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Getting Ready for a Historic Medicaid Redetermination Cycle

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Across the country, health plans, healthcare providers and state Medicaid authorities face a massive surge of uninsured members and uncompensated care when the federal public health emergency (PHE) ends and nearly 80 million Medicaid recipients face redetermination of their eligibility status.  A recent study by Georgetown University’s Urban Institute projects more than 15 million individuals will lose coverage, including many who may actually still qualify, and states and the healthcare organizations they work with are extremely unprepared for this administrative tsunami.

While some states and healthcare organizations are prepared for this surge, many still employ outdated Technologies, highly inefficient and bureaucratic processes and are severely understaffed. Many state health authorities, managed care organizations (MCOs) and health systems have dragged their feet on embracing digital business processes, but old school labor-intensive processes will be insufficient to meet the 2022 redetermination challenge. To make matters worse, this massive redetermination comes at a time of intense churn in insurance coverage with the “great resignation” accounting for tens of millions of job changes in 2021, putting the insurance industry and ACA exchanges in administrative overload before Medicaid reassessment even begins.

The good news is that the resources and know-how exist to navigate this difficult transition without hurting those in need or the healthcare organizations that serve them, but stakeholders have to start planning, organizing and collaborating immediately to be ready for action in 2022.  Across the country, many payers and providers have adopted the technology and business practices required to ensure that redetermination can proceed efficiently and accurately, relying on sophisticated analytics, technology-enabled workflows, multichannel communications and agile operations.

COVID Impact on Health Insurance and Healthcare

In response to the pandemic, congress passed the Families First Coronavirus Response Act (FFCRA) which increased federal matching funds (FMAP) for Medicaid by 6.2%, and prohibited states from redetermining eligibility during the official public health emergency (PHE). With easy access and immunity from redetermination, Medicaid ranks swelled across the country by more than 16% (11M + enrollees).  While these measures have made it easier for the uninsured to get coverage during the pandemic, they have also resulted in a great deal of missing, incomplete and un-vetted paperwork that need to be reassessed and resubmitted as part of the annual redetermination process once the PHE ends.

Red Flags for Redetermination Surge Readiness

CMS has committed to a 60-day heads up before the PHE is ended, and a 12-month window after the PHE officially ends for states to complete the redetermination process for their Medicaid populations.  That may sound like a lot of time, but the temporary FMAP increase is set to end in March of 2022, so there will be a strong financial incentive for states to purge their rolls as quickly as possible.  Unfortunately, some states may find it very difficult to handle the especially large and difficult redetermination process ahead of them efficiently and accurately.

Utah recently provided an example of how the redetermination process can go wrong when it decided to begin redetermination for state enrollees in CHIP, a Medicaid-like program which covers minors.  The state disenrolled 6,000 children, more than 41% of its CHIP population, and officials have since determined that as much as 85% of those disenrolled likely remain eligible.  While uncovering the error is a positive sign, all those families need to go through a re-application process, further burdening them, state health officials and the healthcare providers trying to deliver care.

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Keys to Success

It is a daunting situation, and states and the MCOs and health systems they work with will all play a critical role in successfully navigating through this challenging redetermination process.

In the last decade many payer and provider organizations have learned how to effectively manage the specific challenges of streamlining Medicaid enrollment and handle the on-boarding of large numbers of new members with speed, efficiency and great customer service. In many cases, hospitals and health plans can work directly with enrollees to facilitate completing necessary documentation and work through the re-application process when necessary.

Here are few key areas of focus for stakeholders to navigate the process ahead more effectively:

Automate for Efficiency

  • Use population-level analytics to stratify enrollees based on their specific needs and develop redetermination workflows customized for each group.
  • Combine specialized training at each phase of the process, with automated workflows to ensure efficiency, accountability, and paper-trail.
  • Feed dashboard data to staff facilitators for each member/patient to serve as primary point of contact and troubleshoot specific issues.

Communicate for Cooperation

  • Deploy integrated multi-channel communications to reach enrollees with simple, easy to understand information and instructions.
  • Beware of state-provided contact information which may be out-of-date and mail address only – insurer and provider data will likely be complete and more accurate.
  • Tailor communications to expected preferences, leveraging mail, email, telephone and SMS in combination and adjust mix dynamically based on response patterns.
  • Deliver communications campaigns for notifying members of redetermination process, updating patients frequently on timing and deadlines, providing access to support services, and providing regular status updates.

Be Proactive

  • The PHE termination deadline has shifted, but the March deadline for termination of the emergency FMAP increase has not.  Experts have recommended a phased approach where the redetermination population would be divided up into cadres with deadlines for each group spread out over the year to.  To be ready to start processing enrollees sometime in mid-2022, stakeholders need to start putting the technology, processes and trusted relationships in place immediately.

The kind of multi-stakeholder process involved in managing such a large redetermination cadre will take time to work out and require expert partnerships to be successful.  With the right approach, and intelligent application of modern technology and business processes, states and the payers and providers they work with will have ample opportunity to successfully navigate this challenge. The work these organizations do in the next year can improve access to care, reduce inequities and create a robust digital foundation to support much more accurate and efficient administrative processes for years to come.


Venkatgiri Vandali (Giri) is the President of Healthcare and Lifesciences at Firstsource, a leading provider of Business Process Management services, and is responsible for driving Digital Services and Solutions for Health Plans and Health Plan intermediary markets.

Giri is a seasoned executive with over 25 years of experience in the healthcare and tech space building new businesses from the ground up and providing strategic direction to large enterprises. Prior to Firstsource, Giri was Head of Healthcare BPaaS practice at Cognizant. He is an avid reader and a big fan of cars and long drives.

This article was originally published on Healthcare Business Today.

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