Real-Time Eligibility for Enrollments 

Software Engineering Services to Support Eligibility Determinations

Home » News & Resources » Case Studies » Real-Time Eligibility for Enrollments 

Cogent People provided software engineering services to support consumer eligibility determinations to effectively and efficiently verify their eligibility to purchase health insurance through the Federal Health Insurance Exchanges. 

Key Objectives  

This project aimed to design and implement a modern event-based processing framework extensible to other Marketplace systems and processes for the Centers for Medicare and Medicaid Services (CMS) to streamline eligibility determinations for the Federal Health Insurance Exchanges under the Affordable Care Act (ACA). Goals included: 

  • Reducing SLAs of 2-10 days so customers receive immediate eligibility response to their health care enrollment submissions 
  • Improving consumer and system interactions and reduce operational inefficiencies and costs by eliminating the dependencies on file-based batch data exchanges 
  • Enabling adoption of real-time data across all ES processes 

Key Accomplishments 

To develop recommendations and a streamlined event-based framework, Cogent People: 

  • Performed a comprehensive analysis of modern technology platforms  
  • Designed and implemented a modern cloud-based solution capable of processing thousands of real-time events concurrently 
  • Implemented industry-recognized and proven architecture design patterns for high performance and high availability at lower cost 
  • Established formal system integration services to coordinate the challenges and complexities of external-facing systems 

Notable Outcomes 

Cogent People transformed eligibility determinations on by implementing a modern, real-time event-based system, enabling: 

  • Visibility and Timely Decision-making: Enabled a consistent and reliable view of data across all systems to allow for informed decisions based on the most current information 
  • Data Integrity: Reduced the risk of data loss, corruption, and duplication 
  • Issue Detection and Resolution Improvements: Allowed for faster and more accurate identification and solutioning of discrepancies, errors, and frauds 
  • Operational and Maintenance Cost-savings: Replaced unnecessarily complex and expensive RedHat OpenShift Container Platform with native Amazon Web Services (AWS) Elastic Container Service (ECS)