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  • Writer's pictureGidget Bowers

Complete Eligibility Reset Coming for Medicaid Patients - 3 Things to Know 

Updated: Jun 1, 2023

The Families First Coronavirus Response Act (FFCRA) mandated continuous Medicaid enrollment throughout the federal COVID-19 public health emergency (PHE) period for nearly all of those enrolled in Medicaid on or after the date of enactment on March 18, 2020, through the end of the month in which the PHE declaration ends.

In exchange for meeting these and other provisions, the FFCRA temporarily increased the federal medical assistance percentage (FMAP) by 6.2 percentage points. The continuous enrollment provision suspended Medicaid’s regular eligibility renewal and redetermination process by prohibiting termination of ineligible individuals as a condition of receiving the temporary increased FMAP, except for those who voluntarily disenroll or are no longer a state resident.

What’s the impact?

This will likely lead to a great deal of confusion and denials due to eligibility issues.

Due to Federal Legislation passed in December 2022, the continuous enrollment requirement is no longer tied to the public health emergency end date, and Medicaid programs are required to begin the disenrollment process starting April 1, 2023. Per KFF, it is estimated that this will impact between 5.3 million and 14.2 million people who will lose Medicaid coverage during the 12-month unwinding period.

Who’s responsible?

States will be directly responsible for eligibility redeterminations for Medicaid beneficiaries while CMS will provide guidance and oversight of compliance with Medicaid regulations and technical assistance.

For over a year CMS has been working with state Medicaid and CHIP agencies to develop a state unwinding plan to minimize churning and maximize coverage retention. An informational bulletin (CIB) was issued on January 5, 2023 to provide additional guidelines and provide timelines for states to submit a renewal submission plan.

What actions do you need to take?

1. Ensure that your front end process’ includes running eligibility before every service performed and that proper patient demographics are captured.

2. Know your state guidelines for retro eligibility and claims reprocessing guidelines! Many states, such as Arizona, have retro-eligibility visibility on their websites and may present opportunity a few months after the date of service.

Example: Claim denies for not eligible for June date of service. Patient reapplies for Medicaid but is not finalized until August. The coverage may be retroactive to June, but oftentimes, the plans do not automatically reprocess the claim. ​

3. Develop a plan to go back and retroactively check for updated eligibility to ensure reprocessing is done in a timely manner.​

In a time when every dollar counts, our expert staff can help navigate through denials and capture additional revenue during this 12- month transition. Our seamless onboarding gets you results fast. Contact us today for more information.

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