You Are Here: A Medicaid Unwinding Roadmap

The continuous enrollment requirement for Medicaid enacted during the pandemic public health emergency (PHE) has ended. Now, the process of redeterminations for Medicaid eligibility — often called “the unwinding”— is beginning. In multiple ways, this situation is unprecedented:

  • It’s the first time states are redetermining eligibility for Medicaid after a three-year pause
  • It’s the first time so many recipients could lose coverage at once: by some estimates, up to 18 million could be declared ineligible out of nearly 92 million enrolled
  • It’s the first time many Medicaid enrollees — and the staff members who help administer Medicaid plans — have confronted this challenge

To achieve the best possible results, states and managed care organizations (MCOs) need to equip themselves with as much information, strategic planning and helpful resources as possible. Here are five things to consider as you navigate the unwinding.

1. Think about the tools and partners you already have in place.

Objectively assess your organization’s ability to manage the complexities of the unwinding, from call center support to residency verification, and identify opportunities to leverage existing tools and partners. Your current technology partner, or one well established in the Medicaid space, may be the most efficient and reliable option to help you ramp up workforce capacity, implement new tools to manage the increased volume of work and provide strategic guidance to prioritize areas of focus. This is also an excellent time to examine current processes and policies and explore different ways to improve them.

2. Everything doesn’t have to happen at once.

Looking at the entire volume of work ahead can be overwhelming, so it’s important to remember states have 12 months to complete redeterminations. Processing redeterminations in groups can help to ease the transition — for instance, first tackling those who are likely to be determined ineligible, followed by those who will likely be transitioned to a different Medicaid eligibility group. Completing the process in waves can make redeterminations more manageable while leaving time for appeals and grievances. This can help alleviate some of the administrative burden in the immediate term while setting your program up to efficiently manage this intensive process on a yearly basis.

3. Reinforce contact center capacity with a human touch.

During the unwinding, states are certain to experience much larger call volumes as recipients seek answers or appeal redetermination decisions. Automated voice response tools can be a valuable front line of contact to ease workloads. At the same time, there remains a vital need for personal, human support to answer questions, explain eligibility decisions and direct individuals to other healthcare options. Innovative call center support systems can equip states to handle routine calls while increasing the capacity of staff to provide high-touch support as needed.

4. Prepare for the inevitability of errors and audits.

Increased workloads will inevitably create a higher number of errors, especially among staff members who are dealing with these issues for the first time. It’s vital to have a quality assurance and quality control safety net in place to proactively identify errors, track the effectiveness of unwinding efforts and avoid problems with CMS down the road.

5. You don’t need to go it alone.

Today, Gainwell supports 56 million Medicaid beneficiaries across all 51 states and territories and is uniquely equipped to help manage the many issues surrounding the unwinding. Gainwell can help both beneficiaries and staff by providing workforce support for call centers, delivering analytics to boost accuracy and speed, and offering advanced tools to track quality.

Check out this PHE unwinding infographic for more quick tips.

The editorial staff had no role in this post's creation.