The Medicaid “continuous coverage” requirement, initially implemented during the COVID-19 pandemic, prevented most enrollees from losing Medicaid coverage. Congress ended this protection in 2022, allowing states to resume coverage terminations. Enrollees face challenges like renewing coverage and transitioning to other options. States also grapple with a surge in workload and difficulties in contacting moving enrollees. Enrollment navigators can aid in updating information and guiding enrollees. Advocates play a role in ensuring adequate policies, while vulnerable groups are at risk of losing coverage. Individuals losing Medicaid can reapply, explore marketplace options, or consider CHIP or employer-sponsored insurance.
In March 2020, as part of the pandemic relief efforts in the Families First Coronavirus Response Act (FFCRA), Congress introduced the Medicaid “continuous coverage” requirement, ensuring uninterrupted healthcare access during the COVID-19 crisis. This provision barred most Medicaid enrollee terminations until the public health emergency’s conclusion. However, as of December 2022, Congress delinked this requirement from the public health emergency, marking a pivotal transition. This article delves into the complexities of unwinding continuous coverage, the challenges faced by states and enrollees, and strategies to support a seamless transition while safeguarding healthcare access.
1. What is the Medicaid “continuous coverage” requirement?
In March 2020, as part of the COVID-19 relief provided by the Families First Coronavirus Response Act (FFCRA), Congress allocated increased Medicaid funding to states. To receive these federal funds, states had to meet specific conditions collectively referred to as a Maintenance of Effort (MOE) requirement. Additionally, a crucial component of this MOE was the “continuous coverage” requirement. This requirement prevented states from terminating the Medicaid coverage of most enrollees until after the conclusion of the public health emergency (PHE), as determined by the U.S. Department of Health and Human Services (HHS).
During this continuous coverage period, Medicaid agencies were prohibited from disenrolling individuals from Medicaid unless they voluntarily requested disenrollment, relocated out of state, or passed away. This policy ensured uninterrupted coverage for millions of people throughout the pandemic and played a significant role in preventing an increase in the uninsured rate during the peak of the pandemic.
In December 2022, Congress passed an omnibus spending bill that separated the Medicaid continuous coverage requirement from the PHE, leading to the termination of the continuous coverage protection on March 31, 2023. This change allowed states to resume Medicaid coverage terminations, effective April 1, 2023.
2. What does “unwinding” the continuous coverage requirement mean?
The term “unwinding” refers to the process by which states reintroduce annual Medicaid eligibility reviews after the conclusion of the continuous coverage requirement. During this process, Medicaid agencies follow a specific sequence:
a. Attempting automated renewals: Medicaid agencies first try to complete automated renewals using available information, such as wage data from state databases or information in Supplemental Nutrition Assistance Program (SNAP) records.
b. Sending renewal notices: If automated renewal is not possible, agencies send renewal notices and requests for information to enrollees.
c. Processing responses: When enrollees respond to the renewal notices, agencies review the cases, renew coverage for those who remain eligible, and notify those no longer eligible that their coverage will end.
d. Coverage termination: If enrollees do not receive or understand the renewal request due to address changes or other factors and fail to respond, their Medicaid coverage will be terminated.
The Centers for Medicare & Medicaid Services (CMS) has guided states, allowing them up to 12 months to initiate renewals for all enrollees during the unwinding process. CMS has also issued comprehensive guidance and materials outlining best practices for states to consider during this period.
3. When will states begin to unwind continuous coverage?
At the close of 2022, Congress disassociated the continuous coverage requirement from the PHE, enabling states to initiate coverage terminations as early as April 1, 2023. Throughout the continuous coverage requirement period, most Medicaid terminations and eligibility reviews were temporarily halted. The conclusion of this pause has resulted in a substantial workload for states as they assess eligibility and renew coverage for the millions of individuals enrolled in the program.
The unwinding process allows Medicaid agencies 12 months to initiate renewals and an additional 14 months to complete them, allowing for a gradual distribution of the workload. Some states, including Arizona, Arkansas, Idaho, New Hampshire, and South Dakota, chose April 1, 2023, as the effective date for their initial coverage terminations. Fifteen other states set a date of May 1, with the remaining states selecting dates for beginning coverage terminations in June or July. Medicaid unwinding will not occur as a single event; rather, it will be an extended process, spanning into 2024 for most states.
4. What standards did the 2022 legislation include to mitigate coverage losses?
In addition to establishing a specific termination date, the legislation enacted in 2022 provides states with additional financial support during the unwinding period. Unlike the previous legislation that included a complete sunset of enhanced Federal Medicaid Assistance Percentage (FMAP) funding at the end of the quarter following the PHE, the year-end legislation gradually phases out enhanced FMAP through 2023. This added funding assists states in managing the substantial workload associated with eligibility reviews.
