Covered California to Use AI to Validate Health-Care Eligibility

The state has 100 full-time employees dedicated to determining subsidy eligibility. One CIO thinks they could be freed up to do other things.

by / February 27, 2018

SACRAMENTO, CALIF. — The main government health-care provider for the state of California, Covered California, has ventured into artificial intelligence to validate customer eligibility for subsidies, according to Chief Technology Officer Karen Ruiz.

“We are just starting out,” she said. “We hope to launch this summer.”

The department reviews more than 1 million documents annually to determine eligibility for health-care subsidies.

“Customers must prove citizen status and income to receive subsidies,” she said. 

Covered California is the state's health insurance marketplace. Because of the federal Patient Protection and Affordable Care Act, the exchange enables 1.5 million individuals to purchase health insurance at federally subsidized rates.

The program has 100 employees that work full-time validating eligibility. The state hopes to migrate that activity to AI that will scan documents and clean up the images, identify the documents, extract information and interface with California Healthcare Eligibility, Enrollment and Retention System (CalHEERS), the system that runs Covered California's consumer-facing system for affordable insurance including Medi-Cal. Ruiz says the program then looks up the case number that matches with the information and updates the individual document so that the patient application is complete.

Future phases of the project will include a mobile document capture to allow consumers to use their phones to photograph documents and upload to add to their application. Ruiz also wants to add further automated validation processes for those documents.

“Ultimately we hope to gain costs savings with these automated features and provide a better user experience,” she said.

They also hope to free up the workforce that is spending its full time validating documents, so they can field phone calls instead.

While the state plans to launch in July, she says, “We still don’t have all the necessary (validation) document types in place, but we are growing this slowly. We hope to grow so we are up to par with private insurance companies.”

Covered California is looking to see if chatbots would enhance the user experience as well.

“We hope to use them to relieve consumer frustration, enhance fraud detection and to foster data quality,” she said.

Elizabeth Zima

Elizabeth Zima is a former staff writer for Government Technology. She has written in depth on topics including health care, clinical science, physician relations and hospital communications.