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Medicaid Redetermination Post-PHE: Navigating the Uncertainty


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 This may be due to outdated contact information or failure to complete renewal packets within a specific timeframe.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:

  1. Take a cross-functional, 360-degree approach to better understand members and their communities.
    Medicaid redetermination and reenrollment represents a premier opportunity for plans to better understand their members and the communities they live in. For example, redetermination has disproportionately impacted people experiencing homelessness; here is where the connection to homeless shelters or temporary housing, street medicine, and boots-on-the-ground outreach is critical. Get to know and treat the members you serve. The ability for a plan to look at their membership at a community level and layer over members at medical, behavioral, or social risk who were recently disenrolled, is powerful.
  2. Focus on strategies and best practices to prevent the loss of members due to redetermination.
    Identifying the members’ risks and meeting them where they are is a best practice, proactive strategy for members who may face disenrollment, but there is no consistent process per state. If a state agency puts up a billboard and signs about redetermination, there still needs to be a personal level of engagement. The members are likelier to trust their provider, nurse, therapist, receptionist, community liaison worker, pastor, or their peers at the local hang-out vs. a political entity or even a health plan that tells them they need to re-enroll. Plans can begin to work with navigators, federally qualified health centers (FQHC), faith-based organizations, local charity organizations, mobile markets (Veggie Mobile), farmers markets, grocery stores, and state/county to provide whole community outreach, assistance, and education on why members need to keep their coverage.
  3. Look for ways to leverage technology to automate, streamline, accelerate and improve the member experience associated with the Medicaid redetermination/re-enrollment process.
    Health plans should have a centralized platform comprised of enrollment information, demographics, member preferences, utilization management, case management, complex disease management, social determinants of health, robust reporting, and dashboards. Here they can identify what they know about their members and create a patient and population-level strategy to get ahead of disenrollments.

    With more than 64% of Americans unaware of redeterminations resuming, health plans must leverage their technology before disenrollment. They can build reports to look 12 months out from the enrollment date and utilize the data within their platform to identify high-cost, high-need members at risk of disenrollment, consider social risk factors such as income, food insecurity, housing instability, transportation barriers, and education, and create a high-priority outreach list. The right technology tools will allow health plans, which commonly hold members’ most recent contact information, to capture the address they receive on the eligibility file without overwriting that obtained from the member and share changes with the state entity, when applicable. Capturing (unpaid) caregiver information is essential when building messaging for Dual Eligible Special Needs Plans (DSNP) members.

    When a case manager is working with a high-complex member, quality team members speak to providers or members to close gaps in care. This is an opportunity to have the platform cue (icon or alert) the end user that this member is at risk of losing coverage; it is prime time to have the discussion and, most important, identify any potential barriers for the member related to the re-enrollment process, and help mitigate the barriers. A sophisticated platform can also for automated outreach in the member's preferred language and communication channels and can capture all good faith attempts within the platform to demonstrate compliance.

    Even in cases where eligible members are already disenrolled, health plans should be able to create a chase list that is dynamic and automated as soon as a member falls off the plan and automatically updates when the member re-enrolls. If a member is predicted to no longer need coverage, identify an exchange program to ensure they don't lose coverage. This may also give the member a sense of comfort and increase trust, especially if the member has already had a good experience with the plan; they can keep their existing health plan and care teams and are more likely to transition to an exchange plan.

    Plans should let technology and automated workflows provide cues during unexpected or expected touchpoints with the member; during these touchpoints, a re-enrollment discussion or warm handoff to the appropriate department can occur. Once a member returns, the centralized platform should allow the plan to pick up and provide continuity of care; in other words, the member's pertinent clinical, behavioral, social, and physical health information is still readily available.

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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