A Medicaid agency can have an implementation calendar, a systems roadmap, a training schedule, and a vendor workplan—and still lack a clear answer to one question:
Who is accountable for demonstrating that eligibility decisions are accurate, corrections remain effective, and eligible people retain coverage?
That question belongs alongside every implementation milestone. It should be answered before the next audit requires the agency to reconstruct what happened.
Ownership across the handoffs
Eligibility work crosses organizational boundaries. Policy teams interpret requirements. Systems teams configure rules. Workers review information and resolve exceptions. Contractors support processing. Quality teams examine decisions. Fiscal staff assess payment consequences.
Each function can complete its assigned work while a defect persists between them.
A policy clarification may reach workers before the corresponding system change. A correction may fix one record without reaching similar cases. A renewal may reintroduce a previously resolved error. Evidence available when a decision was made may be difficult to retrieve months later.
The leadership task is to connect those responsibilities into a process that can demonstrate results.
For each significant eligibility risk, someone must be able to answer:
What makes this decision supportable?
Where is the evidence retained?
What happens when the evidence is missing, conflicting, or outdated?
Who can authorize and implement a correction?
Who checks whether that correction remains effective?
Completion is only the first checkpoint
A system change deployed successfully is an implementation result. Whether it produces accurate decisions is a separate question.
A worker completing training demonstrates participation. Whether the worker can apply the rule correctly to a difficult case requires another test.
Closing a corrective-action item documents an administrative step. Whether the underlying defect has stopped recurring requires follow-through.
Agencies need both kinds of evidence. Project reporting tells leaders whether the work was delivered. Operational verification tells them whether it achieved its purpose.
That distinction becomes especially useful when several changes reach the same eligibility process. A successful test of one requirement does not establish that the combined workflow performs correctly.
Make one decision reconstructable
Start with a decision that matters: an income determination, an exemption, a renewal, or the resolution of conflicting information.
Ask a reviewer who did not make that decision to reconstruct it using the retained record.
Can the reviewer identify the information available at the time, its source and relevant dates, the applicable policy version, the reasoning behind the determination, and any subsequent correction?
Can the reviewer distinguish evidence obtained before the decision from information received afterward?
Can the agency explain what happened to coverage and payments while the issue was being resolved?
If the answer depends on locating one experienced employee who remembers the case, the record needs strengthening.
The objective is a usable decision history. That history supports quality review, appeals, corrective action, and later audit examination.
Protect eligible members while correcting defects
Accuracy includes recognizing when a person qualifies and preserving that person’s access to coverage.
A discrepancy should lead to an appropriate review. It should not become an automatic conclusion that someone is ineligible. Missing documentation, stale data, and a substantive eligibility failure require different responses.
A credible control therefore measures both the defect it is intended to detect and the problems it may introduce.
How often are alerts wrong? How long do legitimate exceptions take to resolve? Are decisions reversed? Are eligible members experiencing avoidable interruptions? Does the correction impose repeated work on members, workers, or providers?
Those questions belong in the same performance discussion as payment exposure.
Three assignments for the next leadership meeting
1. Name the accountable owner.
Choose one material eligibility risk. Identify the leader responsible for bringing policy, operations, systems, quality, and fiscal staff together to resolve it. Record the handoffs and escalation path.
2. Test the evidence and correction process.
Select a defined set of decisions. Have reviewers reconstruct them from retained evidence. Where defects appear, document the cause, the correction, its timing, and how similar cases will be identified.
3. Independently verify that the repair holds.
Return to the corrected process after subsequent decisions or renewals. Check for recurrence, new errors, unresolved exceptions, and effects on eligible members. Report what the test establishes—and what remains uncertain.
These assignments can begin with a narrow scope. A limited test with a clear baseline and honest findings is more useful than a broad assurance that cannot be reproduced.
97 or Better™—Before 2029 is an educational invitation to make eligibility accuracy a shared industry ambition.
States, federal partners, researchers, technology organizations, and community partners each hold part of the knowledge needed to improve performance. Shared learning becomes useful when it explains which control was tested, what evidence supported the decision, how the correction worked, and whether the result held.
The next leadership conversation should produce an accountable owner, a testable control, and a date to review the evidence.
Who will demonstrate that the correction worked—and that eligible members remained protected?
Stop the Error Clock — why the timing of correction matters.
From Pay-and-Chase to Prepayment Control — practical preventive controls.
GAO: Improved Oversight Needed of State Eligibility Error Corrective Action Plans — independent evidence on corrective-action evaluation and oversight.
Ralph Choate | Founder, Editor & Principal Author
PERM Insights & Perspectives