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The Return to Normal: Medicaid Redetermination Edition

By the time the end of March rolls around, we will have seen just over 1,100 days of continuous Medicaid and CHIP enrollment. Federal guidance within the 2023 Consolidated Appropriations Act effectively decoupled continuous enrollment provisions from the Public Health Emergency (PHE) and will allow states to resume their redetermination process as soon as April 1st. 

Most states and many plans have already completed the first phase of the unwinding by encouraging enrollees to update their contact information to ensure they receive their renewal paperwork when it arrives in the mail. And while most all of us reading this piece are well aware of where we’ve been over the last year and what the next one might look like, a recent Urban Institute study in December 2022 found 6 in 10 adults in Medicaid-enrolled families were not aware of an upcoming return to the regular Medicaid renewal process.

You’re probably thinking, “How is this possible? It’s all we’ve been talking about and planning for months and months!” Well, maybe we shouldn’t be so surprised. Medicaid/CHIP enrollment increased by 20 million individuals since February 2020 accounting for nearly 30% of all covered lives. That’s 20 million individuals who likely have never completed a traditional or pre-pandemic redetermination and three years since the last time everyone else has. Lest we forget a lot has changed and occurred over the last three years in general.

Stats and surprises aside, we still have a long road ahead of us and a lot of work to do. Thankfully our regulatory friends like CMS and the FCC have stepped up to help keep individuals from slipping through the cracks. CMS has provided a strategic toolkit calling for states and plans to work together in timely sharing of enrollment data and contact information, for states to expedite content approvals or provide pre-approved language for member outreach, and for enhanced processes for moving individuals who no longer qualify for state-based programs to marketplace offerings. The FCC’s recent declaratory ruling that clearly states the provision of a phone number on an enrollment form constitutes as express consent allowing federal and state agencies and their partners to make Medicaid enrollment calls and send text messages without violating call or text prohibitions. Plans should take full advantage of the resources provided to them by incorporating each toolkit and clarified regulation into their overall member engagement strategy.

Learn more about outreach strategies for the end of continuous enrollment by viewing our redetermination webinar series featuring Kaiser Permanente and Mostly Medicaid »

Key Engagement Factors for the Return of Redetermination

Now let’s talk engagement strategy. Most plans will be using CMS or state-approved content and timelines are tight, so there may not be as much room for the creativity we see when dealing with other engagement topics like closing gaps in care or encouraging timely rx refills. That doesn’t mean, however, that you can’t still take a strategic approach in areas where you can still have an impact, such as channels, personalization, and branding. 

Channels: We know one single communication channel isn’t going to be enough, and it’s just not how people are consuming information or connecting to resources. Adult Medicaid beneficiary smartphone or tablet ownership rates are similar to the general US adult population, and 47.4% of dually eligible Medicare beneficiaries report using the internet to get information. An effective and successful engagement strategy is delivered through multiple channels by combining digital outreach like SMS and email with traditional modes of communication like mail and phone calls. mPulse is currently working with over 30 Managed Care Organizations across more than 20 states within different phases of their redetermination efforts to support engagement on all channels and channel combinations.

Personalization: After selecting your channels, be sure the messages you are sending are personalized and relevant to the member. Even if you are using pre-approved language for your redetermination outreach, make sure your salutation and any other merged fields are in the proper case and not all caps. Even an Excel novice can easily convert cells in all caps to proper case by applying a =PROPER formula to your selected cells. Proper case is easy, but what about language preferences? Reaching your Limited English Proficient (LEP) members can be difficult, especially when you don’t know who they are or what their preferred language is. For example, mPulse technology allows for you to go beyond typical language challenges or compliance required taglines by automatically transitioning between English and Spanish in our two-way SMS conversations.

Branding: Brand awareness and recognition leads to trust. You want your members to automatically know who all messages are coming from so they will not only trust it but also complete the desired request or action. Consider other communications that may be coming from your organization around the same time and coordinate your naming conventions to maximize brand awareness. Help get your brand on the right side of the inbox or in their known contacts by encouraging your members to store your phone number or SMS short code on their device or enhance those efforts by deploying mPulse Virtual Contact File (VCF) messages. 

The New Normal for Medicaid

The return to normal, or rather the return to the new normal is here, and there is no slowing it down. This is still uncharted territory with a lot of work yet to be done, but if we have learned one thing here today, it is that working together, maximizing resources, and leveraging technology to provide a personalized member experience will be the key to successful redetermination efforts.

For more insights into how to deliver this experience to your medicaid population, visit our Medicaid Redetermination Resource Hub or view our on-demand webinar series for Redetermination.

What Plans Need to Know About DHCS Latest Release of Guiding Principles

In March 2022, DHCS released key guiding principles and considerations Medi-Cal plans will need to consider when designing programs for their Medicaid members, specifically youth and families. With 1 in 3 Californians insured under Medi-Cal, and over 13 million members at stake, these principles will become key focus areas for plans in 2023 and beyond.

The Challenge

To set the stage, in 2019–20, Medi-Cal brought in more than $65 billion in federal funds and accounted for nearly 16% of all state general fund spending. People with disabilities comprise 9% of Medi-Cal enrollees, and account for 31% of total spending. Children account for 17% of enrollees, but only 6% of the total spend.

And quality measures haven’t seen much improvement, with more than half of the measures staying the same or declining from 2009 to 2018. In summary, quality of care has declined on four measures, and hasn’t improved on 12 measures. What’s worse, three of the four measures that did decline were related to the care of children covered under Medi-Cal. Six of the nine measures related to children declined or stayed the same, with only three measures seeing improvement. The decline in quality prompted state-wide action, which led to DHCS creating 8 guiding principles to improve health outcomes at scale.

This article will look at three of the eight principles and provide plans with insights and opportunities to apply DHCS strategy in supporting families and children covered by Medi-Cal while enhancing health outcomes for the nation’s most vulnerable population.

