The Great Unwinding of the Continuous Enrollment Requirement


The COVID-19 pandemic created an unprecedented burden for healthcare providers, causing ICUs and emergency departments to overflow. Staff shortages driven by infection and burnout were endemic. We don’t know when the PHE will end, but the time to prepare is now. Change Healthcare can help providers deliver real value through enhanced patient experience, reduced uncompensated care, increased efficiency, and revenue.

By: Lukasz Szulc, vice president of technology enablement and transformation and RCM services health systems, Change Healthcare

The COVID-19 pandemic created havoc for healthcare providers, causing intensive care units and emergency departments to overflow. Staff shortages driven by infection and burnout were endemic. In January 2021, the Secretary of Health and Human Services declared a public health emergency (PHE) in response to the impact of the pandemic on our healthcare systems and patients. Although no one knows when it will end, the time to prepare is now, particularly as the government said they will provide only 60 days’ notice when they end the PHE.

Continuous Enrollment Requirement (CER) and its impact 

To help alleviate care payment (and other) issues during the pandemic, Congress passed the Families First Coronavirus Response Act in March 2020. This law created the CER, which dictates that in exchange for additional funds, states cannot require Medicaid and CHIP redetermination until the PHE ends. The CER helps patients who lost income during the pandemic due to furloughs and layoffs. It also benefits providers by helping ensure they receive Medicaid funds for appropriate patients and not worry about disenrollment, denials, and uncompensated care.

According to Kaiser Family Foundation research, the Medicaid population has increased by nearly 25%, or about 17.7 million people, since March 2020. Increases are largest in states that had passed Medicaid expansion, meaning the impact to providers in these states could be most significant. However, states that didn’t expand will still see impact, particularly since these states have the highest percentage of uncompensated care in the nation.

CMS is predicting 17.4%, or 15 million people, will lose their coverage due to loss of eligibility and that another 7.9% will lose coverage despite being eligible due to administrative churn.

States will have 12 months to initiate determinations for eligibility and an additional two months to complete all pending actions for work-in-progress redeterminations. Additionally, states are required to create and publish plans for “unwinding” the PHE.

However, according to the Georgetown University unwinding tracker, only seven states had completed the required unwinding documentation as of Dec. 2, 2022. That means most hospitals in the U.S. may be in the dark about what plans their state is making for the end of the PHE and CER.

CMS has also suggested that providers will want to take similar steps to the states to minimize disruptions to care coverage for patients. Specifically, CMS suggests providers conduct outreach to verify and update contact information for their Medicaid patients, at a minimum, to help minimize disruptions to operations and revenue.

Prepare for land mines

While CMS has said they will provide 60 days’ notice of the end of the PHE, it is still critical for providers to prepare for land mines and have a strategy in place to deliver a seamless patient experience.

  • State action
    States may not do an adequate job of notifying Medicaid and CHIP recipients that they need to go through redetermination, making disenrollment inevitable—even if someone still qualifies for the program. Additionally, it’s possible that states will only reach out to patients via mail. The fewer communication channels that the states use, the less likely they are to reach patients.

  • Timelines
    States have 12 months to process redeterminations plus two months to complete any actions in process. This could delay reimbursement from sources that—according to some providers—are already notoriously slow to pay.

  • Patient cooperation
    According to the Kaiser Family Foundation, Medicaid and CHIP families tend to pay close attention to mail received from the state. However, it has been nearly three years since the continuous enrollment requirement was implemented. Many patients will have moved during that time, making contact more difficult. Additionally, patients who became eligible for these programs for the first time during the pandemic may not be familiar with the redetermination process and may not be as responsive to state communications or the process.
Preparing for the unwinding today, by outsourcing or adopting new technology, can help you mitigate risk and bottom-line impact.
  • Margin impact
    ssues associated with the unwinding may have a negative impact on provider margins at a time when the American Hospital Association says that more than 50% of hospitals will have negative margins this year.
  • Operational impact
    As patients discover that they have been disenrolled, or as they reach out for help with redetermination processes, patient access agents will be inundated with calls. Eligibility and enrollment advisors will see a surge of newly uninsured patients. Benefits advisors will be overwhelmed from helping patients understand their payment obligations under their new benefits (if they qualify for employer, Marketplace, or other commercial care coverage).
  • Rush for staffing and technology
    When the end of the PHE is announced, many providers will need vendor expertise with the right technology and resources. Providers should prepare proactively to avoid facing challenges related to contracting, implementation, and onboarding.

