As we approach 2025, Managed Medicaid health plans are increasingly confronted with the dual challenge of ensuring compliance while delivering cost-effective, high-quality care. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) management is at the heart of this challenge, requiring innovative solutions to improve member outcomes and plan performance. For Medicaid health plans, quality measures such as CAHPS scores, Star Ratings, and reduced hospital readmissions are not merely benchmarks—they are critical to sustaining funding and member satisfaction. Addressing these measures through effective DMEPOS management is essential for long-term success.
The Story Behind Medicaid DMEPOS Management
Sarah, a 57-year-old Medicaid enrollee living in a rural community. After a recent surgery, she needs a specialized wheelchair to regain her independence. However, her journey to obtain this essential equipment is fraught with obstacles. She faces a complex maze of prior authorization requests, limited local providers, and lengthy processing times. These hurdles not only delay her access to the necessary DMEPOS but also affect her recovery and overall quality of life. Unfortunately, Sarah’s story is not unique; it reflects the reality for millions of Medicaid beneficiaries across the United States.
In 2024, over 79 million Americans relied on Medicaid for their healthcare needs1, and a significant portion of this population requires DMEPOS to manage chronic conditions and disabilities. Yet, many Medicaid enrollees encounter barriers that prevent them from obtaining timely and effective care.
79 million Americans relied on Medicaid for their healthcare needs and a significant portion of this population requires DMEPOS to manage chronic conditions and disabilities.
The Challenges Facing Medicaid Health Plans
Timely Access to Care Issues
Timely access to DMEPOS is not just a logistical challenge—it directly impacts key quality measures like hospital readmissions and health outcomes. Rural provider shortages and cumbersome processes exacerbate delays, increasing the likelihood of hospital stays and readmissions. For Medicaid, these setbacks cost an estimated $15,000 per readmission over 30 days2. Access delays and administrative inefficiencies have far-reaching consequences, including lower CAHPS scores and reduced Star Ratings. These metrics are critical for Medicaid plans to maintain funding and member satisfaction, emphasizing the need for streamlined DMEPOS processes.
Administrative and Caregiver Burdens
Beyond access issues, Medicaid health plans face overwhelming administrative burdens. A study from the Center for Health Care Strategies found that the time-consuming processes involved in managing DMEPOS can divert valuable resources away from patient care. Delays in order processing are commonplace; for example, 75% of DMEPOS orders remain unsigned after 30 days4. This inefficiency not only frustrates patients but also complicates health plan operations, leading to higher costs and a diminished ability to serve members effectively.
Additionally, the burden often falls on caregivers, who must coordinate DMEPOS for their loved ones in the face of systemic inefficiencies. For Medicaid populations, particularly those in STAR+PLUS and STAR+KIDS programs, this adds an emotional and logistical strain to caregivers already navigating complex healthcare needs. Ensuring timely and reliable DMEPOS access is vital not only for members’ health outcomes but also for reducing caregiver burnout.
Tomorrow Health Solution: Tomorrow Health stands ready to help Medicaid health plans overcome these challenges. Our technology-enabled platform streamlines the DMEPOS lifecycle, significantly improving operational efficiency. By automating workflows, we can reduce order turnaround times by up to 85%5. This not only alleviates the administrative burden on health plans but also ensures that patients receive their necessary equipment faster, leading to improved health outcomes.
Regulatory Compliance and Adaptability
Health plans must also navigate a rapidly changing regulatory environment. With ongoing policy changes and expansions in Medicaid coverage, staying compliant while managing costs can be a delicate balancing act. Plans that fail to adapt risk facing penalties and jeopardizing their enrollment numbers.
Tomorrow Health Solution: With Tomorrow Health, Medicaid plans can achieve significant cost savings while ensuring compliance with evolving regulations. Our platform guarantees savings of over $3.00 PMPM7, enabling plans to reinvest those funds into member care initiatives or offset rising operational costs. Additionally, our solutions adapt to regulatory changes, ensuring that health plans remain compliant without incurring additional administrative burdens.
The Role of Quality Measures
Quality measures are central to the success of managed Medicaid and Medicare Advantage programs. Metrics such as timeliness of care, patient-reported outcomes, and caregiver experience are not just benchmarks—they’re drivers of funding, member loyalty, and overall plan performance.
Health plans that invest in solutions to address these measures can unlock value in several ways:
- Improved Star Ratings, leading to greater federal bonuses and marketability.
- Higher CAHPS scores, boosting member satisfaction and retention.
- Reduced hospital readmissions and ER visits, aligning with cost-saving goals.
Tomorrow Health Solution: With a 95%6 member satisfaction rate and proven success in reducing delays, Tomorrow Health equips Medicaid plans to excel in these quality measures. Our platform offers the visibility, data, and tools needed to address gaps in care and optimize outcomes proactively.
The Urgency for Action
The clock is ticking. The increasing pressures of enrollment growth, regulatory changes, and rising operational costs demand immediate action from Medicaid health plans. The challenges facing DMEPOS management are not just obstacles; they represent urgent calls for transformative change. By embracing Tomorrow Health’s solutions, Medicaid plans can improve patient outcomes and satisfaction, significantly reduce costs, and streamline operations.
As we reflect on Sarah’s story, let us remember that the challenges faced by Medicaid enrollees are a call to action. The time to act is now. By embracing Tomorrow Health’s solutions, Medicaid plans can directly impact quality measures like Star Ratings and CAHPS scores, driving meaningful improvements in patient outcomes and operational efficiency.
Let’s seize the opportunity to transform DMEPOS management and set a new standard for care.
1 U.S. Department of Health & Human Services. (n.d.). Medicaid and CHIP enrollment data: Report highlights https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html
2 Kaiser Family Foundation. (2023). A look at navigating the health care system: Medicaid consumer perspectives. https://www.kff.org/medicaid/issue-brief/a-look-at-navigating-the-health-care-system-medicaid-consumer-perspectives
3 Healthcare Cost and Utilization Project (HCUP). (2020, November). Conditions with frequent readmissions by payer, 2018. Agency for Healthcare Research and Quality. https://hcup-us.ahrq.gov/reports/statbriefs/sb278-Conditions-Frequent-Readmissions-By-Payer-2018.jsp
4 Aggregate Tomorrow Health Research
5 Tomorrow Health actual results
6 Tomorrow Health actual results
7 Actual Results, MA specifically PMPM, 2024