Want to read about all 8 of the Guiding Principles and recommendations for implementing each one? Download our Medi-Cal Brief »

Strengthen the Coverage Base for California’s Children

  • Premiums will be reduced to zero to ensure accessibility for all Medi-Cal families.
  • Presumptive eligibility will expand to ensure families and children in need can receive care more quickly.


California has ensured a simplified enrollment and eligibility process for Medi-Cal, which has enabled the state to rank among the top third in the county in its child health coverage rates. California reduced the uninsured rate for Latino children to less than half the national average. Unfortunately, progress has declined in recent years, and the uninsured rate is beginning to gradually increase. With zero-dollar premiums and presumptive eligibility, plans will need to onboard and educate members about their benefits faster.

mPulse Improves Member Knowledge of Plan Benefits by 91%

Strategy: Deploy 2-way text messaging to gauge new members’ understanding of plan benefits and available resources, educate and improve utilization of plan benefits.

By using demographic datasets from our SDoH Index, we assessed and segmented the target population. Interactive polls, on-demand resources and open-ended questions were sent to members to continually gather insights while pointing them toward tailored resources.

Outcome: 91% of members found the text messages helped improve their understanding of the plan’s benefits and services. The number of members who reported they would visit the ER for a minor condition dropped from 11% to 4%. The engagement score, based on response and sentiment, was 2.5 times higher than the control group.

Fortify the Pediatric Preventive and Primary Care Foundation

  • A new population health management (PHM) strategy will be implemented to establish a checklist for plans to identify and serve children in need of care coordination.
  • New resources will be implemented in practice transformation for pediatric providers and primary care providers serving pregnant and youth members.
  • An educational outreach campaign will be deployed for EPSDT for members, providers, and MCPs.
  • Improve criteria and procedures used to determine when children receive behavioral health services, specialty mental health services, and substance use disorder treatment.
  • Expansion of preventive pediatric dental benefits.
  • Participate in CMS infant well-child visits learning collaborative for health care payment learning and action network state transformation collaborative (STC).
  • Continued support for the ACEs Aware Initiative and provider training grants.


Early Periodic Screening, Diagnostic, and Treatment (EPSDT) is the foundation for necessary adolescent care. Contract requirements in the upcoming Medi-Cal MCP procurement will create greater visibility and enforcement of EPSDT services under DHCS. Ensuring members receive education and information on the importance of these services is essential in building member self-efficacy.

mPulse Drives 66% Well-Child Visit Attendance

Strategy: Better manage children’s health outcomes by driving awareness of well-child visits, immunizations, and primary care visits via 2-way text messages.

Outcome: 66% of members attended at least one well-care visit. 83% of targeted members had their child vaccinated. 29% of members aged 18-21 successfully transitioned from a pediatrician to a primary care provider.

Get more outcomes and guiding principle recommendations by downloading the complete content »

Strengthen Access to Pediatric Vaccinations

  • Deploy COVID-19 pediatric vaccines to meet California’s “Vaccinate All 58” goals.
  • Develop a Vaccines for Children (VFC) plan with CDPH to increase vaccinations and increase vaccine education.
  • Increase vaccination rate of pregnant Medi-Cal members.


The United States saw a country-wide decline in vaccination rates throughout the pandemic with a 40% reduction in childhood vaccination rates in April 2020. California saw a vaccination rate of 35% in children for 2020. To prioritize increasing the Medi-Cal vaccination rate, more work will be required by plans in developing programs and initiatives that support vaccine education and helping overcome vaccine hesitancy.

mPulse Uses Streaming Health Education to Increase Vaccine Readiness

Strategy: Build self-efficacy and increase vaccine readiness by providing visual storybooks and using behavioral science techniques to help overcome barriers and vaccine hesitancy. 2.6 million messages were sent, and 1.8 million dialogues were initiated in both English and Spanish translation.

Outcome: 18.9% of members replied to a message or clicked a link. 72% of members who interacted with our vaccine storybook were more likely to get vaccinated.

Why Plans Should Leverage Text Messaging Outreach

In 2019, more than 94% of California households had internet access, although significant gaps remain with families of color and lower incomes having less access than white households. With organizations like iFoster, the California Emerging Technology Fund (CETF), and California LifeLine working to provide internet access and cell phones to those who need it most, cell phone and internet access will only continue to increase.

Compliance Considerations

When it comes to healthcare, communicating with members through text messaging can be somewhat daunting. mPulse Mobile is HITRIST, HIPAA, and TCPA-compliant and has deployed programs with leading Medi-Cal plans while ensuring compliance and member privacy is top of mind.

The TCPA healthcare exemption enables health organizations to deliver messages without prior express consent, as long as they abide by the following rules:

  • Must be HIPAA compliant, and not promotional or soliciting.
  • Messages can only be sent to the phone number provides and must state the name and contact information of the sender.
  • Voice messages must be under 1 minute, and text massages less than 160 characters.
  • Messaging frequency needs to be less than once per day, and no more than three times per week.
  • Messages must offer an opt-out and opt-outs must be honored accordingly.

As a company 100% focused on health engagement, security and compliance are mPulse Mobile’s highest priority, and all our solutions are designed with compliance as the foundation.


To improve quality measures and enhance outcomes for Medi-Cal youth and families, DHCS will be enforcing these policies and principles alongside Medi-Cal plans to increase utilization of new resources and services. mPulse Mobile’s suite of solutions are designed to drive engagement and increase utilization of plan benefits. Our frictionless engagement methods are proven to empower health literacy and self-efficacy. By partnering with us, plans can proactively implement DHCS principles into their enterprise strategy to deliver outcomes that matter most: healthier communities and greater quality of care for California’s most vulnerable members.

D-SNP Spotlight, Part 2: Engagement Opportunities within the 2023 Ruling

The CY 2023 Medicare Advantage and Part D Final Rule places a magnifying glass on vulnerable D-SNP members with additional regulations that will require plans to integrate services, adopt new products designed to deepen engagement, drive growth and retention, and inspire meaningful behavior change. Plans must consider these new guidelines when designing their D-SNP engagement programs. Visit Part 1, D-SNP Spotlight: Engagement Opportunities within the 2023 Ruling, to read a summary of the ruling and related changes to D-SNP regulations.

