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off the charts

CMS-Required Tests Are a Chance for Advocates to Improve Medicaid Unwinding Systems

The Centers for Medicare & Medicaid Services (CMS) has required states to demonstrate their readiness to unwind Medicaid continuous coverage — which protected people from coverage terminations March 2020–April 2023— through three testing measures of their eligibility systems. These measures are an opportunity for community advocates to understand and influence the technical systems that underpin the eligibility process, and in turn help protect people from unnecessary coverage loss.

The unwinding period between now and May 2024 will be challenging for enrollees, who risk losing coverage, and for state eligibility workers, who will have to process thousands of eligibility determinations and respond to issues that arise for enrollees and applicants. Whether this influx of administrative interactions goes smoothly will largely reflect the usability and reliability of the technical systems behind Medicaid.

Testing is a crucial step in the technical system development process, allowing developers to identify bugs and issues so they are fixed prior to product launch. It’s also a core component of human-centered design, a process to ensure tools and products meet people’s needs with clarity, consistency, and ease.

Without proper testing, users with more complex situations can fall through the cracks, systems can be overloaded and break down, and people may be prevented from receiving critical services. The widely reported breakdown of the original launch is an example of the severe impact of under-testing a product. and Affordable Care Act enrollment did recover, but a flawed continuous coverage unwinding could lead to loss of coverage for millions of people, including many who remain eligible for Medicaid.

Traditionally, system testing and test planning have been limited to product development teams. However, including community advocates in the process can be a more effective approach, particularly given governmental organizations’ growing focus on user testing and human-centered design. Community advocates have deep real-world experience and a strong grasp of how policies and their implementation affect people, and they can provide development teams a crucial perspective they may be missing.

CMS’ guidance on how states should approach the three system readiness artifacts — implementation and testing plans and test results — can be an entry point for advocates to understand more about systems testing. One document, “Resources to Support System and Logic Testing for Unwinding when the PHE ends,” lays out specific recommendations for testing IT systems during unwinding. (The end of continuous coverage originally coincided with the public health emergency, or PHE.) Another document, the “Medicaid Enterprise Systems (MES) Testing Guidance Framework,” gives information about testing systems more broadly and lists specific expectations for test planning, execution, and operational monitoring.

Advocates, regardless of their technical experience, can help shape the process. And while most states are finished with test planning, test results are pending, and these tests are also required beyond unwinding. So it will be useful for advocates to develop an understanding of the tests’ definitions and purposes and identify opportunities to participate.

Health care advocates and policy experts get involved in system and logic testing by:

  • Providing policy background. The people who write the tests (typically engineers) may not have a deep grasp of policy or client experience. To bridge any gaps, advocates might suggest or participate in a design jam session or hackathon with various stakeholders (programmers, case workers, advocates, designers) who determine which client scenarios should be tested.
  • Providing input based on direct client experience. People’s lives are complicated; unexpected cases often arise that are critical for testing. Using their knowledge of how clients interact with eligibility systems, advocates and others could help identify complex situations that the systems often mishandle.
  • Participating in system testing. These are two of the many types of system testing formats that may be most useful for advocates to participate in:

    • Unit testing checks that a specific function works as expected. For example, a unit test of an address update page would check whether, after clicking “update,” the new address saves in the database. Unit testing is valuable because it helps ensure functionality on small-scale changes that, when broken, could cause large-scale disruption.
    • User acceptance testing is used to verify that the system can support day-to-day business and user experiences. Tests could include specific scenarios such as a case worker’s ability to navigate a page, or a client’s ability to access a chat or notification.

    In both unit and user acceptance testing, advocates can suggest test ideas. A good approach is to consider several questions: What parts of the eligibility process generate the most client complaints? What client circumstances are not covered well by the current system or are more complex than it allows for? Which client populations or scenarios will be most impacted by system changes during unwinding?

With much of test planning complete, advocates who want to understand a state’s approach can find system readiness artifacts online (take for example Louisiana’s and Kentucky’s) or request them from the state. They can then compare them to the expectations in the CMS guidance, as well as their own understanding of the risks of unwinding.

Advocates can also look to participate in system testing as states improve their eligibility systems and execute policy changes during unwinding and beyond. Overall, advocate involvement in the production of system readiness artifacts and testing is valuable, ensuring the broad spectrum of client and caseworker experiences are covered.