Solving Medicaid Redetermination at Scale

It’s even worse than many experts predicted: as of early August 2023, almost 3.9 million people have lost Medicaid coverage as redetermination resumes after the end of continuous coverage under the COVID-19 public health emergency.¹

This mass disenrollment is likely sweeping up Medicaid-eligible patients who may not have gone through a redetermination period before or have changed their contact data or missed a letter or other outreach attempt. Among those states reporting data, 75% of the disenrolled patients had their coverage terminated due to those and other “procedural” reasons.²

Losing true Medicaid-eligible patients will cost health plans and providers vital revenues in the short term. Disenrolled patients who land in the self-pay category likely will delay receiving care due to cost issues. Neglected screenings and care for chronic conditions can lead to higher costs of care and other financial repercussions in the longer term.³

In most cases, providers and payers can’t expect state health agencies to be effective re-enrollment partners. Many state health departments seem to have underestimated the volume and complexity of re-verifying Medicaid eligibility. The US Department of Health and Human Services expressed its alarm at eligible patients losing coverage for procedural reasons, such as not understanding how to complete a form. ⁴

To prevent loss of revenue and maintain continuous care for members and patients, health plans and providers need to act immediately to launch Medicaid reenrollment campaigns.

In our experience, many health plans and providers thought they had sufficient in-house eligibility staff to manage redetermination. However, as the scale of the redetermination effort becomes apparent, it’s clear individual payers and providers typically don’t have the internal resources to contact, educate and enroll thousands of Medicaid-eligible patients. Re-enrollment is a significant administrative burden.  That’s why some providers and payers are opting to work with experienced third-party service providers who can deliver all the requirements of a successful redetermination outreach program.

However, there are caveats. Payers and providers can’t assume vendor eligibility services will be appropriate for managing the redetermination deluge.  When evaluating service providers for re-enrollment management, payers and providers should look for vendors who can deliver the following:

• Outcomes-based pricing model. Many vendors charge a percentage of the initial billings of re-enrolled Medicaid patients. With outcomes-based pricing, healthcare organizations retain those revenues because they pay a flat rate only for successful re-enrollments. This model essentially eliminates financial risk to payers and providers.
• Minimal involvement required from in-house IT. A typical outreach campaign requires only minimal data from in-house systems. IT’s main responsibility should be providing a secure file transfer. In one case, we worked with a provider who simply passed along a file of Medicaid patient contact data provided by their largest managed Medicaid plan.
• Pre-contact screening. A vendor with the right automation tools can analyze the initial contact file to identify eligible patients, eliminate those individuals who now have other insurance coverage and prioritize contacts to get maximum results for effort expended.
• Multiple outreach attempts on a variety of channels. It likely will take more than a single call to reach a patient, so multiple attempts should be built into the agreement. Vendors should use mobile and other digital channels. Our recent Voice of the Member research shows many Medicaid members prefer contact via mobile phone.
• Track and trace capabilities. When contact numbers prove to be out of date, which is fairly common for the Medicaid population, vendors should have resources available to trace a patient’s current contact information.
• State by state Medicaid enrollment expertise and compliance. The vendors’ agents must be experienced and skilled in taking a patient through the enrollment process. Every state has different regulations about marketing health plans, and Medicaid re-enrollment efforts must comply. Vendor expertise in state level regulations is especially critical for plans and providers serving Medicaid members in more than one state. An effective way to evaluate a vendor is to ask for its first pass enrollment rate statistic; a score in the 90s reflects the appropriate level of expertise.
• Follow up and reporting. After a successful contact with a patient, the vendor should follow up to ensure the patient submitted a complete application and then verify the re-enrollment and share that data so providers and health plans may follow up.
• Analytics on all contacts. Information about which channels proved effective for outreach provides intelligence for supplemental contacts, such as follow up and promoting wellness programs.
• High member-patient satisfaction. A vendor should be willing to capture and share net promoter scores among members and patients contacted. The vendor is acting on behalf of a provider or plan, so it’s important to know these scores. Patients and members typically are grateful for the assistance in maintaining coverage, especially when it is offered at no cost to them.

Getting started is relatively easy: while evaluating vendors, providers and payers may run reports identifying individuals enrolled in Medicaid in the last 12-18 months to understand their exposure to dis-enrollment. They also may blanket patient care areas and digital channels with educational materials, such as those created by the Centers for Medicare & Medicaid Services (CMS).

Capturing Medicaid patients on the brink of being disenrolled is critical. Once out of the program, many individuals may not access any health coverage. According to the Kaiser Family Foundation, a year after Medicaid disenrollment, about two-thirds of people had a period of uninsurance.⁵ Deferring care can result in healthcare organizations dealing with more serious and expensive conditions in the future. Other patients may continue to use health services, failing to realize they’ve lost coverage, creating a challenging situation. Providers and payers can help ensure eligible patients get the care they need while mitigating financial and revenue risk by quickly getting re-enrollment efforts under way.

Cognizant TriZetto has provided Medicaid eligibility services for more than 25 years. We have the expertise, experience and scale to help your healthcare organization quickly launch effective redetermination efforts. Each of our team members averages 10-plus years of Medicaid enrollment experience. Our Medicaid first pass enrollment rate is more than 90%, and we routinely record nearly perfect Net Promoter Scores for our clients. To find out more about how we will work with your organization to help eligible individuals retain their Medicaid membership, please visit cognizantrcm.com/eligibility-enrollment.