Medicaid Redetermination for Community Health Centers - Managing Medicaid Changes Before the Visit
This article sums up our recent webinar about Medicaid Redetermination; its history, current and pending challenges for patients and Community Health Centers, and what CHC leaders can do before the patient arrives to give them the support they need while easing administrative burdens. It features John Donnelly (JD), Founder & CEO of FrontRunnerHC.
What you’ll learn:
Discover where coverage problems create extra work and financial risk, from patient check-in through reimbursement.
Learn how to move coverage verification and renewal support earlier (shift left!), giving staff more time to resolve issues.
Identify practical ways to simplify patient outreach and documentation, without adding more disconnected tasks.
Explore measures COOs and CFOs can track together, connecting coverage continuity, staff capacity, and financial performance.
Medicaid Redetermination for Community Health Centers
Here’s the unfortunate dilemma:
A patient arrives for an appointment.
Their Medicaid coverage is no longer active.
Your front desk begins searching for answers.
Your financial team inherits another unresolved account.
And the patient faces uncertainty about their care.
For Community Health Center leaders, these moments bring combined operational and financial pressures.
But there are ways health centers can get ahead of coverage changes before patients arrive. And it begins with a practical approach: understand the patient’s current circumstances, identify what needs attention, and give staff and patients time to act.
For COOs and CFOs, the opportunity is to build a process that makes those distinctions earlier.
Why Medicaid coverage continuity belongs on the leadership agenda
Medicaid redetermination is the process states use to review whether someone remains eligible for coverage.
The coming changes in January, 2027 add urgency. Federal guidelines require more frequent six-month (as opposed to the current 12-month) renewals for most Medicaid expansion adults beginning with renewals scheduled on or after January 1, 2027. Additionally, eligibility will be determined by:
Household income
Family size
Residency
Citizenship or immigration status
State-specific eligibility criteria
80+ hours of documented work per month (this is a new addition)
Leaders need to understand which patients are affected and how their state is implementing the requirements.
At the same time, the operational work can begin now: maintaining accurate contact information, checking coverage, organizing follow-up, and helping patients respond to requests.
Our article on Medicaid redetermination and the mission of Community Health Centers explores how coverage continuity supports patient access and the CHC mission.
For COOs: Find the work that keeps landing at check-in
When coverage questions surface at the front desk, they arrive alongside everything else staff must accomplish.
Someone needs to contact the patient, check payer information, find missing documents, or determine whether another employee has already started helping. Those tasks can interrupt the visit workflow and create repeat work across departments.
For a COO: identify how much coverage work is arriving unexpectedly and what would allow the team to address it sooner.
Review a sample of recent cases:
When did staff first identify the coverage issue?
Was current contact information available?
Did someone own the next step?
Could other departments see what had already been done?
Did the same issue require multiple calls or repeated data entry?
The answers can reveal where a process needs clearer ownership, earlier information, or a simpler handoff.
For CFOs: Look upstream of the unpaid claim
Coverage problems can become financial problems long before a claim reaches billing. A patient may appear as self-pay even though they have active insurance elsewhere. A renewal issue may remain unresolved through the visit. Staff may spend hours researching an account that could have been clarified earlier.
For CFOs, this calls for visibility into the work before the visit as well as the results afterward.
Separate patients with inactive coverage into actionable groups: those with other active insurance, those needing renewal support, and those needing financial assistance assessment. Each group requires a different response.
That distinction also improves financial analysis. Finding an existing policy, helping someone complete a renewal, and assessing assistance eligibility are separate activities with different outcomes. Tracking them separately helps leaders understand where staff effort produces value.
For a closer look at available capabilities, see Medicaid Redetermination Tools: Securing CHC Revenue.
Move coverage work earlier in the patient journey -> Shift left
JD calls this approach “shifting left”: moving information gathering and problem resolution toward the beginning of the patient journey.
“Before the visit is the left. And it’s all the information we need to gather before that patient steps foot in your door.” — John Donnelly
In the webinar, JD discussed looking ahead as far as 60 days before an appointment. That is a planning idea leaders can evaluate against their scheduling patterns, staffing, and patients’ needs.
Start with an upcoming patient group and establish a repeatable workflow:
Confirm patient information. Check contact details and coverage information.
Identify what needs attention. Separate coverage changes, missing documents, and existing open cases.
Assign responsibility. Give each unresolved issue an owner and a next action.
Support the patient. Explain what is needed and how to provide it.
Track the result. Record whether the issue was resolved and confirm coverage again near the visit.
Earlier review provides time to help. A check closer to the appointment accounts for changes that may occur afterward.
Make the patient’s next step easier
Knowing that documentation is missing only helps if the patient understands what to do next.
JD discussed practical options such as text reminders, secure document uploads, electronic signatures, and clear status tracking.
“We want to create that seamless experience for that patient. — John Donnelly
For health centers, that means reviewing the process from the patient’s perspective. Is the request clear? Can they submit the document securely? Do they know whether it was received? Can they reach someone if they need help?
Offer phone or in-person assistance alongside digital options. Patients have different access needs, and a simpler process should give them a workable path forward.
Give COOs and CFOs a shared view of progress
A practical starting dashboard can connect operational activity with patient and financial outcomes.
Measure | What it helps leaders understand |
Percentage of upcoming patients reviewed before the visit | Whether coverage work is moving earlier |
Unresolved coverage issues at check-in | How much unexpected work still reaches the front desk |
Time from issue identification to resolution | Where cases stall or handoffs slow progress |
Active insurance found among patients listed as self-pay | Whether existing coverage is being overlooked |
Staff time spent resolving coverage issues | The capacity required to support patients |
Eligibility-related denials and uncompensated care trends | Whether earlier work is improving financial outcomes |
These are suggested measures for a leadership dashboard. Establish a baseline, define each measure consistently, and review results together.
Start with one patient group, one accountable owner, and a clear follow-up process. Learn what works, then expand.
Explore FrontRunnerHC’s support for Community Health Centers, or connect with our team to discuss your current workflow.
Frequently asked questions
What is Medicaid redetermination?
Medicaid redetermination is the state’s review of whether a person remains eligible for Medicaid coverage. The state may use available data to complete the review or request additional information from the enrollee. Missing a required response can create a coverage interruption even when the person may still qualify.
Will every Medicaid patient need to renew coverage every six months in 2027?
No. The federal six-month renewal requirement applies primarily to most adults enrolled through Medicaid expansion and certain equivalent waiver coverage, with exemptions. It begins with renewals scheduled on or after January 1, 2027. Health centers should confirm the affected populations and transition schedule with their state Medicaid agency.
How can Community Health Centers prepare for Medicaid coverage changes?
CHCs can start by updating patient contact information, reviewing coverage before appointments, identifying patients who need renewal support, and assigning ownership to unresolved cases. COOs and CFOs should also track staff workload and financial outcomes to see whether the process is helping patients and reducing avoidable rework.
What is the difference between eligibility verification and insurance discovery?
Eligibility verification checks the status and benefits of a known insurance policy. Insurance discovery searches for active coverage that may be missing from the patient’s record. Both can help when a patient’s previously recorded coverage is inactive.
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