To qualify for the enhanced match, states must adhere to federal redetermination requirements or other strategies approved by CMS. They must also maintain up-to-date enrollees’ contact information and make sincere efforts to contact enrollees before terminating their coverage due to returned mail.
Furthermore, the year-end legislation establishes clear procedures for CMS to enforce states’ policies during the unwinding process. States are required to submit monthly reports on key unwinding metrics, ensuring transparency and accountability. States failing to meet reporting requirements may experience a modest FMAP reduction for each quarter of noncompliance. CMS may also mandate corrective action plans for states that do not comply with federal eligibility redetermination or reporting requirements, potentially pausing coverage terminations and imposing financial penalties.
5. What challenges will enrollees face in the unwinding of continuous coverage?
As states undertake the unwinding of continuous coverage, several challenges may arise for enrollees, including:
a. Awareness of the need to renew: Some enrollees may have relocated during the pandemic and may not receive renewal notices if they have not updated their contact information with the state.
b. Completing the renewal process: Renewal forms can be confusing, and the steps for enrollees may not be clear. Additionally, not all states offer online or phone-based renewal options.
c. Transitioning to alternative coverage: Individuals no longer eligible for Medicaid may be unaware of other coverage options, such as employer-based coverage or coverage through the Affordable Care Act (ACA) marketplace. They may also lack information on the enrollment process for these alternatives.
d. Coping with loss of coverage: Many people who remain eligible may lose coverage due to paperwork-related challenges and experience gaps in coverage. They will need to reapply to regain Medicaid coverage.
6. What challenges do states face with the unwinding of continuous coverage?
States confront a substantial increase in workload during the unwinding process, involving renewals for their entire caseloads. Meeting deadlines for processing paperwork may prove challenging, potentially resulting in coverage terminations for eligible individuals, in violation of federal rules. Call centers may become overwhelmed, leading to extended wait times. Additionally, many agencies have experienced high staff turnover during the pandemic, leading to staffing shortages and the inclusion of new staff with limited experience in processing Medicaid renewals.
States also face difficulties in reaching Medicaid enrollees who have moved or changed their contact information during the pandemic. As renewals progress, the increase in applications from individuals who are eligible but lost coverage for procedural reasons will further strain state resources.
7. What can enrollment navigators and assisters do to support Medicaid enrollees?
Enrollment navigators and assisters play a crucial role in assisting Medicaid enrollees throughout the renewal process. They can:
a. Help update contact information: Assist Medicaid enrollees in updating their mailing address and phone number with the Medicaid agency, either through an online portal or by contacting the call center, depending on the state’s procedures.
b. Notify enrollees about the renewal process: Inform Medicaid enrollees that they will need to renew their coverage within the upcoming year. Advise them to watch for correspondence from the Medicaid agency and respond promptly to any requests.
c. Aid with the renewal process: Assist Medicaid enrollees in completing renewal forms, gathering necessary documents, and resolving any issues that may arise during the process.
d. Support transitions to other coverage: Assist individuals no longer
eligible for Medicaid in navigating transitions to other forms of coverage, including employer-sponsored coverage and ACA marketplace plans. Ensure they are aware of enrollment steps and potential financial assistance available.
8. What are the key decisions states are making as they unwind?
States are making critical decisions as they plan for and execute the unwinding process, including:
a. Communication strategies: Determining how to inform individuals about unwinding, address updates, renewal timelines, and required steps for renewal.
b. Updating contact information: Deciding how to obtain and update contact information (e.g., address, phone, email) for Medicaid enrollees, potentially through other programs and entities with recent contact with enrollees, such as SNAP and managed care organizations.
c. Renewal timeline: Establishing the duration states will take to review eligibility for their caseloads. While CMS permits up to 12 months to initiate renewals for the entire caseload, individual states set their timelines.
d. Prioritization of enrollees: Determining the order in which enrollees will undergo renewal, whether alphabetically, based on initial enrollment date, or by prioritizing populations more likely to have lost eligibility.
e. Data transparency: Deciding whether to publicly post data required by CMS, allowing stakeholders to monitor state-level trends and issues during the unwinding process.
f. Staffing capacity: Planning to address staffing gaps to ensure timely processing of redetermination functions, given the increased workload.
g. Transition from Medicaid to marketplace coverage: Developing strategies for handling transitions from Medicaid to marketplace coverage in states operating state-based marketplaces.
