Medicaid Redetermination: How Providers and Payers Should Respond

One of the first national measures enacted during the COVID-19 pandemic was a pause in Medicaid redetermination, a process used by states to assess residents’ eligibility for the government-funded insurance program.

Medicaid redetermination was halted in March 2020 to ensure continued access to essential healthcare during the declared Public Health Emergency (PHE). However, states were authorized to restart Medicaid redetermination on February 1, 2023, with possible disenrollments effective as early as April 1. As a result, an estimated 15 million Medicaid enrollees risk losing their benefits.

This article explores the complexities confronting health plans and providers as they assess eligibility for millions of patients, as well as Availity’s efforts to address these challenges.

Medicaid Redetermination Challenges

The return of Medicaid redetermination signifies the potential end of a three-year period of uninterrupted coverage for millions, raising numerous concerns related to accessing a wide range of healthcare services.

First, providers and their patients are confronted with uncertainties in understanding upcoming redetermination dates, and whether Medicaid coverage will continue once they are up for redetermination. The lack of transparency and communications from states adds to the confusion, as providers struggle with comprehending rollout timelines and procedures.

This is causing providers to grapple with identifying coverage status. The situation could result in treating patients with lapsed coverage or affecting pending claims, impacting the immediate healthcare experience and negatively affecting patient care in the long term.

On the other hand, payers face the potential loss of membership as they transition from the expanded pandemic-era enrollment numbers, which saw an increase of nearly 30 percent, accounting to 23 million in growth. Payers now have the task of managing the delicate balance between retaining members and ensuring accurate eligibility assessments.

Restarting Medicaid redetermination presents several risks to both health plans and providers, including:

• Increased claim denials and disruptions to eligibility and benefits workflows
• Increased patient collections
• Unnecessary abrasion in provider engagement initiatives
• Care delays or interruptions for patients unaware of their eligibility status

How Availity Can Help

In response to these challenges, Availity has a range of solutions to support both providers and payers with Medicaid redetermination.

1. New Payer Value Add During the E&B Workflow: Availity’s innovative solution involves notifying providers of their patients’ current Medicaid status. The solution integrates an API that streamlines access and makes the information easier to find. This solution employs a two-pronged approach. As Medicaid redetermination will continue to be an ongoing process, the API provides a long-term option that helps ensure recipients are still eligible for the benefits they’re receiving. 

Utilizing the Availity Essentials portal, providers can easily obtain a patient’s status during eligibility and benefits checks. This API integrates into their workflow, enabling them to simply click a button to access information about the status of a patient’s enrollment or redetermination, and whether they are in good standing, inactive, or due for redetermination.

While the foundation lies in eligibility, in the long term, outreach is also critically important. This solution empowers providers to engage with patients at risk of losing their benefits and offers resources to guide them through the process to help maintain coverage. This ensures that patient needs are met and they have the necessary information, while providing transparency and insight into potential revenue impacts for providers.

2. Critical Messaging Through the 271 Transaction: Payers can now send critical messages within the message segment of the 271 transaction (eligibility and benefit response), enhancing communication and transparency with providers about patient Medicaid status, streamlining processes, and reducing the need for calls to payers.

3. Bundled Solutions for Providers: Availity leverages existing tools, including Advanced Real-Time Eligibility, Self-Pay Eligibility Verification and Financial Profile solutions. This combination aids providers in identifying Medicaid patients who may have obtained medical coverage elsewhere as well as assisting in outlining the appropriate financial path for their patients.

 Benefits of Availity’s Solutions

• Providers: By equipping providers with information about patients’ Medicaid status, Availity’s solutions enable them to engage proactively and offer necessary guidance, reducing patient confusion and care disruptions.
• Payers: The tools provided by Availity facilitate effective outreach and communication with providers, streamlining the process and reducing call volumes. This not only improves payer-provider relationships, but also ensures the smooth transition of Medicaid redetermination.

Looking Forward

As the unwinding of the Medicaid redetermination process unfolds over the next 12 to 18 months, transparency and easy access to information will be crucial. Availity’s solutions are designed to address this need, offering providers and payers a clear path to navigate this complex process. Availity is proud to be paving the way for a more resilient and patient-centric healthcare landscape by facilitating transparent communication, proactive engagement, and access to critical information.