Policy & Practice | Summer 2025

Chart 1: Maturity Curve

mailed-in paper forms. It’s tedious, error prone, and wildly expensive. Now imagine using Document AI to scan, verify, and extract key data automatically 80 percent of the time, no humans needed. That’s not a moon shot. That’s happening now. n Virtual Assistants: You don’t need a 40-person call center when an AI agent can provide each customer with their case status in under five seconds, in the customer’s language, and by phone or text. We can reduce the number of those calls if we can get the work done quickly. Bringing It All Together— Medicaid Express One way to think of maximizing the Maturity Model is to reimagine a self service benefit program—let’s call it Medicaid Express—with end-to-end automation and a no-contact eligibility process. This seamless experience is all about designing the process around the client. It includes AI support, data verification tools, automated document identification, and virtual assistants, all highly attuned to the process. Medicaid Express automatically segments applicants who are likely to qualify for Modified Adjusted Gross Income benefits, including those selecting Managed Care Organization plans, helping them move forward at their own pace while verifying their information and achieving immediate benefits. In the meantime, staff has the

room to focus on applicants needing more attention. This system allows you to reach that vision of shorter processing times, continuing to expand the self-ser vice population, and implementing the automation tools around your eligibility system that unlock capacity. Many integrated eligibility systems started with this hope, but by attempting to handle every case, very few can make it through without tripping into a processing gap that requires worker involvement. Segmentation is an essential element from the Capability Maturity Model that sets capacity free. This Is the Moment We can’t compliance our way to better capacity. We can’t patch our way to better performance. And we definitely can’t wait this out. Federal agencies are no longer content with excuses. Families can’t afford another round of delays. And workers are exhausted from carrying systems not built for the load. But you can build an eligibility operation where staff work on excep tions rather than every case, where clients apply and get help without bouncing between channels, and where technology actually does the work—reliably and at scale. Leverage a capacity-based maturity model that focuses on the outcome and puts pure focus on achieving reliable and effi cient Eligibility Operations. Let’s build the capacity to do more good.

Designing a process that minimizes worker time and identifies where non value tasks are involved is essential. When your staff helps identify error prone steps and tasks that take too long, you’ll get to where you want to be. Some ways you can rethink your processes: n Center the voice of your teams. Sustainable change happens when people buy in. Collaborative sessions for radical process improvement, led by experienced staff, can structure teams that are supportive, focused on outcomes, and understand the goal is the determination of benefits without having to continually ask the client for more information. n Rethink assumptions. We worked with a client’s staff to reimagine the interview process, separating any pre- and post-interview tasks that don’t require an eligibility worker’s direct involvement. With this new process, we reduced a 45-minute interview to a bit more than 10 minutes and freed up significant capacity. Modular technology also plays a vital role in rethinking your processes: n Worker Assistant: An AI-enabled tool can read your policy manual so your staff doesn’t have to. It answers questions instantly, flags training needs, and even helps write better responses. n Documents: Most states still rely on humans to read, sort, and manually enter data from PDFs, photos, and

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