New Work Requirements Are Raising the Stakes on an Already Costly Problem
Federal community engagement requirements take effect January 1, 2027. Most working-age adults eligible for Medicaid through ACA expansion will need to document 80 hours a month of qualifying work, education, or community service, or the income equivalent of about $580 a month in 2026. That activity gets verified at least as often as their eligibility redetermination, which moves to at least every six months for this population.
Some members are exempt, including those who are pregnant, medically frail, or caring for a dependent child under 13. But someone still has to verify and document every exemption.
That's why Medicaid plans are turning to Salesforce Health Cloud, Data 360, and Experience Cloud. With the right implementation partner, plans can track every member's renewal window, match exemptions automatically, and reach members in ways that actually get a response.
Challenge
New community engagement rules and six-month renewals put eligible Medicaid members at risk of losing coverage over paperwork, taking PMPM revenue with them.
Solution
Health Cloud, Data 360, and Experience Cloud track renewal windows, match exemptions, flag at-risk members, and make it easy to submit documentation by text or photo.
Results
Plans keep more eligible members enrolled, lower the cost of each renewal, and protect PMPM revenue and quality scores.
The Challenge
Every procedural disenrollment is a member who was still eligible. And every one hits your plan in more than one place.
Lost Revenue and Higher Costs
A disenrolled member means lost PMPM capitation revenue. It also pushes costs back onto your plan through call center surges, manual re-enrollment processing, and coverage gaps that interrupt chronic disease management until the member re-enrolls. Quality scores take a hit too, since HEDIS and state quality-withhold measures depend on members staying continuously enrolled.
Exemptions Still Take Work
Exempt members don't have to meet the requirement, but your team has to identify and document each exemption. Doing that by hand, member by member, doesn't scale.
Hard-to-Reach Members
Outdated contact information, unstable housing, and limited digital access make traditional mail and generic outreach less effective. The members most likely to fall through are often the hardest to reach.
Spreadsheets Can't Keep Up
Rolling six-month windows for some members and annual windows for others make manual tracking a mess. It's hard to know who's coming due, and harder to know who's at risk.
New Fraud, Waste, and Abuse Exposure
New verification touchpoints create new opportunities for fraud, waste, and abuse. Plans need to watch for it alongside outreach.
The Solution
We help Medicaid plans build a renewal process that finds at-risk members early and makes documentation as easy as sending a text.
Automated Renewal Tracking and Exemption Matching
Data 360 ingests state eligibility and 834 enrollment feeds automatically. Health Cloud Flows calculate each member's individual renewal window: six months for members subject to the new requirement, annually for everyone else. Members get matched against exemption categories like pregnancy, medical frailty, and caregiving.
Predictive Risk Flagging
Non-responders, non-English speakers, members with unstable housing, and others least likely to complete redetermination on their own get flagged for high-touch follow-up before their window closes.
Low-Friction Member Outreach
Timed outreach through email, SMS, and two-way messaging, orchestrated through Flow or Marketing Cloud, prompts members before their deadline. Members can submit income and activity documentation by mobile photo upload without logging into a portal or visiting an office. Members who prefer a portal get step-by-step Screen Flows in an Experience Cloud self-service portal.
Point-of-Care and Community Coordination
Members due for redetermination get flagged to FQHCs, primary care providers, and community health workers, so renewal help happens where members already show up. Agentforce or Flow-based routing alerts care coordinators and community navigators when a member looks likely to lapse.
Fraud, Waste, and Abuse Detection
Detection logic built into the redetermination workflow flags anomalies like duplicate submissions or mismatched employer data for review.
Audit-Ready Compliance and Revenue Reporting
MuleSoft keeps member data in sync with state eligibility systems. End-to-end logs of outreach, submissions, and completions support state contract reporting. Retained-versus-disenrolled tracking shows the PMPM revenue you're protecting.
The Results
More Members Covered, Less Revenue Lost
When renewal tracking runs automatically, your team stops guessing who's coming due. Every member has a window, every exemption gets matched, and every at-risk member gets flagged while there's still time to help.
Outreach gets results because it meets members where they are. A text and a photo upload replace the mailed packet that never arrived. Community partners help members renew during visits they were already making.
The business case follows. Fewer eligible members lost to paperwork means protected PMPM revenue and a lower administrative cost per renewal. Continuous enrollment supports your HEDIS and state quality-withhold performance. And state reporting comes straight from the logs your team already has.
Ready to Protect Every Eligible Member?
The new rules take effect in January 2027. Let's look at your current renewal workflows and state file integration and talk through how fast this can go live.
Retained Members
Protected PMPM Revenue
Audit-Ready Reporting
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