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Medicaid Redetermination Tools

The ZOLL® AR Boost® Medicaid Redetermination Tools Make It Easy to Ensure Continuous Coverage and Verify Third-party Liability

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What is Medicaid redetermination? 

Medicaid redetermination is the process that states use to periodically verify that Medicaid enrollees continue to meet eligibility requirements for coverage and subsequently either terminate or renew enrollees. Low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI) are examples of mandatory eligibility groups. States have additional options for coverage and may choose to cover other groups.i

Caring for patient

What is Medicaid redetermination?

Medicaid redetermination is the process that states use to periodically verify that Medicaid enrollees continue to meet eligibility requirements for coverage and subsequently either terminate or renew enrollees. Low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI) are examples of mandatory eligibility groups, and states may choose to cover other groups.i

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How has the COVID-19 PHE affected Medicaid redetermination?

When the public health emergency (PHE) ends, state Medicaid agencies will have 12 months to redetermine enrollees’ eligibility for Medicaid and then either terminate or renew eligibility.ii

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Who is affected by Medicaid redetermination?

All states must adhere to the federal government’s minimum standards for the program, including rules for Medicaid redeterminations. 

Medicaid Health Plans of America (MHPA) estimates that between 5 and 15 million at-risk adults and children may lose Medicaid coverage and fall through the cracks, even if they are eligible, because state agencies are unable to locate them. As a result, healthcare providers will likely encounter a significant surge in the number of uninsured, self-pay patients who were previously covered by Medicaid. 

Healthcare coverage

How can payers and Medicaid directors quickly redetermine Medicaid eligibility and ensure continuation of coverage?

Medicaid redetermination can be determined through a series of manual processes, including verifying eligibility based on: 

  • Modified adjusted gross income (MAGI) 
  • Income plus assets (enrollees who are 65 or older, blind, disabled, or receiving HCBS or long-term care services) 
  • Household size and Federal Poverty Level (FPL) 
  • Qualifying change in circumstances 

Manual redetermination is a difficult and burdensome process. It is further complicated when the enrollee cannot be located because they have moved, they do not have a phone number, they have not recently been seen by a healthcare provider, etc. Faulty patient demographic data is a primary reason for failed Medicaid eligibility and denied claims. 

Use ZOLL AR Boost Medicaid redetermination tools to quickly find and correct demographic information to determine eligibility

ZOLL AR Boost Demographic Verifier, our demographic redetermination tool, can help ensure continuous enrollment. It automatically and independently obtains and enhances demographic data to support redetermination in real time. Its expansive search verifies patient data from many sources, replaces inaccurate information, and provides a confidence score.

ZOLL AR Boost Insurance Discovery, our retroactive Medicaid tool, can identify patients who are eligible for, but not yet enrolled in Medicaid. Based on customizable business rules, the tool discovers primary, secondary, and tertiary coverage, verifies that the coverage is active and in force, and provides a confidence score for the data.

ZOLL AR Boost Self-pay Analyzer, our Medicaid eligibility predictor tool, scours data approved and regulated for use in healthcare applications to verify identity, percentage of FPL, and provide estimates of household income and size. The tool pulls in financial data and returns recovery and propensity-to-pay scores that inform revenue forecasting and how to manage past-due accounts. The tool can also help with third-party liability and ensuring that Medicaid is the payer of last resort.

Find out how you can simplify the Medicaid redetermination process by using ZOLL AR Boost Medicaid redetermination tools. Request a free sample batch run of your data.

Request a Free Medicaid Redetermination Batch Run

i,ii “SHO # 22-001 RE: Promoting Continuity of Coverage and Distributing Eligibility and Enrollment Workload in Medicaid, the Children’s Health Insurance Program (CHIP), and Basic Health Program (BHP) Upon Conclusion of the COVID-19 Public Health Emergency,” Medicaid website, https://www.medicaid.gov/federal-policy-guidance/downloads/sho22001.pdf, Accessed 15 Jun. 2022.

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