Navigating Medicaid Eligibility Changes Following the End of Continuous Enrollment

The Families First Coronavirus Response Act established continuous Medicaid enrollment during the COVID 19 public health emergency, allowing most beneficiaries to remain covered without undergoing standard eligibility renewals. Beginning March 18, 2020, states were required to maintain coverage for enrolled individuals through the end of the public health emergency period.

In exchange for maintaining continuous enrollment, states received a temporary 6.2 percentage point increase in the federal medical assistance percentage. This policy suspended normal eligibility redetermination processes and limited disenrollment except in cases where individuals voluntarily withdrew or were no longer residents of the state.

As this temporary policy comes to an end, healthcare organizations are entering a period of significant operational and financial disruption.

What Is the Impact?

The unwinding of continuous enrollment is expected to create widespread eligibility changes, resulting in increased claim denials and administrative complexity. Federal legislation passed in December 2022 separated continuous enrollment from the public health emergency timeline and required states to begin eligibility redeterminations starting April 1, 2023.

Millions of beneficiaries are expected to lose Medicaid coverage during the unwinding period, creating uncertainty for both patients and providers. For hospitals and physician groups, this transition increases the likelihood of eligibility related denials, delayed reimbursements, and additional revenue risk.

Who Is Responsible?

State Medicaid agencies are responsible for conducting eligibility redeterminations, while the Centers for Medicare and Medicaid Services provides oversight, regulatory guidance, and technical assistance.

Over the past year, CMS has worked closely with state Medicaid and CHIP agencies to develop unwinding plans designed to reduce coverage disruptions and limit unnecessary loss of benefits. These coordinated efforts aim to balance compliance requirements with continuity of care, but providers should still expect operational challenges throughout the transition period.

What Actions Should Providers Take?

Healthcare organizations must take proactive steps to protect revenue and reduce denial risk during this period of change.

Run eligibility verification prior to every service encounter and ensure patient demographic information is accurate and complete. Frequent eligibility checks are essential as coverage status may change rapidly.

Understand state specific retro eligibility policies and claim reprocessing guidelines. In many cases, patients who initially appear ineligible may later regain coverage with retroactive effective dates. Claims may not automatically reprocess, requiring manual follow up.

Develop structured workflows to periodically recheck eligibility for previously denied claims. Establishing a process to revisit accounts can uncover recoverable revenue that would otherwise be missed.

For example, a claim denied due to ineligibility for a June date of service may later become payable if Medicaid coverage is approved in August with retroactive eligibility beginning in June. Without active monitoring, these reimbursement opportunities are often lost.

Preparing for the Transition

During a time when financial margins remain under pressure, strong eligibility management and denial recovery processes are essential. Organizations that proactively monitor coverage changes, revisit denied claims, and align front end workflows with evolving Medicaid policies will be better positioned to protect revenue.

Experienced revenue cycle teams can help healthcare organizations navigate this transition by identifying recovery opportunities, reducing administrative burden, and accelerating reimbursement during this complex eligibility environment.