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Health plans serving dual-eligible populations face significant regulatory changes from the Centers for Medicare & Medicaid Services (CMS). The 2027 D-SNP requirements introduce significant changes affecting Highly Integrated Dual-Eligible Special Needs Plans (HIDE SNPs) and Fully Integrated Dual-Eligible Special Needs Plans (FIDE SNPs).

While the full rule doesn’t take effect until 2027, certain critical compliance requirements begin as early as 2025, necessitating immediate action. Gaining insight into these changes and preparing now will enable health plans to adapt and strengthen their position with dual-eligible populations.

Key Changes to CMS Requirements  

New regulatory requirements from CMS aim to enhance the integration of Medicare and Medicaid to simplify administration and improve care for dual-eligible beneficiaries. The changes that are in effect in 2025, and the more significant adjustments that health plans need to prepare for in 2027, include:

For 2025, health plans must implement exclusively aligned enrollment (EAE) for FIDE SNPs, ensuring members are simultaneously enrolled in both the Medicare SNP and the affiliated Medicaid managed care plan. They must also establish capitated contracts for HIDE SNPs that cover their entire Medicare service area, including behavioral health or long-term services and supports (LTSS). Plans should have already adjusted their enrollment processes, systems, and state Medicaid contracts.

By 2027, CMS requires all Dual-Eligible Special Needs Plans (D-SNPs) affiliated with Medicaid Managed Care Organizations to operate with exclusively aligned enrollment. Non-aligned SNP enrollments will no longer be allowed, which necessitates operational restructuring. Health plans must proactively prepare by assessing enrollment alignment and communicating effectively with members.

Why CMS is Making These Changes and Why Health Plans Must Act Now

With its latest guidance, CMS addresses historical issues related to fragmented and disconnected care for dual-eligible beneficiaries who previously navigated two separate healthcare systems (Medicare and Medicaid). This led to duplicative processes, multiple insurance cards, conflicting information, care delays, and significant frustration among members and caregivers.

New CMS regulations aim to:

• Ensure integrated, coordinated care across Medicare and Medicaid programs.
• Simplify administrative processes to improve the member experience
• Strengthen accountability and collaboration between Medicare and Medicaid to enhance healthcare outcomes and efficiency.

The transition to integrated Medicare and Medicaid for dual-eligible members is underway, and health plans should seek immediate action due to the operational complexity of this endeavor. Implementing exclusively aligned enrollment and service area adjustments requires significant changes across internal systems, processes, and training.

Additionally, health plans should engage early in state Medicaid negotiations and approvals, which can be a lengthy process. Early compliance with 2027 mandates and beyond mitigates risk and enhances health plans’ competitive positioning.

Immediate Steps Health Plans Should Take for HIDE & FIDE Compliance

The 2027 CMS integration requirements for HIDE SNPs, FIDE SNPs, and D-SNPs raise the stakes for health plans. At a minimum, to effectively prepare for CMS’s upcoming regulatory changes, health plans must assess their current enrollment structures to comply with exclusive enrollment requirements. Proactively engaging with state Medicaid agencies is crucial to secure compliant, capitated contracts that cover necessary service areas and benefits. Clear communication, both internally among teams and externally with members, will also facilitate a smooth transition.

However, investing in advanced technology infrastructure is equally critical. Without a modern care management solution, health plans risk non-compliance, which can lead to CMS penalties. Missteps can disrupt member care, inefficiencies can drain resources, and slow adopters will lose ground to more agile competitors. Modern care management technology is the essential element that helps health plans avoid these pitfalls. With a cutting-edge solution, health plans can optimize enrollment, simplify compliance oversight, and strengthen reporting capabilities This ensures health plans are well-equipped to provide exceptional, fully coordinated care while adhering to regulatory requirements.

How HealthEdge® Supports Health Plan Compliance

The HealthEdge GuidingCare® platform is designed to help health plans navigate regulatory compliance and integrated care delivery as CMS and state regulations continue to evolve. GuidingCare provides robust regulatory support and customizable workflows, enabling health plans to:

• Streamline Compliance. Automate enrollment and eligibility verification processes to reduce administrative complexity associated with CMS and state Medicaid requirements.
• Enhance Care Coordination. Integrate management of Medicare and Medicaid benefits, including behavioral health services and long-term supports (LTSS), to improve health outcomes for dual-eligible members.
• Improve Regulatory Reporting. Leverage comprehensive reporting capabilities for efficient compliance monitoring and auditing to meet CMS and state regulatory requirements.
• Support Operational Excellence. Utilize customizable workflows tailored to the unique needs of dual-eligible populations to facilitate proactive management of regulatory and operational changes.
• Ensure Scalability and Flexibility. Quickly adapt to changing regulations to seamlessly align operations in response to evolving compliance demands.