Why D-SNP? 

D-SNP members offer plans a unique engagement challenge, particularly due to their hard-to-reach reputation and growth potential. There are roughly 4 million D-SNP members nationwide, with 7 million additional individuals remaining eligible. This rapidly expanding population saw a growth increase of 52% since 2018, with an increase of 16.4% in 2021 alone. 

This fast-growing member population qualifies for both Medicaid and Medicare due to their complex needs and requirements. D-SNP members often have a disabling condition, suffer from mental health disorders, receive care from multiple doctors for a variety of health conditions, and/or receive in-home care or other specialized health and social service care. D-SNP members also have access to additional benefits which often include dental care, discounted over-the-counter pharmaceuticals, hearing exams, annual eye exams, and no-cost transportation to health care visits.  

Despite their complex needs, D-SNP members open the door to several opportunities due to the requirements in place that enforce plan coordination and whole person care engagement models. Here are a few opportunities to consider.

Opportunities to Engage and Drive Outcomes  

Cut Through the Competition 

Creating meaningful relationships is the key to retaining members, and the stakes are high when it comes to D-SNP. To retain members, each individual needs to feel seen and addressed. Scaling communications across an entire population is no small feat, particularly when each member has their own unique needs and challenges. 

Personalized omnichannel messaging is essential to creating a valuable experience and allows for resources and services to be delivered on a case-by-case basis through each member’s preferred channel of communication. Conversational AI allows messaging to remain dynamic, while Natural Language Understanding (NLU) analyzes each response. mPulse Mobile uses a combination of industry, public and private data sets combined with plan data to create highly accurate predictions, and continually optimizes dialogs using conversational insights. By sending the right message at key moments, and providing resources and information each member needs most, we can begin building meaningful relationships that reduce churn. 

Break Down the Barriers 

Reaching and getting D-SNP members to engage is a great start, but instilling behavior change and self-efficacy to create action? Definitely a challenge – particularly when we consider the unique needs D-SNP members face. Members face a combination of mental health and physical health challenges, which can include ailments such as substance abuse and comorbidities. They often receive in-home care, reside in long-term care facilities, or have designated caregivers. These situations can create even more barriers to engaging and activating D-SNP members. Despite obstacles, providing relevant and critical care information and resources, particularly benefits they may not be aware they have access to, through their preferred communication channel is a great first step. But how do we create meaningful behavior change? 

We can begin building health literacy by providing powerful media experiences that include interactive and educational modalities. mPulse Mobile offers streaming health education across a variety of health topics. All content is designed by our team of production designers and learning strategists, with the goal to build skills that empower members to own their health and adopt healthier behaviors over time. Not only do we design for health literacy, we design for entertainment and boast a 71% member self-reported likelihood to take action after engaging with our streaming content.  

Drive Value Again and Again 

D-SNP members offer plans tons of flexibility. Because Medicare and Medicaid benefits are tied into a single member, premium dollars increase and open the door to curating much-needed exceptional member experiences. Allowing plan resources and benefits to reach, engage and educate this rapidly growing and vulnerable population is crucial. To attain and retain the market share, developing partnerships with organizations designed to drive repeated value is key. Understanding your member’s needs, using behavioral and learning science to engage and educate them, and driving action at key moments increases member retention, and delivers better health outcomes. 

How mPulse drove a 58% D-SNP Engagement Rate 

mPulse partnered with a national payer who serves over 17 million members nationwide, with D-SNP member eligibility available in 28 states.  


The program focuses on welcoming new D-SNP members to the plan, with an emphasis on increasing awareness and utilization of available benefits and services. By providing a white glove experience, the plan aimed to increase retention of D-SNP members and create meaningful relationships with these members at scale. Additional goals included HRA completion. 


Over the course of three weeks, more than 45,000 D-SNP members were enrolled into a 3-week SMS program. Each week promoted a different service offering, including healthy food card and over-the-counter pharmaceutical discounts, as well as assistance in finding a provider and ensuring members received their ID cards.  


SMS text messages saw a 99% delivery rate with 58% engagement. More than 30% of engagement included link clicks to related plan benefit offerings, which included over-the-counter pharmaceutical discount cards, healthy food cards, and provide finder links.

What’s next?  

By understanding how to reach members with complex needs, plans can cut through the competition and provide unrivaled experiences for D-SNP members. mPulse Mobile is the leader in Conversational AI solutions for the healthcare industry and operates to continually drive outcomes using tailored and engaging digital experiences. Our rich understanding of diverse populations enables our team of behavioral and learning scientists to curate highly tailored programs designed to impact the lives served by our 180+ client roster.

Longest. Unwinding. Ever. The Continuous Wind Down of Continuous Enrollment

912 days sit between the beginning of the Public Health Emergency (PHE) and today, July 26, 2022. The PHE has been renewed 10 times, with the latest extension set to expire on October 13, 2022. There has been no shortage of speculation around the last two extensions, especially after the Biden-Harris administration committed to providing states with at least a 60 day notice prior to its plans to terminate or allow the PHE to end.

In March of 2020, the Families First Coronavirus Response Act (FFCRA) was signed into law. This particular piece of legislation focused on many programs impacting children and families, including but not limited to Supplemental Nutritional Assistance Program (SNAP), the Women Infants and Children (WIC) program, family and medical leave, school lunch, emergency paid sick leave, and state based programs for Medicaid and Children’s Health Insurance Program (CHIP) eligibility and enrollment requirements. The latter of these provisions effectively froze Medicaid disenrollment during the PHE allowing for continuous coverage for current beneficiaries. Prior to the pandemic, states were required to reprocess eligibility for most of its enrollees on an annual basis, this process is referred to as redetermination.  

