Medicaid Payment and Reimbursement

Limit financial risk from Medicaid redetermination

January 24, 2024 11:55 am

Medicaid redetermination isn’t going smoothly. As of late December 2023, the Kaiser Family Foundation found that 71% of Medicaid disenrollments nationwide were for procedural reasons. That means patients are losing coverage because they filled out a form incorrectly or missed a deadline, not because they’re truly ineligible for renewal.

Provider organizations can play a pivotal role in addressing this problem. The millions of patients who are being disenrolled put healthcare providers at financial risk. In the short term, their payer mix will shift as patients fall out of Medicaid and into the self-pay category. In the longer term, providers will likely see rising emergency department admissions, increased costs and reduced revenues from caring for uninsured former Medicaid members. Some providers may already be seeing these lagging indicators.

Healthcare providers can estimate the amount of their Medicaid revenue at risk by calculating their net revenue rate on their gross Medicaid charges. Then they can compare that with the percentage of charges recovered from self-pay patients, which is usually 1% to 2%. By looking up their states’ procedural disenrollment rate, they can estimate the impact on revenue if a similar percentage of their Medicaid population were to become self-pay patients.

Regardless of the calculation used, millions of revenue dollars may be at risk for providers. Fortunately, providers can mitigate the risk by taking Medicaid re-enrollment into their own hands.

By proactively reaching out to patients still eligible for re-enrollment but who might fall through procedural cracks, healthcare providers can help ensure continued access to care for their patients and protect their Medicaid revenue.

Best practices needed to tame the Medicaid re-enrollment tangle

The unique scale and complexity of this re-enrollment period has made it difficult for states to offer comprehensive re-enrollment support to either providers or Medicaid members. In September 2023, CMS asked 30 states to pause their redetermination efforts until they addressed operational issues leading to disenroll­ment of members who should be automatic, or ex parte, renewals.

To help prevent their patients from losing coverage through operational issues and proce­dural errors, providers with substantial Medicaid populations can launch re-enrollment outreach campaigns. Providers can weigh the cost of an outreach campaign against that of their poten­tial Medicaid revenue losses as well as projected payer mix changes.

Following are three best practices that can help providers manage the scale of their outreach initiative and ensure its effectiveness.

1 Prioritize re-enrollment activities

Hospitals and health systems have several options for identifying patients who are at-risk and setting outreach priorities, including the following:

  • Use Medicaid renewal dates. In states that have made Medicaid renewal dates avail­ able via an ANSI 270/271 exchange (see, providers may use these dates to prioritize the order in which they contact patients. In states that cannot provide renewal dates, providers should find out if their Medicaid managed care payers can provide that information.
  • Review utilization. If providers cannot obtain renewal dates, their next best option is to review their utilization records, going back six, 12 or 18 months to identify patients who had multiple visits or inpatient stays during the selected period. Frequency of visits then becomes the prioritization criteria (e.g., patients with three or more visits go to the top of the re-enrollment contact list, and those with two visits are next).
  • Define patient cohorts. Another approach is to prioritize groups of patients regardless of their utilization frequency. Cohorts could be mothers and children or patients with a specific disease or chronic condition.
  • Review state re-enrollment priorities. CMS has required all state Medicaid agencies to submit their re-enrollment communication and activity plans, including their prioritiza­ tion criteria. Providers may review these plans and align their renewal outreach campaign with their state’s strategies and priorities.
  • Screen recent patients. Providers should screen new patients and patients recently seen to determine their eligibility for Medicaid and other coverage. This screening can be accomplished through questions during registration or by the financial assistance office. Providers should inform and educate patients on the renewal process.

2 Emphasize digital outreach

Medicaid members’ range from the very young to the elderly. Healthcare providers need to reach these members and/or their caregivers in the communications channels they prefer. They also should rely on messages that encourage responses while keeping their programs manageable.

Here are tactics that can help.

  1. Put digital first. Sending mail through the post office to addresses that may be several years old wastes time and money. Research shows 96% of Medicaid members access the internet via smartphones and want to connect digitally with providers. Using digital channels first for outreach will enable providers to reach more members. Before launching, however, providers should ensure patient consent forms are up-to­ date and address digital communications.
  2. Update patient contact lists. Working with part­ners that specialize in contact list enrichment is the most efficient way to ensure that contact numbers are as recent as possible. List scrubbing also should include an insurance discovery check so former Medicaid members who now have commercial health insurance or other coverage can be eliminated from the outreach campaign.
  3. Deliver information members can act on. The most effective messages have an easy way for members to act on their re-enrollment information, such as a hyperlink to a state’s re-enrollment portal, or a QR code to a provider’s information site and/or phone number. QR codes, which have embedded hyperlinks, can be printed on posters and flyers. It’s easy for mobile phone users to snap a photo of the QR code to be taken to the relevant website or portal.
  4. Be persistent and use fresh messaging. Given the choice, more than 55%of members will respond to texts over email. Either way, it may still take three or more texts/emails to elicit a response. It’s important to vary the language in texts and email subject lines to avoid message fatigue. Analytics programs can enable providers to track click-through rates and gauge which messages are most effective. Those with more sophisticated analytics can track message effectiveness by various demographics, such as age, location and utilization history.
  5. Include voice and outbound calling. Some members will prefer a live phone conversation to a text. Providers can establish a toll-free number for members to call or include state re-enrollment help-line numbers. Campaigns should include outbound calls to members who did not engage with the digital messages or who did not complete re-enrollment activities after clicking on a link. Outbound call campaigns need to be compliant with the Telephone Consumer Protection Act of 1991.
  6. Use state re-enrollment toolkits. Many states have created information and messaging kits with materials and sample language for communications such as emails, social network messages and posters. Healthcare providers can take advantage of these materials by labeling them with their brands and tailoring the language to their re-enrollment efforts.
  7. Partner with community and faith-based organizations. Food drives, community health fairs and school events all are opportunities for healthcare providers to share re-enrollment information with their target members.

3 Help patients navigate their re-enrollment process

Medicaid members who have not experienced a redetermination period may not understand its purpose or how to re-enroll. Others may need a quick refresher on what documentation they’ll need and where to re-enroll. Healthcare providers can help educate and lead members through re-enrollment activities like the following.

  • Use self-service tools. Many members may simply need to be pointed toward a state reenrollment portal via QR code or hyperlink. It’s helpful for healthcare providers to track how many members in the outreach campaign click on these tools. Those who have not completed the process can then be scheduled to receive a phone call.
  • Provide guided re-enrollment. Providers with certified application counselors can guide members through the re-enrollment process. That guidance may range from helping them log into the state Medicaid portal to staying with the member throughout the entire process. In some states, it’s also possible for agents to help a noneligible patient find coverage through an Affordable Care Act marketplace plan.

Preserving revenues, protecting patients

Research shows uninsured individuals don’t get preventive care, order prescriptions they need or follow care plans. By helping eligible patients enroll in Medicaid and, when appropriate, helping others find appropriate coverage, healthcare providers can protect their patients’ access to care. Furthermore, preserving revenues and their payer mix with proactive re-enrollment outreach helps ensure providers are equipped to care for their respective patient communities for the long term.


googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text1' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text2' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text3' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text4' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text5' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text6' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text7' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-leaderboard' ); } );