Today, we’re proud to announce that Socially Determined has built the industry’s first, best data product to identify and stratify Medicaid members for redetermination.
With Socially Determined, health plans and risk bearing provider organizations can now pre-emptively find eligible individuals facing social barriers to recertification and confidently act.
The challenge and its clinical and financial impacts
How it works and proof of concept
The Burden of Medicaid Redetermination
As of February 2026, the post-COVID return of Medicaid eligibility redetermination has dropped enrollment by 19%, representing 18 million disenrollments. This has resulted in an estimated $169B shift in public funding away from risk-bearing entities charged with caring for these populations. In October 2023, 72% of disenrolled people were due to procedural issues rather than eligibility. Of those disenrolled, 75% are facing elevated social risks that create barriers to navigating those procedural issues.
The health consequences are also dire. 23% of those disenrolled report living without health insurance at all, meaning chronic conditions go unmanaged and ED utilization is avoidably high.
Financially, the zero-sum, pooled-risk nature of Medicaid means the budget to provide care for still-enrolled members is radically reduced, leaving clinicians and payers scrambling to cover costs and effectively manage the federal program.
To address the problem, risk-bearing entities (payers, providers, states, etc.) have already invested in tools that assist people in the redetermination process. However, the same social risks that often make Medicaid members eligible in the first place are also barriers to using those tools.
The only way to begin to address the problem of eligible beneficiaries facing procedural disenrollment is for the organizations managing the program to identify them ahead of time and reach out.
Unfortunately, the sheer scale of redetermination can make that feel impossible.
Fortunately, at Socially Determined, we do the impossible part for you.
In 2023, our data science team began a project to identify Medicaid beneficiaries that were eligible but at risk for disenrollment and facing barriers to recertify. That incredible work since has grown into a scalable data product that scores the likelihood that an individual is at risk for not recertifying against their likelihood of qualification.
In short: If you give us your Medicaid rosters, we can identify the members most likely to be eligible but facing barriers and provide you a ranked list.
That means now you know exactly who to contact first and how to help them stay covered.
How Socially Determined’s Medicaid Redetermination Data Product Works
Effectively, we apply the same approach we use for social risk calculations, focusing on:
- The chance information about redetermination has already reached an individual
- What about a living situation may make someone likely to remain eligible and yet not renew
- And finally, if there are barriers to navigating the recertification process itself
The above criteria account for dozens of data points, such as internet access, transportation, household composition, financial status, and education level.
Our redetermination model, applied to a member roster, provides you with a list of high-probability qualified individuals, each scored based on likely health-related social needs (HRSN) that may prevent them from starting the recertification process.
Reducing Churn, Preserving Participation Funding
In any value-based contract, addressing churn is a never-ending battle. MLR, quality bonuses and penalties, and RAF capture and accuracy are all vulnerable to churn in a way that can feel uncontrollable by the participating plans.
The surge in redetermination disenrollments is disruptive to all the above, while also having a direct impact on available funding to provide care.
For example, a highly complex but well-managed individual is a known quantity within a population. But a procedural disenrollment can lead to a substantial care gap. Their quality-of-life plummets and if they can ever regain Medicaid coverage, the clinical damage is done. The previously managed costs have also now spiraled out of control.
What we’re offering is a chance to proactively know who is at risk for redetermination churn but eligible to remain and, with the broader toolset available in SocialScape, know what barriers they will face that you can help them navigate.
That means you can spend smarter, restore or improve stability in your populations, and ensure better lives for your members. Do you only have time or resources to reach out to 100? 1,000? 10,000 members facing redetermination? With our help, that process now starts with you already having a ranked list.
This isn’t a hypothetical, either. In 2025, we conducted a case study on a medium sized Medicaid plan. The top 1% of most at-risk individuals as recommended by our redetermination score had a non-renewal rate of approximately 53%.
The average Medicaid risk-pool funding PMPY for plans is around $9,400, though for more complex individuals it can easily reach $14,000.
Had this plan pursued only the top 1% of members recommended by our Redetermination Score and achieved a 100% renewal rate among those who otherwise would not have re-enrolled, they could conservatively have protected $2.9M in Medicaid funding.
Medicaid works best when the data is accurate and the people who need the most support have it. That requires eligible people to retain coverage and ensures payers receive value-based payments aligned with the risk they have adopted. We’re proud to provide a tool to help Medicaid plans continue to provide necessary care and protect the revenue they need to pay for it.
If you’d like to learn more about our redetermination data product, reach out today.