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Oklahoma HCA Delivers First Real-Time Eligibility System

Organization Now Saves More Than $18MM per Year

The Oklahoma Health Care Authority (OHCA) is a state agency that administers the state Medicaid and Children’s Health Insurance Program (CHIP). OHCA is the primary state agency charged with controlling the costs of state-purchased health care. As such, their mission is to purchase state and federally funded health care in the most efficient and comprehensive manner possible while optimizing the accessibility and quality of health care.

Project Overview
Oklahoma was the first state to implement a web-based, fully automated, real-time eligibility determination system. This system – powered by business rules – has dramatically reduced costs and improved enrollment.

State Sponsored Medical Programs
The state’s legacy system for determining eligibility and enrollment for state medical programs had several problems, including:

  • Eligibility and enrollment was limited to county office hours
  • Applicants could wait up to 30 days for an eligibility decision
  • Eligibility was left to individual interpretation
  • Process may differ by county
  • Imprecise data
  • 500,000 uninsured Oklahomans

The state launched an ambitious project to modernize this system. The new web-based system:

  • Provides Comprehensive web application for state sponsored medical programs
  • Streamlines and automates policy, processes, and access to services
  • Delivers real-time eligibility determination and enrollment

Goals of the project included:

  • Allow applicants to apply 24hrs/7days per week
  • Provide real-time eligibility determinations
  • Apply policy uniformly to all applicants
  • Streamline the business process
  • Normalize data
  • Reduce the number of uninsured Oklahomans

Building the System
OHCA outsourced much of the building of the new system. However they sought to retain control of the execution of their business decisions. They chose InRule to author and execute business rules and to provide the ability to rapidly adapt to constantly changing eligibility policy.

Major components of the system include:

  • Gather application data
  • Perform verifications and request documentation
  • Calculate household size
  • Determine eligibility for programs
  • Dispose of prior eligibility
  • Request enrollment
  • Notify applicant of decision

The OHCA Rules Engine and Data Exchange Manager used InRule’s rule authoring tool, irAuthor, out of the box to author the rules supporting Medicaid and CHIP policy.

Business Benefits
The new system went live in September 2010. The benefits derived from the new system are many:

  • Speedier enrollment for applicants
  • Immediate decision
  • Real-time reply/notification
  • The number of uninsured people in OK has dropped since implementation of the system:
    • Age 0-17 uninsured 2009: 17%
    • Age 0-17 uninsured 2011: 6%
  • Consistent application of accurate policy
  • Reduced costs
    • Average Savings: OKDHS Cost Allocation
    • $4.5 Million per quarter – or $18 million per year

“In 2010, we changed how Medicaid works. Soon we can change the way government works.”

Rules Engine and Data Exchange Manager
Oklahoma Health Care Authority


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