Investing in a care management platform such as GuidingCare strategically positions health plans for the future. The solution enables payers to meet immediate regulatory demands while establishing a strong foundation for long-term operational success, exceptional care management, and advanced member experiences.

Achieve Compliance and Operational Efficiency

By proactively addressing these new requirements related to dual-eligible populations, your health plan can meet compliance timelines, minimize disruption, and deliver superior member experiences. HealthEdge is committed to supporting health plans as they navigate these critical changes.

Contact us today to learn how GuidingCare can help your health plan stay ahead of evolving regulations.

Want to learn more about how solutions like GuidingCare empower health plans through compliance support? Read our blog, Adapt to CMS Standards and Improve Star Ratings with Digital Care Management .

 

Artificial Intelligence (AI) is transforming healthcare by helping payers streamline operations, reduce costs, and enhance experiences for staff, members, and providers. However, health plans must look beyond technology to fully realize AI’s potential. They must address the cultural shifts needed within their organizations to support adoption—like recognizing the benefits for all stakeholders, and building trust in the responsible, sustainable use of AI.

The Importance of AI in Healthcare

AI has the potential to revolutionize how health plans operate. It can increase automation, reduce training times, lower costs, and improve staff efficiency. Embracing AI is critical for health plans who want to stay competitive and meet the evolving needs of members and providers.

According to McKinsey & Company, health plans that embrace digital and AI transformation stand to achieve significant financial and operational gains — it could save health plans up to $1.2 billion and grow revenue by another $1.2 billion for every $10 billion in revenue. In addition, Gartner predicts AI will help reduce health plan administrative costs by up to 30% by 2027, and nearly all health plans are expected to adopt AI solutions by 2026.

Why Adopting Healthcare AI Is More Than Just the Technology

Adopting AI is not just about deploying new software or automating workflows. Implementing AI-powered solutions requires rethinking manual processes for staff and establishing trust in new experiences for members and providers. Health plans must cultivate a culture of innovation and adaptability to fully benefit from AI tools. This includes helping staff see AI not as a threat to their roles but as a tool to amplify their impact.

Understanding Cultural Resistance to Adopting AI Tools

AI adoption can encounter resistance rooted in organizational culture. Common challenges include:

• Skepticism about AI’s potential. Staff may question AI’s potential benefits and may resist its adoption due to concerns over its ability to improve productivity, solve complex problems, and enhance decision-making processes.
• Fear for job security. Many people fear that AI will result in job loss and are resistant to its adoption for this reason. It is important to address this concern by highlighting the potential for AI to create new jobs and improve existing ones.
• Reluctance to change workflows. Some people may resist AI adoption due to a reluctance to change established workflows and processes. It is important to provide ongoing training and support to help people adapt to new technologies and ways of working.

Acknowledging and proactively addressing these concerns is essential. Through our own experience accelerating AI innovation and close collaboration with health plans, HealthEdge® has identified change management best practices that every health plan should consider.

3 Best Practices to Accelerate AI Adoption at Health Plans  

1. Conducting Ongoing Workshops and Training Sessions

Education is one of the most effective ways to address resistance and increase engagement. Hosting AI workshops and training sessions can give staff clarity on the long-term plan for AI solutions, how the new technologies will benefit them, and the opportunity to explore use cases, see the technology in action, and ask questions.

Successful training sessions often include:

• Role-based walkthroughs of AI-driven workflows.
• Peer-to-peer Q&A.
• Clear guidance on how AI will enhance their daily responsibilities.
• Compelling communication and examples of how AI will benefit members and improve outcomes.

This engagement clarifies AI’s benefits and establishes a foundation of trust.

2. Sharing Success Stories Within the Organization

Sharing early success stories from champions and pilot projects reinforces the benefits of AI and makes the value feel more real.

For example, demonstrating how a care manager streamlined their workflow using AI-generated member summaries or how claims staff reduced turnaround time with automated validations provides peers with concrete examples of AI’s potential.

Peer validation is a powerful tool. When staff hear directly from colleagues about improvements in accuracy, efficiency, or member experience they are more likely to embrace the change.

