Leveraging FHIR as Medicaid Public Health Emergency Unwinding Commences

Edifecs attended the 2023 State HIT Connect event on March 6-8 in Baltimore, Maryland, where state Medicaid agencies gathered to discuss the most pressing issues facing the industry. At the top of the list stood the unwinding of the Medicaid Continuous Enrollment Provision of the Families First Coronavirus Response Act (FFCRA), which allows state Medicaid agencies to restart eligibility redeterminations after a hiatus during the Public Health Emergency. 

Throughout the Covid-19 pandemic, Medicaid enrollment grew from 71 million beneficiaries in December of 2019 to a record-breaking 91 million in October of 2022. On March 31, 2023, the Continuous Enrollment Provision decoupled from the Public Health Emergency, and states are now allowed to resume redeterminations and disenroll beneficiaries who are no longer eligible. According to estimates from the Department of Health and Human Services¹, as many as 15 million people will lose coverage in the ensuing year, half of whom are children. 

State Medicaid agencies are tasked with the immense effort of resuming this operation at a scale never before seen, while continuing to carry out their mission of providing healthcare coverage to the underserved people of our nation. In the opening keynote of the State HIT Connect Summit, Kia Banton, the Deputy Director of Division of State Systems/CMCS Unwinding Team at CMS described CMS’s definition of success as “nobody loses healthcare coverage.” While acknowledging that zero churn is impossible, Deputy Director Banton stated that “systems are what are going to make unwinding successful. The programs will have to be able to lean on their systems for success.” 

At Edifecs, we agree with Deputy Director Banton. In recent years, the healthcare industry has pivoted to make healthcare data interoperable, with CMS leading the charge to make claims data accessible between patients, payers, and providers. Payers of all types continue to work hard to meet these mandates. We believe that PHE Unwinding creates a scenario where payers and state Medicaid agencies can leverage these investments to ensure their constituents have the right data to provide a seamless experience as Medicaid beneficiaries move to exchanges and employer-provided coverage.  

In recent years, payers have worked diligently to implement new interoperability capabilities that have been mandated by CMS, such as creating a Patient Access API to provide members full access to their claims and encounter information, including cost, as well as a defined sub-set of their clinical information through third-party applications of their choice. Many payers have approached this purely from a compliance perspective and have not strategically evaluated how these investments can be practically used to deliver value to their members and reduce costs associated with churn. We believe that PHE Unwinding surfaces a real-world application for these investments. As Medicaid beneficiaries begin to experience redeterminations, many will need to bring their data with them. Using the mandated access to their PHI will enable them to  reduce gaps in care, improve their experience in selecting new coverage, and reduce and simplify call center interactions. Just as the pandemic catalyzed many positive changes, the PHE Unwinding has the potential to unleash the value of interoperability and secure a trajectory in which healthcare data is truly able to be applied to improve the cost and quality of care.  

As the 2023 Best in KLAS® CMS Payer Interoperability vendor, Edifecs is committed to the future of interoperability. In addition to providing data access and continuity as patients move between health plans and providers, Edifecs’ Unified Gateway Platform is enabling new use cases such as value-based payments and automated electronic prior authorizations. To learn more about how Edifecs can help you meet your interoperability goals, contact us today.