Workflows Built for Waivers, Carve-Outs, and State-Specific Requirements

Regulatory change isn’t a quarterly event, it’s constant. Each year, CMS releases the Medicare Advantage and Part D Advance Notice followed by the Rate Announcement, setting off plan modeling, benefit updates, and operational changes that can’t wait for long IT projects. 

At the same time, D-SNPs must align with State Medicaid Agency Contracts (SMACs) under 42 CFR §422.107, contracts that spell out exactly how MA organizations and states will coordinate benefits, data, and member communications for dual-eligible populations. Requirements vary by state and evolve over time. 

And modernization pressures continue: CMS’s Interoperability and Prior Authorization final rule adds new expectations for data exchange and prior authorization transparency on a fixed timeline, changes that ripple through intake, review, notification, and reporting processes. 

Bottom line: health plans need operations that can pivot quickly without rebuilding core systems.

How AxisCore Helps

AxisCore uses modular workflows and a rules-based engine so your teams can configure and administer plans with minimal IT involvement. Think building blocks: assemble the steps you need, attach the rules that govern them, and move from policy to production faster, without custom code each time.

What “modular” looks like in practice

• Eligibility & program routing – Determine whether members fall under standard MA, D-SNP, or a state-specific arrangement, then route to the right processes.
• Benefit administration – Apply benefit design differences (e.g., supplemental benefits by county or contract) using rules that reference CMS guidance and state terms.
• Authorization & notification flows – Orchestrate intake, clinical review, decisioning, and member/provider letters with configurable steps and deadlines.
• Appeals & grievances – Enable state-specific content, timelines, and tracking alongside standard MA requirements.
• Data exchange hooks – Drop-in connectors for file-based or API-driven feeds to meet emerging interoperability expectations.

Why This Matters Now

1) State-specific D-SNP expectations keep changing. 
States can impose integration, data-sharing, and notification provisions through the SMAC. When an annual update lands, operations must reflect it quickly (e.g., new notification content or data exchange cadence). Our rules layer isolates those state deltas so operations, not developers, can roll them out safely. 

2) Policy updates arrive on fixed clocks. 
The Advance Notice/Rate Announcement cycle drives yearly recalibration across benefits, bids, and downstream processes. Modular workflows let you model and implement changes earlier, so member communications, producer training, and internal QA aren’t squeezed at the end. 

3) Carve-outs and waivers are operationally real. 
Programs frequently carve out specific benefits to different administrators. A clear example: California’s Medi-Cal Rx moved pharmacy benefits out of managed care to fee-for-service in 2022, a large-scale operational shift that required new routing, data exchange, and member messaging at launch. Our approach treats carve-outs as configuration, not re-engineering. (Medicaid example used to illustrate carve-outs.)

4) Interoperability & prior authorization standards are maturing. 
CMS’s recent rule sets new requirements for how payers exchange data and communicate PA decisions, affecting intake, review, and notification steps. HealthAxis workflows already segment those steps, so updating logic, payloads, and timelines is a targeted change, not a system overhaul.

How AxisCore Delivers

Configurable – Tailor workflows to your organization’s needs and to regulatory specifics:

• Parameterize timelines, content, and routing by state, contract, or line of business.

• Reference rule sets (e.g., D-SNP contract terms, MA communications standards) directly in workflow logic to drive consistent outcomes.

Reusable – Leverage pre-built modules across teams to increase efficiency and consistency:

• Standard steps—eligibility checks, UM review gates, A&G queues, provider/member notifications—are drag-and-drop.
• Shared components lower training overhead and reduce variance across markets.

Scalable – Evolve and expand workflows without disrupting existing systems:

• Introduce a new state requirement or benefit carve-out by adding a branch with its own rules, no code freeze, no parallel stack.

• Version workflows, test safely, then promote to production on your timeline.

Scenarios your Team Can Act on Immediately

• A state updates its D-SNP SMAC: Add a new notice template and data-sharing cadence; apply only to members in that state and product line through targeting rules.
• Annual MA changes: Adjust benefit logic following the Rate Announcement while preserving last year’s configuration for audit traceability.
• Benefit carve-out or vendor change: Reroute pharmacy or behavioral health transactions to a different administrator; update member and provider letters accordingly. (Illustrated by the Medi-Cal Rx carve-out example.)
• Interoperability/PA updates: Insert new API calls or decision-explanation steps into the existing authorization flow, rather than rewriting it.

Governance you Can Trust

• Transparent rules: Every decision path is visible and explainable for regulators and auditors.
• Version control & rollbacks: Promote, compare, and revert workflow versions as needed.
• Separation of duties: Business owners manage rules; IT governs environments and integrations.

What your Organization Can Gain

• Speed to market: Convert policy into production changes faster—without monopolizing scarce engineering time.
• Lower operational risk: Centralized rules reduce one-off exceptions and help ensure consistent compliance.
• Cost control: Reuse modules across lines of business and states; focus effort where regulations truly differ.

Let’s Make Policy Agility your Competitive Advantage

HealthAxis gives your plan the operational flexibility to adapt quickly to policy or benefit changes across Medicare Advantage, D-SNP, and Medicare programs—without disrupting the systems you rely on every day.

If you’re preparing for state-specific updates, planning for the next Advance Notice/Rate Announcement cycle, or mapping to new interoperability expectations, we’d welcome a conversation about how our modular workflows and rules engine can help. Schedule a discovery call today.