Medicaid and CHIP enrollments have increased by approximately 19% or 13.6 million enrollees between February 2020 and September 2021 with an additional 1.2 million enrollees added to the roster since the September report. To offset increased program spending coupled with decreased state tax revenue, the FFCRA authorized a 6.2 percentage point increase in the Federal Medical Assistance Program (FMAP) and in return expected continuous enrollment. This FMAP bump will continue through the end of the first quarter in which the PHE ends. 

When the End Comes…

Now that we’ve covered some of the basics, let’s look what it means for the plan when the PHE and continuous enrollment ends, and redetermination resumes for its beneficiaries. The end of continuous enrollment is expected to create the single largest health coverage transition since the first Marketplace Open Enrollment. Due to the high volume of unprocessed eligibility renewals and the increase in membership, states have been given a 12-month unwinding period to manage this administrative task. The Department of Health and Human Services (HHS) has issued an Unwinding Toolkit and CMS has encouraged states to only process 1/9 of its total caseload in a single month; processing more than this creates an increased risk of people falling through the cracks and being unnecessarily disenrolled resulting in a loss of coverage and potential increase of additional administrative work to bring them back in.  

Keep in mind each state will have its own pathway and plan to work through this transitional phase. For example, some states have indicated they will target enrollees who appear to no longer be eligible first and others plan to conduct renewals on a monthly basis based on the individual’s initial enrollment month and some states have also reported they plan to process the backlog as soon as 3-6 months with others using the full 12 plus months.  

Projections for total Medicaid and CHIP growth during the pandemic and scenarios calculating total loss of coverage continue to shift and grow with varying levels of certainty and range from 5 to 14 million enrollees losing coverage. Even at the lowest end of the loss projections, five million people is an awful lot! While some loss may not be preventable, complete, and total disruption can be avoidable for those who be eligible for coverage on a Marketplace (aka Affordable Care Act or ACA) plan. This shift to retention will be more bearable and less burdensome if American Rescue Plan Act (ARPA) subsidies continue for the estimated 13 million Marketplace enrollees currently receiving a premium reducing subsidy.  

Planning for the Unwinding of Continuous Enrollment

So, we’ve covered some basics on what it means for the plan (a lot of work ahead), what it means for the member (a lot of uncertainty still remains), and now about what it means to everyone in between which in this instance is us, mPulse and that’s where I start to get excited. There are phased approaches and best practices from our friends in California who have been given the green light to reach members in just about any way possible even allowing plans to solicit opt-in consent for future updates by text message to the East coast where communications to CoverVA enrollees in Virginia are being encouraged to update their contact information by signing up for email or text alerts and following via social media.  

I’m no math whiz, but this one is easy: X + 14 = Regular Redetermination Resumes 

With X being the unknown number of additional PHE extensions and 14 the number of total months allowed to manage the backlog at the end of the PHE you’ll find yourself back where you were before COVID-19 was a household name. Regardless of where you are in your own state’s phase approach, you can count on trusted partners like mPulse to engage the unengaged and reach the unreachable in your membership. Not sure where to start? Reach out to learn more about the power of SMS and find out how many of your contact numbers are mobile vs. land lines.

CMS 2023 Ruling’s Impact on D-SNP Populations, Part 1

The Centers for Medicare & Medicaid Services (CMS) released the Contract Year 2023 Medicare Advantage and Part D Final Rule. The ruling places a spotlight on the vulnerable D-SNP population, and places health plans in a challenging yet opportunistic position to engage these notoriously difficult-to-reach members.

2023 Ruling’s Impact on D-SNP at a Glance 

Enrollee Participation in Plan Governance 

MA organizations offering a D-SNP must establish at least one enrollee advisory committee in each state to solicit input from member experiences. The sample must include those enrolled in D-SNP and garner input from members regarding access to services, coordination of services and health equity. 

Opportunity: Feedback will help identify and address barriers to care, which will allow plans to further assess their series and processes to ensure a better member experience, while also collecting valuable data regarding their unique member population.

Standardizing Housing, Food Insecurity, and Transportation Questions of Health Risk Assessments (HRAs)

Initial and Annual assessments will be conducted to evaluate each member’s physical, psychosocial, and functional needs. HRAs must include one or more questions on housing stability, food security, and access to transportation.  

Opportunity: Visibility of member needs will enable plans to address the unique needs of each member, allowing better access and resource allocation of plan offerings and services.

Refining Definitions for Fully Integrated and Highly Integrated D-SNPS 

Beginning in 2025 and in years following, FIDE SNPs will have aligned enrollment and cover Medicare cost-sharing and Medicaid benefits for home health services, medical supplies, and behavioral health services between the state and the MCO, with the same legal entity as the FIDE SNP. Additionally, HIDE SNPs have service that overlaps the plan’s Medicaid managed care plan with the state. This rule will organize Medicaid long-term services while supporting Medicaid behavioral health services affiliated with FIDE SNPs and HIDE SNPs.  

Opportunity: Create better integration between FIDE SNPs and HIDE SNPs, whose definition and intricacies have previously lacked consistency.

Additional Opportunities for Integration Through State Medicaid Agency Contract

D-SNP contracts will be required through the state agency to provide benefits/ arrange a provision of benefits. New pathways will require aligned enrollment and establish contracts that only include one or more D-SNPs within a state and use integrated materials and notices for members. 

Opportunity: Members have clarity of their coverage and benefits. Star Ratings are assigned at the contract level, which means this rule provides greater transparency on D-SNP quality ratings and will allow CMS to identify disparities between beneficiaries and interventions. This will improve federal and state oversight and scale information sharing.

Attainment of the Maximum Out-Of-Pocket (MOOP) Limit

Plans must establish a limit on beneficiary cost-saving for Medicare Part A and B services after the plan pays 100% of the costs. Current guidance allows MA plans, including D-SNPs to not count Medicaid-paid amounts or unpaid amounts towards the MOOP limit, which results in increased state payments of Medicare cost-sharing and disadvantages providers serving D-SNP members. The MOOP limit within the plan will be calculated based on total cost sharing, regardless of whether it was paid by the beneficiary, Medicaid, secondary insurance, or left unpaid. 

