Optum Community Engagement Verification

[SOFT MUSIC PLAYING IN THE BACKGROUND THROUGHOUT THE VIDEO]

[On-screen text: Optum]

[On-screen text: Optum, Community Engagement Verification (CEV) Solution, Modern verification. Minimal disruption]

NARRATOR: Welcome. Today we're going to walk you through the Optum Community Engagement Verification Solution, a streamlined, data-first approach that helps states meet H.R. 1 requirements without rebuilding eligibility systems. We'll show you how the components work together, what the experience looks like for staff and members, and how states can implement this quickly and safely.

[On-screen text: Our broad experience in all 50 states and D.C. Partnering to enhance Medicaid and HHS performance and member well-being:

Eligibility and enrollment solutions, Enterprise warehouse and analytics, Other population health management solutions, Contact center services, Program and policy consulting, Long-term services and support solutions, Behavioral health services, Fraud, waste and abuse detection, Provider management services]

Before we jump into the demo, here's the foundation it's built on. Optum works in all 50 states, across eligibility, data analytics, call centers, and program operations.

[On-screen text: We listen first, then deliver, Understanding each state’s unique needs and priorities. We innovate responsibly, Leading the way with responsible AI, analytics and technology to solve today’s toughest challenges. We build for impact, Solutions that drive measurable improvements in health, efficiency and equity. We stand by our partners, Long-term commitment, proven results and a shared mission for healthier communities]

This broad footprint allows us to design solutions that fit easily into existing environments. And that's exactly what we've done here. Everything you'll see in this walkthrough reflects real challenges states have shared and real constraints they're facing.

[On-screen text: High risk of coverage loss: No eligibility system rebuild, Modular and configurable, Data-first verification]

Let's briefly frame what you're about to see. H.R. 1 adds new community engagement verification requirements and very tight timelines. So our goal is simple. Create a solution that performs verification around the eligibility system, not inside it, making it fast to implement and low risk to maintain.

[On-screen text: What states are saying:

-          “The timeliness are aggressive – we need clarity on CMS expectations for good-faith progress and exceptions through 2028.”

-          “This is a multisystem lift (eligibility, MMIS, call centers, data exchanges), not just a policy memo.”

-          “Our biggest risk is avoidable churn among working-poor adults and people with unstable employment or housing.”

-          “We’d like to align HR1 requirements with existing SNAP/TANF work programs to avoid duplicative tracking.”

-          “We need clear standards on acceptable verification data sources and how much can be automated.”

-          “Shared tools and technical assistance from CMS and partners would help us move faster and more consistently.”]

States told us they need automation, clarity, and minimal disruption. They want to avoid coverage loss caused by missing paperwork. They need verification that spans multiple systems – eligibility, MMIS, data exchanges – without forcing major redesign. And they want tools that reduce burden on members and staff. Everything in this demo is built to address exactly those pain points.

[On-screen text: The HR1 reality for states. The operational lift behind community engagement verification.

-          Short timeline: New federal requirements take effect in January 2027, Full CMS guidance is expected mid-2026, States must begin implementation before guidance is final.

-          Constraints on staff and funding: Staff turnover remains high, HR1 adds new work without dedicated funding, Systems and staff are already managing continuous policy and system change

-          High risk of coverage loss: Many people who are working have unstable jobs or hours, Missing paperwork – not ineligibility – is the biggest risk

-          Unclear verification rules: What data sources will CMS accept? Where can automation replace manual review?]

H.R. 1 goes live on a fast clock, with guidance still evolving and staff already stretched. That's why a separate verification service is so important. It lets you meet deadlines without rewriting rules engines, retraining staff, or overhauling workflows.

[On-screen text: A few things that matter more than architecture. Practical guardrails states need to put in place for HR1]

Before we show you the components in action, here are the guardrails that shaped the design.

[On-screen text: Eligibility system = System of record: Existing eligibility system remains the system of record, Systems that support eligibility decisions require CMS certification which adds cost and can delay delivery by more than a year]

One, the eligibility system stays the system of record.

[On-screen text: Minimize workflow changes: Staff capacity is already limited, New systems mean more training, errors and delays]

Two, staff workflows stay the same.

[On-screen text: Audit-ready transparency: Verification results must be traceable and explainable, States need clear records for audits, appeals and oversight]

Three, every verification result must be traceable for audits.

