Policy & Practice | Spring 2026

In that sense, delivering a first-class Medicaid experience isn’t just aspi rational—it’s practical. Streamlined processes stabilize participation and reduce error rates. Integrated systems restore staff capacity, shifting effort away from routine processing and back toward helping the people the program serves. Moving Beyond the “Eligibility Beast” Eligibility systems are essential but highly complex infrastructure—fre quently fragmented and difficult to update. Staff often must navigate multiple systems, reenter data, and develop workarounds to compensate for aging technology. Over time, eligibility operations can become what many refer to as “the beast”: a sprawling mechanism that consumes staff capacity and inhibits flexibility. The strain of this system is evident. Eligibility workers juggle large case loads amid persistent workforce vacancies that average 17 percent and rise as high as 40 percent in some states with substantial time devoted to administrative tasks rather than complex case resolution. 3 H.R. 1 creates an opportunity to take a smarter approach. Instead of layering more requirements onto an already fragile foundation, states can strategically modernize their Medicaid systems from the ground up. By bringing Medicaid eligibility closer to a marketplace-style experience— with a single point of entry, unified workflows, and embedded decision support—agencies can consolidate MAGI and non-MAGI pathways and pull data directly from trusted sources. Models such as Medicaid Express automate routine determinations, resulting in fewer manual touchpoints, far shorter processing times, and greater program integrity. Modernization is not about removing the human element, as some people fear; it’s about restoring it. Automation handles predictable transactions, freeing skilled staff to focus on cases that require human judgment, empathy, and insight. In a future defined by workforce con straints, this rebalancing may prove essential.

experience. Modern, end-to-end eligi bility and enrollment solutions—such as Medicaid Express, developed by Vimo to support H.R. 1 implementa tion—offer a model for how that future can take shape. According to the Centers for Medicare & Medicaid Services, many Medicaid applications take up to a week to process, while others take more than 45 days. 2 Improving the Medicaid journey for consumers means closing that gap. By automating verification, embedding community engagement tracking and supports into workflows, and integrating plan selec tion into one unified system, modern eligibility platforms prove that with thoughtful design, compliance and operational excellence can coexist. A redesigned client experience might include: n Adaptive online applications that dynamically adjust to individual circumstances n Real-time data integrations that verify income and community engagement participation whenever n Highly automated workflows capable of delivering eligibility determinations in under 30 minutes in most cases n Immediate transitions from eli gibility approval to guided plan selection and enrollment within a single digital experience n Supportive tools to help applicants verify engagement and get personal ized assistance In this model, compliance is built into the system’s architecture—future ready by design. Modernization alone may not offset broader coverage reductions, but applying marketplace-style design to Medicaid can make the program more resilient. When eligibility systems adopt HIX features, states can reduce the administrative friction that leads to coverage gaps. Clear products reduce failure demand, minimizing repeat contacts, paperwork, and avoidable disenrollments. possible, reducing or even elimi nating document uploads and follow-up requests—a critical element in providing low-error, no-touch transactions

In many states, residents who qualify for subsidized coverage through the Health Insurance Exchange (HIX) already experience streamlined digital applications, real-time verification, and guided plan selection. Yet individuals and families whose incomes qualify for Medicaid often encounter a markedly different process—one that may be slower and less supportive. As H.R. 1 reshapes eligibility operations, it also presents an opportunity to close that experience gap and apply proven marketplace principles more broadly across Medicaid. Reimagining Medicaid goes well beyond a technical upgrade. It reflects a philosophical shift in public service delivery, signaling a commitment to designing systems that are intuitive, responsive, human-centered, and grounded in program integrity within a supportive infrastructure. Turning Compliance into Transformation Historically, federal policy changes have layered new obligations onto already complex eligibility infrastruc tures. The result is often more manual processing, greater fragmentation, and a heavier strain on staff. H.R. 1 could easily follow that pattern, but it doesn’t have to. Rather than merely adding com plexity, states can modernize Medicaid in ways that align regulatory compli ance with superior service. Applying the streamlined principles seen in many HIX platforms—including adaptive applications, integrated verification, and immediate enroll ment pathways—allows agencies to meet new federal standards while improving both the customer and staff

Sean Toole is the Senior Vice President for Vimo.

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