The Medicaid Redetermination – Hanging Off the Edge of the Cliff

Day Egusquiza
Member, ACPA

The end of the COVID-19 public health emergency brought with it the end of the broadened criteria to qualify for Medicaid and the need for those Medicaid beneficiaries to requalify to retain Medicaid coverage. Many had predicted that there would be a large group of existing Medicaid patients who would not requalify for Medicaid once the redetermination/rescreening had begun. It was thought the largest group would move to commercial insurance (over the last 3 years, had a job that offered insurance) with the remainder who did not qualify being moved to the Marketplace/Exchange with assistance with premiums and deductibles for lower income enrollees – too much for Medicaid but not able to afford regular insurance. 

What was likely greatly understated was the way that each of the states could decide on their own process for screening/which group to do ‘auto’/ which group to do first, etc. and that the majority of the ‘rejections for coverage’ would be from what is referred to as procedural/administration issues. Wow- the volume of patients being moved off coverage is astounding. How will the patient know how to get re-evaluated for coverage? There are very specific timelines to protect coverage while the appeal is occurring (15 days from notice) and then 90 days for appeals. One of the primary reasons was the patient did not have a good address so the notice for required information was not received; the patient did not have all the required financial information as Medicaid is an income based program. 

With the magnitude of rejections – averaging 75% of all applicants being rejected nationwide for procedural issues – the financial, mental and emotional health of our patients is being severely impacted. The redetermination process required each state to do extensive outreach to prevent inappropriate denials. Unfortunately, the Kaiser Family Foundation ‘s survey in early summer found approximately 65% of the Medicaid population did not realize this was happening.

The patient stories of care being discontinued – for children in ongoing treatment, appointments being cancelled as no insurance - all are concerning.

What is the role of the healthcare provider to assist each pt in their overall understanding of what is occurring? How can the internal Patient Financial Navigator lead the hospital’s, provider, other healthcare providers with a defined set of outreach to assist with finding coverage or filing an appeal, to try to prevent coverage gaps?

The potential increase in bad debt is significant. 

The action to reduce this while being proactive to reach out and prevent more procedural denials can be mitigated by a powerful internal, organized provider outreach effort. It will more than pay for itself!

When we think about the mission for our PFS team, mine was always:    

“My patient did not ask to be sick
My patient did not ask to have their life disrupted.     
My patient did not ask to have their insurance pay so little or nothing at all
My patient is sick and scared. 
How can I help you navigate thru the Business of Healthcare?”

The Medicaid Redetermination process is one of the most significant public health challenges healthcare providers and community outreach is facing. We can help!

Day Egusquiza is Founder and President of AR Systems, Inc. & Patient Financial Navigator Foundation, Inc.