Navigating Medicaid Redetermination while Improving Chronic and End-Stage Kidney Disease Management
Author : Resham Puri, Associate, Strategy & DevelopmentMedicaid redetermination, the process of ensuring that beneficiaries maintain eligibility by verifying their qualifications, has long been an unwieldy yet necessary activity within the framework of Medicaid programs. This process has become increasingly significant in the wake of a substantial surge in Medicaid and CHIP enrollment, which escalated by a remarkable 29.8%, encompassing a staggering 21.2 million new enrollees from February 2020 to December 2022.1 Amid this growth, the relevance of Medicaid redetermination takes center stage as the continuous enrollment provision ends. At the end of 2022, the 2023 Consolidated Appropriations Act was signed. As a result, continuous enrollment was no longer considered part of the public health emergency and eventually terminated.
While each state has its own policies to manage renewals, many patients are losing coverage altogether. The end of states’ pandemic enrollment policies has already resulted in the loss of coverage for many Medicaid beneficiaries, with nearly 11 million members impacted nationally as of this month.2 Re-enrollment rates have been further stunted by long phone call and appointment wait times.3 Many of those disenrolled are losing coverage due to procedural issues rather than ineligibility. While it is possible for those who are ineligible and/or disenrolled to get coverage under the Affordable Care Act, many still remain uninsured.
The complexities of Medicaid redetermination are further compounded in the post-COVID landscape. Divergent state timelines and regulations dictate the redetermination process. Although many were disenrolled on March 31, 2023, redetermination is expected to continue through early 2024. Member churn, which was nearly nonexistent during the pandemic, reemerges as a concern and will affect many Medicaid enrollees and health plans.4 Notably, this impact will be felt more acutely by vulnerable populations, who are already at a heightened risk of losing their coverage.
Financial Impact of Redetermination
High Medicaid redetermination rates affect the entire healthcare ecosystem, ushering in financial, administrative, and membership stability implications that cannot be overlooked. Changes in enrollment and membership stability can directly affect revenue, as a decrease in membership can translate to fewer government Medicaid payments. Medicaid’s financial importance to health plans can also be understood from the lens of comprehensive risk-based managed care. Plans receive a fixed monthly capitation rate for Medicaid-covered services, bearing the risk of managing costs within the allocated amount. Conversely, plans can retain unspent funds from payments for covered services and contractual obligations.5
Administrative costs will also continue to increase as health plans grapple with the complexities and high volume of redetermination paperwork and eligibility verification.6 Additional time and resources will need to be channeled into ensuring compliance with the various requirements of the redetermination process. Additionally, disenrolled members may resort to increased emergency department visits, posing financial challenges for hospitals who are liable for some or all of these costs.7
Changes in the risk pool dynamics, triggered by Medicaid redetermination, can also lead to financially inadequate premium rates. The composition of the risk pool reflects the health status of individuals within it. Any notable law and regulations changes pertaining to insurance plans can sway the composition of this pool.8 The ramifications of Medicaid eligibility redeterminations on individual health insurance market enrollment, as well as their impact on risk pool and premium dynamics, remain uncertain but merit close attention.
Distinctive Challenges in CKD Management
A lack of continuity in care due to disenrollment poses significant challenges in managing chronic conditions, such as chronic kidney disease (CKD) and end-stage kidney disease (ESKD). When losing Medicaid coverage, patients also lose any associated benefits such as medical transportation and home health aides. The loss of transportation to dialysis/medical appointments and losing in-home support can impact patients’ health outcomes, mental health, and utilization costs.
Studies reveal that poor continuity of primary care affects approximately 1 in 5 CKD patients, resulting in increased rates of all-cause and potentially preventable acute care utilization.9 The kidney disease population is also highly comorbid; for example, only 4% of CKD3 patients don’t have any comorbidities.10 Timely identification and appropriate medical care can potentially delay cases of ESKD as well as avert complications associated with common comorbidities such as diabetes and colorectal cancer.11
The kidney disease population is also often characterized by its vulnerability, and there is a high probability that Medicaid patients who lose coverage will grapple with the complexities of managing their disease, primarily due to the loss of any clinical support.12 Statistics underscore the vulnerability of this population, with 35% of individuals with kidney failure being African American, despite comprising only 13% of the total population.13 Latinos, too, face disproportionate challenges, being 1.3 times more likely to have kidney failure.14 These disparities underscore the urgency of addressing CKD and ESKD management within the context of Medicaid redetermination.
Lower rates of early detection and diagnosis, coupled with reduced access to education, exacerbate the challenges faced by kidney disease patients. Early education emerges as a potential solution to delaying progression of kidney disease, as studies highlight its positive impact in preparing these patients for the complexities of managing their health.15
Addressing Redetermination Challenges with Proactive Kidney Disease Management
Engaging with proactive CKD and ESKD management solutions offers vital support to chronic disease patients navigating Medicaid redetermination. At Strive Health, our team includes dedicated licensed clinical social workers, community health workers, and patient navigators who play an important role in assisting patients in managing the administrative aspects of the redetermination process. Their consistent contact ensures a seamless transition through the redetermination process, and over 70% of Strive-enrolled patients exhibit engagement levels that surpass clinical touchpoint targets.16 For patients facing inevitable disenrollment despite administrative efforts, Strive Kidney Heroes™ will also explore eligibility for other health plan and CMS offerings and aid in enrollment and transition of coverage. Strive has also demonstrated a statistically significant impact on slowing disease progression by up to 50% based on a recent eGFR propensity study.
Discussing strategies for engaging and educating Medicaid beneficiaries with CKD becomes paramount in empowering them to take control of their care. The impact of patient engagement on adherence and outcomes is promising,17 and it emerges as an effective tool in navigating Medicaid redetermination successfully.
Managing redetermination is an unavoidable facet of enrollment and disenrollment for Medicaid populations, with implications that necessitate continued management. Challenges in CKD and ESKD management within this context are significant but can be mitigated through engagement and education. By enhancing CKD and ESKD management within the framework of Medicaid redetermination, Strive not only improves patient outcomes but also contributes to the stability and success of health plans and providers.
16 Based on Strive 1/1/21 to 1/1/23 for all operating markets. Clinical touchpoints are defined as an in-person or video visit or a meaningful completed phone call.