In this opinion piece, Karen shares some of the critical issues related to re-enrolling members subject to Medicaid redetermination and covers some of the most important critical success factors for organizations seeking to optimize their response.
To ensure access to care during the COVID public health emergency, state agencies were directed to keep Medicaid beneficiaries enrolled regardless of changes to their eligibility. That continuous coverage ended on March 31, 2023, and while states are staggering their redetermination processes and following different timelines, many recipients saw disenrollment emails hit their inboxes that very day.
From my perspective as a leader in an organization that helps healthcare organizations deliver whole-person, holistic care to individuals in the Medicaid population, it is apparent that the best practices for managing the re-enrollment process are poorly understood and the response to Medicaid redetermination has been largely haphazard.
The State of State-by-State Redetermination
Data shows that Medicaid/CHIP enrollment increased significantly during the coronavirus pandemic, growing by 21.2 million enrollees or 29.8% from February 2020 to December 2022.This means that in addition to the language, cultural and socio-economic factors that already make navigating Medicaid challenging for many, almost a third of members have never experienced re-enrollment and may need additional support with the process.
According to KFF, across all states with available data, 73% of all individuals disenrolled had their coverage terminated for procedural reasons. This may be due to outdated contact information or failure to complete renewal packets within a specific timeframe. Re-enrollment can be especially challenging for people with limited English or disabilities who face the most significant risk of losing coverage.
Note that CMS has paused Medicaid disenrollment in many states for failing to comply with federal rules, and many members disenrolled for procedural reasons are still eligible for Medicaid (including retroactive coverage for care received while eligible but disenrolled). So, there is still ample opportunity for plans to adjust their approaches to reenrolling members subject to redetermination to help them avoid gaps in care and minimize the impact on plan revenue and quality reporting.
Best Practices for Managing Medicaid Reenrollment
As experts continue to weigh in on responding to the redetermination process, many related questions have surfaced for payers: What can we learn from this experience? How can we best assist our members with re-enrollment? What can health plans do to prevent loss of members due to Medicaid redetermination/re-enrollment? Are plans that manage Medicaid enrollees prepared to address the revenue risk they may face due to changes in enrollment? How does a plan remain nimble during and after the redetermination process plays out?
Answers to these questions are complicated, but three key principles to keep in mind are:
After the Unwinding
During this time of uncertainty, it is estimated that community health centers (CHCs) that rely heavily on Medicaid revenue will have an estimated decrease in total health center revenue by 4% to 7% nationally, with an associated loss in patient capacity of 1.2 to 2.1 million patients and a staffing capacity loss of 10.7 to 18.5 thousand staff members. The financial impacts are staggering, potentially leading to a loss of $1.5 billion to $2.5 billion in patient revenue, or approximately 5.5% of total CHC revenue. CHCs will struggle to provide community members with necessary healthcare when revenue is impacted. It is resulting in (potentially) sicker return members due to a lapse in care.
The financial impact on health plans and the overall delivery system has yet to be determined. Most importantly, the impact on members who lose coverage and don't regain coverage either through another means or re-enrollment can lead to catastrophic costs in the future. By taking the above steps and making this a group effort, healthcare organizations can play a role in mitigating these financial implications while also helping members maintain their care.
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