Planning for Eligibility Redetermination Post-Public Health Emergency

Updated on August 12, 2021
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By Nathan Allen, Senior Vice President, Eligibility Practice Team Leader at Firstsource 

During the ongoing Public Health Emergency (PHE), the Families First Coronavirus Response Act (FFCRA) offers enhanced Medicaid funding to states meeting certain conditions, including maintaining continuous enrollment for members who might otherwise be ineligible. As a result, almost every state’s Medicaid population has expanded since the onset of the global health crisis.

After declining between 2017 and 2019, Medicaid enrollment grew by 13.1% between February 2020 and January 2021 – a reflection of the increased job losses, and resulting loss of income, in the wake of the pandemic. As a result, hospitals are seeing more Medicaid patients than self-pay.

What does all this mean for states and hospitals when normal operations resume at the end of PHE?

Transitioning back to normal operations

The end of PHE will mean a return to normal Medicaid enrollment and eligibility redetermination process. While federal guidelines provide broad guidance on how to transition, there are no detailed directions and states are also constrained by a short timeframe for doing so. In December 2020, CMS indicated that states will have just six months to catch up on eligibility requirements following the end of the month in which the PHE ends. States that do not meet the outlined timelines will face increased risk of audits and remedial actions. 

The question then is how can states navigate the transition while minimizing lengthy application delays and mitigating erroneous disenrollment? Finding optimal answers to this question is crucial from both the patients’ and health systems’ perspective.

While individual state enrollment numbers vary, almost all states have millions of Medicaid enrollees who need continuous care. According to the Commonwealth Fund, of the more than 68 Mn beneficiaries enrolled as of July 2020, 44% were children, 56% were adults and 14% were beneficiaries with disabilities. Clearly, erroneous/delayed enrollment could impact healthcare access to millions of Americans in need. 

At the same time, it can create significant financial implications for health systems.  They could lose an average of $250 – $350 per month, per member – this means that losing even 1000 members could translate to $2.5 Mn – $3Mn in lost revenues.

Challenges standing in the way

The situation presents several unprecedented challenges to states at a time when their resources are already under pressure. They must catch up on a huge backlog of auto-renewed clients (who have not been subjected to eligibility verification for over 12 months) within a short time span of six months.  This is easier said than done given that:

  • A majority of the Medicaid enrollment and eligibility verification processes are still manual and paper based. While some states are moving to online form filling and submission, digital adoption is still in a nascent state.  
  • There is lack of clarity around the process – nearly 40% of Medicaid beneficiaries are unaware of the nuances of the process. 
  • The onus to submit forms in a timely manner rests with enrollees and states are dependent on member cooperation to revalidate the information – if a member does not act, it results in loss of coverage. But the reality is nearly 50% of enrollees rely on telephone, mail and in person applications and delayed submissions could result in a large chunk of disenrolled members, impacting revenues.

Two-pronged approach to easing the transition

The good news is states can take a two-pronged approach to ease the transition and enhance member experience. One – reduce the complexities around the enrollment process, expand patient outreach, and enhance enrollment support to proactively prevent lapse of Medicaid benefits. Two – streamline the process of Medicaid eligibility and enrollment. 

A built-for purpose digital engagement and eligibility verification platform can help achieve both objectives by:

  • Enablingdigital deflection through multi-channel outreach based on member preferences – QR code on paper form, Email, Text, Phone with call back options – and directing them to the state’s online portal or a built-for purpose microsite. 
  • Capturing the necessary information on the site using a replica of a pre-filled renewal application.
  • Leveraging rules-driven eligibility checks to identify potential members that meet the criteria set by states and flag them for faster qualification.
  • Offering a self-service portal to support24 x 7 self-service on a variety of devices like smart phones, tablets, PCs or Macs, provide access to state-specific application forms, and enable members to upload necessary documentation. 
  • Enabling end-to-end omnichannel tracking and reporting for granular insights.

Supplementing the platform with voice outreach, both outbound and in-bound, can further enhance the effectiveness of the digital solution. For those states that allow providers to perform member outreach, the solution can be deployed at the provider end to further ease the burden on the state.

Seamlessly winding down continuous enrollment

Even as states prepare for the transition, yet another factor will likely play out. As the vaccine rollout accelerates and people return to the workforce, the number of people eligible for Medicaid is expected to drop, leading to an increase in the number of self-pay patients. While this could vary based on the geography and demographics, it has major implications for providers. If a patient does not qualify for Medicaid, digital-first solutions can also help providers identify alternate funding sources.

As states look to improve member retention while complying with CMS mandated timelines and providers seek ways to strengthen their revenue integrity, digitally enabled solutions are emerging as the answer. On the one hand, they help enhance patient engagement and enable them to seamlessly navigate the redetermination process, improving access to care as well as the financial experience. On the other, they help increase Medicaid renewals and identify alternate funding sources, accelerating and protecting revenue for providers.


Nate’s tenure with Firstsource spans over 22 years and includes Receivables Management, Eligibility Services and Transformation Technology experience. As the Senior Vice President, Eligibility Practice Team Leader, Nate will continue to focus on ways to drive innovation to the Firstsource eligibility business. Nate is a subject matter expert on our MFocus® solution and the Eligibility Mobile App and has been a leading driver behind the success of these projects. His operational know-how, client relationships and business acumen combined with his ability to collaborate across various functions in the successful development and deployment in eligibility solutions, makes Nate a vital asset to the Firstsource team. Nate received his Bachelor of Science in Financial Management from The Ohio State University, is an HFMA Certified Revenue Cycle Representative (CRCR), and has completed the Health Enterprise Network (HEN) Healthcare Fellows program. 

The Editorial Team at Healthcare Business Today is made up of skilled healthcare writers and experts, led by our managing editor, Daniel Casciato, who has over 25 years of experience in healthcare writing. Since 1998, we have produced compelling and informative content for numerous publications, establishing ourselves as a trusted resource for health and wellness information. We offer readers access to fresh health, medicine, science, and technology developments and the latest in patient news, emphasizing how these developments affect our lives.