By Susan Baker, Executive Vice President and General Manager, Integrated Health Solutions
Medicaid is one of the most complex healthcare programs in the United States, serving more than 90 million Americans through a combination of federal and state-administered programs, eligibility categories, and waiver authorities. The program finances acute care, behavioral health, long-term services and supports (LTSS), and home- and community-based services (HCBS) for older adults, children, individuals with disabilities, and medically vulnerable populations.
The complexity is further shaped by the use of Section 1915(c) and other waiver programs, which allow states to tailor eligibility rules, covered services, enrollment caps, and care delivery models for specific populations such as individuals with intellectual and developmental disabilities (I/DD), serious mental illness, traumatic brain injuries, and medical fragility. Many states operate multiple waiver programs, each with distinct clinical, financial, and functional eligibility criteria, assessment instruments, level-of-care requirements, and redetermination schedules. Nationally, millions of beneficiaries receive HCBS services through these waiver programs, while states simultaneously manage waiting lists, cost-neutrality requirements, provider network adequacy, workforce considerations, continuity of care, and federal compliance obligations.
Determining eligibility for Medicaid waiver services requires specialized clinical and administrative processes, including functional assessments, medical necessity reviews, PASRR screenings, behavioral health evaluations, financial eligibility determinations, and ongoing reassessments. These evaluations often require coordination among State Medicaid Agencies (SMAs), managed care organizations, independent assessors, physicians, hospitals, nursing facilities, and community providers. The resulting operational environment demands sophisticated clinical oversight, regulatory expertise, interoperable technology systems, and scalable assessment operations capable of managing high volumes of complex, time-sensitive determinations while maintaining compliance with evolving federal and state requirements.
For beneficiaries and families, navigating multiple assessment and enrollment pathways can feel like a maze. Many SMAs are addressing this challenge by implementing coordinated, single-point-of-entry assessment models. This approach, often referred to as No Wrong Door, helps connect people to appropriate programs in a quick, efficient, and consistent manner.
When assessment processes are spread across multiple programs, systems, or entities, SMAs may face added administrative complexity and resource demands. In some states, assessment responsibilities are distributed across numerous organizations, which can create opportunities for duplication, variation, and delays as individuals move through the steps required to access services.
These challenges are often the result of program complexity, legacy systems, state-specific waiver structures, funding considerations, and evolving policy requirements rather than any single operational decision. Even so, a more coordinated assessment model can help reduce administrative burden, improve consistency, and support a more streamlined experience for individuals, families, providers, and state staff.
For many SMAs, a single point of entry can be an important strategy for improving access to care, administrative efficiency, and beneficiary experience.
SMAs that implement a unified model can realize several important benefits:
Reduced administrative burden. A consolidated assessment system can substantially reduce administrative complexity for SMAs by limiting the need to maintain multiple call centers, duplicative enrollment infrastructure, or parallel assessment workflows.
Faster access to services. A unified process can help reduce wait times and support more timely access to care, including for individuals who may be eligible for multiple programs. After implementing Acentra Health’s unified assessment system, one state saw the average wait time for home- and community-based services drop from more than 100 days to 14 days for eligible individuals, an 86% improvement.
Improved connections to appropriate programs. A No Wrong Door approach can help reduce the risk that individuals are redirected multiple times or miss connections to programs for which they may be eligible.
Greater consistency and transparency. Consistent assessment processes help ensure that individuals receive access to the same information and enrollment pathway regardless of their circumstances. This can support equity, transparency, and more predictable program administration.
Less burden for providers and care partners. A coordinated model can also reduce administrative burden for providers. Assessors can coordinate with primary care providers and other clinical partners to gather needed documentation and support timely determinations.
Acentra Health partners with states to design unified assessment approaches that reflect each state’s programs, populations, policy requirements, and operational realities. With the right model, SMAs can improve access, strengthen consistency, and support more timely, person-centered connections to care.
A unified assessment program is not a one-size-fits-all solution. It works best when it is tailored to a state’s waiver landscape, technology environment, clinical standards, stakeholder priorities, and beneficiary needs. Designed well, a No Wrong Door model can help states simplify access while preserving the flexibility and accountability required in Medicaid programs.