More than 90 million enrollments in Medicaid and CHIP were reported in September 2022.

In fact, the number of beneficiaries covered by the Medicaid program increased by 40% back in 2018 and covered about 73 million, from 55 million since the time the affordable care act was passed. This growth has attracted more health insurers, healthcare service vendors, provider-led health plans, and investors to the program. Along with that, the COVID-19 pandemic has also increased demand for Medicaid programs as they expedite coverage for eligible individuals.

Growth in Medicaid is expected to continue on the upward trajectory as the program expands to accommodate the complex high-needs populations into managed care. Efforts to improve Medicaid enrolments continue as states explore ways to implement tech innovations to managed care models to improve quality and efficiency, increase budget predictability, and control costs.

Medicaid aims to be a trillion-dollar program by 2026. It also promises to cover a much wider demographic with capabilities that are deeply tailored to meet the needs of every subsegment.

The program that now covers one in five Americans, including many with complex and costly needs for care, is extremely focused on growing enrolments. However, a new influx of enrolments can be debilitating for legacy, back-end infrastructure. Modernizing Medicaid and shifting from monolithic Medicaid Management Information Systems (MMIS) to modular Medicaid Enterprise Systems (MES) is now essential.

Along with this, modernizing Medicaid programs will demand a focus on the following aspects.

Crossing the Data Chasm

Medicaid programs have to be aligned with each state’s standards of eligibility and how they address the health needs of their population. Apart from addressing needs like long-term care support, mental health, children’s and women’s health, etc., many states have outsourced care coordination to private managed care entities. These privately managed care bodies are often reluctant to share data which limits the availability of timely clinical, financial, and administrative data for overseers. The absence of real-time data further makes it hard to manage and monitor enrolments.

Modernization plans, as such, must focus on improving access to and analysis of clinical, administrative, and operational data. Improving data and analytics capabilities can provide valuable insights into program performance and address population health needs more accurately and proactively.

Standardized, Automated, and Modernized Process

Standardizing, automating, and modernizing processes is another aspect that needs to be covered in the journey to modernization. Implementing standardized, automated, and modernized process enables easy management and retention of critical enrolment information across multiple business lines.

Modern, scalable, automated, end-to-end enrollment management solutions become essential to support growing Medicaid needs. They also consolidate enrollment data across partners and drive automation for greater visibility. Further, they relieve IT teams from sorting through siloed sources of member data while also driving timely communication and issue resolution.

Modularity Is Essential for Operational Transformation

Most Medicaid programs rely on dated, legacy monolithic MMIS systems. The Enterprise Data Warehouse (EDW), Independent Verification & Validation (IV&V), Pharmacy, and Integrated Eligibility all lie in separate modules in a majority of the MMIS systems. As Medicaid agencies feel the need to improve outcomes and increase transparency, modularity becomes a crucial goal for modernization.

Modular systems become even more essential as new regulation adherence becomes essential for compliance and data availability increases. Monolithic, legacy systems do not offer the flexibility and agility needed to improve operational effectiveness and costs.

Modular systems are more extensible and offer greater interoperability. They can connect key stakeholders, streamline processes more effectively and provide greater and more secure information access, thereby driving operational transformation.

Configuration or Customization – Making the Right Choice

The conversation on modernization almost always veers toward customization. It is the same in the case of Medicaid as well. Modernizing strategic business processes might warrant more customized processes. Combating fraud or improving delivery and payment capabilities might warrant customization of systems and processes. However, sometimes customizations can be limiting and expensive.

While driving innovations in areas of say, delivery, and payment, are warranted, opting for configurability and identifying the ideal candidates for the same in the modernization journey can offer distinct advantages. Employing a well-built, robust, and comprehensive configurable system on a modular, cloud-hosted platform offers many benefits. New feature adoption, scaling the user base, managing load, driving availability and adaptability also become easier and less expensive with a configurability focus.

Process Automation and Information Sharing

Medicaid modernization is not just about technology but about driving enablement. Be it members, workers, providers, managed care organizations, and other business partners, the modernization efforts have to help these stakeholders capture, share, and use information effectively, efficiently, and securely.

Intelligent process automation will become essential to quickly and accurately process millions of documents to serve the constituents and also meet deadlines. However, it is important to ensure that the automation solution automatically classifies, extracts, and enriches data from any document type, regardless of structure, quality, and text type. It should also provide a high degree of accuracy, customization opportunities, and fast, easy, and secure deployment.

Process automation reduces manual effort and improves accuracy. It drives reliable, accurate, and timely information sharing that makes claims processing faster, reduces waste, improves costs, and prevents fraud.

Mobile Enablement

Studies have previously revealed that 86% of the general adult population and Medicaid beneficiaries (both) use smartphones. Most Medicaid users also use mobile technology to manage their health. 37% of the users, for example, measure fitness and health improvement, 27% monitor health issues such as blood sugar, and 24% receive alerts or reminders to take prescription drugs, etc., through their smartphones.

Even low-income beneficiaries use smartphones. Mobile enablement and mHealth applications can play an integral role in driving greater access and improving care for the overall population. Mobility lowers costs, improves quality, and increases access to care, even for rural and underserved populations.

Mobile health apps can also better track medication needs and dosage instructions, send alerts and messages for chronic disease management, and offer healthcare providers and specialists more means to communicate effectively and coordinate care better.

In a Nutshell

Kyyba acknowledges the obstacles confronted by Medicare customers and is dedicated to delivering comprehensive solutions that cater to their requirements. Through our proficiency in healthcare technology and streamlining processes, we can assist customers in simplifying their enrollment and eligibility verification procedures, capitalizing on Ai driven process automation to enhance productivity, as well as improving data management and information-sharing practices.

Our adaptable and customizable solution approach offers versatility, scalability, and compatibility to ensure a seamless transition toward modernized platforms. By leveraging mobile integration be it Native Apps or Hybrid apps built mHealth applications connected to EHR systems, we can empower customers with the ability to enhance access to healthcare services while promoting patient engagement through effective communication and coordination among healthcare stakeholders.

Collaborating with Kyyba within the Medicare sector has the potential for better results, heightened efficiency levels, as well as enhanced accessibility of healthcare services for both customers themselves as well as beneficiaries. Get in touch with us today!

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