Note: This post was originally written in Q32022; since original publish date, the Biden administration has extended the Public Health Emergency (PHE) to January 11, 2023. The administration has indicated it will provide a 60 day notice before enacting the end of PHE. For Healthcare Providers & State departments, this has bought much needed time. But as the TBD date is inevitable, now is the time for action.
Over the past several months, a massive social-impact issue that could leave millions of vulnerable Americans without health insurance has gained well-deserved attention, but not enough. Given the harsh eligibility-elimination outcomes of a new CMS mandate, we should all be concerned about the long and “Unwinding” road ahead. Here’s why:
If you haven’t heard about it yet, The Center for Medicare & Medicaid Services (CMS) announced a Medicaid and CHIP (Children’s Health Insurance Program) “Unwinding” program slated to begin on October 13th, 2022. Let’s talk about the planning, effects & what’s involved with this new CMS mandate, starting by framing it in easy-to-understand terms.
First, what exactly is the new CMS Continuous Enrollment “Unwinding” mandate? What’s behind it and what does it mean for the public?
FACT: As a result of COVID-19 related legislation to Medicaid and enrollment flexibilities adopted by states, enrollment in Medicaid and the Children’s Health Insurance Program known as CHIP has grown to a record high
FACT: As of January 2022, nearly 87 million individuals are enrolled in health coverage provided through Medicaid and CHIP
FACT: That’s an enrollment increase of over 23% (that’s +16.3 million individuals!) between the time frame of February 2020- January of 2022
FACT: During this period, States received as much as a 6.3% increase in subsidies to support these additional recipients
So what does this mean? Quite simply, it means that more people than ever are receiving critical health services from the Medicaid and CHIP programs.
Ok- fast forward to today; pandemic-related chaos and overwhelm have (arguably) sustainably subsided. CMS has announced it’s going to unwind those enrollment flexibilities and go back to the standard policies and processes used to validate eligibility.
Right now, the estimates are that as many as 15 million people (out of 87 million enrolled) are going to be the victims of ineligibility for the health programs they’ve been relying on for medical care since 2020. It is further estimated that 6.8 million recipients who will remain eligible, could lose their coverage because of an administrative issue.
There’s all sorts of challenges with this, as you can imagine, but the onus is on the state departments of Health and Human Services.
As recently as this month, as part of a program that CMS has put together to support the states in this effort, they have published a summary of best and promising state practices. CMS did this one time before, in April 2022, and now last month, a second summary in September 2022
What was interesting in this summary was the acknowledgment of the labor shortage within the state departments and how to overcome it so there would be necessary labor to tackle the critical first steps in the “Unwinding” program:
Unwinding Step One: Identify ALL Medicaid/CHIP enrollees, then,
Unwinding Step Two: Locate them, then
Unwinding Step Three: Communicate with them and put them through a re-enrollment process.
Cumbersome? YES. But doable if understaffing across all 50 states wasn’t the current reality.
But aside from the social-impact perspective, maybe the number one problem is the gaping holes in state staff levels.
So in September, CMS comes out and essentially says,
Listen, we acknowledge the staffing reality and we have some suggestions that start with hiring more people. How?
- Outsource some level of this
- Bring back retired employees
These are all good thoughts but will it overcome the mountain of work ahead of these states? That’s yet to be seen.
Now let’s take this forward. Assuming staffing levels are shored up and identifying enrollees is underway; the next step is successfully contacting them to communicate critical info and eligibility process/unwinding program details.
Assuming they’re contacted and found to now be ineligible, they’ll have to get set up to get marketplace. Where? Are they going to enrollmarketplace.gov? No one exactly knows.
If “ineligibles” follow through, go to Marketplace and enroll in new coverage, is that going to solve all potential problems of the CMS Unwinding program?
That’s a giant and looming question mark.
Maybe this seems like a problem relegated to States and Medicaid programs, but it’s far more encompassing.
Looking at this as a longer-term picture, I see this as two distinct problems.
Recapping the main points of the first challenge as I discussed above (what I view as the upstream half of the two-part problem) is:
- From where will the labor required to identify the approx. 15 million ineligible recipients materialize? And how long will this entire process take?
- How will states deal with extensive competing priorities that place equal/equal+ demand on their labor resources?
