Key takeaways from MESC:
- Use the data and infrastructure you already have before asking members to provide more.
- Build community engagement workflows around the cases that need attention, not a single process for every member.
- Treat implementation as a partnership across Medicaid, HIEs, providers, technology teams, and community organizations.
January 1, 2027 is getting closer, and states are moving from understanding the policy to figuring out how all of this will work in practice. Who needs to report? What information does the state already have? And how do you build all of that without creating another giant administrative burden for members and your teams?
I had the opportunity to moderate a session with Sarah Young, Deputy Commissioner at the West Virginia Department of Health and Human Services, Brandon Marsh, IT & Data Director at West Virginia University Health Affairs Institute, and CITIZ3N’s Rob Miller focused entirely on those questions.
Many of the challenges we discussed weren’t unique to West Virginia. They came up repeatedly throughout the Medicaid Enterprise Systems Conference (MESC). Here are the conversations I think state teams should be having now.
States Don’t Need to Start Community Engagement Implementation from Scratch
States already have more infrastructure to work with than we sometimes give them credit for.
During a session on using Health Information Exchange data to support Medicaid work requirements, Jessica Kahn of McKinsey, Craig Behm of CRISP, Melissa Kotrys of Contexture, and Herminio Navia of New Jersey Medicaid discussed how HIE infrastructure could support medical frailty determinations and help prevent avoidable coverage loss.
Medical frailty isn’t necessarily something you can determine from a single diagnosis. States may need to consider hospitalizations, procedures, lab results, treatment history, medications, functional impairment, and other clinical information. Much of that information already exists.
Melissa described an HIE network spanning more than 1,400 organizations across Arizona and Colorado. New Jersey discussed infrastructure connecting hospitals, tens of thousands of providers, and hundreds of long-term care facilities. States may be able to use those existing networks for new verification use cases.
That fits closely with something Rob Miller emphasized during the Medicaid Work Requirements session:
"The member is the last data source." Rob Miller, General Manager & Senior Vice President, CITIZ3N Government Solutions
The flow is simple. Check the information you already have first; then determine what you still need from the member.
The HIE panel discussed how Medicaid claims data can lag roughly three to six months, while clinical and encounter information flowing through HIE may become available within days or weeks.
Consider a new Medicaid applicant who has no claims history but recently experienced a hospitalization relevant to a medical frailty exemption. The information may exist even if it hasn’t reached the data source the eligibility system traditionally relies on.
Colorado offered a good example of what can happen when eligibility teams have better access to that information. Contexture reported that HIE access helped reduce average disability determination processing time from approximately eight months to 38 days.
States should be asking what reliable information already exists across their programs and partners before creating a new request for the member.
Community Engagement Verification Needs More Than One Path
Some people will meet community engagement requirements with information the state can verify automatically. Some will require member action and manual review.
Building one workflow for all of them creates unnecessary work.
That was central to our West Virginia discussion. The operating model we walked through begins by determining applicability and exclusions, checking trusted data sources, and looking for opportunities for automated resolution. Targeted outreach and caseworker review come into play when the available information isn’t enough.
The HIE discussion showed just how many options states have. An eligibility worker could access clinical information through an HIE portal. States could send member files to an HIE for matching. More mature models could use automated matching, APIs, clinical summaries, or exemption indicators returned directly into eligibility workflows.
States don’t necessarily have to jump straight to the most automated model either. They can start with the infrastructure and processes they have today and build toward greater automation.
“You don’t need to automate everything on day one. Start with the data and infrastructure you have, then build from there as your needs evolve.” Rob Miller, General Manager & Senior Vice President, CITIZ3N Government Solutions
Verification, exemptions, member workflows, outreach, case review, reporting, and partnerships need to behave like one operating capability, not six disconnected workstreams.
The technology matters, but so do ownership and decision rights. Who is responsible when a case doesn’t resolve automatically?
Providers and HIEs Can Be Part of the Member Outreach Strategy
One of my favorite examples from MESC came from New Jersey because it showed that better data doesn’t only improve verification. It can improve outreach too.
New Jersey described an existing process where the state identifies Medicaid members who may be at risk of disenrollment. The HIE then identifies providers who have active care relationships with those members and securely gives those providers information they can use to conduct outreach. Instead of another generic communication coming from an unfamiliar source, a member can hear from a provider they already know.
According to the presentation, the approach was associated with approximately a 6% reduction in disenrollment among members reached through the process, representing roughly 22,000 people maintaining Medicaid coverage.
We’ve spent a lot of time talking about how states should communicate community engagement requirements. But communication doesn’t have to mean another letter, text message, or portal notification from Medicaid. States should be thinking about the organizations members already interact with and trust.
Health plans, providers, HIEs, community organizations, and other partners can all have a role.
Community Engagement Is a Data and Coordination Challenge
Implementing community engagement requirements is going to require much more than adding another eligibility workflow. States need to know what data is available and what happens when the information isn’t enough.
There is already a lot of infrastructure in place. The opportunity is to connect it in a way that makes compliance easier to verify, gives workers better information, focuses manual effort where it’s needed, and keeps members from having to prove something the government could have figured out itself.
The states that are best prepared for January 1 will be the ones bringing eligibility teams, HIEs, health plans, providers, community organizations, technology partners, and other stakeholders into the conversation now.
If your agency is working through its approach to community engagement requirements, we’d love to compare notes on what you’re building and what we’re seeing across states.
Or you can connect with me directly on LinkedIn.
Enjoy the bonus dog picture!