3. Setting Clear and Achievable Goals

Setting clear, achievable AI goals helps focus teams and creates accountability.

The goals should be:

• Aligned with key priorities such as reducing claim rework, improving HEDIS scores, or boosting member satisfaction.
• Measurable and time-bound.
• Communicated frequently to reinforce purpose and progress.

A strong goal framework clarifies the AI strategy for staff and helps them feel part of the “why” to accelerate AI adoption and integration.

Realizing Operational Value: Communicating the Vision

Once a health plan establishes cultural readiness, it can focus on realizing its broader AI vision. For example, HealthEdge defines its AI vision as creating value for health plans in three key areas:

• Intelligent Claims Operations.  Automate every aspect of adjudication with AI, including contract management, adjudication, fraud detection, and improved financial accuracy.
• Proactive & Integrated Care. Improve care and cost outcomes while driving care team quality and efficiency through predictive insights, automation, and tailored care support.
• Elevated Member & Provider Experience. Enable personalized experiences at scale to meet member and provider needs across intelligent content, workflows, and data.

Each health plan should convey an outcome-focused vision that aligns with its organizational goals. This establishes a framework for clear communication that flows through new capabilities, reimagined workflows, and enhanced experiences. 

Key Takeaways for Health Plans: AI Readiness Checklist

Successful AI adoption requires more than next-generation, AI-powered capabilities. Based on HealthEdge’s journey with AI, we see that it requires:

• Cultural readiness and open communication
• Strong change management and leadership support
• Ongoing training and employee engagement
• Clear alignment between AI and business priorities and goals

When these elements are in place, health plans can confidently advance their AI strategy and deliver measurable improvements in healthcare and financial outcomes.

Innovate with a Partner That Understands Healthcare Digital Transformation

HealthEdge understands that adopting AI isn’t just about deploying new technology. It’s about enabling strategic, sustainable transformation centered on the needs of your organization, your teams, and the members you serve.

From identifying the highest-impact use cases to implementing AI responsibly and supporting long-term change management, we’re here to help health plans move forward confidently. Our approach combines deep healthcare expertise, proven technology, and a commitment to transparency and trust.

Contact us to discover how HealthEdge solutions leverage AI to help transform operations and outcomes for healthcare payers.

Not ready for a discussion? Discover how the HealthRules® Payer solution helped Medica health plan transform claims operations through strategic automation. Read the case study.

Gartner, Predicts 2025: AI Reshapes How U.S. Healthcare Payer CIOs Do Business, 16 January 2025

GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved.

 

Now more than ever before, health plans are recognizing the importance of holistic care delivery to improve outcomes and reduce costs. Social determinants of health (SDOH) such as food security, transportation, and housing stability significantly impact member health, making it crucial for payers to adopt solutions that integrate medical and community-based support.

Wellframe, a HealthEdge solution, is taking a major step forward in this effort by pursuing the National Committee for Quality Assurance (NCQA) Wellness and Health Promotion (WHP) Accreditation in 2025.

Why NCQA Accreditation Matters

NCQA is widely recognized for its commitment to quality measurement, transparency, and accountability in healthcare. For health plans, working with NCQA recognized vendors provides several advantages:

1. Trust and Reliability: NCQA recognized vendors are held to high standards, ensuring their solutions align with evidence-based best practices.
2. Regulatory Alignment: Recognition helps health plans stay ahead of regulatory requirements from CMS and state Medicaid programs, particularly as policies related to health equity and SDOH rapidly change.
3. Operational Efficiencies: Health plans partnering with NCQA recognized vendors may benefit from oversight relief and automatic credit in their own NCQA surveys, reducing administrative burdens.
4. Better Outcomes and Cost Savings: Studies show that coordinated care and strong member engagementlead to improved health outcomes and reduced healthcare costs.

By pursuing NCQA WHP Accreditation, Wellframe is reinforcing its commitment to alignment with NCQA standards. Delivering high-quality, evidence-based digital health management solutions empowers members to engage with their health plan care team and supports health plans in meeting their clinical quality and health equity initiatives.