Take steps now to protect patients and revenue

While the situation may sound dire, providers who prepare will be able to mitigate a good portion of the unwinding impact. The following high-level steps can help providers prepare for the unwinding.

  •  Assess current payer mix
    Analyze your current payer mix. What percentage of your patient population are currently relying on Medicaid and CHIP for their healthcare costs? What percentage of that population is currently active (under care or has upcoming appointments)? If you need to create budget requests to help your organization manage the unwinding, you could get a rough approximation of the financial impact on your organization by multiplying the number of active Medicaid and CHIP patients by your average Medicaid reimbursement. 

    Additionally, what social determinants of health is this population dealing with? Do you have patients who need help processing their redetermination? Has your state provided outreach materials in all the languages that your Medicaid population speaks? Think about what steps your organization may have to take to reduce revenue impact. 

  •  Determine technology and process needs
    Think about your needs in terms of technology, people, and processes. What digital tools do you have available for patient outreach? Are there aspects of your outreach that you can automate? Is your messaging crafted to incite action on the patient’s part?

    How are your current staffing levels? Are you already feeling the pinch of the labor shortage? Are you prepared to deal with a significant increase in denials?
  •  Educate yourself and your team 
    Reach out to your state Medicaid manager. How is your state handling the unwinding? What steps are they taking to communicate with Medicaid patients? Are they partnering with providers for communications?

  •  Develop a plan
    After you’ve done your analysis and learned what your state and other providers are doing, develop your plan.

    Can you plan an outreach campaign to alert Medicaid and CHIP patients to redetermination needs? What media will you use? Patient outreach should be evaluated on a person-by-person basis: some people prefer digital outreach, like text messages and email; others prefer to talk to someone on the phone; still others want face-to-face or print mail communications.

    Do you need to contract for labor or technology? Who are you going to partner with? How will you get new people onboarded and trained? What other steps can you take to alleviate any surge of calls or eligibility needs, for example, can you reschedule non-emergent appointments? 

  • Elevate the topic to leadership
    Ensure that your leadership understands the potential impact of the unwinding on both operations and revenue. What commitments can they make to help mitigate the impact? 

  • Leverage a technology vendor’s expertise
    With so many healthcare providers moving toward outsourcing all non-clinical functions, the unwinding may be a good time to evaluate the impact of outsourcing your front end – patient access call center, financial clearance, eligibility and enrollment, and more – and reallocating your existing team members to other revenue-optimizing activities.

    Change Healthcare’s Front End Accelerator solution seamlessly blends technology, live agents, and advisors to help you through the unwinding and deliver real value in the form of increased patient engagement, reduced uncompensated care, and improved early collections. It will also help you increase efficiency and revenue while delivering a frictionless patient experience. Some of the key benefits include:

    • Pre-registration—Update demographic, guarantor, and insurance information for scheduled appointments.
    • Scheduling—New and existing patients, labs, radiology, and procedures. 
    • Physician and employee referrals—Finding the right doctor, at the right time, at the right practice. 
    • Patient portal support—Technical help desk for patient access portals.
    • Outbound and inbound calls/tasks—Smart wait lists, recalls, appointment reminders, campaigns, patient hotline, vaccine program support, and after-hours patient access support. 
    • Transitions of care—Follow-up for patients discharged from hospital or ED to make sure they receive appropriate follow-up care. 
    • Financial clearance—Eligibility verification, prior authorization services, and pre-visit collection support. 
    • Nursing solutions—Rx refill requests, nurse triage, scribe nursing messages.

Front End Accelerator exceeds the performance of point solutions by enabling collaborative handoffs between functions for improved accuracy and efficiency, shorter wait times, and reduced denials to help you increase revenue while delivering a frictionless patient experience.

Unwinding other flexibilities associated with the public health emergency 

In addition to the Medicaid and CHIP CER, CMS put into place many other flexibilities intended to soften the impact of the PHE on healthcare providers and patients. They have been soliciting input from providers and patients throughout the PHE and plan to keep some of those flexibilities in place. However, the majority will be ending when the PHE ends. It is crucial that providers continue to monitor CMS communications to know which flexibilities will end.

Front End Accelerator can help you ensure that you are well prepared for the end of the CER and drive value to your organization. 

Key Takeaways

  • The CER during the public health emergency has helped hospitals decrease uncompensated care and Medicaid/CHIP patient “churn.”
  • The PHE has been extended, but eventually it will end.
  • Once the PHE and the CER end, hospitals will be faced with a wave of disenrollments, causing increased uncompensated care and denials.

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