Medicaid Member Reconciliation · Before January 1, 2027 · for Health Plans
The Members on your eligibility file every month.The Patients your contracted providers actually see.
FHG converts your claims data into a Member-by-Member reconciliation asset you share with your network — every Member, every month. Not as oversight. As a tool your provider partners need and don’t have.
The state Medicaid agency is hiring KPMG, Deloitte, and the rest to modernize antiquated COBOL eligibility systems for a 6-month redetermination cadence none of them were built for. Downstream — your network of FQHCs, DPHs, IDNs, primary-care groups — absorbs the chaos the state can’t. You can be the antagonist that makes it worse, or the benevolent partner that carries them through. Eight Rolling-12 cycles to January 1, 2027; four weeks to your first FHG baseline.
All Plan Lines of Business
Inside the oval: the 320,000 Medicaid Members on your eligibility file. Outside-oval hatched: Patients your in-network providers see who AREN’T on your plan — competitor lives flowing through your network. Inner orange: Members on your eligibility file but never seen by any in-network provider — PMPM paid, zero clinical contact.
What FHG sees · Natively bilingual
Medicaid Members on your eligibility file that your network has seen and documented. Members on your file that your network has never seen — the ones your providers most need help finding. Patients your network sees today — on a competitor plan’s roster, not yours. You hold the data that connects all three.
My network providers can’t weather 6-month redetermination on their own. The state can’t fix its eligibility systems fast enough. We’re the ones who can carry our network through — if we choose to be the partner they need, not the antagonist that makes it worse.
— Plan President, on the choice ahead of every Medicaid MCO before January 1, 2027
What FHG makes operational today
Reconciliation insights FHG surfaces — shareable with your network
The Pond · Rolling 12
Total Member
Months
3,600,000
Rolling 12
Members
Eligible
320,083
Rolling 12
Members
with claims
245,084
Rolling 12
The denominator is your plan’s. The reconciliation is what makes the Member-level reality shareable with your network. Every Member, every month — already operational today.After 1/1/27: every MEDS renewal cycle compresses to 26 weeks. Your network providers will not absorb that cadence on their own — not with the state’s COBOL eligibility infrastructure as the upstream choke point. You can carry them through, or watch them break.
Population to surface together · PCP Panel Reconciliation
Your network providers carry the burden of every Medicaid Member you assign them. 108,000 of them have never set foot in the practice. Surfacing those Members — named, by panel — is the single most valuable thing you can hand back to your network. Operational outreach. Real Patients to find. Not punishment for missed contact.
↓ click any node to drill into Members
Source · Data Ingestion 1 — Plan-side Member ReconciliationToday: 108,000 Medicaid Members at $1.7B PMPM, never seen by your network. After the storm: every MEDS renewal cycle compounds the gap — your network can’t recover Members it never knew it had. You can hand them back the list.
Population to surface together · Members Hours From Care
Border counties, far-rural service-area edges, ZIP-code residency mismatches the state’s eligibility system never caught. On your roster, on paper. Unreachable by your contracted PCPs in practice. 4,200 Members in this archetype demo — named, mappable, your network can plan around them.
↓ click any node to drill into Members
Level 1 · Active Claims Universe
FHG starts with every Member on your plan who generated claims activity in Rolling 12.
245,000 Members on this Medicaid-MCO archetype demo — your plan’s active-claims universe.
Level 2 · Claims-vs-Roster Split
Split by whether claims data shows a Member-resident address inside your contracted network footprint.
200,000 with claims + verifiable address; 45,000 on roster but produced no claims at all — CalAIM-style network-adequacy attestation gap.
Level 3 · Members Hours From Care
4,200 Medicaid Members on your roster but at addresses outside any contracted PCP’s reasonable reach. $68M PMPM paid against Members your network is structurally unable to serve. Not your network’s fault. Not the Member’s fault. A reconciliation surface only you can build.