How Wellframe Supports Person-Centered Community-Based Care

Wellframe is already playing a crucial role in addressing SDOH. The platform integrates digital health management with personalized coaching, helping health plans identify and support members’ social and clinical needs. Some key capabilities include:

• Health Coaching & Self-Management Tools: Wellframe provides evidence-based resources that can be used by the health plan’s care team during health coaching. Self-management tools are available to help individuals navigate their health journeys, including managing chronic conditions, mental health, and lifestyle changes.
• Comprehensive Health Appraisals: The platform facilitates health appraisals, which may also be known as health risk assessments, that include questions on social determinants of health, helping to identify members who may need additional support.
• Personalized Outreach & Engagement: Wellframe’s digital capabilities allow health plans to proactively reach members with tailored interventions, ensuring that populations with new or emerging risk receive the support they need.
• Community Resource Connections: Through partnerships with organizations such as Unite Us, Find Help, and 988 crisis services, Wellframe helps connect members with community-based organizations that address SDOH.
• Data Exchange & Integration: Wellframe facilitates data sharing between health plans, providers and members, enhancing care coordination and ensuring that data is meaningful and actionable.

These capabilities already position Wellframe as a powerful tool for addressing health inequities and enhancing member engagement. However, NCQA certification will take these benefits to the next level.

The Impact of NCQA Recognition on Wellframe’s Capabilities

With NCQA accreditation, Wellframe will be able to offer even greater value to health plans, particularly in the areas of quality measurement, engagement, and health equity. Here’s how:

• Enhanced Standardization & Quality Assurance: NCQA accreditation ensures that Wellframe’s wellness and health promotion programs meet rigorous nationally recognized standards, validating the effectiveness of its health assessments, self-management tools, and member engagement strategies.
• Improved Regulatory Standing for Health Plans: Wellframe’s WHP Accreditation will provide health plans with automatic credit during NCQA surveys for Population Health standards for Health Appraisals and Self-Management Tools, reducing administrative costs associated with maintaining their own Health Plan Accreditation (HPA).
• More Robust Measurement of Outcomes: NCQA requires WHP accredited vendors to continuously measure and improve their effectiveness. Wellframe will leverage these insights to refine processes, data collection, and educational content to help ensure greater impact on clinical outcomes
• Strengthened Member Trust & Adoption: NCQA’s standards are designed to encourage members to engage with their care team and promote a collaborative care model with industry-leading quality benchmarks. This will further boost the effectiveness of Wellframe’s digital engagement strategies.
• Greater Alignment with Value-Based Care Models: As the industry shifts toward value-based care and shared provider risk arrangements, NCQA accreditation will reinforce Wellframe’s role in helping health plans accurately measure quality and improve overall population health

Overcoming Challenges in Addressing Needs of a Population

While solutions like Wellframe are making strides in addressing specific needs of members, challenges remain. Health plans often face hurdles such as data integration complexities, regulatory uncertainties, and member engagement barriers. However, Wellframe’s approach, coupled with NCQA WHP accreditation, will help mitigate these challenges:

• Data Silos: Many health plans struggle with fragmented data systems that prevent a holistic view of member needs. Wellframe’s advanced interoperability capabilities improve data sharing across stakeholders.
• Regulatory Compliance: As Medicaid, Medicare, and commercial payers increasingly incorporate SDOH into quality metrics, NCQA accreditation helps ensure that Wellframe remains aligned with industry best practice and standardized metrics.
• Member Engagement & Digital Literacy: By leveraging mobile-first strategies and personalized care management, Wellframe helps bridge digital literacy gaps and deliver tailored health support to members.

Looking Ahead: The Future of Wellframe & NCQA Accreditation

As Wellframe progresses toward achieving NCQA accreditation in 2025, health plans can expect even stronger alignment with industry standards and clinical best practice metrics. The combination of Wellframe’s innovative technology, evidence-based content and NCQA-backed credibility will provide health plans with an unparalleled tool to advance population health and address social determinants of health.

Ultimately, Wellframe’s NCQA accreditation will not only enhance the quality and effectiveness of digital health engagement but also reinforce health plans’ ability to deliver holistic, person-centered care. By proactively addressing members’ unique needs, health plans can improve member outcomes, reduce costs, and drive long-term sustainability in an increasingly value-driven healthcare environment.

Wellframe’s pursuit of NCQA accreditation underscores the company’s dedication to improving clinical quality, health industry innovation, and equitable person-centered care.

Do you want to learn more about how your health plan can use digital care management solutions to meet care managers and members where they are? Watch our on-demand webinar.

 

Payment integrity solutions are becoming an increasingly essential part of payers’ digital ecosystems. An integrated payment integrity platform can work with a health plan’s existing technology solutions to detect, correct, and prevent improper payments—helping to ensure payments are made accurately and efficiently.