[On-screen text: Data before paperwork: Check trusted data sources first, Ask members for documents only when needed, Minimize new manual work for staff]

And four, we always use data before paperwork. These principles guide the workflow you're about to see.

[On-screen text: Two paths states can take. The key difference isn’t what gets done, but how much the eligibility system must change.

1)      Build into the existing eligibility system: States extend their existing eligibility system to perform community engagement verification by adding new rules, workflows and document review processes.

-          What this typically involves:              

o   Policy and rule updates within the eligibility system

o   Updates to staff workflows and processing steps

o   Testing and regression as rules evolve

-          Best fit when: The platform is flexible and actively maintained

-          The state can make and deploy changes quickly

2)      Use a verification hub (preferred)

-          Faster, flexible, lower risk

-          What this typically involves:

o   APIs to receive verification results and reason codes

o   Configuration to map verification outcomes into existing eligibility rules

o   Automated verification checks run outside the eligibility system

-          Best fit when:

o   Eligibility system vendor contracts or governance limit rapid system changes

o   Existing portals have low adoption or poor use experience

o   The state needs flexibility to adapt as guidance evolves]

In most states, the fastest and lowest risk option is to keep eligibility where it is and add a verification hub alongside it. That's the model we're going to demonstrate. Eligibility sends a request, the hub runs automated checks, and the results return back instantly, without staff leaving the system they already use. Here's the full picture.

[On-screen text: Four components work together

-          Your eligibility system (System of record)

o   Eligibility decisions

o   Staff workflows

o   Document reviews

o   Notices and appeals

-          Eligibility decisions and staff actions remain in the existing system.

-          Integration layer

o   Secure APIs that pass verification results into existing eligibility workflows

-          Verification services

o   Run real-time data checks and return verification status and reason codes with audit support]

The eligibility system triggers verification.

[Animation, arrows pointing from left to right, from “Your eligibility system” to “Verification services]

Our verification services run data checks in real time.

[Animation, arrows pointing from right to left, from “Verification services] to “Your eligibility system”]

If the data confirms compliance, we send results and reason codes straight back into existing screens.

[On-screen text: Member portal, Used only when needed to report activities, submit documents, check status and get guidance]

If more information is needed, only then do we prompt the member through the optional portal.

[On-screen text: AI-assisted automation document classification, confidence, scoring and anomaly detection]

AI supports the process by reading and classifying documents, but never making eligibility decisions. It simply gives staff stronger, clearer information without changing their workflow.

[On-screen text: Verification services, Automated verification services: A centralized verification service that checks trusted data sources first and returns clear verification results to the eligibility system]

[On-screen text: Features: Confirm identity in real time, Verify work and employment data, Leverage SNAP and TANF program participation data, Support cross-program verification, Return clear verification outcomes, Maintain audit-ready records]

Let's walk through the first step, automated verification. When eligibility sends a request, our services check wage data, SNAP, TANF participation, and education data, whatever sources your state chooses. If the data confirms that the member meets the requirement or qualifies for an exemption, we return that result immediately with a clear explanation. No staff review, no paperwork, no delays.

[On-screen text: Verification sources, States early on multiple sources, prioritized to reduce burden and improve accuracy.

-          Government data sources

o   State wage + workforce

o   SNAP/TANF

o   Education enrollment

o   Veterans Affairs and Corrections

o   Medicaid EDW]

-          Commercial/third-party data

o   Employment and income verification

o   Identify and address verification

-          Member-reported information (last resort)

o   Portals, mobile apps, call centers and paper forms

o   Self-attestation supported by targeted validation (e.g., risk-based reviews, sampling]

States decide which data sources to use and the order in which they're checked. Think of this as a configurable rule set. Prioritize state wage data, layer in SNAP, TANF information, then education enrollment, then third-party sources. Every result is fully traceable. You always know what data produced the verification.

[On-screen text: Member portal (used only when needed), a mobile-friendly, WCAG-compliant portal. Mobile-first, Guided document upload, Simple activity reporting, Faster issue resolution]

[Simulation, smartphones displaying Optum member portal]

[On-screen text: *These images are for illustrative purpose only and may not represent the latest product features or design. Specifications and content are subject to change without notice. All trademarks and brand elements remain the property of their respective owners.]

