With redetermination now twice as fast, health plans face unprecedented pressure to protect membership, revenue, and trust.
By: Wendi Summers, EVP & General Manager, Carenet Health
The Medicaid redetermination process is undergoing another change. Under the new six-month eligibility review cycle, health plans will face the most sustained operational pressure since the unwinding of the COVID-19 Public Health Emergency (PHE).
According to the Kaiser Family Foundation (KFF), more than 86 million Americans were enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) at the height of the PHE — and nearly 15 million lost coverage during the 2023–2024 unwinding. In some states, more than 70% of those losses were due not to members being ineligible, but to issues such as missed paperwork, outdated contact information, or confusion about the process. Now, with eligibility checks happening twice a year, those avoidable disruptions will only increase. This churn not only disrupts care, it also drains revenue through lost premiums, costly re-enrollments, and higher downstream medical expenses.
This six-month cadence is the ultimate stress test for Medicaid operations. It will magnify inefficiencies, widen cracks in engagement, and expose the difference between organizations that simply process members and those that protect them. Most vendors will sell compliance; few will help you turn this moment into proof that your plan delivers value, equity, and stability.
For Medicaid leaders, the stakes are not abstract. Every unnecessary disenrollment represents more than a line item on a financial report — it’s a patient who may miss essential medications, a family facing stress and uncertainty, a child skipping preventative care, or a vulnerable member left without access to food, housing, or transportation support. The Medicaid and Children’s Health Insurance Program (CHIP) Payment and Access Commission (MACPAC) reports that churn drives up administrative costs and increases downstream medical expenses when members re-enter coverage sicker and with more acute needs. The human and financial costs both compound if left unaddressed. These risks fall hardest on vulnerable populations — especially those facing housing instability or language barriers — who are most likely to be disenrolled despite still being eligible.
Recognizing the Real Challenge
Compliance is table stakes. True differentiation will come from your ability to protect coverage and safeguard people’s health. That requires moving beyond transactional notices and reminders toward multi-channel, multilingual, and personalized engagement that builds trust and meets members where they are — helping them navigate complexity without losing focus on their well-being.
How to Protect, Not Just Process
- AI + Human Orchestration: Use automation to reach members at scale and humans where empathy and complexity demand it. Our experience shows that combining AI-driven outreach with live support not only boosts contact and completion rates but also reassures members in moments of uncertainty.
- On-Demand Clinical & Non-Clinical Support: Provide immediate access to the right expertise so members don’t face weeks of waiting or gaps in care when eligibility questions arise.
- Cost Optimization: Reduce administrative waste and avoid unnecessary medical spend by resolving eligibility issues the first time and maintaining continuity of coverage.
Together, these capabilities form an orchestrated system — where AI handles scale and precision, and human expertise ensures no member falls through the cracks. This is what Powering Change looks like: moving beyond processing to protection.
The six-month cycle is no longer a distant policy change — it’s the new reality. The question isn’t whether your plan can process eligibility checks. It’s whether you can protect coverage, preserve trust, and prove value in the toughest environment Medicaid has ever faced.
- How is your organization preparing for this cycle?
