On May 17, 2021, Softheon presented with a group of four healthcare leaders at the 2021 Virtual State HealthCare IT Connect Conference regarding the upcoming clog of Medicaid reassessments. States have been at a standstill from disenrolling anybody from Medicaid during the Public Health Emergency (PHE); as the PHE draws to a close, a backlog of Medicaid cases will need to be reassessed for eligibility. States must be ready to expedite this process to prevent a further accumulation of claims.
Medicaid Enrollments Soar, But States Are at a Halt
Craig Kennedy, CEO of Medicaid Health Plans of America, shed light on the current Medicaid landscape. The Centers for Medicare and Medicaid Services (CMS) granted Medicaid waivers to states to ease pressure on eligibility processes. At the same time, the Families First Coronavirus Response Act (FFCRA) provided a Medicaid funding boost to states that did not terminate most individuals from the Medicaid rolls. Due to the combination of these endeavors, Medicaid enrollment is up an average of 14.5% across 21 states. Some states have seen an even starker increase in enrollment — especially Utah, experiencing a 25.5% surge.
Indiana Stays Ahead of the Clog of Reassessments by Planning in Advance
Due to the PHE, states have been granted flexibility in the timeframes within which they must process applications, appeals, and other actions. Therefore, Medicaid eligibility workers will be faced with a large clog of reassessments and other case actions to complete when the PHE ends.
Nonis Spinner, Medicaid Eligibility Director at the Indiana Family and Social Services Administration, spoke about Indiana’s approach to Medicaid reassessments. Within six months of the end of the PHE, Indiana will need to have worked through the backlog of postponed work. Spinner explained that once Indiana resumes disenrolling individuals from Medicaid, it anticipates that its Medicaid application numbers will also increase; the clog of reassessments has the potential to be exacerbated by the introduction of new applicants.
Under the assumption that the PHE could potentially last all of 2021, Indiana is revisiting the decision to hold off certain redeterminations. Indiana is currently exploring ways to send mailers out to allow members to report changes while preventing individuals from being disenrolled during the PHE in an effort to prepare for the clog of reassessments.
After the PHE ends, Indiana plans to send notices to any individuals that currently need to verify information to maintain their coverage. If they do not respond to these notices or are determined to be ineligible based on their response, they will receive one final closure notice giving them their appeal rights before the final closure action is taken.
Softheon Breaks Down How States Can Focus Their Eligibility and Enrollment Actions
Policy experts at Softheon discussed how CMS expects states to begin returning to normal Medicaid operations. Unfortunately, many states face challenges because of the volume of outstanding eligibility and enrollment actions accumulated during the PHE. States that received a temporary Federal Medical Assistance Percentage (FMAP) increase under the FFCRA have been unable to terminate Medicaid coverage for most people who are no longer eligible during the PHE.
Softheon outlined five areas where CMS says states need to focus their eligibility and enrollment actions. States must develop Post-COVID Eligibility and Enrollment Operational Plans that address:
(1) Completing pending work that was delayed due to the PHE;
(2) Processing current cases that require action within CMS required timeframes;
(3) Adopting a “risk-based approach” to address pending eligibility and enrollment actions;
(4) Prioritizing case actions for individuals who are most likely to be no longer eligible for coverage.
Technology Partners can Save State Resources During the Medicaid Reassessment Process
States are partnering with third-party technology vendors to streamline their Medicaid reassessment initiatives. Illinois in 2012 contracted with a third-party vendor to help with Medicaid reassessments. Cases with high unreported income and resources, primary residency, or benefits in another state were flagged for review. As of November 2014, Illinois found 234,000 individuals who were no longer eligible for Medicaid.
Pending legislation in Iowa, Ohio, Montana, and Utah has the potential to heavily impact Medicaid verification processes, allowing states to partner with third-party vendors for eligibility assessments. Legislation under consideration in the Ohio Senate, S.B. 17, would require eligibility redeterminations for all enrollees who had not been redetermined in the prior 12 months. Additionally, Ohio’s Medicaid agency would need to seek CMS’ permission to redetermine all Medicaid enrollees who received 3 or more months of benefits during the PHE.
Softheon continues to closely monitor this legislation in all four states and is communicating with its contacts at the Center on Budget and Policy Priorities (CBPP), who have concerns about these bills.
Softheon’s Innovative Approach to Medicaid Reassessment Reduces Administrative Overhead for States
Michael Sasko, VP of Government Solutions at Softheon, concluded the presentation by describing the proprietary software for income and asset verification that four states have entrusted Softheon to implement. Sasko also discussed Softheon’s Medicaid Reassessment Service (MRS), which utilizes a two-step process involving batch file and risk scoring, to determine Medicaid eligibility to existing recipients. Softheon frees state resources and saves money through its innovative approach to verifying high-risk enrollees.
Softheon currently performs Medicaid reassessments for Indiana. At the end of every month, Indiana sends 25,000 to 50,000 Medicaid cases to Softheon for immediate evaluation and response. Softheon in turn provides risk scores (i.e., red, yellow, green) for eligibility workers to prioritize their work.
Post public health emergency (PHE), CMS requests that States reassess their Medicaid population for eligibility. Softheon currently provides daily Medicaid and HHS Asset Verification Service (AVS) to 4 US States.
1. PROVIDE A LIST OF ENROLLES
Softheon only needs the first name, last name, SSN and address to reassess Medicaid eligibility. All data is securely transmitted utilizing database encryption in accordance with Softheon’s PCI-compliant architecture.
2. RECEIVE A DETAILED RISK SCORE ANALYSIS
Softheon returned data includes a prioritized list of members to confirm edibility, based on a highly- configurable thresholds specialized for Medicaid eligibility.
Through Softheon’s Medicaid
Reassessment Service, States benefit from external analysis of current Medicaid populations in a single vendor solution
ROBUST RETURN OF VERIFICATION DATA
The Medicaid population evaluation includes:
Identity Confirmation, SSN check, Residence in State, Financial Assets, Real Property and Motor Vehicle
USER-FRIENDLY RISK SCORE
Results returned via a Risk Score to target and prioritize eligibility reassessments (Scored 1-100 and color coded Red-High Risk,
Yellow-Medium Risk and
COMPETITIVE PRICING AND FAST RETURN TIMES
Priced as onetime fee per member beneficiary checked – supported by robust analytics – states can quickly conduct Medicaid reassessments in near-real-time up to overnight batch processes
For more information about Softheon’s external MRS, please visit our website or contact Michael Sasko at 916-802-0638 or firstname.lastname@example.org.
Meet the Author
Josh Schultz is a Senior Policy Analyst at Softheon, where he advises the company on health policy issues affecting businesses and government health agencies. Prior to Softheon, Josh worked for a non-profit agency assisting Medicare beneficiaries, a technology company, and consulting firms.