This article will guide you through common payment integrity challenges for health plans, the importance of leveraging a modern, integrated payment integrity solution, and how to prepare for the future.

The Importance of Payment Integrity for Health Plans

Payment integrity refers to the processes and technologies used to ensure that payments from health plans to other organizations are accurate, timely, and compliant with all relevant guidelines and regulations. The payment integrity process verifies that claims are paid correctly to prevent overpayments, underpayments, and instances of fraud.

Payment integrity is crucial for health plans to maintain financial health, operational efficiency, and a competitive edge. By ensuring payments are accurate and timely, health plans can reduce overpayments and recover funds from errors, improving their overall performance. This accuracy also builds positive relationships with healthcare providers, leading to smoother collaborations and fewer disputes. Additionally, strong payment integrity helps health plans avoid non-compliance risks and protect their reputation.

Common Payment Integrity Challenges for Payers

Health plans face numerous challenges in maintaining payment integrity. Managing multiple third-party vendors, dealing with complex IT systems, and navigating intricate healthcare billing processes make it difficult to ensure payment accuracy. For instance, the U.S. Government Accountability Office reported over $100 billion in improper Medicare and Medicaid payments in fiscal year 2023.

Additionally, constant regulatory changes require continuous updates to payment integrity processes. These regulatory pitfalls have intensified with evolving data privacy and security laws, along with data interoperability mandates. This requires health plans to seek solutions that are HIPAA compliant, tech-forward, and capable of reducing administrative burdens while maintaining patient privacy and ensuring provider and member satisfaction.

The Role of Advanced Payment Integrity Technologies for Health Plans

Ensuring pre-payment accuracy is crucial to prevent overpayments and fraud, which requires advanced data analytics and real-time capabilities. Health plans that have adopted payment integrity solutions have seen significant improvements, helping reduce unnecessary medical expenses and control costs. The use of advanced data analytics and real-time processing are becoming increasingly important, as these technologies help identify and correct billing errors before payments are made, reducing the need for post-payment recovery efforts.

By adopting robust payment integrity solutions, health plans can significantly reduce unnecessary medical expenses and control costs, ensuring a more efficient and effective healthcare system.

5 Key Impacts of a Payment Integrity Solution

As we look ahead to the future of healthcare delivery, adopting the right digital solutions will be key to strengthening payment integrity in the face of changing trends. Emerging technologies, regulatory updates, and evolving industry practices can be leveraged to enhance accuracy, reduce errors, and prevent fraud. Let’s explore how innovative solutions can drive better outcomes and support more effective payment integrity strategies.

1. Medical Loss Ratio (MLR): Health plans are under increasing pressure to meet the Affordable Care Act’s Medical Loss Ratio (MLR) requirements, which ensure premium dollars go toward patient care and quality improvements. Payment integrity solutions automate claims processing, cutting down on administrative costs and errors. This reduces unnecessary spending, enhances efficiency, and helps health plans stay compliant with MLR rules.

2. Enterprise Payment Integrity: Aligning all departments towards common goals is key to successful payment integrity. This enterprise approach prevents errors, optimizes reimbursement processes, and enhances financial performance. Integrated solutions foster collaboration, enabling earlier identification of errors and empowering informed decision-making. These strategies not only prevent inaccuracies but also optimize reimbursements, driving stronger financial performance across the organization.

3. Pre-Pay Accuracy: Preventing errors before they occur is more effective and less costly than addressing them retroactively. Payment integrity solutions prioritize pre-pay accuracy by automating verification processes and leveraging real-time analytics to flag potential issues. It reduces administrative strain, minimizes post-payment recoveries, and builds trust with providers through clear, accurate reimbursement practices.

4. Real-Time Capabilities: Real-time data and advanced analytics help detect patterns and address inefficiencies the moment they arise. These systems improve claim accuracy, eliminate processing bottlenecks, and deliver actionable insights that allow for smarter, faster decision-making.

5. AI in Fraud Detection: AI is revolutionizing fraud detection in healthcare by swiftly analyzing large datasets to spot anomalies that human analysts might miss. By integrating machine learning and predictive tools, organizations can automate the fight against fraud, reduce financial losses, and align with evolving regulations.

