Medicaid Redetermination Is Not a Payer Problem — It Is an Operational Workflow You Need to Own

Every FQHC in Maryland has patients who are about to lose Medicaid coverage. Not because they are ineligible — because nobody told them their redetermination deadline is 60 days away.

Redetermination is not new. What is new is the scale. During the COVID-19 public health emergency, Medicaid maintained enrollment for nearly all beneficiaries without requiring renewals. That pause is over. States are now cycling through their entire Medicaid population, and for some patients this is the first redetermination they have ever completed.

On top of that, Section 71119 of the One Big Beautiful Bill Act introduces Medicaid community engagement requirements beginning January 2027. Under the new law, up to 320,000 Maryland Medicaid members will need to demonstrate at least 80 hours per month of qualifying activity — employment, volunteering, job training, or education — to maintain coverage. Affected members will also shift from annual to six-month renewal cycles, requiring income verification and activity documentation twice a year.

The Maryland Department of Health has launched a statewide "Medicaid Check-In" campaign to help members understand the changes. But the operational burden of managing this at scale falls on the organizations that see these patients — and that means FQHCs.

Who Is Exempt

Not everyone is affected. The following groups are exempt from the community engagement requirements:

• Children under 19
• Adults 65 and older
• Pregnant individuals
• People with disabilities
• Caregivers of young children
• Those managing serious health conditions

Your eligibility and care coordination teams need to be able to identify exempt patients proactively — not wait for them to lose coverage and appeal.

The Operational Gap

Most FQHCs learn about a coverage lapse the same way: a claim gets denied. By then, the visit has already happened. The 340B pricing is lost. The patient may not come back.

The gap is not eligibility knowledge. It is detection speed. How many days elapse between a patient's coverage lapsing and your team finding out?

If the answer is "when the claim bounces," you are operating reactively. Every day of delay costs you a billable encounter, a 340B-eligible prescription, and — in many cases — a patient who now thinks they are uninsured.

CRISP: A Resource Maryland FQHCs Should Be Using

CRISP (Chesapeake Regional Information System for Our Patients) partners with Maryland Medicaid to provide healthcare delivery sites with monthly lists of patients approaching their redetermination deadline within 90 days.

The file includes patient contact information so your outreach team can act before the deadline passes — not after.

To access the file, your organization must be a CRISP participant (a HIPAA-covered entity with a signed participation agreement) with active CEND panels containing currently enrolled Medicaid patients. If you are an FQHC in Maryland and you are not receiving this file, contact your CRISP outreach representative or reach them at 877-952-7477.

CRISP provides:

• A Medicaid Redetermination Overview (updated January 2025)
• A File User Guide explaining how to interpret and act on the data
• An FAQ covering eligibility and access requirements

These resources are available at crisphealth.org/medicaid-redetermination.

What Providers Should Be Doing Now

The Maryland Department of Health guidance for providers is clear: you are a trusted messenger. Patients will ask you about eligibility, renewal timelines, and what the work requirements mean for them. Be ready.

Practical steps:

1. Assign ownership. Someone on your team — eligibility, care coordination, or population health — needs to own the redetermination outreach workflow. If nobody owns it, nobody does it.
2. Get the CRISP file. If you are not receiving monthly redetermination data from CRISP, request access today. This is the earliest warning system available to Maryland providers.
3. Stratify by risk. Not every patient on the list carries the same financial exposure. Patients on specialty medications, patients with high visit frequency, and patients whose coverage lapse would trigger 340B pricing loss should be prioritized.
4. Outreach before the deadline. A phone call or text 60 days before redetermination is worth more than a retroactive eligibility appeal. Use the contact information in the CRISP file to reach patients directly.
5. Post educational materials. Download the MDH toolkit and post flyers in waiting rooms and check-in areas. Include information in patient portal messages and appointment reminders. Direct patients to MarylandHealthConnection.gov/Checkin.
6. Document every outreach attempt. Whether the patient responds or not, document it. This creates an audit trail and supports future retroactive eligibility claims.
7. Identify exempt patients now. Screen your Medicaid panel for patients who qualify for exemptions — disability, pregnancy, caregiving, serious health conditions. Flag them before the system flags them for noncompliance.
8. Track outcomes. Did the patient complete redetermination? Did they lose coverage? Was it procedural (missed paperwork) or substantive (income change)? This data tells you whether your outreach workflow is working.

The 340B Connection

Every patient who falls off Medicaid without your knowledge takes their 340B eligibility with them. If you are dispensing medications at 340B pricing to a patient who is no longer covered, you have a compliance problem. If you are not dispensing at 340B pricing because you did not know they were still covered, you have a revenue problem.

Coverage verification and 340B program integrity are the same workflow. Treat them that way.