What is Medicaid Redetermination, why is it happening, and when does it take place?

Medicaid redetermination is the process of reviewing an individual’s eligibility for Medicaid coverage to ensure that they still meet the program’s requirements. It is a periodic reassessment of a person’s income, assets, residency, and other factors that determine their eligibility for Medicaid benefits.

States are restarting the redetermination process due to the end of the Public Health Emergency (PHE) stemming from the COVID-19 pandemic. The PHE provided the government the temporary ability to ensure coverage for populations disproportionately affected by the pandemic and lessen the financial impact for providers, and payors. This included pausing the redetermination process for patients on or eligible for Medicaid during this time.

According to an estimate done by the Kaiser Family Foundation, over 14 million patients will lose coverage through this redetermination.

The Medicaid redetermination process has already begun in many states as the PHE officially ended in March 2023. State Medicaid agencies have begun to inform relevant stakeholders with varying degrees of success. This is due to states having their own procedures for conducting redeterminations along with using non-uniform methods of communication. 


What do payors need to know?

Payors need to fully understand the specific Medicaid redetermination process in their specific states as it will impact their various health plan operations and revenue associated with membership. Members must complete the redetermination process in order to continue receiving Medicaid benefits, if they are eligible. State agencies can provide inconsistent data in terms of membership impact and termination dates which can affect internal and external planning and communications. With many of their members potentially losing coverage and being denied care, payors could be on the receiving end of both provider and member abrasion beyond their control. Proactive messaging to providers and members will minimize unwanted surprises and mitigate abrasion.


What do providers need to know?

Some of the patients attributed to your system or clinic may be affected by Medicaid redetermination. This could lead to denied reimbursement or coverage from the payor for services rendered. Providers should encourage their Medicaid patients to complete the redetermination process on time. Providers should be prepared for potential interruption in coverage with their patients, which can affect timeliness of care and care planning while they navigate coverage options.


How can payers and providers collaborate to make the transition as smooth as possible?

Come to the table together in the name of member/ patient well-being. Oftentimes, payors and providers are tackling this issue in a silo when they have the same goal in mind. Working together to understand impact, timing, and mitigation strategies will provide a transparent process and will build good will between the participating parties. Identify those patients proactively so that both parties know how to engage the patient in a way that will minimize coverage disruption.


Educate members/ patients. Payors and providers can work together on creating the necessary information and communication plan to the member/patient. This can include what documents they need to collect, how to contact the enrollment broker in their state to submit the necessary documents, and advise on specific deadlines.


Leverage scalable digital solutions: Payors and providers should leverage digital solutions to ensure both parties have the most up-to-date information as possible. This could include a solution that houses the necessary information that providers and patients need to know about the process as well as a live list of redetermination eligible members/patients.

Stellar Health works with many payors and providers that are being affected by Medicaid redetermination. On top of incentivizing for the closure of care gaps on a monthly basis, Stellar is helping both parties with redetermination to:

  • Flag members at-risk of losing coverage to the provider and staff by aggregating data from the payor.
  • Facilitate the delivery of  payor-approved documentation and collateral to the provider and staff with exactly what actions the member/patient needs to take.
  • Run patient engagement promotions with corresponding compensation for time spent on these efforts to get the redetermined-eligible patients in to see the provider prior to their termination date. 
  • For background to the Stellar model, Stellar incentivizes non-clinical staff to call patients to bring them in for their Annual Wellness Visit (AWV) and pays them on a monthly basis for the work done to schedule this visit. Given this, Stellar may provide additional incentives to Stellar users at the system/ clinic to call redetermined-eligible patients in for their AWV ahead of their termination date to ensure 1). The patient is aware of the redetermination process and action they need to take and 2). The provider addresses the patient’s clinically relevant outstanding care gaps. 


Contact us to discuss how Stellar can assist in your Medicaid Redetermination strategy and promote collaboration between payors and providers.