A Health Center's Guide to Medicaid Redetermination

What it is, what's changing in 2027, and how your team can keep patients covered

For community health centers, Medicaid coverage underpins patient care and financial stability. When a patient loses coverage, it is rarely because they stopped qualifying. More often, a renewal notice went to an old address, a form went unanswered, or a document was never uploaded. Redetermination is one point at which eligible patients can lose coverage for procedural reasons, and health centers are well placed to help prevent these gaps.

This guide covers the basics of Medicaid redetermination, the federal changes expected in 2027, and practical steps your team can take to help patients maintain coverage.

What Is Medicaid Redetermination?

Redetermination, also called renewal or recertification, is the periodic process through which a state Medicaid agency confirms whether an enrollee continues to meet eligibility requirements.

States must first attempt to renew coverage using reliable information already available to them. This process is known as an ex parte renewal. If the state cannot confirm eligibility through available data, it generally sends the enrollee a renewal form. It requests any necessary information or documentation, such as proof of income or household changes.

Missing a deadline or failing to provide requested documents can terminate coverage, even when someone remains eligible. This is known as procedural disenrollment.

During the post-pandemic Medicaid unwinding, procedural terminations became a major concern because eligible people could lose coverage simply by not completing the renewal process.

Why Medicaid Redetermination Matters Now

Ending the pandemic-era continuous enrollment requirement did not eliminate Medicaid renewal challenges. New federal requirements under the 2025 reconciliation law, Public Law 119-21, commonly known as the One Big Beautiful Bill Act (OBBBA), introduce additional eligibility checks for certain adult Medicaid populations.

Key provisions include:

• Six-month eligibility redeterminations. Beginning January 1, 2027, states must generally redetermine eligibility every six months for specified adults enrolled through the Medicaid expansion pathway, subject to statutory exceptions.
• Work and community engagement requirements. Beginning in 2027, certain adults generally must demonstrate 80 hours per month of qualifying work, community service, job training, or education, unless an exemption applies. Implementation and verification procedures will depend on federal guidance and state processes.
• Changes to retroactive coverage. For specified Medicaid expansion adults, the retroactive coverage period is reduced to one month before the application month, subject to applicable exceptions.
• Future cost-sharing changes. Certain expansion adults may be subject to new cost-sharing requirements beginning October 1, 2028. The law provides protections and exclusions for specified services and populations.

These changes do not apply identically to every Medicaid enrollee. Eligibility group, exemption status, and state implementation all matter.

For the latest federal guidance, consult the Centers for Medicare & Medicaid Services (CMS) Medicaid eligibility and renewal resources.

Because implementation details may evolve, health centers should verify current timelines, exemption categories, documentation rules, and state-specific procedures before updating patient-facing materials.

What These Changes Mean for Health Centers

More frequent renewals, combined with new verification requirements for certain adults, mean more opportunities for patients to miss a deadline or encounter a coverage gap.

Health centers should prepare for:

• More patients needing renewal assistance.
• Eligible patients losing coverage because of incomplete paperwork or missed notices.
• More uninsured visits and uncompensated care when health centers don't promptly address coverage gaps.
• Greater pressure on enrollment counselors, community health workers, billing teams, and front-desk staff.
• Additional coordination between patients, state eligibility agencies, and Medicaid managed care plans.

The health centers best positioned to manage these changes will treat redetermination as an ongoing, team-wide workflow rather than a one-time outreach campaign.

A Practical Medicaid Redetermination Playbook

1. Know Your Patient Population

Use your EHR or practice management system to identify Medicaid patients, distinguish relevant eligibility groups, and, when available, record upcoming renewal dates.

For patients potentially subject to the new requirements, establish a process to identify those who may qualify for exemptions and those who may need help documenting qualifying activities.

Avoid assuming that every adult enrolled in Medicaid expansion is subject to the same rules. Eligibility and exemption determinations should follow current federal and state guidance.

2. Verify Contact Information at Every Visit

Outdated phone numbers and mailing addresses can prevent patients from receiving important renewal notices.

Make contact verification part of every check-in. Ask whether the patient's address and phone number are current, confirm their preferred communication method, and encourage them to update their information directly with the state Medicaid agency when necessary.

Where permitted, your team can also document email addresses and preferred languages to support more effective outreach.

3. Build Renewal Checks Into Existing Workflows

Integrate eligibility and renewal checks into scheduling, registration, and patient intake.

A simple question such as, “Do you know when your Medicaid coverage is due for renewal?” can help identify patients who need assistance before their deadlines.

Establish a regular process to review coverage status, identify recent terminations, and route cases needing immediate attention to enrollment staff.

For organizations also working to improve coordination across clinical and community services, see SocialRoots.ai's guide to automated patient referral management.

4. Equip Enrollment Counselors and Navigators

Train certified application counselors, navigators, and other enrollment personnel on the new requirements and the state procedures that apply to your patient population.

Training should cover:

• Renewal deadlines and submission procedures.
• Work and community engagement requirements where applicable.
• Exemption categories and the documentation needed to establish them.
• State eligibility portals and available assistance channels.
• Procedures for responding to coverage termination notices.

Consider cross-training community health workers, medical assistants, and patient-facing staff to recognize renewal issues and connect patients with qualified enrollment support.

5. Reach Patients Before Their Deadlines

Use appropriate communication channels, including telephone calls, text messages, patient portal notifications, and mailed reminders.

Keep messages short, clear, and actionable.

For example:

“Your Medicaid renewal may be due soon. Please check your renewal notice and contact our team if you need help completing the process.”

Offer walk-in assistance, extended hours, and telephone support where resources permit. Translate materials into the languages your patients use, and ensure communications are accessible to people with disabilities or limited digital access.

