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Eligibility management - a perfect opportunity for business rules

One of the most common uses of decisioning technology in Government is the management of eligibility. As you will see this is mostly a rules and compliance issue, though there may be a role for analytics in deriving some of the rules. In an eligibility situation you are typically trying to make it easy to do several things:

  • Manage the rules of who is eligible for what
  • Make it easy to change these rules as regulations change and court rulings are made
  • Empower those who might or might not be eligible to find out without having to call someone – to "self serve"
  • Regulate transactions based on eligibility, either by allowing/disallowing them or by executing them in the context of the regulations.

These characteristics make it clear how business rules are an ideal technology. For example, a large retirement association has created an online site that will allow government employees to check their benefit status, explore other benefit opportunities, and submit requests. The application is for pension fund management and handles more than 100,000 members. All the domain knowledge for pension administration has been externalized from legacy code to business rules, allowing those who understand the rules to manage them. These rules determine benefits eligibility, calculate benefits, and validate data allowing for members to self-serve with the transactions for which they are eligible.

Similarly a US State wanted to allow parents to determine online whether or not their children are eligible for state-sponsored healthcare benefits. The business rules power a health care benefits portal - users log on to the site and enter in specific information. Rules then analyze the user’s entry to determine benefit eligibility and costs. This health care benefits portal is available online 24/7/365 making it easier for parents to find out what their eligibility is and to carry out relevant requests for payment. The rules themselves are easily maintained by non-technical business people who understand the complex layers of regulation involved, ensuring that the portal stays up to date and accurate.

Although eligibility is a rules-based problem, descriptive analytics can sometimes be useful in deriving business rules for use. For instance, a regulation might require that a certain percentage of those applying be allowed a benefit and descriptive analytics could be used to determine a set of rules that would identity the top (or bottom) x percent. Descriptive analytics might also be used to consider the impact of the rules as more and more court rulings are insisting that rules can be biased if their effect is biased even if the rules themselves have no specific bias coded into them.

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