Solving Medicaid Membership Reconciliation Across State Lines

With the Vast Differences in Medicaid, Learn How This Solution Can Help with Membership Reconciliation

Julie SkeenMay 23, 2017

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Medicaid is the single largest provider of health insurance in the United States, covering nearly 75 million people, according to the Centers for Medicare & Medicaid Services (CMS). Medicaid is an integral part of healthcare in the United States because it covers many low income individuals and families.

As part of the Affordable Care Act (ACA), Medicaid was supposed to expand eligibility to all eligible individuals with incomes under 138 percent of the Federal Poverty Line (FPL). However, the Supreme Court found it unconstitutional to force states to expand Medicaid and determined that Medicaid expansion should be left up to the individual states to decide.

Thirty-one states and the District of Columbia opted to expand Medicaid, which extended medical care to a large number of previously uncovered individuals, but left all states free to administer their state-level programs at their discretion, beyond the federally mandated requirements around covered populations and services. This makes member reconciliation particularly challenging for multi-state payers, because every state has unique Medicaid requirements. In addition, there is little consistency across state lines when it comes to how states reimburse payers.

Combine that with the possible changes the new administration will make and membership reconciliation becomes a major headache.

Possible Changes to Medicaid 

One thing we know for sure is that the new administration wants to repeal and replace the ACA. Their first attempt failed, and their second attempt at the American Health Care Act (AHCA) narrowly passed through the House of Representatives. Now the Senate Republicans have vowed to write a new bill from scratch. Whatever the final product, one likely outcome of ACA repeal and replace is that Medicaid expansion will likely be phased out. Currently, Medicaid covers about 19 percent of the population, but that could go down slightly to about 17 or 18 percent.

Another likely fundamental change is how the federal government funds Medicaid. Currently, states receive federally matching funds with no pre-set limits. Proposed ACA replacement legislation would cap the federal Medicaid contribution, and shift financing to either per capita or block grant funding. With increased financial responsibility, states would also be given greater regulatory autonomy over their Medicaid programs. States’ Medicaid budgets would be significantly impacted, and they would likely look for ways to aggressively cut cost, leading to  requirements for Medicaid recipients that previously weren’t allowed. For example, a state may require that certain Medicaid recipients show proof they are looking for work to retain benefits.

These possible changes would complicate member reconciliation even more. There is no one-size-fits-all solution for membership reimbursement when each state has vastly different rules and requirements. There is, however, an adaptable solution for reconciliation that can work in every state.


Organizations can use an automated reconciliation solution that easily executes complex rules automatically run in the background to catch membership errors at the source, and provides continual monitoring to ensure maximum data integrity from source to destination.  Regardless of state-specific processes for sending and receiving enrollment data from the state or third-party vendors, you can ensure the accuracy of all data as it enters and propagates through your systems. Payers can rely on the continued integrity of their data, and additional value is delivered through 100 percent visibility into all reconciliation points. Flexible reporting and dashboards assure quick notice of error and allow for prompt prioritization and resolution of exceptions.

Finding and reconciling issues early on speeds up the member enrollment process and avoids errors that can pollute other downstream processes. When membership errors are found too late, investigation and correction can be time-consuming, and resultant delays can cause both embarrassment and customer service issues.

A highly configurable, automated membership reconciliation platform can be quickly adapted to meet state-specific regulatory demands, and provides the peace of mind that all systems are performing flawlessly and operational efficiencies are maximized. And when an error occurs, it’s quickly flagged to be fixed before it can impact members, business or bottom line.

To learn more about an all-inclusive data intelligence platform to help with member reconciliation, check out the data sheet below.

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