Community Engagement Verification Made Simple

H.R. 1 is bringing sweeping change to Medicaid across eligibility, financing, and service delivery. Medicaid agencies across the country are acting now to begin implementing the new program integrity measures. One provision in H.R. 1 is particularly concerning for states: community engagement verification.

This is the requirement to verify that certain adult beneficiaries meet work and community-engagement standards to maintain enrollment in Medicaid. In theory, compliance sounds straightforward. Yet in practice, the risk of unnecessary member churn, staff overload, and damaging headlines is very real. Fortunately, states that excel in executing community engagement verification can unlock benefits that go far beyond compliance.

A Perfect Storm of Challenges

State Medicaid agencies are no strangers to change. They know that it is inevitable, and they have a long track record of successfully adapting to new mandates.

But community engagement verification is different.

Multiple issues are coming together for a perfect storm of challenges. The timeline for establishing a fair and flexible verification process is tight. States may have to act before all federal guidance is finalized. CMS has indicated that there will be very limited (if any) waivers for extension. There are also resource constraints. Eligibility teams already stretched by redeterminations now face yet another compliance sprint. The stakes are high, too. Inaccurate disenrollments can trigger audit findings and push eligible members off coverage.

The Fundamentals of an Effective Approach

The good news is that there is a way through these challenges that does not require states to modify their already complex eligibility systems. States can execute community engagement verification and do much more than satisfy H.R. 1 auditors. They can extract the process out of the eligibility system, handling it with a flexible, cost-effective, modular, portable, self-contained platform that can seamlessly connect in and out of the eligibility system with APIs. An approach like this that is independent of the eligibility system but integrated with it gives states the agility they need to flex fast with change. It is also fully auditable and reportable.

Think of this mandate not as just a compliance obligation, but as a value creation opportunity. With cleaner eligibility files, states can free up dollars for care and modernization. With a transparent and respectful process, states can build member trust. Finally, strong community engagement verification processes can become ready frameworks for future eligibility initiatives.

To realize this added value, start with the fundamentals of an effective approach to community engagement verification:

• Member-First Design. When auto-verification is not available, member self-attestation workflows should be mobile-friendly, multilingual, and status-tracked in real time. This can reduce call-center spikes as well as the frustration that leads to unnecessary churn.  

• Omnichannel Outreach. Meet members on their terms to drive engagement and compliance. Outreach through multiple channels including text, email, IVR, mail, and high- touch case worker interactions. From there, capture documentation once to avoid redundant uploads and lost PDFs.

• Data-Enabled Verification. Reduce the onus of verification on members and applicants by ingesting multiple data sources (wage, university, volunteerism, etc.). This enables quick and seamless auto-verification, avoiding human error and ensuring accuracy.

• Continuous Visibility. Create a data-driven picture of community engagement verification. Use dashboards and dynamic visualization to understand verification rates by region, demographics, and MCO to redeploy outreach budgets where they matter most.

• AI-Enabled Workflows. Integrate AI to prevent fraud, waste, and abuse, streamline end-to-end processes, and increase accuracy in determination.

• Cost-Conscious Procurement. Lower upfront costs and optimized operational costs to achieve state objectives.

Get Started: Top Priorities for Today

With such a tight timeline and so much at stake, it can be overwhelming to know where to start with community engagement verification. We recommend that states prioritize four key actions:

1. Decide on state-specific objectives. Identify what additional state specific objectives need to be achieved in addition to compliance (e.g., additional outreach, referrals.)
2. Select the right partners. Choose data partners with a national footprint and proven Medicaid scale to avoid piloting on members’ backs.
3. Develop meaningful KPIs. Set KPIs that matter, (e.g., ensure 90% of targeted members are verified within 60 days, with less than a specified percentage of improper disenrollments, and hold stakeholders accountable.)
4. Consult with partners. Work with partners that have done eligibility verification work in the past as there have been many lessons learned that can mitigate mistakes and maximize results.

H.R. 1 turned community engagement from concept to mandate. Now, all eyes are on states to implement community engagement verification. Challenges exist, and the timeline is tight. But there are also opportunities for states to put members at the center and leverage data-driven processes to meet two critical goals: complying with the mandate and strengthening the Medicaid program for members.