Medicaid Eligibility System Failures: How MCOs Can Take Action
Medicaid MCOs play a key role in ensuring that millions of vulnerable Americans receive essential health services. However, a growing issue is affecting many MCOs nationwide: the failure of Medicaid eligibility systems in several states. These state-provided systems, often developed and operated by external contractors, have been plagued by errors that disrupt the enrollment and eligibility processes, resulting in the wrongful disenrollment of thousands of beneficiaries.
The Issue: Faulty Eligibility Systems
Across the country, Medicaid eligibility systems have repeatedly failed to determine accurately who qualifies for continued Medicaid coverage. Some common issues include:
• Sending incorrect notices to beneficiaries
• Failing to properly update addresses
• Freezing systems, causing delays in processing
MCOs Are Key Players in Mitigating the Impact
The challenge is that many MCOs may not be aware that they are impacted by these Medicaid eligibility system errors. If your organization relies on unverified state-provided Medicaid eligibility and disenrollment data, it could jeopardize beneficiaries’ health by creating coverage gaps caused by disenrollment errors. These errors not only threaten the health of Medicaid beneficiaries but also the financial stability of MCOs.
If you are operating in the following states, your MCO is likely affected by these issues (this list is not exhaustive):
• Maryland
• Delaware
• New Jersey
• Virginia
• Florida
• New Hampshire
• Maine
• Tennessee
• Georgia
As entities responsible for ensuring continuous coverage and delivering quality healthcare, MCOs have the responsibility to address disruptions caused by eligibility system failures. Whether it’s correcting wrongful disenrollments before its too late or catching potential issues before they occur, MCOs are on the front lines in minimizing the consequences of these system errors. This is particularly critical during times when Medicaid unwinding waivers are in place.
Steps MCOs Can Take to Address the System Errors:
Advocacy and Collaboration: MCOs should trust but verify the data provided by the state to address member disenrollment errors before they become irreversible. This can be achieved by implementing advanced retention analytics, overseen by Medicaid experts, to quickly identify and correct disenrollment inaccuracies.
Prompt Action and Support: MCOs play a critical role in assisting beneficiaries impacted by eligibility system errors. To prevent disenrollment, MCOs must promptly create and submit the necessary evidentiary support to state agencies.
Prioritize Communication: System errors can create confusion for Medicaid beneficiaries. MCOs should prioritize clear, proactive communication to ensure beneficiaries are informed and supported throughout the process.
Prepare for System Failures: MCOs should have contingency plans to quickly identify and address issues as they arise. Monitoring disenrollments in high-risk populations, such as those in MLTSS, SSI groups, and children, can help mitigate issues before they become irreversible.
The Bigger Picture: Addressing Systemic Challenges in Medicaid
As states continue to modernize and automate Medicaid eligibility systems, underlying technological issues have become more apparent. Technology may fail, but the commitment to care and health equity cannot. For MCOs, this presents an opportunity to be champions for the very individuals who depend on these systems to access essential healthcare coverage.
Agilian is here to support you. We’ve helped recover tens of millions of dollars in revenue lost by MCOs facing similar challenges. Let’s work together to address the impact of Medicaid eligibility system failures and ensure that vulnerable beneficiaries receive the care they deserve.
Learn More
For a more in-depth article of how Medicaid for millions in America hinges on eligibility systems plagued by errors, check out the full article by KFF Health News [here].