9. What key strategies should advocates encourage state agencies to implement if they have not yet done so?
Advocates can play a pivotal role in ensuring that states implement policies to safeguard coverage and offer solutions when challenges arise during the unwinding process. Advocates may consider exploring the following issues with state agencies:
a. Increasing ex parte renewal rates: Inquiring about the steps the state is taking to boost ex parte renewal rates, where eligibility is determined without requiring enrollee action.
b. Data monitoring: Evaluating the state’s approach to monitoring the unwinding process and its ability to adapt based on data.
c. Staffing plans: Inquiring about the agency’s staffing plan for handling the increased casework, especially regarding processing renewals and addressing phone inquiries.
d. Enrollee prioritization: Understanding how the state prioritizes different groups of enrollees for renewal.
e. Handling returned mail: Examining how the state manages returned mail and outdated contact information.
f. Updating contact information: Inquiring whether the state includes enrollment assistant contact information on Medicaid notices.
g. Collaboration with organizations: Assessing whether the state partners with other organizations, such as community health centers, to support enrollees through unwinding.
h. Tracking and sharing data: Inquiring about the data the state intends to track during unwinding and when it plans to share this data with stakeholders.
i. Communication plan: Understanding the state’s communication plan for coordinating with advocates, providers, and partners during the unwinding process.
j. Outreach and communication: Examining the state’s strategies for outreach and communication with enrollees about unwinding, including mailed notices, text and email communication, public-facing outreach, and social media campaigns.
k. Utilizing information from other programs: Inquiring about how the state leverages data from other programs, such as SNAP, to retain eligible individuals in Medicaid.
l. Facilitating transitions: Exploring how the state helps individuals connect with alternative sources of coverage, including the Children’s Health Insurance Program (CHIP) and marketplace plans.
10. Who is at risk of losing Medicaid coverage despite still being eligible?
Despite remaining eligible for Medicaid, many individuals are at risk of losing their coverage during the unwinding process due to procedural reasons. These reasons may include unnecessary paperwork requests, long wait times at call centers, and other administrative hurdles. Researchers estimate that approximately 6.8 million people could lose Medicaid coverage for procedural reasons.
Groups particularly at risk include:
a. Individuals who have moved: Those who have changed their residence during the pandemic and have not updated their contact information with the state may not receive renewal notices, putting them at risk of coverage loss.
b. Non-return of renewal information: Enrollees who receive renewal notices but fail to complete and return them on time, often due to unfamiliarity with the process after not undergoing renewal in the past three years.
c. People of color and children: A study conducted by the U.S. Department of Health and Human Services (HHS) projects that these groups are more likely to lose coverage for procedural reasons during unwinding, even though they remain eligible for Medicaid.
Additionally, some individuals will lose Medicaid coverage because they are no longer eligible, often due to increased income or changes in their circumstances.
11. What should people do if they lose their Medicaid coverage?
Individuals who lose their Medicaid coverage have several options depending on their circumstances:
a. Reapply for Medicaid: If someone believes they are still eligible for Medicaid but didn’t complete all the required steps for renewal and contacts the state within 90 days of their Medicaid coverage ending, states are typically required to accept their renewal paperwork and process it without requiring a new application.
b. Enroll in marketplace coverage: In states that use HealthCare.gov, the loss of Medicaid triggers a special enrollment period, allowing individuals to enroll in marketplace coverage at any time until July 31, 2024, even outside the annual marketplace open enrollment period. Additionally, in these states, people with incomes up to 150 percent of the poverty line may enroll in marketplace coverage at any time. Policies vary in states that operate their health insurance marketplace.
c. Apply for CHIP: Children whose families are no longer eligible for Medicaid may be eligible for the Children’s Health Insurance Program (CHIP). Guardians of children who lose Medicaid coverage should apply for CHIP, either directly with the state agency, through the CHIP program, or via the marketplace if applicable.
d. Enroll in employer-sponsored insurance (ESI): Some individuals may have access to employer-sponsored coverage. If this coverage is considered affordable (not exceeding 9.12 percent of household income in 2023), they are not eligible for financial assistance for marketplace plans and should enroll in ESI within 60 days of losing Medicaid coverage. Changes in the affordability test for family members of an employee in 2023 may make some individuals who were previously ineligible for premium tax credits now eligible.
Unfortunately, in states that have not expanded Medicaid, certain individuals may have limited options for affordable health insurance. This includes young adults who have aged out of Medicaid, parents with extremely low incomes who no longer have dependent children at home, and individuals who received Medicaid during pregnancy but are past their state’s postpartum eligibility timeline. These individuals may fall into the Medicaid “coverage gap,” as premium tax credits typically require income above the poverty line.