Opportunity: More equitable payments for providers serving D-SNPs. This will result in increased bid costs, and increased Medicare spending, which will be offset by lower federal Medicaid spending. The net federal 10-year cost is estimated at $614.8 million. 

As plans heighten their attention and focus on D-SNP members with the new ruling in mind, several opportunities surface and a more robust engagement model that provides an exceptional experience becomes critical. Look out for Part 2, D-SNP Spotlight: Engagement Opportunities within the 2023 Ruling, to learn how plans can upgrade their engagement strategy to drive proven outcomes with D-SNP members. 

Member Communication for the Home COVID-19 Test Coverage Mandate and Other Rapid Response Programs

Beginning January 15th, the Biden Administration required health insurers to cover the costs of up to 8 at-home COVID-19 tests per month for their privately insured members. This not only helps reduce or eliminate up-front costs of Americans seeking an at-home solution to COVID-19 testing, but it also helps dull the pain points of finding testing facilities when needed.

The mandate, which quickly became breaking news, was a welcome announcement for health care consumers, but it threatened to strain insurers who were given official notice just days prior to its effective date. In the last two weeks, we’ve heard from many of our healthcare partners about the challenges this presents during an already busy season. Plans found themselves in a difficult position needing to communicate as quickly and accurately as possible while maintaining their current programs and managing their open enrollment period (OEP).

Easy Rapid Roll-out Practices for Your Members and Organization

Between call-center re-routes, at-home test kit availabilities, and managing the member experience, staying agile after this announcement can become both overwhelming and costly. This is not the time to trial and error communication with your populations.

Relying on the methods you have already been using for member communication is your best bet in yet another unpredictable turn during the pandemic, and there are several distinct best practices plans can follow to handle unexpected situations like this as they arise.

To start, use the quickest and most impactful means of communication with your members first. 3.8 billion people own a smart phone and SMS is a reliable source of fast communication. If that line of communication is already set up with your population, connecting them with resources after any sudden event will be much simpler. The minimum data requirements we recommend for our at-home testing mandate outreach or similar programs are the member’s first and last name, date of birth, mobile phone number, and address.

Channels like SMS are ideal for reaching consumers quickly but implementing a multi-channel approach by including email and even IVR channels is an option, too. For example, using a consumer’s preferred method of outreach, like IVR, to authenticate mobile numbers and direct them to two-way automated workflows can be an effective tool, allowing your organization to provide cost saving information within hours while still utilizing all lines of preferred communication.

Whatever the channels you choose, we recommend providing comprehensive education and resources by redirecting consumers to trusted information sources, such as an interactive FAQs page or links to valuable sites like USPS How to find a test site. This reduces the chance of them calling their plan for information that is thorough and easily accessible elsewhere. In the case of this at-home test mandate, providing them information on their pharmacy or a link to all in-network pharmacies near them can also help the plan save money on reimbursement costs.

Orchestrating this outreach early and getting in front of the member with the correct messaging before they reach out to your call centers can help mitigate costs in any situation, but it can be especially helpful after the at-home mandate announcement. It will not only help ease the influx of calls to a costly call center, but it will also lead your membership to the resources they need to secure their at-home tests at a more reasonable cost to the plan.

Another rapid roll-out best practice we recommend is partnering with a solution provider which has the technology in place to quickly deploy two-way messaging at scale. The ability to have bi-directional conversations to address the specific questions of each member individually (ideally through natural language understanding technology) will significantly improve the efficacy of your program. And with this partnership in place, you won’t need to focus on setting up member communications in the middle of figuring out execution. You can lean on your solution provider to build and deploy the program for you.

Interested in learning more? Watch our on-demand webinar on at-home covid-19 mandate best practices and rapid response solutions »

The most important factor, however, is acting quickly. If your outreach provider has contingencies in place for last-minute events like this, they will most likely be able to stand up a solution that has all our best practice elements included in a timeframe of two to three weeks or less.

How Does This Fit Into the Member Journey?

Though communication surrounding this mandate is trickier than other rapid responses, swift messaging to member populations is still essential. When a health plan reacts quickly to market changes and provides helpful information to ease members and patients through a complicated and cumbersome process, they become trusted partners throughout that member’s journey. The right communications from a trusted authority, reduce the complexity this new mandate has presented, and others to come, and will prevent misinformation that members face. If your organization has a communications partner with experience standing up programs quickly, then it can feel easier on the member to get common questions answered, find vaccine sites, and submit claims, etc. – further reducing barriers to crucial and accurate information.

And with CAHPS right around the corner, what better timing to solidify that spot as your member’s trusted source of information that is preventative and timely? Further strengthening trusted relationship between plan and member.

Understanding your membership and leaning on the information you have, such as their preferred language, the channels your healthcare consumers use, and the right contact information will go far when your organization needs to pivot and deploy information timely and most efficiently.

COVID-19 Home Test Coverage Takeaways

If your organization is currently using SMS to outreach to your populations, you are in the perfect position to outreach quickly and at scale, and you only have to switch out standard messaging with the right messaging for the moment. An easy framework for rapid rollout solutions your organization has at the ready, is a sure-fire way to communicate all new breaking information.

Then working with your solution provider to craft the perfect messaging or leaning on your solution provider’s behavior science technology will impact how swiftly your organization can easily respond in moments when messaging is not able to take the priority–like we saw just a few weeks ago many other times throughout the pandemic. The focus can remain on execution while your automated solution provides your membership with what they need to feel like they can come to you for the most reliable trusted resources at any time.