HealthEdge Source™ is a comprehensive payment integrity solution designed to streamline and enhance the accuracy of healthcare claims processing. With advanced editing, real-time analytics, and powerful pricing algorithms, it ensures claims are paid accurately and swiftly, cutting down on manual processes and unnecessary costs. The flexibility of the HealthEdge Source solution lets health plans adapt to new regulations, integrate systems seamlessly, and scale into new markets.

Pre-pay and Post-Pay Strategies

With these benefits in mind, it’s essential to understand the strategies that underpin effective payment integrity. These strategies can be broadly categorized into prepay and post-pay methods:

Prepay Strategies

Prepay strategies focus on preventing incorrect payments before they happen. This involves:

• Custom Edits: Implementing automated business rules to catch errors before claims are processed.
• Preauthorization: Requiring preauthorization for certain types of care to ensure the validity of claims before treatment.
• Data Validation: Cross-referencing claims with other data sources to verify accuracy.

Post-Pay Strategies

Post-pay strategies involve auditing and recovering incorrect payments after they have been made:

• Post-payment Audits: Reviewing claims after payment to identify and recover overpayments.
• Retrospective Analysis: Using historical data to identify patterns of fraud or abuse.
• Recovery Efforts: Working with third-party vendors to recover funds from incorrect payments.

HealthEdge’s shift from Payment Integrity to Payment Accountability emphasizes an enterprise-wide approach that focuses on measuring cost avoidance instead of just recovery.

Maintaining payment integrity is not just a regulatory necessity, but a strategic advantage for health plans. By leveraging advanced technologies and adopting comprehensive strategies, health plans can achieve significant cost savings, improve operational efficiency, and foster better relationships with healthcare providers.

Are you ready to learn more about how HealthEdge Source can enable your health plan to pay claims quickly, accurately, and comprehensively the first time? Watch our on-demand platform demo.

 

Prior authorizations remain one of the most complex and time-consuming administrative processes in the healthcare industry. Inefficient processes can aggravate provider abrasion and delay patient care, leading to increased costs and decreased member satisfaction. Transitioning to automated prior authorizations can give health plans the opportunity to streamline administrative workflows, facilitate care delivery, and improve provider relationships.

This article explores the challenges of traditional prior authorization methods, the benefits of automation, and how health plans can implement solutions that not only meet compliance requirements but enable strategic growth.

The Challenge of Prior Authorizations

Prior authorization is the process by which a provider requests approval from a health plan for specific healthcare services to ensure they are covered and qualify for payment.  Although essential for care coordination and cost control, the prior authorization process has traditionally been a source of inefficiency and frustration across the healthcare system.

Why Are Prior Authorizations an Industry Pain Point?

For providers, conducting manual prior authorizations via phone, fax, or email can detract from their focus on patient care and cause significant administrative burden. Some of these challenges include:

• Time-consuming Work: On average, providers and staff spend 24 minutes per prior authorization request when using phone, fax, or email according to the 2024 CAQH Index Report. For those working through health plan portals, each prior authorization takes 16 minutes per transaction. Multiply this by hundreds of requests weekly, and it’s clear how much time this process takes away from patient engagement.
• Care Delays: Lengthy approval processes can take days or even weeks, leaving patients waiting for critical treatments or tests. This delay can lead to poorer health outcomes and member dissatisfaction, as well as more costly care in the future.
• Provider Frustration: Complex plan requirements, inconsistent data availability, and low adoption of automated systems can further complicate the prior authorization process, diverting attention from patient care and contributing to provider abrasion.

The Centers for Medicare & Medicaid Services (CMS) recognized the negative impacts of inefficient prior authorization processes and issued the Interoperability and Prior Authorization Final Rule (CMS-0057) in January 2024. Among its requirements are the adoption of HL7 FHIR-based APIs to support real-time data sharing of prior authorization requests between providers and health plans and faster approval timelines, with deadlines approaching for compliance in 2027.

Why Should Payers Automate Prior Authorizations?

Automating prior authorizations benefits all stakeholders in healthcare. For health plans, it simplifies workflows, supports compliance, and generates significant cost savings. It also alleviates the administrative burdens on providers and opens the door to better patient outcomes.

Tangible Cost and Time Savings

The financial impacts of automation are clear. According to the 2024 CAQH Index Report, each manual prior authorization costs approximately $5.28 per transaction, but automation slashes that cost down to $0.07 per transaction. This translates to a savings of more than 98% per transaction—a game-changing improvement when scaled across hundreds of thousands of transactions per year.

