Eligibility and enrollment modernization: streamlining at scale
While states vary widely in the maturity of their eligibility systems, several shared challenges persist: high renewal volumes, staff shortages and reliance on manual processes. Federal guidance emphasizes automation as a key strategy during unwinding and beyond, encouraging states to increase ex parte renewals and enhance system workflows.4
Concrete modernization opportunities:
- Automating verification and reducing documentation requirements
- Increasing ex parte rates
- Integrating eligibility across programs such as supplemental nutrition assistance program (SNAP) and temporary assistance for needy families (TANF)
Even without specific state reported automation outcomes, CMS’s guidance underscores that automation is central to timeliness, accuracy and reduced administrative churn.
Data integration and program integrity: improving accuracy and reducing waste
High quality data is foundational to oversight, managed care performance and payment integrity. States like Washington have undergone CMS program integrity reviews to strengthen oversight of managed care encounter data, fraud detection and compliance. The Washington FY2020–22 program integrity review offers a case study in how states can bolster managed care oversight and improve data validation processes.5
Key opportunities for Medicaid directors:
- Standardizing data quality expectations for managed care organizations (MCOs)
- Improving encounter data validation workflows
- Strengthening interagency data sharing, especially with public health and social service systems
- Leveraging audit findings to update contract compliance expectations
These improvements yield higher quality performance measurement, more accurate rate setting and reduced exposure to improper payments.
Care Management & Avoidable Utilization: A Clear Opportunity for Impact
While specific state outcome numbers were unavailable for validation, robust national evidence shows the magnitude of avoidable utilization:
- Up to 13% of adult hospitalizations and 8% of pediatric hospitalizations are considered potentially preventable.6
- Emergency department (ED) utilization for primary care-treatable conditions costs 10 to 12 times more than outpatient management.6
These statistics highlight why care coordination, chronic disease management and integration of social drivers of health remain high leverage areas for Medicaid agencies.
Additionally, predictive analytics models — such as those evaluated in Medicaid population health research — demonstrate strong potential for early identification of high risk members. Waymark’s models, for example, showed more than 90% accuracy in predicting avoidable emergencies or hospital events within Medicaid populations, offering a national benchmark for what artificial intelligence (AI) supported care management can achieve.7
Using these tools, states can better target:
- High risk chronic disease populations
- Maternal health risk prediction
- Dual eligible care coordination
- Preventive care outreach
Even without state specific outcomes, these validated models demonstrate clear potential for improving quality and reducing avoidable costs.
Member experience and access: addressing high call volumes and documentation barriers
During and after the unwinding period, states faced extraordinary inbound call volumes. National analyses highlight widespread challenges:
- High wait times
- Increased abandonment rates
- Insufficient staffing
- Confusion around renewals and coverage status
A national toolkit for call center performance improvement outlines strategies states can adopt to address these issues, such as staffing models, use of self service tools and workflow redesign.
Improving constituent experience directly influences:
- Renewal completion rates
- Compliance with CMS reporting requirements
- Health equity and trust
- Administrative cost burden on state staff
While specific state metrics (e.g., a 25% call volume reduction) were not supported by public data, national guidance provides a solid foundation for directors to drive performance improvements.
Strengthening managed care oversight
As more states rely heavily on managed care, oversight of plan performance, encounter data and program integrity becomes increasingly critical. One state’s performance audit of Medicaid MCOs highlighted actionable findings around:
- Fraud prevention
- Encounter data accuracy
- Oversight processes
- Penalties and corrective actions
Directors can use similar audit frameworks to strengthen state level oversight, enhance contract management and establish MCO accountability.
The road ahead: a realistic, evidence based modernization strategy
Based on current validated data, Medicaid directors can pursue the following pillars:
