Medicaid MCOs Brace for Return of Churn, Other Challenges

by Lauren Flynn Kelly

As a condition of receiving enhanced federal funds during the COVID-19 public health emergency (PHE), states were required to take certain steps to ensure continuous Medicaid and CHIP coverage for most enrollees, leading to a nearly 18% jump in Medicaid enrollment. But with the latest PHE extension set to expire on Jan. 16, states will no longer receive such funds and will therefore no longer be required to maintain continuous coverage, although CMS has given them 12 months after the month in which the PHE ends to complete eligibility redeterminations. As a result, supporting states’ reverification efforts and ensuring that eligible members stay on the rolls or have a viable landing spot will be critical to Medicaid managed care organizations this year, industry experts tell AIS Health. 

Redetermination can cause ‘chaos and crisis’ 

• “The biggest challenge for Medicaid MCOs in 2022 will be churn,” asserts Jerry Vitti, founder and CEO of Healthcare Financial, Inc., a firm that connects low-income, elderly, and disabled populations with Medicaid and other public benefit programs. 
• “With redeterminations looming, we will see a ‘chaos and crisis’ situation when enrollees are cut off from crucial access to care. There are administrative factors that can trigger the disenrollment of truly eligible enrollees, such as improperly recorded address changes and data problems and mismatches in a state’s electronic eligibility determination system.” 
• The Association for Community Affiliated Plans (ACAP), which counts 78 safety-net plans among its members, has been actively promoting continuous coverage for all people covered by Medicaid after the PHE ends. The association supports a provision in the Build Back Better Act that would establish 12-month continuous eligibility for children covered by Medicaid and CHIP. 
• Previous research suggests that more than 1.5 million people in 2018 lost Medicaid and CHIP coverage, largely as a result of states’ complex redetermination processes. 

Plans, states should invest more in SDOH 

• Meanwhile, plans are likely to make significant investments in identifying and addressing social determinants of health (SDOH) such as food insecurity as well as tackling behavioral health and substance use disorder, Vitti predicts, advising that states help fund improved case management for payers. 
• Given that states have additional cash from pandemic-relief legislation, Vitti is optimistic that they will spend those extra funds on “broadening the mission of Medicaid MCOs” in addressing SDOH. 
• Vitti says an example worth keeping an eye on is the California Advancing and Innovating Medi-Cal (CalAIM), a multiyear initiative that began on Jan. 1 to bring about delivery system, program and payment reform in California’s Medicaid program. 
• Another item to watch will be “how strongly CMS will look to add any type of health equity or SDOH requirements as part of MCO contracts,” weighs in Thomas L. Johnson, executive director of the Population Health Alliance. 

From Radar on Medicare Advantage