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