The Real Cost of Losing the Right 5% of Members
For Medicaid MCOs, about 5% of members drive outsized clinical and financial impact. Losing them to procedural disenrollment erodes margin and destabilizes care. High-need members often churn because of paperwork rather than eligibility. When this occurs, plans forfeit higher payment rates linked to complex care and invite avoidable costs from higher acuity needs. The fastest way to protect both outcomes and margin is to retain the right 5%.
The members at stake are part of Managed Long-Term Services and Supports (MLTSS) and Aged, Blind, and Disabled (ABD) programs. Plans receive higher capitation to coordinate intensive medical, behavioral, and long-term support for these groups. When coverage lapses, care plans will stall, medications go unfilled, and utilization shifts toward more costly emergency care. The result is a setback for clinical stability, financial performance, and community health.
Churn is inevitable, but losing the right 5% is not. Preventing disenrollment among MLTSS and ABD members is the fastest way to ensure continuity of care.
Proof of Impact
The payoff is immediate and compounding. A recent Agilian client tested a targeted approach. Care Managers focused on MLTSS and ABD members at risk of losing coverage due to upcoming termination dates, grouping them into cohorts by termination month. (A cohort in this case refers to all members scheduled to lose coverage in the same monthly cycle.) This ensures outreach teams can plan and execute their efforts in a structured way, so no member is overlooked.
The result was narrow in scope with significant impact. In one termination-month cohort, 14 MLTSS members were reinstated, producing $81,057 in retroactive capitation monthly ($972,684 annually). When 12 ABD members returned, it added $11,729 PMPM for the plan ($140,748 annually). As more members are restored, the PMPM effect compounds bringing in revenue that would otherwise be lost.
Why It Matters
Interruptions in coverage do not remove the need for care but shift it into more costly settings. The National Association of Community Health Centers reports that Medicaid lapses are linked to skipped chronic care, missed screenings, and gaps in primary care. These patterns raise system costs and worsen outcomes for the members at highest risk.
For plans, the numbers are straightforward. The members with the highest capitation and needs are the ones who suffer the most harm from churn. By retaining these members, care continuity and financial stability strengthens.
MCOs that invest in eligibility monitoring and streamlined redetermination processes will be better prepared for upcoming work requirements and six-month renewals. These efforts help members stay connected to the care they need while reducing the risks of coverage gaps.
How to Solve it
State files are only a starting point. Plans can strengthen outcomes by combining these inputs with their own insights including past redetermination outcomes, member contact preferences, and field notes from care managers. Outreach efforts generate data while reinstatements reveal flags that matter most.
By focusing retention on high capitation populations and mobilizing care teams to keep renewals on track, plans can protect revenue while ensuring members keep the life-sustaining coverage they depend on.
Success will come from precision over scale. Begin where the impact is the greatest, with the MLTSS and ABD, and grow outward.
Proactive segmentation and predictive flags make it possible to identify members most at risk before the renewal window closes.
Combining insights from direct member interactions with system data strengthens the approach and extends it beyond the initial cohorts.
As target populations expand, plans can protect more members, stabilize capitation, and reduce costly disruptions without overwhelming care teams.