6. Help Patients Prepare Documentation

Some patients may already satisfy applicable eligibility or work requirements but need assistance documenting their circumstances.

Depending on the individual's situation and state rules, relevant records may include pay stubs, school enrollment information, qualifying activity records, or documentation supporting an exemption.

Help patients understand what their state requires, where to submit the information, and how to confirm receipt. Do not assume that collecting documents at the health center completes the state's verification process.

7. Establish a Plan for Patients Who Lose Coverage

Create a rapid-response process for patients whose Medicaid coverage has ended or is at risk of termination.

Your workflow should identify the reason for termination, contact the patient, determine whether they can submit additional information, and connect them with the appropriate eligibility office or enrollment counselor.

Where available, help patients explore reconsideration or reinstatement procedures and applicable deadlines. These options vary by state and circumstance.

For patients no longer eligible for Medicaid, consider referrals to Marketplace coverage, health center sliding-fee programs, or other appropriate assistance.

8. Coordinate With External Partners

Work with your primary care association, Medicaid managed care plans, local community organizations, and county eligibility offices.

These partners may offer enrollment resources, outreach assistance, eligibility information, or referral pathways that complement your own efforts.

Health centers can also strengthen coordination between medical and social services. Learn more about clinical and social care integration through closed-loop referrals.

9. Measure What Is Working

Track a consistent set of operational measures to see whether your efforts help patients maintain coverage.

Useful measures include:

• Renewal completion rates.
• The number of patients with upcoming renewal deadlines.
• Coverage terminations and identified reasons.
• Coverage gaps among your patient population.
• Time between termination and reinstatement, where applicable.
• Patient outreach and successful contact rates.

Review these measures regularly and use the findings to adjust staffing, outreach schedules, and enrollment workflows. The data can also support discussions with leadership, funders, and policymakers about the resources required to maintain coverage continuity.

Preparing Your Staff and Budget

Redetermination support requires time, coordination, and reliable information.

Assess whether your current enrollment capacity can accommodate more frequent renewal activity and additional documentation needs. Estimate the financial impact of coverage losses and identify opportunities to support enrollment staff or community health workers.

Brief clinical, billing, registration, and front-desk teams on the changes. Staff members don't need to become eligibility experts, but they should know how to spot a potential coverage issue and direct patients to the right person.

Clear responsibilities and consistent handoffs can help your organization respond without placing the entire burden on one enrollment team.

Note: A Patient Message Your Team Can Adapt

Depending on your eligibility category, your Medicaid coverage may need to be renewed more frequently starting in 2027. Keep your address and phone number up to date with your state Medicaid agency, open any mail about your coverage, and respond to renewal requests by the deadline. If you receive a notice and need help understanding what to do next, contact our team. We're here to help you navigate the process and stay connected to care.

The Bottom Line: Help Patients Maintain Coverage Without Overburdening Your Team

Medicaid redetermination presents a significant operational challenge for community health centers, but it is also an opportunity to strengthen patient engagement and maintain continuity of care.

The challenge is scale. With more frequent renewals for certain populations and additional verification requirements on the way, enrollment teams may struggle to reach every patient before every deadline through manual outreach alone.

That is where GridSocial's AI Agentic Caller comes in.

GridSocial by SocialRoots.ai supports automated member outreach and renewal-related workflows, helping health centers manage routine communications while keeping their staff involved in eligibility decisions and cases that require personal assistance.

How GridSocial's AI Agentic Caller Can Support Your Team

• Educate and verify. The configured calling workflow can explain renewal timelines, verify member identity using approved procedures, and check renewal-related information.
• Keep contact details current. The workflow can confirm contact information and flag reported changes that may need updating in the appropriate system.
• Support renewal readiness. Calls can remind members about documentation, flag questions that need follow-up, and connect members with enrollment staff for help with state-specific requirements.
• Connect members to care. When configured, outreach can help identify unmet care needs and support appointment scheduling, allowing teams to address access barriers alongside coverage concerns.
• Fit your health center's workflow. Configurable scripts, multilingual conversations, and reporting help organizations tailor outreach to their patient populations and operational needs, depending on the capabilities and integrations available in their implementation.

If a member needs human assistance, the workflow can direct them to the appropriate enrollment team or appointment process when those options are configured.

Automation should complement, not replace, qualified enrollment support, official eligibility determinations, and the privacy and consent safeguards required for member communications.

Ready to help patients navigate Medicaid renewals? Explore the GridSocial Medicaid Redetermination solution or book a demo to discuss how automated outreach could support your health center's workflows.

Important: Medicaid requirements, effective dates, exemptions, and implementation procedures can change and vary by state. Verify current requirements with CMS and your state Medicaid agency before using this article to guide eligibility decisions or patient communications.

Sources

• Centers for Medicare & Medicaid Services (CMS). Eligibility, Enrollment, and Renewal Tools and Resources. Federal guidance and technical resources on Medicaid and CHIP renewal processes.
• Centers for Medicare & Medicaid Services (CMS). Basic Requirements for Conducting Ex Parte Renewals of Medicaid and CHIP Eligibility. Guidance on using available information to renew eligibility without unnecessarily requiring enrollee documentation.
• Centers for Medicare & Medicaid Services (CMS). Conducting Medicaid and CHIP Renewals During the Unwinding Period and Beyond: Essential Reminders. Guidance on renewal procedures and preventing inappropriate coverage losses.
• Congressional Research Service. Health Provisions in P.L. 119-21, the FY2025 Reconciliation Law. Congressional analysis of the reconciliation law, including eligibility redetermination provisions.