Let’s switch gears to understanding the second half of the equation; the “downstream” issue extending beyond the social impact and ramifications for individuals who will now be ineligible for Medicaid and CHIP coverage. We cannot forget about medical Providers and how they’re going to be impacted.
Massive Impact to Providers: CMS Unwinding Mandate
There’s a recent report done by Extelligence Healthcare Media which says current claim denial rates are as high as 80% for some marketplace Payors. Current, as in today, before any of the additional stressors of CMS Unwinding even begin. Providers are already facing 80% denial rates related to marketplace payors; implications of millions of soon-to-be ineligible individuals will clearly exacerbate and intensify the denial rate. It’s a significant problem.
Additional data in a 2020 survey from Rev Cycle Intelligence that says over one-third of hospital execs report claim denials had increased over 20% in the past five years.
We’re all aware of the slim margins Providers make as is, and we also know the number one reason for a Payor to deny a claim is incorrect eligibility. Simply put, an individual is just not eligible for the coverage they seek. Ineligibility reasons stem from admin (name changes, incorrect address, data not syncing) all the way to more involved eligibility considerations.
In Healthcare we all like to talk about Epic. We like to talk about Cerner. We like to talk about the positive impact created for Providers and patients who use these EHR platforms.
But there’s one thing that an EHR can’t do. It can’t make bad data good.
The adage of garbage in, garbage out, still applies. Yes, in 2022, we’re still haunted by the detriment of bad data.
Of late we seem to live in a world where some believe the EHR is the holy grail to fix all problems. But if core patient data is incorrect, it doesn’t matter if you’re working in a Cerner, Epic or AthenaHealth environment. Take your pick, the data is still bad.
So now keep in mind there’s 15 million people who are potentially going to lose coverage from the Medicaid and CHIP Continuous Enrollment Unwinding program, meaning millions of new instances for bad data potential.
I want to share a final statistic that will likely put a finer point on this whole process required to locate and communicate eligibility changes with the affected individuals. One of the largest trends we witnessed during the pandemic was that people became more transient than ever before – they relocated at record high numbers:
- In the past 6 months, Florida alone saw an increase of close to 270,000 residents,
- Colorado saw an increase of 250,000 residents,
- Since the start of the pandemic, 22% of Americans have moved between states
Extracting the data, if we have: 87 million recipients @ a 22% relocate rate – that equates to over 19 million people. And that math is based on a single-year view only.
To frame this challenge in terms we can all understand:
- 87 million people receive health benefits via Medicaid and CHIP (that’s 26% of the US population)
- 15 million are expected to be deemed as ineligible when re-enrollment begins
- 6.8 million could remain eligible but will likely lose coverage due to an administrative error
- 19 million people who receive benefits likely relocated during the pandemic
Are you starting to see why I started this discussion by saying we should all be concerned about the social impact this mandate will have on the country and the communities where we live?
Hope won’t cut it: what can Providers (& the rest of us) do?
We can sit around hoping states get people to come out of retirement, reprioritizing their lives to help bolster state staffing levels. We can hope that these 15 million people are easily identified, located and that once they’re located, they actually go to the marketplace as directed. And that if they do make it to the marketplace, they take the steps required to find medical coverage for themselves and/or their families, enroll accordingly, and then, after that’s all finished, they update their provider with the new coverage information.
It doesn’t take a rocket scientist to see the flurry of pitfalls in that workflow.
I see the whole scenario as a bad bet with low success likelihood because simply put, the entire process I’ve just outlined is underscored in many ways by waiting, dependency & reactivity (in addition to the sheer unpredictability baked into so many unknown variables). Because the waiting game in this outlined scenario is high, there’s much time for a known problem to become worse.
But is there another option and if so, how does it work?
There is, but first things first, if you’re a Provider and you’re not running bulk eligibility for your patients you believe currently qualify for Medicaid or CHIP, I’d like to suggest that you start immediately:
MY SUGGESTION FOR PROVIDERS: Providers should start bulk eligibility through their financial clearance provider, run this check at least monthly, and more ideally, 2x/month.
This will give Providers a continuous flow of the rejections and denials that can be put into a queue for proactive outreach prior to that individual scheduling an appointment, coming in for medical care or worse, having the claim denied after treatment.
This brings me to a second and equally important step: REACH OUT TO YOUR PATIENTS PROACTIVELY.