Today: 4,200 Members the state’s eligibility system can’t see as unreachable. After Jan 1, 2027: 6-month MEDS renewal notices land at addresses hours from any contracted PCP — the residual doubles. Share the list back to your network so they can plan transportation, telehealth, mobile-clinic outreach — before the renewal hits.
Source · Data Ingestion 2 — Member Geography vs. Network ReachToday: 4,200 Members at $68M PMPM hours from any contracted PCP. After the storm: doubled. Your network can’t outreach to Members they can’t see — you can show them.
Roster to clean together · Ghost PCPs on the Panel
Long-departed from the contracted practice. Specialty-only NPIs your file carries as PCP-of-record. NPIs that never billed under the contracted TaxID. Medicaid Members assigned to clinicians who can’t deliver care. Your providers are taking the heat for ghosts on the roster they didn’t put there. Cleaning the file together is the partnership move.
↓ hover any row to see the narrative
Ineligible-Clinician mistake-type distribution · N = 207
| Clinician | NPI | Members | Activities | Total Charges | Specialty | Mistake reason |
|---|---|---|---|---|---|---|
| Prov 19021 | 1528063500 | 400 | 1,845 | $1,641,533 | Primary Care | Departed 2024 |
| Prov 3798 | 1104388644 | 104 | 612 | $985,233 | Cardiology | Not PCP-able |
| Prov 11240 | 1294560011 | 247 | 1,103 | $722,109 | Primary Care | Never at TaxID |
| Prov 8821 | 1098765432 | 312 | 1,544 | $1,123,901 | Primary Care | Departed 2021 |
| Prov 22200 | 1609890250 | 879 | 3,859 | $1,489,071 | Family Med | Off-contract 2023 |
Source · Data Ingestion 3 — Plan + Network Roster ReconciliationToday: 207 ghosts on this Medicaid-MCO archetype roster — not your providers’ doing. After the storm: attestation cycles compress to every six months. Your network can’t fight ghosts they can’t see. You can show them the list.
Cadence to share with your network · MEDS Renewal Volatility
Adds. Drops. Net. FHG tracks every Medicaid Member transition through MEDS, month over month. The state’s eligibility system can’t share this cleanly — the antiquated COBOL stack the modernization consultants are trying to fix wasn’t built for 6-month cadence. You can. Share the cadence back to your network so they can staff for it.
↓ hover any month for the numbers · flip Storm mode to see the cadence change
Source · Data Ingestion 1 — MEDS Renewal HistoryToday: Nov / Dec MEDS-renewal outliers under annual-renewal cadence. After the storm: every 26-week cycle is an outlier — your network needs visibility to staff and outreach. You hold the cadence the state can’t cleanly share.
Be the partner your network can’t build without.
The state can’t modernize fast enough. Your providers can’t absorb the cadence alone. You can carry them through.
Talk with FHGSibling Use Cases
Plan shares MEDS cadence with its network· Plan + Network reconcile the panel together· Plan carries Member-outreach lists back to network· Plan + Network clean ghost PCPs together· Monthly Member Reconciliation
Member-level drilldown
Level 1 · Your Eligibility Denominator
FHG starts with every Medicaid Member on your plan’s eligibility file in Rolling 12.
320,000 Members on this Medicaid-MCO archetype — the reconciliation universe you can share with your network.
Level 2 · PCP-Assignment Split
Split by whether your plan’s file lists a PCP-of-record for the Member.
240,000 have a PCP on file with your network; 80,000 do not — orphans on the roster, neither your providers nor you know who’s minding their care.
Level 3 · Members Your Network Never Met
108,000 Medicaid Members assigned to your contracted PCPs but never seen by any of them. $1.7B in PMPM paid against zero clinical contact. Your providers carry the responsibility; none of them know which Members they’ve never met.
Today: $1.7B PMPM, no encounter, no relationship. After Jan 1, 2027: 6-month MEDS renewal cycles break PCP continuity faster — every renewal grows this column; your network can’t outreach to Members it doesn’t know it has. Sharing this list back is the partnership move.