Civitas Answers FAQs: HIEs, RHICs, HDUs, and Medicaid Redetermination

The following questions are commonly asked of the Civitas staff about the work we do with HIEs, RHICs, HDUs, and Medicaid redetermination. This article is contributed by Alan Katz , Civitas' Associate Director of Advocacy and Public Policy. Thanks for reading!

Q: Could you provide an overview of the work that Civitas Networks for Health does in the Context of Medicaid Redetermination??

A: Medicaid redetermination is fundamentally about data exchange and analysis among five key stakeholder groups: patients, providers, SMAs, MCOs, and other public benefit programs. Civitas represents the organizations that link all five categories of stakeholders, which makes our members integral to the redetermination process in states and regions around the country. Health Information Exchanges (HIEs) provide the digital and human infrastructure that connects the stakeholders and executes data functions, while member Regional Health Improvement Collaboratives (RHICs) provide additional population-specific and data-derived products (e.g., quantitative and qualitative assessments, and performance metrics). The emerging Health Data Utility (HDU) frameworks in several states, such as Maryland and Nebraska, incorporate more expansive elements of both.?

Patient data – within the bounds of HIPAA and other relevant federal and state privacy laws – is the key operational resource for Civitas members. Civitas members aggregate, attribute, enhance, and transfer this data on Medicaid beneficiaries to providers, SMAs, MCOs, and other government actors (e.g., SNAP, TANF state agencies). Some members also operate direct patient interfaces that can notify those at-risk of losing their Medicaid coverage – but in every case, members collaborate with providers at the point of care, where clinicians are in the best position to tailor data inputs for flexibility and effectiveness. Further “up the chain” in the health data ecosystem, Civitas members mediate and facilitate exchange between Medicaid and non-Medicaid MCOs in real-time – given that about half of the 15 million people HHS expects to lose Medicaid coverage will not be eligible to re-enroll, redetermination is as significant for ACA marketplace insurers as it is for Medicaid. SMAs also utilize files that have been compiled by some Civitas members specifically for the redetermination process in order to meet their monthly reporting obligations to CMS under the FY 2023 Appropriations Act.

Q: How important is interoperability in the redetermination process??

A: No part of the redetermination process can run smoothly or effectively without a baseline level of technical interoperability between stakeholders' digital platforms. Civitas and its members have been extremely active in working to move the needle toward interoperability both within states and at the federal level (as a voice for TEFCA and the ONC’s information blocking rules), and the complex multi-source, multi-platform demands of the redetermination process are a case study in why this is necessary.

Q: How can collaboration and coordination between Medicaid agencies, healthcare providers, community organizations, and other stakeholders be improved to streamline the redetermination process and ensure seamless transitions in coverage??

A: In Civitas’ conversations with our members, the most important factor in successful stakeholder collaboration during the redetermination period has been a commitment to proactive outreach and engagement from the stakeholders themselves. While essentially all HDUs, HIEs, and RHICs have been involved in the process to some degree as data repositories, those states where the SMA has worked in a more direct and systematic way with the HIE and providers to use the available data for redetermination prep have had notably productive outcomes. One major factor that we’ve seen influence the practical extent and effectiveness of SMA-HIE-provider collaboration is the legal permission structure in place – the minority of states with explicit “opt-in” consent models face more barriers to effective larger-scale collaboration, and the redetermination experience in these states may serve as an impetus for transitioning to more efficient “opt-out” structures.

Q: What are some specific examples of Civitas members’ work during the redetermination process???

A: One leading example of successful proactive collaboration is CRISP - Chesapeake Regional Information System for our Patients in Maryland. Maryland Medicaid reached out to CRISP starting in January, and the two identified FQHCs as particularly important venues for improving data exchange with MCOs and managing the potential fallout from unanticipated coverage losses – including loss of health care services for high-need patients and logistical disruptions at clinics. CRISP worked with Maryland Medicaid to create a monthly redetermination status report and then worked with the FQHCs on a pilot to match their patient panels with the patient dates of redetermination and other relevant clinical/financial information. In this way, the FQHCs were able to conduct targeted outreach to patients slated for redetermination within the next 90 days, helping them navigate the process. CRISP has since expanded the pilot from FQHCs to all of its participant providers, and today about 40 organizations statewide receive monthly redetermination files representing about a quarter of a million patients.??

Another example comes from Detroit, where 美国韦恩州立大学 ’s regional PHOENIX system partnered with Medicaid MCO Molina Healthcare to engage beneficiaries at statistically high risk of “falling through the cracks” during the process – those who have been selected for redetermination, but who have not had a medical screening exam in the past year. These patients were invited to free screenings and consultations with Molina reps and Community Health Workers (CHWs) in community venues, which included linkages to care for medical and “wrap-around” social service needs. Patients who lose Medicaid coverage via redetermination are still provided with free screening and prevention services, directed and logged by the PHOENIX system. Similarly, Hixny in eastern New York (one of the state’s six regional HIEs) has modified its system of individual patient records (a.k.a. “profile cards”) to flag patients based on redetermination criteria and NCQA ’s Healthcare Effectiveness Data and Information Set (HEDIS) clinical metrics (diabetes, cancer, HBP) to facilitate single-point MCO outreach to these individuals. Hixny has partnered with MCOs on free community screening efforts and runs its own direct-outreach program based on health-related social needs accessible through its online patient interface.?

Around the country, HIEs have played a leading role in producing tailored demographic files that cross-reference Medicaid beneficiary status with geographic determinants for use by Medicaid and non-Medicaid MCOs alike. The multi-state designated HIE CyncHealth ’s work has been particularly notable in Nebraska and Iowa, as have the activities of the state-run SHARE system in Arkansas.

For more insights and resources about these topics, please visit the Civitas website.