Now let's look at what happens when the data can't confirm compliance. That's when the member portal comes in. It's mobile first, simple, and only used when absolutely necessary. Members can upload documents, report work or education activities, or submit exemptions.

[Smartphones being highlighted in red]

Behind the scenes, documents are automatically sorted, read with OCR, and checked for completeness. States see fewer paper forms, fewer phone calls asking for status updates, and faster turnaround because the portal guides members through what's needed.

[On-screen text: Integration layer

-          Integration layer

o   Connects the portal and Verification Hub to existing systems – No rebuild needed

-          Value

o   Shared layer for verification results-reducing duplication and enabling modernization]

All of this flows through the integration layer, the plumbing that keeps everything connected without changing your systems.

[On-screen text: Aligned identifiers, Secure APIs, Real-time updates, Full audit logging]

It aligns identifiers, uses secure APIs, and sends updates in real-time. It also logs everything for audit and appeals, and it becomes a reusable foundation for future modernization across programs.

[On-screen text: Timeline:

-          0-2 weeks, Kickoff and planning

o   Align on scope, target populations, governance and verification data sources

-          5 weeks, Blueprinting and configuration

o   Map workflows, finalize verification data sources and define how verification results integrate with the eligibility system

-          11 weeks, API development and integration

o   Build and test APIs and data exchanges to return verification status and reason codes to existing eligibility workflows

-          17 weeks, Readiness and deployment

o   Complete readiness activities and deploy the state-branded portal and verification services to production]

The big advantage here is speed. States can typically go from kickoff to production in just a matter of weeks because we're configuring, not rebuilding. Integration is predictable. Testing is straightforward, and you can phase in components over time.

[On-screen text: How this works: What staff actually see

1)       Requires no new staff systems or portals, and no new workflow training.

2)      Integrates directly into the systems that eligibility staff already use – no new system.

3)      Through standardized APIs and event-driven updates, the solution ensures:

-          Workflows remain exactly as they do today

-          Verified data and statues appear inside current screens

-          No new logins or dashboards

-          Implementation in months, not years]

From the staff perspective, nothing changes. They stay in the same eligibility system. They simply see new verification results show up, just like other electronic verifications today.

[On-screen text: This is modernization without disruption.]

No new screens, no new dashboards, no new workflows.

[On-screen text: Why states choose this model?

-          Dimension

o   Who performs verification

o   Eligibility decisions

o   Use of AI

o   Audit and appeals

o   Staff experience

-          Optum community engagement verification

o   Automated services feeding state systems

o   Remain state eligibility system

o   AI assists verification only (no decisions)

o   Fully contained in state system of record

o   No new staff systems or workflow context

-          Other solutions

o   Vendor platform and staff

o   Returned from vendor

o   AI used for matching and decisioning

o   Split across vendor and state

o   New vendor tools and workflows

o   Higher certification and government risk]

States choose this approach because it minimizes risk. Verification is automated, but eligibility decisions remain where they belong, in the state's system. AI assists rather than decides. And because everything flows through the state system of record, audits and appeals stay clean and defensible. It's modernized verification without imposing new workflows or new vendor run decisioning.

[Animation of graphics: a thumbs up, a clock with hands moving, a piggy bank with a coin going in and out of the slot, a rocket ship flying, gears spinning]

[On-screen text: Key takeaways

-          Lower-risk path

o   No rip-and-replace required

-          Fast time to value

o   Live in 4-6 months

-          Fully fundable

o   Eligible for 90/10 federal match

-          Future-ready

o   Supports expansion to other programs like SNAP, TANF and broader integrated eligibility modernization

-          Modular, reusable technology

o   States can start with HR1 compliance and later extend the same components to other processes]

To wrap up, this model can help provide a lower risk path to H.R. 1 compliance. It's fast to deploy, fully fundable with 90-10 match, and ready to extend to SNAP, TANF, and future modernization. Most importantly, it enhances verification without disrupting eligibility. We're here to help you explore what this could look like in your state.

[On-screen text: Optum, Let’s connect: optum.com/stategov *Optum confidential and proprietary for internal use and evaluation only. Not for distribution outside your organization. All data shown does not contain actual client names, addresses or health information.]