Starting December 31, 2026, every Medicaid expansion state must redetermine eligibility every six months instead of annually. Seven to ten million people are projected to lose coverage, most for paperwork reasons, not eligibility reasons. Every one is a patient who stops showing up and a claim that never gets paid.
We codify your state’s redetermination and managed-care billing requirements into a deterministic rules engine that checks every patient record before a renewal date passes or a claim goes out. Your team gets a prioritized list of what needs attention, and why, in plain language.
Under H.R. 1, Medicaid expansion adults move from annual to six-month eligibility renewals for renewals on or after December 31, 2026. Traditional Medicaid populations (children, pregnant women, elderly and disabled enrollees) remain on annual cycles. The provision cannot be waived under Section 1115.
For behavioral health providers and FQHCs, this doubles the number of times each year a patient can fall out of coverage because a form did not get returned. The population least equipped to manage recurring paperwork is the population you serve.
Implementation timing and state rules vary. Some states began early enforcement during 2026. Others delayed portions to January 2027. Several, including Indiana and West Virginia, have proposed applying six-month redeterminations beyond the federally required expansion group. We build against your state’s actual rules, not the federal floor.
Operating in California? See the Medi-Cal and CalAIM version →
Sources: H.R. 1 (Working Families Tax Cuts legislation) §71107; CMS State Medicaid Director letter SMD #26-001 (March 6, 2026).
A patient’s redetermination date passes. Nobody flagged it. Nobody knew the address on file was stale. Coverage lapses mid-treatment, the patient stops coming, and sessions you already delivered become unbillable.
The documentation was thorough. The care coordination happened. But a modifier did not match the managed-care plan’s specific requirement, and the claim came back denied weeks later, when reworking it costs more than it recovers.
The state Medicaid agency asks how a service met medical necessity. The documentation exists somewhere across three systems and a shared drive. Assembling the answer takes a week of staff time you did not budget.
We take the requirements you actually operate under (the federal six-month mandate, your state’s managed-care billing standards and each plan’s modifier and coding rules) and codify them into deterministic rules that evaluate every record before it matters.
Every patient scored against their renewal date, contact information currency and documentation completeness. Your care coordination team gets a weekly prioritized outreach list: who needs attention, what is missing and how many days remain.
Every claim checked against the documentation, coding and modifier requirements for that service, that payer and that program, before it is submitted, not after it is denied.
When something fails a check, your billing specialist sees what failed, why it matters and the steps to fix it, with a citation to the exact state or plan requirement behind it. No decoder ring required.
Every evaluation is timestamped and immutable. When your state Medicaid agency or a managed-care plan asks how a determination was made, the answer is already assembled: data, rule, reasoning step, outcome.
SUD treatment programs, outpatient mental health practices and community behavioral health agencies where Medicaid is the majority of revenue. Your patients are disproportionately affected by redetermination churn, and behavioral health documentation is among the most complex in any state program.
FQHCs managing renewal navigation across large patient panels, often with community health workers doing it patient by patient. We turn that into a systematic, prioritized weekly workflow.
Organizations accountable for network-wide compliance performance, where a provider’s documentation gap becomes your state contract problem.
Enterprise pharmacy operations platformFor Luveo Health we codified 28 compliance rules across 7 operational workflows (DEA, DSCSA, HIPAA, USP 797 and state Board of Pharmacy) and layered a governed copilot that translated every outcome into cited, plain-language guidance for pharmacy technicians.
Across a 30-scenario structured evaluation: zero hallucinated rule keys, zero fabricated regulatory citations and zero guardrail violations. Delivered in two four-week cycles.
Read the case study →If we can scope it into a four-week cycle, we will tell you exactly what that includes and what it costs. If we cannot, we will tell you that too.
Book a 30-minute scoping call →Hi. Ask me about our services, the four-week cycle, PHI and security, or the Luveo case study. Every answer links to where it comes from.