Jul 14, 2026 – By Nilay Patel, Executive Vice President and General Manager Despite a dip when COVID-era provisions ended, Medicaid enrollment continues to go up. In 2024, Medicaid enrollment increased by about 30% since February 2020. And in March 2026, the Kaiser Family Foundation shared that the Medicaid/CHIP enrollment reported by the Centers for Medicare & Medicaid Services (CMS) enrollment has increased by just over 4 million people since 2020, despite large swings during the pandemic period. Many states struggle to attract and retain providers in their Medicaid networks. In the face of a growing Medicaid population, to provide the care members need, it is crucial that State Medicaid Agencies (SMAs) do whatever they can to enroll providers of the right types, in the right places, to care for their clients. One way to do this is to make the enrollment process as frictionless as possible by selecting the right enrollment platform. Efficient, easy provider enrollment is the first step to ongoing provider engagement It’s crucial to have healthcare providers available to care for Medicaid clients wherever and whenever they need it. SMAs can take steps to meet providers where they are by making enrollment as simple and straightforward as possible. This sets the stage for a strong, ongoing relationship with providers. Here are 4 steps SMAs can take when choosing an enrollment platform to promote a robust network and provider engagement: 1. Make enrollment as streamlined as possible As the number of patients outpaces the number of providers, they are having to take on larger and larger patient loads. Plus, providers have growing administrative burdens, and they are already tasked with enrolling with multiple different payers. Providers are stressed and busy, so it is essential that Medicaid enrollment processes are understandable, require minimal effort, and are processed and approved quickly. The SMA’s first impression with a provider is during the enrollment process, which set

Jun 30, 2026 – By Nilay Patel, Executive Vice President and General Manager, HealthTech Systems When you hear the words "claim denial" or "encounter processing," it's easy to assume that the organization handling those transactions is making decisions about a person's medical care. In reality, claims and encounters processing occurs after healthcare services have already been delivered. Claims and encounters processing is fundamentally different from clinical decision-making. Understanding this distinction is important for healthcare providers, Medicaid members, policymakers, and the public. What Are Claims & Encounters? After a patient receives healthcare services, providers submit official documentation so they can be paid for the care they have already delivered. What is a Claim? A claim is a request for reimbursement, or payment, submitted by a credentialed healthcare provider. It includes information such as: The services provided Dates of service Diagnosis and procedure codes Provider information Patient eligibility details Claims are reviewed to ensure they meet program and policy requirements, comply with applicable regulations, and contain accurate information before the payment is issued. What are Encounters? Encounters differ from claims. They document healthcare services provided to beneficiaries enrolled in managed care plans. Unlike traditional fee-for-service claims, encounter data helps states and health plans track services delivered, monitor program performance, and meet reporting requirements. Important note: Both claims & encounters are administrative records of patient care for services that have already occurred. Acentra Health’s Role in the Claims & Encounters Process Acentra Health offers a Claims, Encounters, and Financial Management Solution that helps state and federal healthcare programs, such as Medicaid and Medicare, process large volumes of claim and encounter records accurately and efficiently. Acentra Health’s technology solutions autom

Jun 25, 2026 – By Nilay Patel, Executive Vice President and General Manager, HealthTech Systems Medicaid agencies are operating in a shifting environment. Federal oversight is increasing. Provider shortages continue to strain access. Program integrity expectations are rising. At the same time, states are being asked to modernize operations, reduce administrative burden, and protect public funds without disrupting care delivery. Against this backdrop, the Centers for Medicare and Medicaid Services (CMS) has directed states to strengthen provider revalidation through enhanced verification, risk-based oversight, and more comprehensive implementation planning. For Medicaid leaders, this is more than another compliance requirement. It is a test of whether provider management systems, data, and workflows are prepared to support the next phase of Medicaid oversight. Provider Revalidation Is Now a Provider Management Challenge Historically, provider revalidation has been viewed as a periodic administrative task. Today, it affects nearly every aspect of Medicaid operations, including: Program integrity Provider enrollment and credentialing Network adequacy Provider directory accuracy Payment accuracy Beneficiary access to care As expectations evolve, provider revalidation is becoming part of a broader provider management strategy designed to maintain trusted provider networks while safeguarding public resources. For Medicaid leaders, this is a program accountability issue. For technology officers, it raises questions about system flexibility, automation, and data quality. For procurement, it highlights the need for solutions that can adapt as policy and operational requirements change. Data Quality Drives Effective Oversight Strong provider management starts with trusted provider data. Many agencies still manage provider information across multiple systems and workflows. When data is incomplete, outdated, or inconsistent, states may struggle to prioritize risk, maintain accurate provider d

