Phased noncompliance procedure

Context

Disenrolling a Medicaid beneficiary is high-stakes. The Centers for Medicare and Medicaid Services (CMS) requires a documented due-process procedure: statutory notice, an active cure period, case-worker review, an alternative-eligibility check, and a hearing notice, in that order. Skipping or reordering steps creates legal liability. A naive implementation that treats the procedure as a checklist (with operational shortcuts available to staff under pressure) cannot defend the audit posture when a wrongful-disenrollment lawsuit arrives.

Decision

Civitas Compliance enforces the noncompliance procedure as a 15-phase machine with explicit valid-transition tables. Phases cannot be skipped or reordered. Disenrollment-deadline violations raise an exception in code, not a policy warning. The platform structurally refuses to disenroll a beneficiary before the statutory deadline has passed. The case-worker review exit is role-gated; only authorized staff can advance the procedure past that phase.

Consequences

Statutory due process is enforced structurally, not by training. New procedural steps require schema migration and a code change, which produces a documented audit trail of when and why the procedure changed. Auditors can verify procedural compliance by inspecting the ledger transitions. Operational cost: edge-case scenarios (court orders, retroactive restorations) require new phase transitions, which requires engineering effort. The discipline is uniform; staff cannot route around the procedure by clicking through faster.

Alternatives considered

• Policy-based check at deployment time. Rejected: bypassed by hot-fix code paths and operational shortcuts under pressure. The check must live in the code path itself.
• Workflow engine with configurable transitions. Rejected: configurable means tweakable, which means the audit trail of “why did we transition to disenrolled?” can change. The phases need to be hard-coded against the statute.