Innovation Key to Tackling Medicaid Redetermination Challenge

As a result of the Families First Coronavirus Response Act (FFCRA), Medicaid programs were required to keep citizens continuously enrolled through the COVID-19 public health emergency (PHE). These continuous enrollments ended on March 31, 2023, resulting in what many call the unwinding of Medicaid. 

In June, the Kaiser Family Foundation (KFF) estimated that between 8 million and 24 million people will lose Medicaid coverage during the unwinding of the continuous enrollment provision. The unwinding of Medicaid has become one of the most significant challenges facing state health agencies. 

The Medicaid redetermination process has become mired in procedural challenges during the renewal process, resulting in CMS pausing Medicaid redeterminations in six states. 

In August, CMS also sent a letter to Medicaid directors in all 50 states that evaluated performance on Medicaid call center wait times, call abandonment rates, rates of procedural terminations, and average wait times for applications to be approved. Overall CMS found that 36 states were falling short on meeting the regularity requirements. 

State and local HHS agencies are clearly in the midst of a public health emergency and are finding themselves challenged with processing Medicaid redeterminations at record levels as they resume regular eligibility operations following the end of the Medicaid continuous enrollment condition. 

In addition, many of these agencies are dealing with eligibility and enrollment systems that have been in place for 10 years, or even longer. As a result, these systems are hitting “legacy” classification, and lack modern features to keep up with the current Medicaid redeterminations challenge. 

With the immense ebb and flow of eligibility applications and redeterminations, it is clear that data is key to overcoming this challenge. On top of this, an astounding level of data is increasing every day, along with the demand to leverage this data to meet citizens’ needs.

Automating Legacy Systems 

Fortunately, state health agencies can address these challenges by automating legacy data systems without needing to invest in full IT modernization. 

Legacy systems are essentially mission-critical systems that contain custom code and business processes designed to serve citizens. Part of the challenge is the lack of automation to deal with high volumes of eligibility redeterminations and disenrollments while ensuring coverage continuity for eligible members.

It is possible to create a path to accessing and engaging with data on legacy systems to break down data silos while enhancing overall processes. By combining these modernizing citizen-focused interfaces, agencies can streamline the Medicaid reenrollments, while reducing errors. 

For example, process mining can help agencies pinpoint processes for improvement and allow simulation of the new processes. These types of solutions can run on top of an eligibility and enrollment existing process engine, providing insights into bottlenecks or outliers.

These solutions also offer easy-to-use interfaces that can help business analysts visualize areas of improvement. New processes can also be simulated before going into production for testing desired outcomes and adjusting as necessary.

Many states are also exploring moving their eligibility and enrollment systems to the cloud, which offers new ways to integrate data more effectively to meet citizen needs.  

This transition can be made seamlessly by quickly integrating applications in the cloud, while also offering end-to-end monitoring to follow the complete flow of transactions across multiple applications. As a result, users can easily visualize integration processes and simulate to-be scenarios to assess impact. 

Regardless of the complexity of the data, common integration scenario templates can provide a quick start to integration development. In addition, key solutions allow agencies to pull data from any source across the HHS landscape, which can include data warehouses or legacy mainframes into one common picture. 

By providing an updated visual interface through a range of pre-built connectors, agencies can easily ingest, transform, and deliver data to the desired destinations. This enables them to detect patterns, anomalies, and trends in real time, which can be used for predictive analytics or immediate decision-making around the redeterminations issue. 

The unwinding of Medicaid is presenting a significant challenge for states, as well as for citizens who have relied on receiving this critical healthcare coverage.  Fortunately, updating the manner in which we engage with legacy systems, and better leveraging the data housed in those legacy systems, provides a path for agencies to ensure that citizens don’t lose coverage due to administrative and procedural issues. 

About Chris Oskuie

Chris Oskuie is the Vice President, State & Local Government and Education Sales at Software AG Government Solutions.  Chris has more than 20 years of experience working with Federal and State Government programs. For the past four years, Chris has led a team of experts that helps government agencies modernize how citizens and state employees engage with and access legacy systems through data and event-based integration.

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