Medicaid Redetermination: Tips to Eliminate Abrasion for Medicare Duals Members

The Medicaid redetermination process has been underway since April 2023. States have been implementing the redetermination process to meet the 12-month timeframe required by the Centers for Medicare & Medicaid Services (CMS). There was a recent update on the redeterminations targeted towards Medicare Dual Eligibility Special Needs Plans (D-SNP) and Program of All-Inclusive Care for the Elderly (PACE) programs in a recent memo.

Lawsuits are developing due to redetermination issues that result in high volumes of members losing coverage because of administrative reasons instead of eligibility. Recent reports from the Center on Budget and Policy Priorities highlighted longer call wait times and processing times. These delays have an impact on member access to care and experience with the health system for members enrolled in D-SNP programs.

Many Medicare Advantage (MA) plans are still not sure what the impact of the Medicaid unwinding will have on their membership, Star Ratings and risk adjustment. Healthmine is sharing responses to some of the most frequently asked questions we’ve received.

What is the Impact on HEDIS Continuous Enrollment?

HEDIS continuous enrollment is at the organization level. Members who remain with the same MA organization but transition to a different Plan Benefit Package or contract will be considered continuously enrolled from a HEDIS perspective.

What is the Impact on Stars Measures?

There won’t be as much of an impact on the Stars voluntary disenrollment measure. As beneficiaries lose Medicaid eligibility, they will be involuntarily disenrolled from their D-SNP if they do not re-qualify during the plan-defined deeming grace period.

The Stars measure health plans should be monitoring due to the disenrollment are the Complaints About the Health Plan (CTM) as members call 1-800-MEDICARE regarding their involuntary disenrollment. Enrollment and disenrollment issues tend to be the primary CTM category for most plans.

What is the Impact on Risk Adjustment?

CMS encourages plans to enroll low-income beneficiaries by providing financial incentives through premium subsidies, cost sharing, reinsurance, and HCC coefficient risk adjustments. Many of these financial benefits are determined based on the date of enrollment in low-income programs. So, as states progress through Medicaid redeterminations, it’s critical that health plans help members appropriately retain their low-income subsidy (LIS) and Dual status to ensure members receive the benefits they deserve, and plans are appropriately paid through the risk adjustment model.

5 Strategies to Reduce Member Abrasion

As a health plan with Medicare duals members, here are the top five strategies to reduce the risk of interrupting member access to care and negatively impacting essential Medicare programs that depend on the Medicaid eligibility.

1. D-SNP health plans can continue to provide care for members that lose coverage but are expected to meet criteria within six months. D-SNPs are expected to provide members a written notice within 10 days of learning the loss of Medicaid eligibility. The D-SNP plan will not be held responsible for covering what the state was supposed to cover from the Medicaid funds.
   1. Ensure that plan has policy in place regarding the grace period prior to disenrollment of the member.
   2. Ensure staff is trained on the policy.
   3. Ensure systems are set up to not kick off processes and rather, pend disenrollment process for the grace period if that’s what the plan decided to do.
   4. Ensure that policy is applied uniformly to all members that are similarly situated.
2. Be proactive and begin informing all your D-SNP members of the redetermination process and what to look for. Offer members assistance with completing the forms or identify and refer members to any state-run assistance programs.
   1. Use multiple channels to inform members of this important renewal process.
   2. Train all staff that may interact with members (member services, care management, sales, etc.) to recognize this issue when members call. Perhaps they were informed by the news, or received communication from state or plan.
   3. Train staff to assist members in gathering best available evidence needed for redetermination.
   4. Train staff to assist members in understanding all options.
   5. Train staff in special enrollment periods and assisting with enrollment to another contract plan if possible.
   6. Create a centralized repository for all related materials, such as copies of state/plan letters, news articles, policies and procedures, or scripts.
3. Create a one-page cheat sheet, that can be used with internal and external partners, highlighting the key issues and messages.
4. Work with providers to help with updating member contact information and making sure renewal forms are sent to the correct address.
5. Work with providers and vendors to help aid with notifying members during appointments and engagements.

Healthmine has a team of Medicare and Medicaid experts who are skilled at working with plans to:

• Assess and develop strategic approaches to improving Stars ratings. 
• Conduct a gap analysis and develop mitigation efforts to meet compliance requirements based on the most recent NCQA and CMS rules and regulations.
• Develop training for internal and external care teams regarding the most recent Medicaid redetermination efforts.

To learn more, contact Ana.Berridge@healthmine.com.