For Medicare, Medicaid, and Dual Special Needs plans, the past 12 months have been marked in part by the significant regulatory and policy shifts, particularly concerning Medicaid redetermination, duals alignment, and increased oversight by states to ensure carriers’ compliance with contracts.
At Wider Circle, we are at this intersection, serving as partners to health plans and providers in service of our mission to connect neighbors for better health. When we look at these developments, we see a common thread: increased member centricity in the regulatory direction; streamlining administrative process; delivering better value; and continued focus on consistency and quality of care.
Medicaid redetermination stands as a cornerstone to ensure continued access to vital health care services for millions of individuals across the United States. Over the past year, regulators and state agencies have undertaken reforms aimed at streamlining redetermination processes, reducing administrative burdens, and enhancing outreach efforts to ensure individuals maintain their Medicaid coverage. Notable initiatives include the expansion of digital platforms for redetermination submissions, increased use of data analytics to identify eligible recipients, and the implementation of automatic renewal systems to prevent coverage gaps.
One example of such reform is the Medicaid and CHIP Coverage Continuity Final Rule issued by the Centers for Medicare & Medicaid Services (CMS) in December 2023. This rule aims to simplify the redetermination process by allowing states to leverage verified data from other programs, such as the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), to streamline eligibility determinations. By reducing paperwork and administrative hurdles, this policy change enables community health organizations to focus resources on delivering essential care to those in need.
Duals alignment, the integration of care for individuals eligible for both Medicare and Medicaid, has emerged as another critical area of focus in community health policy. It’s no secret that dual-eligible individuals often face complex health care needs and fragmented delivery systems, leading to disparities in care quality and outcomes. In response, states have been actively pursuing strategies to align Medicare and Medicaid benefits, improve care coordination, and enhance health outcomes for this vulnerable population.
In the past year, several states have implemented innovative models such as Highly Integrated Duals Special Needs Plans (HIDE-SNP) and Managed Long-Term Services and Supports (MLTSS) to better serve dual-eligible individuals. These initiatives aim to provide comprehensive, person-centered care that addresses both medical and social determinants of health. For instance, California's Cal MediConnect program integrates Medicare and Medicaid benefits under a single managed care plan, offering enrollees access to a coordinated network of providers and support services.
Recently, we’ve all seen headlines noting incumbent Medicaid plans losing bids, purportedly for failing to comply with standards set forth in the state contracts. In recent months, states have enhanced oversight mechanisms and introduced new performance measures to monitor the quality and effectiveness of Medicaid and Duals Eligible Plans. For example, states like New York have implemented value-based payment models such as the Delivery System Reform Incentive Payment (DSRIP) program which incentivizes providers to deliver high-quality, cost-effective care while prioritizing health equity and patient-centered outcomes. By aligning financial incentives with performance goals, these models promote accountability and drive continuous improvement in community health delivery.
At Wider Circle we often see the downstream impact on members and patients of such macro changes–be they positive or negative. And, importantly, while these shifts are individually important, there is a broader movement afoot toward member and patient centricity. Health plans and providers who continue to lean into this and plan more broadly are likely to find themselves best positioned to meet and exceed not just the letter of these changes but the spirit in which they are intended.
References:
- Centers for Medicare & Medicaid Services. (2023, December). Medicaid and CHIP Coverage Continuity Final Rule. [Press Release].
- California Department of Health Care Services. (n.d.). Cal MediConnect.
- New York State Department of Health. (n.d.). Value-Based Payment.
About the author
Brett Zelkind is the chief strategy officer at Wider Circle, where he oversees strategic direction and execution toward achieving the company’s long-term vision.
Before joining Wider Circle, he held the same role at andros, where he led business development efforts, secured funding, managed mergers and acquisitions, and transitioned the company from a point solution into a full platform offering. His previous experience includes management positions at WellCare Health Plans, Mazars, and Marwood Group.
Zelkind holds an MBA from the University of Delaware and a BA from the University at Buffalo. With his pragmatic approach and deep industry knowledge, Brett drives Wider Circle's strategic initiatives forward, ensuring impactful growth and development in the health care sector.