Analysis of April 1, 2021 Supreme Court Ruling on the TCPA

Big news for healthcare organizations that have been hesitant to fully leverage text messaging due to conservative interpretation of the Telephone Consumer Protection Act (TCPA). On April 1, 2021 the Supreme Court ruled that automated messaging did not fall under the TCPA if the system sending the messages was not an automatic telephone dialing system (ATDS). The court’s definition of an ATDS was very narrow. Whether storing or producing numbers to be called, the equipment in question must use a random or sequential number generator to be considered an ATDS. Therefore, if organizations, healthcare or not, are not using an ATDS to send messages, then those messages do not fall under the TCPA. The ruling provides additional protections that should persuade more conservative organizations to adopt prior express consent strategies.

The TCPA was established in 1991 to protect consumers from the growing number of telephone marketing calls. In 2013 and 2015 a series of carve-outs added provisions for healthcare related calls and messages where consumers who have knowingly released their phone numbers to a HIPAA compliant entity (or its Business Associate) have effectively given their invitation or permission to be called at the number which they have provided, absent instructions to the contrary. The call or message must fall within the scope of the consent that it was provided. Most commonly, this means if an individual provides their mobile phone number e.g. filling out an application form (paper or online) for health coverage or signing up to a medical practice, then they have provided consent for that company or another operating under a BAA to use that number to contact that individual.

If you applied to a state Medicaid agency for health coverage and provided your mobile number on that enrollment form, then after coverage was granted you received a message from the managed care organization you had been assigned to, it would not a be a surprise. More likely it would be a good experience. Maybe even expected.

But some healthcare organizations have taken a more conservative interpretation of the law and require the strictest consent requirements: prior express written consent. Applying prior express written consent to the above example, in addition to providing their number when enrolling at the state level, the member would have to specifically provide written consent (typically, by providing their number again, checking a box to confirm consent, or texting in a keyword) in order to receive automated communications from that health plan managing their benefits. This approach significantly reduces the percentage of members who can benefit from valuable informational messages to help them manage their health.

Unless healthcare organizations are using a system that has the capacity to generate and store random or sequentially generated phone numbers, which is extremely unlikely, this Supreme Court ruling means messages they send to patients and members do not fall under the TCPA. There is no law regulating their messaging, minimizing any risk of class action litigation.

However, member consent is part of providing a positive experience. That’s best practice. So, what the ruling effectively means is that in addition to the protections afforded by consent, healthcare organizations have another layer of protection by falling outside of the ATDS definition. Depending on how organizations have previously interpreted TCPA, here is some guidance to help align on a new approach:

Organizations that have historically obtained prior express consent

  • These organizations do not need to adjust their approach. Using prior express consent means they can engage the majority of the members and drive optimal value out of the SMS channel.

Organizations that have historically required prior express written consent

  • Business leads should work with their legal teams to transition to a prior express consent strategy. Any concerns about the prior express consent approach are mitigated by the additional protections afforded by the Supreme Court ruling.

Organizations that have historically received phone numbers from a 3rd party

  • Business leads should assess the context of how individual numbers were originally provided. If the number will be used to engage individuals on topics related to the scope of how it was provided, then the business leads should work with their legal teams to transition to a prior express consent strategy.

The definitions of ATDS apply to both pre-recoded voice calls and text messages. However, following the Supreme Court ruling, adapting consent strategies for text messaging is clean compared to pre-recorded voice calls or IVRs. Within the TCPA, pre-recorded voice calls have additional areas of regulation pertaining to how the mobile number was gathered and these areas must be taken into account when conducting automated calls. There are more protections for sending automated text messages than there are for pre-recorded voice calls.

The ruling is favorable for organizations across industries, but it is unlikely to lead to dramatic changes to how organizations use the SMS channel. Firstly, considerable industry self-regulation exists, such as carriers’ ability to block automated spam calls. The CTIA (industry body for the wireless communications industry) provides strict guidance on how messaging programs should be managed and has the power to shut down non-compliant messaging programs. Secondly, it is in the interests of brands to follow best practices and deliver excellent consumer experiences. The Federal Communication Commission (FCC) that oversees the TCPA may react to the Supreme Court ruling by updating the law, but the manner and urgency of its response will in part be driven by whether brands put consumer interests at the fore and self-regulate best practices for consumer messaging engagement. If the FCC does act, and it has no obligation to do so, any new consent rules would have prospective effect only.

For healthcare organizations that have been slow to adopt text messaging engagement due to TCPA regulations, the ball is firmly in their court. The TCPA is vague in parts and while many organizations see the opportunity the prior express consent approach, they hold-back because of uncertainty of the language. Now that the risk of class-action litigation has been largely ruled-out, these organizations have a significant opportunity to leverage the SMS channel more.

Our Reaction to the Two New TCPA Rulings from the FCC

This past Thursday, June 25, 2020, was a busy day for the Federal Communications Commission (FCC) and their oversight on the Telephone Consumer Protection Act of 1991 (TCPA). That law, and the FCC rules enforcing it, create the primary regulatory structure that guides how automated outreach via phone and text to cell phones lawfully happens in the US. As a result, mPulse is always monitoring FCC rulings, federal court cases, and Congressional actions that relate to how our customers can ensure they are always compliant with the TCPA. So, when the Commission issued two binding Declaratory Rulings relating to the TCPA last week, we knew it was important to examine what was (and wasn’t) changing as a result. Here is our breakdown of the two new rulings. (Note: I’m not a lawyer and this should not be taken as legal advice.) 

P2P Alliance Petition 

What it isThe FCC ruled on a 2018 request from the Peer 2 Peer (P2P) Alliance asking for clarification on what constitutes an “auto-dialer” that calls or texts cell phones. This definition is key to determining if the TCPA applies to a technology platform.  

