibility
processing for the HCBS population. We developed a process to
aggregate data across multiple sources to ensure members were
allocated to the appropriate HCBS plan, with accurate effective dates,
in a timely fashion to improve the member and provider experience
and ensure continuity of care.
evolenthealthservices.com
WHAT WAS
AT STAKE
Confusion surrounding
member eligibility can
have clinical and financial
impacts. For example:
• Claims paid or denied
in error, resulting in
dissatisfied providers.
• Customer service
representatives and care
coordinators unable
to speak with newly
eligible members about
available services
