The 2025 federal budget reconciliation bill reshapes Medicaid coverage by tightening work requirements, increasing Medicaid eligibility checks, and shortening grace periods, all without additional federal funding to help states implement them. Understanding what Medicaid eligibility redetermination means for members and MCOs is essential. This change brings significant strain, but also opportunity to create a stronger and more resilient healthcare system.
During Medicaid unwinding, states struggled to reactivate dormant eligibility verification systems. According to the Georgetown Center for Children and Families, call center wait times soared and error rates climbed as renewal notices overwhelmed administrative staff. Many states now face a shift from yearly Medicaid redeterminations to semi-annual redeterminations and monthly work requirement reviews, which will put similar stress on states to strengthen staffing and upgrade technology. MCOs will need to navigate Medicaid eligibility issues when redetermination frequency increases in 2026 and help members adapt to Medicaid eligibility work requirements leading up to 2027.
How MCOs Can Help Members Navigate New Work Requirements
MCOs play a key role in helping members close documentation gaps so they stay enrolled and avoid care disruptions. The Agilian Playbook outlines actionable steps MCOs can take now.
- Engage withpolicymakers and advocacy groups.
MCOs can use their Medicaid data and member experiences to inform and influence waiver design and implementation. We saw MHPA and ACAP do just that in their November 3 letter to CMS Administrator Mehmet Oz regarding the implementation of work requirements and effective outreach. Engaging with federal and state policymakers as well as advocacy partners helps ensure a more human-centered approach to work requirements, leveraging what MCOs are best at doing.
- Invest in technology and outreach.
Outreach will be core to success under the new statutes and forthcoming CMS rules for Medicaid. By investing in reporting tools, Medicaid analytics, and automated and direct reminders, MCOs can help beneficiaries navigate new requirements and avoid losing coverage due to administrative barriers.
- Collaborate across the ecosystem.
MCOs should collaborate with providers, other health plans, and state agencies to coordinate outreach, share data, and minimize coverage disruptions during this transition. We’re seeing this already in MHPA and ACAP coordinated advocacy that all levers being used to ensure continuity of care.
- Train and equip frontline staff.
Frontline staff are the first and best point of contact for many members. MCOs can train service teams and care coordinators to clearly explain new rules, deadlines, reporting steps, and how members can ensure their information is up to date.
- Leverageoutreach and data disciplines
Apply the outreach and data learnings developed during the Medicaid Unwinding. These same strategies can help keep beneficiaries covered and reduce churn under the new work requirements and more frequent Medicaid redeterminations.
A Better Way Forward
Change does not have to mean disruption. MCOs will continue to be the difference that drives continuity of care by reducing Medicaid member churn and improving Medicaid retention. By using available data, coordinated outreach and education via care coordinators and automated tools, and following strategies like those outlined in the Agilian Playbook, MCOs can turn federal policy change into an opportunity to strengthen coverage and deliver better outcomes for Medicaid beneficiaries. Implementing a compliance-ready outreach plan will help MCOs keep members engaged and maintain coverage as new Medicaid work requirements take effect.
