As anticipated, unwinding the Medicaid continuous coverage requirement in place throughout the COVID-19 public health emergency is a massive undertaking. Although states are quickly working to ensure compliance with federal ex parte rules, remedy system glitches, and re-enroll individuals who have been procedurally disenrolled, challenges remain.
The resumption to normal Medicaid eligibility determination and disenrollment processes includes addressing many factors that may affect individuals’ eligibility, such as:
- Missing or outdated consumer contact and eligibility-related information, limiting states’ ability to reach individuals and/or assess their current eligibility for the program
- Income increases pushing individuals past the Medicaid eligibility threshold, most often resulting from employment changes, including new jobs and wage increases
- Individuals aging out of Medicaid and qualifying for Medicare or becoming dually eligible for both programs
- Geographic transitions of people out of state and potentially into another state’s Medicaid program
- Other significant life events, including marriage, employment, and death, that may affect access to other coverage sources (including dependent coverage) or general eligibility for coverage.
State leaders are working diligently to understand these and other changes from the past three years and, where needed, support individuals’ transitions into new sources of coverage. This has required ongoing efforts to improve data infrastructure, transfers and tracking, and implementation of innovative and ongoing outreach campaigns to increase awareness about Medicaid unwinding and coverage options for those who no longer qualify for the program. Beyond the critical work of state Medicaid agencies, this involves dedicated coordination across key partners to support coverage retention.
Coordination with State-Based Marketplaces
In states that operate their own health insurance marketplaces, marketplace and Medicaid officials are collaborating more than ever to smooth transitions into marketplace coverage. This includes the development of coordinated outreach and marketing campaigns designed to mitigate confusion for consumers and ensure that communication is accessible across different populations. For example, California’s Medicaid and marketplace agencies have worked in partnership on an outreach campaign translated into 14 languages, while Pennsylvania is timing text campaigns to correspond with important deadlines based on when people are transferred from Medicaid.
States have also invested in purposeful enhancements in eligibility and data transfer systems that improve the capacity of state-based marketplaces (SBMs) to identify, track, and reach out to those eligible for marketplace coverage. SBMs are also actively supporting their Medicaid partners with call centers, online supports, and in-person assisters (e.g., navigators, brokers, community assisters) so that consumers can be connected with appropriate coverage resources regardless of how they come in contact with the marketplace.
Some SBMs have developed new relationships with their Medicaid programs’ existing community partners to increase knowledge about the availability of the marketplaces for those losing coverage. Others are broadening relationships with new partners cultivated during the pandemic — such as public health professionals and vaccine providers — to ensure they also are aware of and can help direct individuals to appropriate coverage.
Additionally, several SBMs have adopted new policies — from auto-enrollment to flexible special enrollment periods — to ease the processes through which those exiting Medicaid can enroll in marketplace coverage. (For more, see “The Role of State-Based Marketplaces in Medicaid Unwinding.”)
Leveraging the Reach and Influence of Managed Care Organizations, Providers, and Employers
Many states are looking to key consumer touchpoints, including managed care organizations (MCOs), providers, and employers as critical facilitators to both spread awareness about Medicaid unwinding and help link individuals who are no longer eligible for the program to other sources of coverage.
Approximately 72 percent of Medicaid members are enrolled in a managed care plan operated by prominent health insurers, many of which also offer plans through the health insurance marketplaces. With such a large footprint, these plans can not only provide information about unwinding and help individuals renew their Medicaid coverage if they remain eligible, but also inform them about their options if they no longer qualify for Medicaid. According to a KFF survey, 25 states send lists to MCOs of individuals disenrolled from Medicaid. Additionally, Medicaid managed care plans that also offer qualified health plans (QHPs) can assist with transferring these individuals to marketplace coverage. A recent survey found that in states that allow MCOs to conduct outreach during the federally required 90-day reconsideration period (a time frame in which procedurally disenrolled individuals can return their renewal form and/or necessary information to determine eligibility without having to submit a new application), nearly all MCOs are calling, texting, and emailing members, and 58 percent have staff assisting individuals with applications.
