The Redetermination Readiness Checklist: Ensuring Continuity of Coverage for Eligible Medicaid Beneficiaries

November 18, 2021 Katie McKillen

Medicaid enrollment is expected to shrink by millions next year, and health plans need robust outreach programs to make sure eligible beneficiaries don't lose coverage unnecessarily.  

As early as January 2022, the federal government will potentially declare an end to the COVID-19 public health emergency. At that time, as state Medicaid programs begin "unwinding" several changes made during the emergency, a major focus will be on the need to resume normal eligibility determination and enrollment for millions of low-income Americans. 

This undertaking includes disenrolling those individuals no longer eligible for Medicaid, a process paused by federal relief legislation during the emergency. Latest guidance indicates that states have up to 12 months after the emergency to resolve any pending eligibility determinations.  

The task is enormous, as are the stakes for Medicaid beneficiaries and health plans. According to a study in September by The Urban Institute and Robert Wood Johnson Foundation, by the end of this year Medicaid enrollment will reach more than 76 million nonelderly individuals, an increase of nearly 17 million people since the pandemic began. By the end of 2022, the states' redetermination efforts will result in a drawdown of 15 million beneficiaries, the same study projects. 

Inevitably, millions of these Americans will move off Medicaid coverage because they now exceed the income thresholds. However, millions of others eligible for Medicaid could be at risk due to unmanageable workloads or staff to support continuous enrollment. If this resumption of enrollment and disenrollment processes is not orderly and thorough, we risk leaving behind many eligible people who are still struggling to recover from the COVID-19 upheaval. More vulnerable populations, such as those without college degrees and Black women, remain millions of jobs behind where they were before the pandemic. A poorly executed redetermination process could cause beneficiaries' coverage to lapse and compound the challenges they face. 

Health plans are already bracing for lost premiums due to an exodus of ineligible members. They are also vulnerable to the loss of premiums for eligible members who don't complete their eligibility paperwork on time, resulting in gaps in continuous coverage. These gaps can add up to millions of dollars in lost premiums for a Medicaid plan due to small lapses between eligibility segments. 

With so much at stake for their members, Medicaid plans can't afford to delay their preparations for the end of the emergency. At Evolent, we're helping our health plan partners, who oversee more than 1 million Medicaid lives, to take a rigorous, comprehensive approach that engages members at multiple touchpoints to help them re-confirm their eligibility. And if they are no longer eligible, we help them transition to other coverage that they can afford.

Below are the broad outlines of the ways Medicaid plans can help ensure that all members understand the redetermination process, know their deadline and what steps they need to take. For a more detailed dive, get our Redetermination Readiness Checklist to take a closer look at all the tactics we've identified.

Lay the Data and Analytical Groundwork  

Success depends on having accurate member eligibility data, integrating it with your administrative and clinical systems and making it actionable. This data starts with having a member's redetermination date, one data element most health plans often rely on the state to provide. Aside from knowing each member's redetermination date, look across your membership to gain insights on a population level. Can you identify certain members who are more likely to not complete their paperwork on time—such as those with language barriers or whose Medicaid coverage has lapsed in the past? They may need a warmer touch. Are there certain population risk groups (rate cells) that tend to lose coverage more frequently? These may need close attention and coordination with the state. Are there certain ZIP codes where more members are coming up for renewal around the same time? Perhaps a community event or outreach can better support these members.

Consider adding an alert to your core administration platform, as we've done at Evolent, to notify customer service representatives, Care Advisors and others when they open a member's record that their redetermination date is approaching within 60 days (or when the state typically sends paperwork), and they can remind the member. 

Capitalize on Member Touchpoints with the Plan

Getting anyone to complete a government form can be a challenge, and for Medicaid beneficiaries, that difficulty is compounded by other factors—for example, the fact that they move frequently and may not get forms in the mail.   

To overcome such barriers, health plans need to over-communicate with members and consider every conceivable touchpoint as an opportunity for engagement. Any time a member calls in to the plan, if their redetermination date is near, customer service representatives should be prompted by the alert to educate the member on the steps needed to maintain coverage.  

Strategic outbound communications are also key. About 45 days before the redetermination date, plans should send texts and robocalls to make sure members got their redetermination paperwork and ask if they need assistance completing it. Live calls should target those members identified as needing a warmer touch.

Messaging should also be added to member newsletters, postcards and other outreach, including live events such as health fairs. For higher risk members, outreach techniques should also consider the value of allowable incentives, such as nominal gift cards or raffles, to increase the likelihood of completing their redetermination paperwork. To maximize ROI, analyze your membership to target those who are most likely to be motivated by the offer.   

Engage the Full Care Team in the Redetermination Process

While hearing from a health plan is key, members are more likely to follow the advice of their health care providers.  We recommend re-educating providers on the importance of member's completing their redetermination process timely to ensure there's no disruption to their care.  Sharing peak times of member redetermination with the provider may help them engage patients who may otherwise miss the opportunity to complete their redetermination process.

_q_tweetable:If this resumption of enrollment and disenrollment processes is not orderly and thorough, we risk leaving behind many eligible people who are still struggling to recover from the COVID-19 upheaval._q_ 

Plans can give providers an additional nudge by regularly reporting back their retention performance through analytics. Medicaid plans should send each primary care group a monthly report on their retention rate—using the number of members with redetermination date in a given month as the denominator and the number who are still eligible with the plan 30 days after that date as the numerator. Showing providers their rate and how it compares to a benchmark of their peers will hopefully encourage them to keep pace with or surpass others.

Care managers, social workers and others who interact with members should also be cued to bring up the importance of re-establishing eligibility.

Don't overlook the potential role of pharmacies. Members who rarely visit a physician may still make frequent trips to pick up prescriptions. Having an integrated data hub supports sharing of the redetermination date to downstream functions to increase visibility to more than just the medical care team. Consider printing the redetermination date with a clear call to action on the paperwork that comes with their fill.

Ensure Continuity for Ineligible Members

As the unwinding begins and it becomes clear which members are no longer eligible for Medicaid, there will be many who still qualify for heavily subsidized coverage through an exchange plan. To ensure continuity of coverage, plans should help transition members to these other plans that provide continuity of care. Health plans offering a commercial insurance product will be well positioned to funnel those members to new coverage without risking a lapse in care, and while keeping their same primary care provider. 

High member churn is a given in Medicaid plans. However, the upcoming redetermination process will be unlike any we've seen before. Plans that prepare early, leverage data and analytics, and take an all-of-the-above approach to communicating with members will be in the best position to keep them continuously covered and protect their premium.  

Download the Redetermination Readiness Checklist

About the Author

Katie McKillen

Katie McKillen serves as regional president of market operations for Evolent Health Services. Over the last four years at Evolent, she has focused on Medicaid health plan operations via a strategic partnership model. Katie started her health care career working in nonprofit hospital management consulting, where she addressed issues of access to care and patient financial advocacy. She later joined the Peace Corps, combining her interests in international health, travel and community development as she served two years in Armenia. Katie has worked on a variety of health care initiatives, including housing impacts on health, financial infrastructure of domestic violence centers, access to healthy food, and population health analytics. She holds a master’s degree in Health Policy & Management from Harvard’s School of Public Health.

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