Jun 22, 2026 – 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 expe

Jun 2, 2026 – By Meghan Harris, President and Chief Operations Officer Mental Health Burden According to the World Health Organization, an estimated one billion people[1] live with a mental health or addictive disorder. That’s one out of every eight people on the planet. In the U.S., estimates suggest that only half of people with mental illnesses receive treatment.[2] And according to the Substance Abuse and Mental Health Service Administration (SAMHSA)’s National Survey on Drug Use and Health, only a small proportion of individuals who need substance use treatment receive it, leaving approximately 90% who go without treatment.[3] The burden of mental health disorders and the associated economic costs are enormous — to individuals, the economy, and society. Despite growing awareness, physical and behavioral health services largely operate separately, with minimal coordination. This fragmentation leads to gaps in care, inappropriate treatment, increased hospitalizations, and, ultimately, higher costs.[4] CMS and Medicaid use “behavioral health” as an umbrella term that encompasses mental health, substance use disorders (SUD), and other behavioral conditions.[5] Medicaid and Behavioral Health Mental health issues disproportionately affect those on Medicaid. According to the Kaiser Family Foundation, more than one in three adult Medicaid enrollees have a mental illness and Medicaid enrollees diagnosed with mental illness have higher rates of chronic conditions and substance use disorder compared to those without a mental health diagnosis.[6] Given this, it’s no surprise that Medicaid is also a major source of financing for mental health services. The Medicaid program finances more than one-quarter of the U.S. spending on behavioral health care; it is, by far, the largest single source of funding for public mental health services. However, Medicaid coverage for mental and behavioral health services varies significantly by city, county, and state. While all state Medicaid programs mu

May 15, 2026 – By Susan Baker, Executive Vice President and General Manager, Integrated Health Solutions States have developed a wide range of services to help individuals who have disabilities or chronic conditions and need long-term care. Over 30% of Medicaid expenditures go toward long-term services and supports (LTSS) for both institutional and home-based care. Because LTSS programs often span multiple waiver authorities, eligibility pathways, delivery systems, and community partners, creating a seamless beneficiary experience can be operationally complex. Many states are balancing modernization efforts with evolving federal requirements, workforce considerations, and the need to preserve continuity of care for vulnerable populations. As part of these ongoing modernization efforts, some State Medicaid Agencies (SMAs) are exploring opportunities to further align enrollment and assessment processes to support both operational efficiency and person-centered care. Because eligibility and assessment requirements often vary across programs, beneficiaries and caregivers may experience multiple touchpoints during enrollment and reassessment. To help LTSS beneficiaries access services that support them in living as independently and safely as possible in the setting of their choice, many SMAs are exploring ways to further align and streamline enrollment and assessment processes. These modernization efforts can enhance person-centered care while also helping states improve coordination and administrative efficiency. Improving Enrollment and Assessments with Technology Advances and Person-Centered Care When states implement a unified enrollment and assessment process, they can create more coordinated access points where assessors determine eligibility and beneficiaries receive consistent information and support across programs and regions. This approach can help streamline communication while maintaining a person-centered experience regardless of a beneficiary’s location, provider, or ci

May 13, 2026 – By Nirav Dalal, Senior Vice President of Sales Leadership With more Medicaid Management Information Systems (MMIS) moving to modular, multi-vendor models, vendor selection is no longer just about technology; it’s about building a network of partners who work together to deliver better outcomes for priority populations. The shift is reshaping Medicaid operations and demands a more strategic, deliberate approach to vendor selection. There is no single path to modularity. The “modularity sequence” varies widely. Some states begin with a single module, such as provider management or claims, while others procure and implement multiple modules concurrently. Each approach brings different levels of complexity, integration risk, and dependency management. Vendor strategies must align not only with technical requirements, but also with where the state is in its modernization journey and the pace at which it plans to expand. They should also reflect the needs of the broader ecosystem, including managed care organizations, beneficiaries, providers, and other connected stakeholder groups and systems to maintain continuity across the enterprise. Here are the top three considerations for State Medicaid Chief Information Officers (CIOs) and Chief Technology Officers (CTOs) to make confident choices and build a high-performing, resilient system: 1. Identify Vendors with Proven Collaboration Skills While technical expertise is crucial, the real value in a multi-vendor ecosystem comes from how well vendors work together to deliver a seamless experience across the enterprise. This is especially important given that states adopt modularity at different speeds, with some introducing vendors incrementally and others onboarding several simultaneously, placing varying demands on coordination and integration from day one. Advanced systems should have no problem being technically integrated, but managing the operational handoffs between vendors and ensuring alignment are the true challenges

Mar 19, 2026 – By Ryan Bosch, MD, FACP, Chief Health & Informatics Officer As state Medicaid agencies adopt modular, specialized systems to meet Centers for Medicare and Medicaid Services (CMS) requirements, they gain flexibility but lose a single, unified view of their data. Each module stores and organizes data in its own way, which makes it efficient for generating reports from that specific system, but harder to combine and use data across systems. Meaningful data-to-action insights, especially in population health and value-based care, only emerge when data from multiple modules and external systems is brought together in a shared, structured format. When data is integrated in this way, it enables broader analysis, deeper insights, and more coordinated action. Acentra Health, an AWS Advanced Partner, serves numerous state Medicaid programs, federal agencies, and commercial clients. We address the multi-system data analysis challenge through our Unified Data Platform (UDP) built upon a unique cloud-based data foundation designed to support scalable, cross-domain analytics while preserving operational flexibility. A Unified Operational Data Store Foundation Model Managing a Medicaid program’s performance requires both operational awareness and a longitudinal perspective. Leaders must use data to answer questions like: Is eligibility determination accurate and occurring within required timeframes? Are prior authorizations correct, and are they being managed efficiently? Are claims processing smoothly or encountering delays? Are providers legitimate, and are they being paid accurately, and on time? Acentra Health’s UDP, powered by our own proprietary data model and the AWS secure cloud infrastructure, is designed to help answer these questions, supporting timely reporting, service line benchmarking, and predictive analytics for Medicaid programs. Our Whole Person, Whole Population (WP2) Data Model Acentra Health's UDP goes well beyond legacy data warehouse aggregation. With t