What happened: The Commission’s Consumer and Government Affairs Bureau (CGB) made two key rulings. First, they clarified that an auto-dialer must store or generate random or sequential phone numbers and call them without human intervention. They specifically clarified that a technology platform where a human had to manually enter each number prior to calling or texting would not be subject to the TCPA, no matter how fast they would be able to call or text. Second, the FCC reiterated a long-standing view that, even when using an auto-dialer subject to the TCPA, calls and texts made to cell phones with the consumer’s prior express consent are permitted. They also took a moment in the ruling to note, “The Commission has repeatedly made clear that persons who knowingly release their telephone numbers for a particular purpose have in effect given their invitation or permission to be called at the number which they have given for that purpose, absent instructions to the contrary.” They finished by saying that if P2P was an auto-dialer, but was only calling or texting consumers who had provided their cell phone numbers to the calling parties, those calls/texts would be permissible because they were made with prior express consent. 

What it means: Because of our scale and the crucial nature of the calls and texts (among other channels) our platform powers for our healthcare customers, mPulse has always operated under the assumption we fall under the TCPA, even as the definition of an auto-dialer has been debated in federal courts. So, our operations won’t change due to any update to that definition. The reiteration that providing a mobile phone number constitutes prior express consent, absent instructions to the contrary, is a good and clear reinforcement of the FCC’s view of how consumers can opt into non-marketing text and phone outreach.   

Text of ruling:  

Anthem Petition 

 What is it: The CGB also ruled on a 2015 request from Anthem that was asking for an expansion of the exemptions for healthcare messaging under the TCPA. Specifically, Anthem asked for the FCC to rule that calls and texts from Anthem (and plans or providers in general) that concern healthcare should not need to have prior express consent as long as consumers have an easy opportunity to opt out. The existence of a prior established relationship between the plan and members is enough, in their argument, to start that outreach. Second, they asked that broader healthcare calls/texts should be exempt from the TCPA entirely because they are welcomed by consumers and represent urgent healthcare concerns. Specifically, Anthem listed calls/texts on subjects like preventive medicine outreach, case management, to “educate members about available services and benefits,” and the use and maintenance of benefits.   

What happened: The Commission declined to grant Anthem’s requests. They emphasized that consent must be obtained prior to starting outreach regardless of an existing relationship, but noted that healthcare callers should have little problem obtaining that consent. The FCC also disagreed with a few of the Anthem petition’s arguments for making a content-based exception to the TCPA for non-emergency healthcare calls and texts.  

What it means: The FCC’s ruling is positive in a number of ways. This was the first time that the FCC directly addressed calls and texts that health plans typically send their members. The FCC’s treatment of Anthem as a healthcare entity – consistent with their definition of a “healthcare provider” as a HIPAA-covered entity and/or their business associates as those terms are defined under HIPAA – helps health plans get clarity that the TCPA protections for healthcare calls and texts – which require prior express consent instead of the prior express written consent that general marketing calls require – apply to their health-related messaging as well as those from hospitals or doctors’ offices. Ultimately the FCC’s move to look at health plan calls and texts and determine that no change was needed gives us confidence in the compliance procedures we have helped our plan customers follow for over a decade.

Text of ruling:

Reaction and Analysis: Office of Civil Rights Takes a Position on Text Messaging in Healthcare

If you ask a group of people that work in healthcare about whether texting is a compliant form of communication, you are likely to get a wide variety of answers: “you can,” “you can’t,” “you can, but no PHI,” “PHI is fine.” There has long been a desire for clarity on this grey and murky topic.  At HIMSS 2018, Roger Severino, Director of the US Department of Health and Human Services Office for Civil Rights (OCR), shed some much welcome light on compliance around healthcare texting.

Before we get to Severino’s comments, let’s address why everyone is so confused.

Two types of texting defined

There are two different types of texting that operate very differently and serve very different needs but are both commonly referred to as the same term, “texting.” The first type is what general consumers think of as texting, or Short Message Service (SMS) to use its technical term. This is the texting that is a default app on your phone and paid through your carrier that many people use to send and receive texts every day. It is unsecure. For clarity, I will refer to this as SMS. The second type is proprietary app based, with multiple different app providers. It is used by healthcare providers (mostly doctors and nurses) to communicate to one another on patient-related care inside and outside the walls of the health center. It can also be used by providers to communicate with patients provided the patient has downloaded and created an account for the app being used. It is secure. For clarity, I will refer to this as Secure Texting.

PHI and texting

Handling PHI through texting is the source of a lot of confusion and debate. Because of their Provider-to-Provider focus, Secure Texting needs to meet certain technical standards for HIPAA compliance:

  • encryption of message data in transit and at rest
  • reporting/auditability of message content
  • passcode enforcement
  • authentication
  • permissions management capabilities

With these safeguards in place, PHI of all risk levels can be communicated through that channel.

SMS is an unencrypted channel, so one might assume no PHI can be sent. Actually, that is not true. Encryption is not mandated. Instead healthcare companies must assess whether encryption is a reasonable and appropriate safeguard in its environment, when analyzed with reference to the likely contribution to protecting PHI. If encryption is not deemed reasonable and appropriate, the covered entity must implement alternative safeguards.

Because the SMS format is fundamentally incapable of encryption, companies have the discretion to make a case-by-case determination under HIPAA whether it is reasonable and appropriate for SMS texts to contain PHI.  A key factor is the nature of the PHI to be disclosed. Many healthcare companies are comfortable including low risk PHI in SMS texts, such as a patients first name, the fact the patient has a medical appointment, or has a medical condition (without specifying what the medical condition is). So, under current policy, while it is not explicitly defined, low risk PHI can be sent through the text channel within the boundaries of HIPAA guidelines.

The 2017 Clarification on Secure Texting and Patient Orders 

Since 2011, there has been considerable back-and-forth on whether Secure Texting can be used for communicating patient orders. In December 2017, the Joint Commission issued a clarification explicitly stating the use of Secure Texting for patient orders is prohibited. The document also recommended healthcare organizations should have policies prohibiting the use of SMS for communicating PHI. Expanding on this statement, the Joint Commission explained ‘Organizations are expected to incorporate limitations on the use of unsecured text messaging in their policies protecting the privacy of health information’ Joint Commission 2017. This position is in-line with the broader HIPAA Security Rule policy requiring healthcare organizations weigh the risks and benefits of sending unencrypted text messages.

