What Medicaid Redeterminations Mean for Qualified Health Plans

Redeterminations are the annual processes that respective states put in place to reevaluate a member’s eligibility for Medicaid. Income, assets, age, status, and disability designations are all considered to make final determinations for continuation of coverage. During the Covid-19 Public Health Emergency (PHE), states paused annual redeterminations and Medicaid enrollees were granted certain flexibilities—such as continuous health insurance coverage—without annual redeterminations. With the PHE ending, those redeterminations will begin again as early as April. Keep reading to learn what this could mean for Qualified Health Plans (QHPs) on the marketplace exchange.

Qualified Health Plans should be preparing for a potential influx in members

We know that this past annual enrollment period broke records across the country, and for the ACA with over 2.3 million members newly eligible for Qualified Health Plans. As the PHE ends, state redeterminations may leave up to 14 million people seeking health coverage on the exchange in April. But with an overwhelming number of marketplace coverage options, it begs the question: what makes your health plan stand out among the steep competition? If you haven’t thought about this yet—now’s the time.

We don’t foresee health coverage on the exchange slowing down anytime soon. That’s why issuers should always be implementing improvement strategies that align with their goals for growth.

Ask yourself the following questions: 

  • Where are our members utilizing their plans the most?
  • Are we evaluating our benefit structures annually?
  • What incentives do we offer our members—and are we clearly communicating them?
  • How can we get creative in our member-first approach?
  • Do we have the resources to support our goals?

Don’t let day-to-day QHP operations hinder opportunities for growth

Developing a plan—and roadmap—for seamless growth is time-consuming and may a challenging initiative on top of day-to-day tasks like accommodating new policy, ensuring compliance with new state and federal laws/rules, and completing filings successfully and on time. But it’s the most critical component of future success.

Here are the top 6 things your plan should be focusing on right now:

  1. Evaluating the best outreach channels for your specific members Historically, QHP members have faced barriers to technology. Whether you plan to implement text, Robo calls or printed mail collateral, it’s important consider your distribution channels and evaluate your strategy.
  2. Developing educational materials for your members about the renewals of their coverage  Always keep health literacy top of mind. Keep educational materials simple, meaningful and easy-to-understand.
  3. Ensuring compliance with state agencies (Division of Insurance, State Exchange)  This step may be cumbersome and frustrating but taking the time to solicit approvals from your DOIs and agencies will not only save you money but also prevent compliance, legal, and competitive boundary issues.
  4. Considering partnerships that engender growth  Do you have the right resources in place—talent, admin support and skills—to take on a potential influx of new members? If not, consider partnering with an expert vendor who can advise your internal IT, BI, analytics and warehouse teams to ensure the business requirements are in place.
  5. Developing standard operation procedures and process documents for internal activities  It’s important to document the gaps within your internal organization. There will be staff turnover and organizational changes. As resources shift, you’ll need a point of reference for your teams to ensure security of process and information.
  6. Drafting talking points for your customer service staff—there will be calls! Prepare your call centers by drafting high-level talking points for your service managers. Set up a quick call and train your CSRs on how to manage member escalations.

With the pause on annual redeterminations for continuous Medicaid coverage coming to an end, QHPs should see this as a major opportunity to attract new members. Whether you plan to optimize your performance within an existing market or explore new market opportunities and development, it’s critical to take the time to develop a roadmap. And, while working on your strategy for growth, it’s important to remember that each state you play in has respective regulations that you must follow. Keep compliance and strategy at the forefront of your execution. The last thing any Issuer wants is a hole or gap when 2024 plan-year filings are due. Consider partnering with a vendor who can keep up with the day-to-day tasks of QHP compliance and filing, so you can focus on a growth-minded 2024 and beyond.

ClearFile keeps up with ever-changing federal and state regulations, handling every detail—so you don’t have to. This alleviates the burden placed on your internal teams and frees up dollars you can reinvest in your business. We empower your team to grow membership by entering and meeting filing requirements of existing and new marketplaces and states. We’ll also share strategic insights on market opportunities and areas for improvement. We are your first line of defense for CMS and/or state questions—we’ll vet the questions and make sure they’re answered on time.

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