Unwinding Medicaid Continuous Coverage: Understanding the Importance of a Solid Eligibility Verification Strategy and PBE

 

January 17, 2023

What is Medicaid Unwinding (also called Unwinding Medicaid Continuous Coverage)?

The Medicaid continuous coverage requirement is a policy that was put in place during the COVID-19 pandemic to ensure that individuals remain eligible for Medicaid coverage even if they experience changes in income or family size that would typically make them ineligible. The requirement was implemented as part of a federal law that provided additional funding to states to help them maintain Medicaid coverage during the public health emergency (PHE). Under this requirement, individuals can keep their coverage unless they voluntarily disenroll, move out of the state, or pass away.

The continuous coverage requirement was originally set to end the month after the COVID-19 public health emergency expired, as declared by the Secretary of the U.S. Department of Health and Human Services. However, a recent spending bill passed in December 2022 changes this and sets April 1, 2023, as the end date for the continuous coverage requirement, regardless of whether the PHE is still in effect.

The end of the continuous coverage requirement will mean that states will begin the process of “unwinding” the coverage by reviewing the eligibility of every person enrolled in Medicaid. This process will determine who is still eligible for coverage and who should be removed from the program. The federal government has given states up to 14 months to complete the unwinding process, but each state will determine its own timeline for the process.

What this means for hospitals and other providers

The process of “unwinding” Medicaid may cause a significant number of individuals to lose their Medicaid coverage, with estimates suggesting that over 15 million beneficiaries could be affected. This could result in an increased burden on hospitals to screen patients for charity care, financial assistance, and collection activity. It will likely also result in financial challenges for hospitals and other healthcare providers who do not have a solid system in place for verifying patients’ eligibility, such as a higher rate of denied claims and increased costs for uncompensated care.

What providers can do to stay on track during Medicaid unwinding

The most effective process for preventing eligibility-related denials is to run insurance eligibility multiple times throughout the patient encounter, including:

  • When scheduling appointments
  • Before appointments
  • At check-in
  • After appointment
  • On a regular cadence for some patients/payers
  • Before claim submission

The last one here, before claim submission, is key as it relates to Medicaid unwinding. There are solutions like SSI’s Pre-billing Eligibility (PBE) Edits that help by offering a final eligibility check at the time of billing translation to protect against rejections and denials related to eligibility.

Conclusion

The end of the continuous coverage requirement for Medicaid, has the potential to greatly impact not only patients, but healthcare providers as well. The process, which involves reviewing the eligibility of every person enrolled in Medicaid, may result in a significant number of individuals losing coverage. This could lead to an increase in uninsured patients seeking care at hospitals, as well as financial challenges for healthcare providers who do not have a robust system in place for verifying eligibility. To stay on track during the unwinding process, providers can implement best practices such as regularly running insurance eligibility checks throughout the patient encounter and utilizing solutions like Pre-billing Eligibility Edits. By being proactive, providers can minimize the potential negative impact of the unwinding process on their patients and their own bottom line.

For more information on SSI PBE, contact us or request a demo.

 

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