For providers, automation saves an average of 14 minutes per transaction, allowing staff to focus more on patients instead of navigating bureaucratic hurdles.

Improving Care Delivery

Automation doesn’t just improve efficiency—it plays a critical role in care delivery. Reducing delays in approvals allows patients to access treatments faster, leading to better clinical outcomes. With fewer administrative bottlenecks, providers can deliver the timely care patients need without additional frustration.

What Capabilities Do Health Plans Need to Address Inefficient Prior Authorizations?

To improve prior authorization processes, health plans must look beyond the basics of CMS compliance. Proactively implementing automated solutions can help improve operational efficiency, reduce costs, and strengthen provider relationships. Payers should look for scalable solutions that offer:

• High Data Capacity: Payers need tools capable of ingesting and sorting high volumes of dynamic business data involved in prior authorizations.
• User-Friendly Workflows: To ensure the system is always up-to-date, health plan administrators should be able to easily input files and have the solution quickly process these changes.
• Flexibility for Diverse Business Needs: Payers need the ability to create multiple decision-making entities to tailor solutions by business line or operational need.

Prior Authorization Catalog from HealthEdge®

Automation involves intelligent technology and rules-based engines that streamline the complexity of prior authorization decision-making.

The Prior Authorization Catalog from HealthEdge is an advanced rule processing engine that automates prior authorization decisions. It is a scalable solution that is designed to handle high volumes of data, enabling payers to support complex decision automation. The tool simplifies workflows for health plan administrators, allowing them to drop a file with updates and have the tool automatically process the changes. Prior Authorization Catalog also supports organizational growth as payers can maintain multiple catalogs for different lines of business or environments.

For organizations that leverage several solutions to manage prior authorization decisions, Prior Authorization Catalog can triage and route incoming authorization requests to the appropriate system for processing.

Automated Prior Authorizations for “Gold Card” Providers

There are many ways health plans can leverage Prior Authorization Catalog and one of the top use cases is Provider Gold Carding. With the Prior Authorization Catalog, a Gold Card provider can submit a prior authorization for a specific service group. The catalog automatically processes the prior authorization based on predefined rules from the payer.

From there, the Prior Authorization Payer Catalog automatically approves, pends, or indicates if authorization is not required based on the member, service group, and provider gold carding combination. This automated decision-making is possible because Prior Authorization Catalog can process significant amounts of data, representing all possible combinations of provider NPIs, CPT codes, date ranges, and more.

What’s Next for Health Plans?

The healthcare industry continues to evolve. Automated digital solutions give payers unprecedented opportunities to reduce administrative costs, optimize workflows, and improve patient experiences. By leveraging integrated tools like Prior Authorization Catalog, health plans can position themselves as industry pacesetters, delivering efficient and effective processes that align with the needs of patients, providers, and policymakers.

With ongoing regulatory changes and the growing demand for streamlined care delivery, now is the time for payers to act. Explore how your health plan can best leverage Prior Authorization Catalog. Contact HealthEdge Professional Services today.

Medicaid is a lifeline for millions of vulnerable citizens, providing essential healthcare services. However, traditional Medicaid programs often require innovation and flexibility to meet the evolving needs of vulnerable populations. Enter 1115 Medicaid waivers—state-driven initiatives that allow for experimental, pilot, or demonstration projects aimed at:

• Improving care delivery
• Enhancing cost efficiency
• Addressing social determinants of health (SDOH)

For health plans participating in these waiver programs, success hinges on their ability to coordinate care, ensure compliance, manage social services, and track outcomes effectively. This is where GuidingCare®, the care management and population health platform from HealthEdge®, comes in.

By streamlining workflows, removing data silos across systems, and facilitating care team member engagement, GuidingCare helps health plans navigate the complexities of 1115 waivers while optimizing care for Medicaid beneficiaries.

What Are Medicaid 1115 Waivers?

Section 1115 of the Social Security Act grants states the authority to implement innovative programs that deviate from standard Medicaid rules. These waivers allow states to test new care delivery models, improve efficiency, and better serve populations experiencing greater health disparities. Some common focus areas of 1115 waivers include:

• Expansion of Medicaid coverage to populations not traditionally covered
• Integration of behavioral health and physical health services
• Addressing Social Determinants of Health (SDOH), such as housing, food insecurity, and employment support
• Value-based payment and alternative payment models (APMs)
• Improving maternal and infant health outcomes
• Reentry services for justice-involved individuals

Widespread State Participation in 1115 Waiver Programs

As of January 2025, nearly all states have at least one active Section 1115 waiver, with some states operating multiple waivers simultaneously. These waivers enable states to test innovative approaches in Medicaid, addressing diverse areas such as behavioral health integration, social determinants of health, and care transitions for individuals reentering the community from incarceration.