If you don’t have one, you’ll need a program or process to proactively contact your patients who are currently covered by Medicaid and CHIP.
Provide them the information they need to re-enroll and re-certify their eligibility. Don’t wait around for your state to contact them because there’s really no telling how effective that process will be.
You as the Provider should contact them. You should push them to action. It’s all published in CMS.Gov and I’ll provide links to resources you can provide to your patients at the end of this article. Contact your affected patients; use the links to these resources to help them help themselves (and in turn, help your practice minmize or avoid damaging consequences of the Unwinding mandate. Initiating your own effort to locate these people is easier said than done given you may be facing your own staffing shortages, but the payoff will be in spades and gold.
And finally. Encourage the individuals you reach as part of your proactive outreach program to look for coverage at marketplace.gov. Gaining coverage from that model if they are denied under eligibility rules for Medicaid and CHIP is going to be critical to maintaining the health and well being of our communities in addition to sustaining the financial integrity of your organization.
With this proactive action plan in mind, let’s go back to the data for a moment: 15 million people are about to lose coverage.
Is this realistic or am I painting a dramatic worst-case picture?
Of course it’s dramatic. 15 million is a very high number; possibly even exorbitant. Is it possible? Yes. Is it probable? No. But let’s say even 50% of the total number is more realistic.
7.5 million is still a lot of people and cause for legitimate concern.
While this broad and incredibly important outreach to millions of people might seem an insurmountable task, I’m sure we’ve all witnessed the way scalable, reliable cloud technology works to alleviate obstacles presented by even the most daunting and dire business challenges. With the right technology, a team of experts guiding a process and a bit of runway to put a plan into action, it’s possible to get in front of nearly any problem before it wreaks havoc.
You can get ahead of this by working with partners like Acqueon. Here’s what the Acqueon team, and our outbound, omnichannel Campaign Management & Real-Time Intelligence platform, is doing to help our Healthcare customers tackle the CMS Continuous Enrollment Unwinding mandate:
Use the pre-built outbound campaign scripts we’ve built for Providers (and for States because we’re helping them too) to proactively push critical information to affected individuals. Most importantly, use our Campaign Manager solution and to accomplish the initial challenge of connecting with them. Intelligent campaign management technology is going to be vital for finding people on the communication channel where/when they’re most likely to interact whether via phone call, email or text/SMS).
You can easily layer in Acqueon’s pre-built campaigns to whatever contact center, CRM or EHR solution you’re already using. Acqueon is designed as a plug-and-play, seamless integration and we’ve designed this pre-built offering specifically to help Providers and States tackle the CMS Unwinding program requirements. Acqueon’s platform supports the huge task at hand and can proactively push messages to individuals via e-mail, voice calls, SMS, text— or all of the above. This is how you’ll scale the effort to reach and communicate with droves of people who need to take fast action and ultimately, provide their new enrollment details to Providers.
Acqueon’s mission at large is to transform the future of conversational engagement and believes strongly that proactive engagement is the centerpiece of that goal. It’s a strategy perfectly aligned with the needs of next steps for supporting Providers with the CMS mandate. Pushing personalized communication at scale and to a high extent, via automation using text and e-mail campaigns will drastically cut down staffing required to accomplish otherwise daunting outreach efforts.
Who can use Acqueon’s pre-built CMS Unwinding omnichannel Campaign Management solution? Everyone from the Providers to the State Department of Health and Human Services. Our pre-built campaigns use our ready-made scripts, your patient data, and the communication is pushed through our advanced Campaign Manager.
That’s one giant way Acqueon can help you get ahead of this.
What Happens Next
Perhaps the first thing I should have addressed in this article is the fundamental “right thing to do” component of this entire situation. Anyone in healthcare at the Provider or State level is committed to the health and well-being of our communities and bottom line, prioritizing outreach that helps people live healthier, longer, better quality lives is our responsibility and privilege. It’s the right thing to do, right?
Let’s not wait and risk another public health emergency. You can take action and Acqueon can help. Let’s make sure our most vulnerable don’t get overlooked and underserved. Let’s work together to keep Providers financially fueled and capable of serving our communities rather than further mired down in the administrative tangles of labor shortages and claim denials.
We can do this together. If you’re a Provider or State worker who needs help with what comes next, contact Acqueon and we’ll start the journey to tackle the CMS Unwinding Program, proactively.
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