Similarly, health care providers can play an important role in both educating patients about how to renew their Medicaid coverage, as well as referring them to consumer assistance options if they need to find another source of health coverage. The American Academy of Pediatrics has a resource page for pediatricians about Medicaid unwinding with specific suggestions about how they can help children remain covered.
In addition, the Centers for Medicare and Medicaid Services (CMS) has encouraged employers to allow employees and their dependents who lose Medicaid coverage to enroll outside of typical annual open enrollment periods to avoid potential gaps in coverage. Specifically, CMS suggested that employers should extend the period for special enrollment in their plans beyond the 60-day minimum period for individuals who lose Medicaid coverage to ease enrollment in an employment-based plan.
Supporting On-the-Ground Resources
Local consumer groups, community-based organizations, and advocates are important partners in spreading information about Medicaid unwinding and coverage options, especially across communities that may be traditionally hard to reach.
States have looked back to how they engaged individuals during previous outreach campaigns to leverage some of those lessons learned. For example, in Massachusetts, Health Care for All (HCFA) — a grassroots organization with strong connections to many marginalized communities — supports outreach to Medicaid enrollees, which includes efforts such as neighborhood canvassing conducted by individuals from the targeted communities. The state’s health insurance marketplace and Medicaid agency are working in tandem with HCFA on these initiatives.
As mentioned previously, SBMs support brokers, agents, navigators, and enrollment assisters as they work directly in communities to assist individuals who are no longer Medicaid-eligible with enrolling in other sources of coverage. Some SBMs, like Maryland’s, encourage these entities to proactively contact individuals who might be affected to check their options. Idaho’s SBM has built a system to identify and notify its partner agents and brokers about affected clients.
Working to Understand Coverage Transitions
Some states are publishing unwinding data that indicate whether individuals disenrolled from Medicaid are transitioning to marketplace coverage, and SBMs with their own eligibility platforms can also share data on the outcomes of these transitions. As highlighted by the State Health Access Data Assistance Center, as of October 2023, 11 of the 18 SBMs with their own eligibility platforms are providing information about individuals transitioning from Medicaid to marketplace coverage. Specifically, seven states report whether individuals were QHP-eligible, 10 states indicate whether individuals selected a plan, and five states report whether individuals received financial assistance.
There is also interest among states in identifying whether individuals no longer eligible for Medicaid are transitioning to employer-sponsored insurance (ESI). Kentucky is leveraging limited third-party liability data available from some insurers to track whether Medicaid enrollees may have moved into ESI. Additionally, CMS is planning to release data about which coverage sources individuals disenrolled from Medicaid are transitioning to, including ESI.
Helping Individuals Re-enroll in Medicaid Coverage
In addition to helping individuals no longer eligible for Medicaid transition to other sources of coverage, given the high rates of procedural disenrollments, some states are also implementing efforts to assist individuals who may still be Medicaid-eligible to re-enroll into the program. States such as Michigan and Minnesota have extended the time provided to individuals to send in their renewal paperwork. In Arizona, approximately 25 percent of individuals who were initially disenrolled for not responding to the Medicaid agency’s request for information have completed their renewal paperwork within the 90-day reconsideration period. The state is using a live chat feature to answer questions, conducting automated phone calls when renewal mail is returned, has improved search features on its website to help individuals find enrollment assisters, and recently launched a tool, AHCCCS Connect, that provides personalized reminders to members. Additionally, in a July 2023 National Association of Medicaid Directors survey of states about Medicaid unwinding, 82 percent of Medicaid programs indicated that they would extend the 90-day reconsideration period — which generally only covers enrollees whose eligibility is based on modified adjusted gross income — to all Medicaid members. In addition, the majority of states reported providing outreach and education to members about re-enrolling in the program if eligible during that time frame.
With the continuing rising costs of health care, it is as critical as ever to support consumers’ access to affordable coverage. As states continue with the process of Medicaid unwinding, they are continuing to home in on the most effective strategies for ensuring that individuals remain enrolled in health coverage.