The HIPAA Omnibus Final Rule

In 2013 the HIPAA Omnibus Final Rule allowed healthcare providers to communicate PHI with patients through unencrypted e-mail as long as the provider informs the patient that their e-mail service is not secure, gains the patient’s authorization to accept the risk, and documents the patient’s consent. This clarified the use of email for provider to patient communications. (Just to be clear providers cannot communicate PHI to one another using unencrypted e-mail).

Notably, the rule did not mention anything about SMS, which is somewhat frustrating as SMS is the most widely adopted communication channel by just about everybody. Some interpret the rule as applying to SMS as well because both are unencrypted electronic channels. Others want more clarity.

Clarity from OCR

Speaking at the HIMSS health IT conference in Las Vegas on March 6, Roger Severino, said that healthcare providers may share PHI with patients through standard (SMS) text messages. Providers must:

  • warn their patients that texting is not secure
  • gain the patients’ authorization
  • document the patients’ consent

Severino’s comments are yet to make it into policy, but the OCR has long-promised guidance on this topic. As the country is in a period of intense deregulation, it is reasonable to assume a ruling on the topic is imminent.

What does this mean for healthcare companies?

That depends on whether the healthcare company is already using SMS to reach and engage their patients. Many companies have well-established SMS programs. SMS has bubbled to the top as the most effective channel to engage patients about their health:

  • Increased chronic condition medication adherence from 30% to 44% in a non-adherent Medicare population read more
  • Reduction in members reporting they would use the Emergency Department for a minor condition from 11% to 4% read more
  • Reduction in procedural no-goes by 50%

Many healthcare companies are comfortable with the unencrypted nature of the channel and include PHI in line with their compliance department’s requirements. For these companies my advice would be to continue to drive as much value through the SMS channel while meeting current compliance guidelines. These companies will then be in a position to capitalize most when there is a change in policy that increases the breadth of use cases for which SMS can be used to engage patients and health plan members.

For companies that are not using the SMS channel to engage patients, I see this as clear notice that SMS is a channel where you should invest. 95% of the adult population uses the SMS channel and 98% of SMS texts are read. No other channel has that level of adoption and engagement. Because of this reach, the impact of the SMS on both clinical and administrative outcomes is well established and will only go up with policy that increases the breadth of use cases for which the channel can be used.

Healthcare Apps: The Good, The Bad, The Ugly

It is hard to imagine a week going by without hearing about a new app in the healthcare industry. It makes sense, though. As mobile devices become more sophisticated and better protected (was anyone else’s mind blown when Apple launched fingerprint technology?), consumers feel safer using them for important activities and sharing private information. The impact of apps in healthcare seems largely positive and they should only become more important as technology and regulations continue to evolve, but plenty of skepticism still remains.

First, a few quick facts to define the landscape:

To summarize, consumers continue to perform more activities on mobile devices than ever before, a very small portion of available health-related apps are downloaded, and the majority of apps are used only once.

There is a clear issue with getting consumers to actually use apps. After all the time, money, and energy spent building an app, marketing it, and finally earning a download only to find that consumers never come back is frustrating. These stats are even more depressing when there are so many valuable apps currently available and in development. Companies are spending big bucks to develop apps that may change healthcare forever.

Today alone, there are two featured stories on about exciting new apps. One monitors respiration real-time while the other coaches kids to help them lose weight. This is not an unusual day. Apps with concepts like this are announced and released all the time. There are even companies like Zoom+ that are trying to bring healthcare almost entirely to the mobile phone. (Keyword being “almost.” It’s tough to imagine a phone performing an appendectomy.)

So the future for healthcare apps is simultaneously extremely bright and somewhat murky. The technology and abilities are mind blowing, yet adoption and use remain a challenge. Intelligent text messaging is a key to increasing adoption and getting consumers to complete the activities an app requires to remain valuable to them.

Here is an example:

There are a variety of apps that help consumers manage their health, be it overall fitness, diabetes, medication adherence, or any number of other health issues. Many of these apps require data from consumers in order to be effective. This data typically comes either from wearables that sync with the app, consumer-input data, or a combination of both. When consumers download the app, they typically log in, provide basic info, and then start looking around at all the features and overall experience. All is going fine and well until the consumer encounters something that requires a second effort on their end. Providing their current weight requires them to go step on scale and return; a prompt to sync a wearable could send them into an online shopping environment loaded with distractions. And then they lose momentum, interest wains, and they never return.

The challenge with apps is they require the consumer to click on them, and in healthcare likely log in, every time they use them. This is an unavoidable barrier unless security and regulations change dramatically. So how do organizations get consumers to care enough to log into an app regularly?

Here are some ideas:

  • Push Notifications: When a user enters an app for the first time, ask them to turn on push notifications. This enables the app to send alerts or reminders to the user on their mobile device. Downside: Many users (roughly 60%) do not opt-in to push notifications.
  • Digital Marketing: Once a consumer downloads the app, targeted online marketing can remind them about the necessity of the app. Downside: Expensive with limited data to judge success.
  • Text Messages: An intelligently-timed text message can encourage consumers to take the action the app requires (like measuring weight) and log back in with a simple tap of the link. Now the app has the information it needs to be more valuable to the consumer which is likely to increase adoption. If not, another intelligent text should do the trick. Example Text: Joanna, don’t forget to take your blood pressure and post it link to app so we can keep your doctor up to date.

Seeing the level of innovation in mobile healthcare is completely thrilling. It really feels like the dawn of a new era. Making sure consumers do their part and experience this innovation through apps requires an extra step to keep them engaged. By leveraging push notifications, ongoing marketing, and text message workflows, organizations are likely to see much stronger app use numbers and generate better outcomes across the board.

mPulse Mobile is the industry leader in a variety of healthcare solutions to support over 200 use cases. Driving traffic to apps is one of them. mPulse also creates intelligent workflows for two-way interactive text messaging that engages patients and consumers to get the information and care they need.