How NPs and PAs Can Help Patients Who Are Losing Medicaid Coverage

If you’re a physician associate or nurse practitioner who accepts Medicaid, patients who have lost coverage or may lose it soon are likely top of mind. Beyond how these Medicaid qualification changes may affect your practice financially, no one becomes a clinician expecting to turn away patients for care. 

What’s Changing with Medicaid — and Why It Affects Your Practice

Federal Medicaid eligibility changes took effect, restricting coverage for certain lawfully present immigrants, including refugees and other previously eligible groups. The changes have already affected patients and families who rely on Medicaid for essential care. 

They add to Medicaid policy changes states have already begun implementing this year that are estimated to increase the number of people without health insurance by 7.5 million in 2034, according to KFF. 

Here’s what’s coming:

Beginning Jan. 1, 2027, states generally must implement new Medicaid community engagement requirements for certain adults, unless they choose an earlier implementation date. These requirements could affect as many as 10 million Americans who remain otherwise eligible for Medicaid but struggle to meet or document program requirements.

Losing coverage forces more people to choose between their health and other expenses. It can disrupt treatment, delay diagnoses and lead to more expensive emergency room visits at safety-net hospitals.

How NPs and PAs Can Help Patients Navigate Medicaid Loss

For nurse practitioners (NPs) and physician assistants (PAs), these changes create an important clinical challenge of how to help patients access care when insurance coverage is uncertain.

Although you can’t control eligibility rules, you can help your patients prepare for coverage changes, understand their options and develop plans to avoid interruptions in medically necessary treatment.

Step 1: Identify Which Patients Are at Risk Before Coverage Ends

One of the most important steps NPs and PAs can take is to identify coverage concerns before they become barriers to care. 

Many patients won’t realize their insurance is at risk until they seek care and find out their coverage has been eliminated. They may have received notices from their Medicaid agency but didn’t understand the information or the steps required to maintain coverage, or they may have moved and never received notice.

Consider making insurance status part of routine patient conversations.

During appointments, ask patients whether they received notices about insurance changes and whether they have concerns about future coverage.

You can also contact patients in your practice who have historically used Medicaid to ensure they’re aware of any changes to requirements.

Obviously, these conversations should be handled sensitively. Providers should not assume a patient’s Medicaid eligibility or immigration status based on appearance, language, nationality or other personal characteristics.

Step 2: Help Patients Understand the New Medicaid Requirements

Not every patient affected by upcoming Medicaid changes will necessarily lose coverage.

Under the new community engagement rules scheduled for 2027, certain adults will need to demonstrate qualifying activities, such as employment, education or community service or meet an applicable exception or exclusion.

Many patients who qualify may still need assistance understanding how to verify and comply with the new rules. Others may qualify for an exclusion or exception because of their medical circumstances or other eligibility factors and need help understanding how to respond. 

Encourage patients to:

• Keep their contact information current with their state Medicaid agency
• Open and respond promptly to official Medicaid notices
• Ask about applicable exclusions, exceptions and documentation requirements
• Seek enrollment assistance if they receive a termination notice or believe their eligibility has been determined incorrectly with Medicaid’s local help service or their state Medicaid agency

Avoid guaranteeing that a patient qualifies for Medicaid or a particular exemption. Final eligibility decisions are made through the appropriate government program.

Step 3: Use Remaining Coverage to Prioritize Preventive Care

For any patients at risk of losing insurance, the remaining coverage period is an important opportunity to address unmet health needs. Review the patient’s medical history, current conditions and preventive care needs to determine any services that should be prioritized.

For example, a patient with hypertension or diabetes who expects to lose coverage may benefit from a follow-up appointment to assess disease control, review medications and discuss how to continue treatment if financial circumstances change.

Of course, coverage doesn’t guarantee every service will be paid for. Prior authorization requirements, cost-sharing and other plan restrictions may still apply.

The goal isn’t to order additional services while insurance is available. Clinical decisions must remain based on medical necessity, established guidelines and the patient’s individual needs.

Step 4: Connect Patients with Free and Low-Cost Healthcare Options

Patients who lose insurance may assume they can no longer afford medical care. Your job is to help them understand that other options may be available.

One important resource is the federally qualified health center (FQHC) system.

FQHCs and other Health Resources and Services Administration (HRSA)- supported health centers serve patients regardless of insurance status and use sliding-fee schedules based on patients’ ability to pay.

You can find a location in your area here.

Additional resources may include community clinics, hospital financial assistance programs, local health departments and nonprofit organizations.

NPs and PAs should also encourage patients to explore whether they qualify for other insurance coverage.

Patients who lose Medicaid or Children’s Health Insurance Program coverage may qualify for a special enrollment period through the Health Insurance Marketplace. Under current federal Marketplace guidance, eligible individuals generally have 90 days after losing Medicaid or CHIP to select a Marketplace plan, although eligibility and enrollment procedures can vary.

Patients can explore their options at HealthCare.gov.

Step 5: Build a Continuity-of-Care Plan Before Coverage Lapses

Even with proactive planning, some patients will lose insurance. When that happens, the clinical priority becomes helping patients maintain access to appropriate care, especially when an interruption could cause harm.

For patients with ongoing medical needs, NPs and PAs should consider developing a continuity-of-care plan that addresses:

• Medication management: Review whether patients can afford their prescriptions and explore clinically appropriate alternatives, generic medications or available assistance programs. 
• Follow-up care: Identify essential appointments and determine whether the patient can continue receiving care through the current practice or needs another provider.
• Specialist referrals: Help patients locate appropriate specialists or safety-net facilities when continued treatment is necessary.
• Medical records: Facilitate appropriate transfers of medical information so receiving providers have the clinical history needed to continue treatment.

What Are Your Legal Obligations When Patients Lose Insurance?

Supporting patients through insurance disruptions can raise questions about billing, financial assistance and professional obligations.

For example, you may be able to offer discounted services, sliding-scale fees or other financial assistance to uninsured patients. However, waiving copayments or deductibles for patients enrolled in federal healthcare programs raises separate compliance considerations.

Be sure to follow established financial assistance policies and review payer contracts and applicable requirements before changing charges.

Losing insurance doesn’t automatically require you to provide unlimited free treatment, but abruptly ending an established clinical relationship may raise patient abandonment concerns. Your state laws and professional standards may require advance notice, appropriate transition arrangements and assistance transferring care.

If your patients want to pay cash, keep in mind the federal No Surprises Act requires you to provide uninsured or self-pay patients with a good-faith estimate when requested.

Navigating these changes, especially with longtime patients, makes these days especially challenging for providers and patients. Still, as an NP or PA, you can do what you can to help patients prepare. By identifying coverage risks, providing clear information and coordinating appropriate referrals, you can reduce avoidable disruptions and help patients make informed decisions about their health.

CM&F Group helps NPs and PAs protect their careers and practices with professional liability insurance designed for healthcare professionals.

*Disclaimer: This article provides general educational information and doesn’t constitute legal, medical billing or insurance eligibility advice. Medicaid eligibility, professional obligations and financial assistance requirements may vary by state, payer and practice setting. Providers should consult appropriate authorities and qualified professionals for guidance specific to their circumstances.