Why Compliance Alone Won’t Solve Medicaid Redetermination

If you’re a Medicaid leader in one of the top 20 states by enrollment, the six-month eligibility review cycle is about to redefine your operational reality.  

Kaiser Family Foundation (KFF) data shows that procedural disenrollments accounted for the vast majority of coverage losses during the recent COVID-19 Public Health Emergency unwinding. In some states, more than 70% of those losing Medicaid did so because of missed forms, outdated contact information, or confusion about the process — not because they were ineligible. Now picture that churn risk doubling in frequency.  

Here’s the problem: too many organizations are approaching the six-month cycle with a compliance-first mindset. They’re focused on checking the regulatory boxes rather than protecting coverage. Our competitor analysis found that most vendors lead with “eligibility verification” and “document processing” in their messaging. Few speak directly about member stability, equity, or retention.    

The Cost of Churn Is More Than Numbers 
Disenrollment is expensive — both operationally and in terms of Americans’ health and quality of life. The Medicaid and CHIP Payment and Access Commission (MACPAC) reports that churn increases administrative costs, disrupts care continuity, and worsens outcomes. The real-life impact of disenrollment shows up in many ways for members: 

• Missed medications due to coverage gaps, increasing the risk of ER visits or hospitalizations 

• Interrupted preventative care 

• Stress and confusion for families, especially those with children, elderly, or disabled members 

• Disproportionate burden on vulnerable populations

Balancing Automation and the Human Touch 

This is where the future of Medicaid engagement lies: 

• Automation where it works best — AI-driven inbound and outbound support that scales across channels, languages, and member segments. 

• Humans where they’re essential — empathetic outreach that reduces fear and confusion about forms, deadlines, and eligibility. 

• First-contact resolution — connecting members to the right solution immediately, reducing repeat calls and stress. 

• Bilingual agents with cultural understanding — building stronger connections with members by speaking their language and addressing unique cultural needs, which drives higher response and retention. 

• Follow-up support — connecting members to SDoH resources such as food, transportation, or housing 

 A Smarter Path Forward 
As part of our Powering Change commitment, we see redetermination not as a bureaucratic burden, but as a proving ground. It’s the moment to show your members — and your regulators — that you deliver value, equity, and stability when it’s needed most. A smarter path forward isn’t only about delivering value, equity, and stability; it also protects members’ health and dignity. 

Ready to make changes in your approach to redetermination? Connect with us to explore starting points and ROI.