In 2022, the number of individuals in the U.S. without health insurance reached a record low of 8 percent. These gains are largely due to the success of federal and state efforts to connect individuals to health coverage during the COVID-19 pandemic, as well as the Medicaid continuous coverage requirement, which has provided states with an enhanced federal match with a corresponding requirement to keep individuals enrolled for the duration of the federal COVID-19 public health emergency (PHE).
The Consolidated Appropriations Act enacted in December 2022 delinks the Medicaid continuous coverage requirement from the COVID-19 PHE, ending the protection on March 31, 2023 (along with a phase-down through 2023 of the increased federal match rate). Many policy analysts, advocates, and state officials are concerned that this unprecedented process of unwinding the continuous coverage requirement will result in unnecessary coverage losses — reversing the recent coverage gains and leaving millions of individuals without access to health care services. An estimated 15 million people are expected to lose coverage, and nearly half of those individuals — 6.8 million — are anticipated to still be eligible for Medicaid but may lose coverage due to procedural reasons. These include enrollees not completing renewal forms or states being unable to contact individuals because they have moved.
State Medicaid agencies are hard at work to prepare for this massive eligibility redetermination process and are implementing efforts to transition individuals found ineligible for Medicaid to other sources of coverage. In advance of the unwinding process, the Centers for Medicare and Medicaid Services (CMS) has required that states develop plans for how they intend to approach redeterminations and the resumption of normal eligibility determination and enrollment operations. Although these plans do not have to be released publicly, some states have shared their plans or summaries of their approaches with partner organizations and the public. The following describes some of the key elements of these plans, such as how states are intending to streamline and prioritize the overall redetermination process, manage their workloads and bolster the Medicaid workforce, and track key metrics during the unwinding period.
The End of the COVID-19
Public Health Emergency
State Strategies for Prioritizing Redeterminations
As they unwind the Medicaid continuous coverage requirement, states will have a 12-month period to initiate eligibility redeterminations for all enrollees of Medicaid and the Children’s Health Insurance Program (CHIP) and 14 months to complete all pending eligibility actions. CMS has provided states with flexibility to determine how they will prioritize renewals, changes in circumstances, and eligibility verifications, resulting in a wide variety of approaches. Specifically, CMS guidance allows states to select among four risk-based approaches:
- A population-based approach that focuses on certain groups of individuals
- A time-based approach in which states complete the oldest pending actions first
- A hybrid approach that combines the population- and time-based strategies
- A unique state-developed approach
A number of states are focusing on conducting renewals based on the enrollee’s traditional renewal month. For example:
- Michigan and Washington will maintain beneficiaries’ current renewal month and will conduct a full renewal at the next scheduled renewal month.
Some states that are prioritizing redeterminations by population are choosing to focus on ensuring that individuals most likely to be ineligible are disenrolled earlier during the unwinding period and that those most likely to be adversely affected by disenrollment remain covered for as long as possible. For example:
- Oklahoma will review the circumstances of each Medicaid enrollee and categorize them as high or low risk. High-risk enrollees include those with children under five years of age or those with chronic health conditions, in the middle of an episode of care, with no other coverage source, with recent claims, and/or with high financial need, such as those with incomes under 228 percent of the federal poverty level. These members will have their eligibility redetermined later during the unwinding period and will remain in coverage for a longer time.
States choosing to adopt a hybrid approach will prioritize certain populations while running most of their redeterminations on their normal schedule. For example:
- Tennessee will prioritize redeterminations based on their existing renewal dates but will also prioritize members who have not been renewed or had an update on their case since the existing eligibility system went live in 2019.
- New Jersey will stay on the existing renewal schedule for most of its enrollees except for select subpopulations the agency has determined will require extra attention from eligibility staff. Most members who fall into any of these groups will be evenly distributed across the 12-month unwinding period to help manage the workload.
- Utah will also review most cases during their regularly scheduled review month, although cases that have been held open will be prioritized by those with known eligibility issues and then those with no review completed during the PHE.
Finally, some states are developing their own prioritization strategy that ensures that pending actions are handled appropriately, mitigates unnecessary disenrollments, and facilitates coverage transitions into the marketplace. For example:
- Georgia has developed an unwinding approach that will focus on meeting four target metrics, including aligning Medicaid renewals with Supplemental Nutrition Assistance Program, or SNAP, and/or Temporary Assistance for Needy Families, or TANF, renewals and maintaining coverage for pregnant people and certain individuals with long-term disabilities or complex medical needs for as long as possible.
As part of all of these approaches, states are aiming to conduct as many renewals automatically through an ex parte process that leverages available data sources to confirm member eligibility and minimizes the burden on both enrollees and state staff.
Leveraging Partnerships with Managed Care Organizations
In many states, Medicaid managed care organizations (MCOs) will play a critical role in the unwinding process. Throughout the pandemic, Medicaid members may have more frequently interfaced with their MCO than the Medicaid agency itself. Flexibility under Section 1902 (e)(14)(A) waivers allow states to leverage MCO member data during the unwinding to update beneficiary contact information and help connect to members who may not have interacted with the Medicaid agency since the continuous coverage protections were put in place.