For instance, 26 states and the District of Columbia have pursued reentry waivers to improve continuity of care for individuals exiting correctional facilities. This widespread adoption underscores the critical role of Section 1115 waivers in enhancing Medicaid programs across the United States.

Additionally, several states have reported measurable successes in their 1115 waiver programs:

• California’s Whole Person Care (WPC) Program reduced inpatient admissions and emergency department visits among high-risk populations, while improving housing stability for Medicaid members experiencing homelessness.
• Illinois extended postpartum Medicaid coverage from 60 days to 12 months, resulting in increased postpartum care visits, reduced maternal complications, and expanded mental health support.
• Alaska’s behavioral health waiver helped increase access to mental health and substance use disorder treatments, reducing crisis hospitalizations and improving long-term recovery outcomes.

Because these programs vary significantly across states, participating health plans must adapt to unique regulations, reporting requirements, and care models—a challenge that requires agile and scalable technology solutions.

5 Ways GuidingCare Enables Your Waiver Program Success

GuidingCare is designed to support the complex requirements of Medicaid Managed Care, making it an ideal platform for health plans engaged in 1115 waiver initiatives. Below are 5 key ways GuidingCare helps health plans succeed.

1. Comprehensive Care Management & Coordination

1115 waivers often prioritize whole-person care, integrating medical, behavioral, and social services. GuidingCare provides comprehensive care management solutions to help plans:

• Deliver the right care at the right time through a comprehensive, integrated member centric platform, with one record for holistic care of the member and one single solution for care management, utilization management, appeals & grievances, and more
• Identify populations with complex care needs through predictive analytics
• Coordinate multidisciplinary care teams, including physicians, behavioral health specialists, and community-based organizations (CBOs)
• Create and track individualized care plans tailored to specific waiver requirements
• Ensure seamless transitions of care to reduce hospital readmissions

2. SDOH Integration

Many 1115 waiver programs emphasize non-medical drivers of health, such as housing, transportation, and nutrition. GuidingCare supports SDOH initiatives by:

• Embedding SDOH assessments into care workflows
• Tracking member needs and referral status for services like food assistance, housing support, and job training
• Integrating with community-based organizations (CBOs) for closed-loop referrals and follow-ups
• Generating reports on social needs trends to support program evaluation and regulatory compliance

Automated Workflows & Compliance Support

Each 1115 waiver program has its own unique compliance requirements, including mandatory reporting, member tracking, and quality benchmarks. GuidingCare automates these processes by:

• Configuring workflows to match state-specific requirements
• Automating documentation to track waiver-related interventions and services
• Providing real-time dashboards to monitor program performance
• Facilitating regulatory audits by maintaining comprehensive care records

These automation capabilities reduce administrative burden, enhance accuracy, and ensure timely compliance reporting.

Real-Time Data & Interoperability

Data integration is critical for health plans participating in 1115 waiver programs. Many initiatives require real-time data sharing across Medicaid agencies, healthcare providers, and community organizations. GuidingCare supports interoperability by:

• Integrating with state Medicaid systems, health information exchanges (HIEs), and electronic health records (EHRs)
• Enabling real-time data exchange to track member services and outcomes
• Providing robust analytics and predictive modeling to assess program effectiveness
• Ensuring compliance with federal and state interoperability mandates

By breaking down data silos, GuidingCare enables holistic, data-driven decision-making that improves care quality and cost efficiency.

Member Engagement and Self-Service Tools

Many 1115 waiver programs emphasize patient-centered care and engagement strategies to empower Medicaid members. GuidingCare and the Wellframe solution from HealthEdge work together to enhance member engagement through:

• Multichannel, multimodal communication for the entire care team (text, email, chat, and phone outreach) via web, mobile app, and more
• Secure member portals for care plan access, appointment scheduling, and progress tracking
• Personalized health education resources tailored to individual needs
• Automated reminders for preventive care, wellness visits, and screenings

By promoting member activation and adherence, health plans can improve health outcomes and program effectiveness.

Learn more about how GuidingCare can support your Medicaid initiatives by contacting the HealthEdge GuidingCare team today.