MCOs can also provide additional outreach to their enrollees to urge them to complete the renewal process or transition to another source of coverage. The following are several strategies states are pursuing with their MCOs to prevent unnecessary coverage losses:
- Along with 6 other states and DC, Kentucky has an approved Section 1902(e)(14)(A) waiver that will allow MCOs to automatically reenroll a beneficiary in the managed care plan if they fall off Medicaid and re-enroll within 120 days.
- New Hampshire worked with its MCOs to develop phone scripts for enrollee communications about continuous coverage and the need to submit redetermination applications. The state Medicaid agency will provide a monthly roster of members receiving redetermination notices so that the MCOs can conduct proactive outreach.
- Arizona Medicaid and its MCOs are working in tandem to obtain updated contact information for members who may have moved during the pandemic. These strategies include:
- Updated policy guidance to ensure individuals retain coverage when mail is returned with an in-state forwarding address.
- Ongoing outreach campaigns and the addition of messaging on state websites to encourage members to update their contact information.
Unwinding Dashboards
Several states have developed internal dashboards to keep track of key metrics during the unwinding process. According to the Georgetown University Center for Children and Families’ 50-State Unwinding Tracker, 16 states plan to post these dashboards or general unwinding data publicly with regular updates. These include the following:
- Nevada will release an unwinding eligibility dashboard that will be updated each month. Metrics will include enrollment by week, call efficiencies and state workload levels, and annual renewals due and account transfers to Nevada Health Link.
- California will release a PHE Unwinding Eligibility Data Dashboard that will report monthly throughout the unwinding period on application, enrollment, and renewal measures such as the number of renewals completed via ex parte.
- Utah intends to be transparent about providing monthly tracking data with key enrollment metrics and information about workload during the unwinding period.
Strengthening the Workforce
Unwinding the Medicaid continuous coverage requirement will be a monumental task for state Medicaid agencies given the tremendous number of redeterminations that will need to be processed and the likely large volumes of returned mail for individuals with outdated contact information. Workforce turnover during the pandemic and high staff vacancies present additional challenges for Medicaid agencies. Further, for states that have recently hired new eligibility workers, these individuals may not have experience with conducting Medicaid disenrollments and may need extra training and support.
To alleviate these challenges, Medicaid agencies have identified strategies to increase workforce capacity and reduce workload for eligibility workers. These include:
- Alabama plans to recruit retired state employees to support the beneficiary staff during the unwind. In addition, the ALL Kids CHIP staff will assist in processing modified adjusted gross income applications.
- Colorado established an Overflow Processing Center to support county-based eligibility workers that will be inundated with work.
- Michigan has appropriated a one-time amount of $20.9 million to support existing staff reassignments, local county office eligibility staff onboarding, staff training, and resources for PHE-related redeterminations.
- Virginia hired temporary contracted staff to augment the existing workforce. Some staff were hired to assist local agencies in clearing backlogs and making manual corrections in preparation for the unwinding. In addition, the agency is seeking additional state funding to support payment for overtime during the unwinding period.
Like Medicaid agencies, state-based marketplace officials are concerned about how to maintain a reasonable workload for their staff while providing assistance to the influx of consumers navigating the qualified health plan (QHP) enrollment process. These include:
- Massachusetts will recruit and train additional call center staff to help manage increased consumer demand.
- Nevada’s exchange plans to leverage funding from a CMS State Exchange Modernization Grant to support additional customer service representatives to reach out to former Medicaid enrollees who may be eligible for exchange coverage. These staff will be trained in specific Medicaid transition plans to help connect consumers to plans on the marketplace offered by their MCO carrier to help make the transition as easy as possible.
- Vermont has authorized call center staff to verify and update contact information when consumers call in to ensure that the exchange has the most up-to-date contact information on hand.
Simplifying Coverage Transitions
In states with state-based marketplaces, officials are committed to leveraging their flexibilities to ease transitions from one source of coverage to another. These include:
- In Nevada, when Medicaid enrollees are reviewed and determined ineligible for the program, their information will automatically be sent to the state’s marketplace, where their available information pre-populates a QHP application. The consumer will be sent a unique code to claim their application and account.
- In Massachusetts, QHP applicants will have an option to be automatically enrolled in zero-dollar premium coverage if they qualify, without needing to shop to find the lowest cost plan.
- Pennie, the Pennsylvania state-based marketplace, will provide consumers with additional time to transition to a QHP through an extension of the “Loss of Other Coverage” special enrollment period (SEP). The extended SEP will be available for 120 days after losing Medicaid coverage, which doubles the amount of time that consumers traditionally have to shop and enroll in a QHP. In addition, the state will allow individuals and families to select an earlier effective date for the first 60 days of their SEP window.
- California (PDF) and Rhode Island have designed and will implement programs to automatically enroll individuals losing Medicaid into a marketplace plan. Learn more about Rhode Island’s auto-enrollment program in the NASHP blog post “Rhode Island Looks to Auto-Enrollment to Ease Transitions from Medicaid to Marketplace.”
Although states will face tremendous challenges during the unwinding period due to the sheer numbers of individuals that need to be renewed, state leaders are working diligently to implement programs and policies designed to prevent unnecessary coverage losses.
