The federal government ensured that people enrolled in Medicaid could maintain their coverage for the duration of the COVID-19 public health emergency (PHE). Now, with the PHE officially over, states are restarting their processes of periodically redetermining eligibility for Medicaid. States began assessing eligibility for the 87 million Medicaid enrollees as early as February, and most states started disenrolling people by June. As of late July, almost 3.8 million people had lost their coverage.
Overall, an estimated 15 million people are expected to lose Medicaid coverage during the redetermination process. Some of these individuals will qualify for no or low-cost premiums in the health insurance marketplace; others have enrolled in another health insurance plan during the pandemic. Some are still eligible for Medicaid but may lose coverage for administrative reasons, including not having a current address on file, submitting an incomplete renewal application, not applying for a renewal, or submitting a late application. These are called procedural or administrative terminations, and many individuals who lose coverage this way may resume Medicaid coverage after a period of being uninsured. For people in states that have not expanded Medicaid eligibility under the Affordable Care Act, there are few affordable coverage options.
Early Trends and Concerns
While states are required to submit specific data to the federal government, they do not have to make that information publicly available. Most publicly available redetermination data come from less than half of states and may represent anywhere from under a month to up to four months of data. While there is wide variation in the disenrollment rates across states (e.g., 8% in Wyoming, 82% in Texas), the procedural termination rate appears to be very high.
The rate could be high in some states because they’re starting with individuals they believe are no longer eligible for Medicaid. This means procedural terminations could decrease as those states move on to people still presumed eligible. Not all states are publicly sharing information or the same information, making it difficult to speculate about the varying disenrollment rates in states or among specific populations.
The Center for Medicare and Medicaid Services (CMS) is closely monitoring states and released data in July highlighting terminations for the first month of disenrollments in a few states, along with call center wait times in all states. CMS has offered states a range of options and flexibilities to reduce procedural terminations and also has new enforcement capabilities under the Consolidated Appropriations Act (CAA). If CMS finds that a state is not meeting the conditions laid out in the CAA, the agency can pause procedural terminations in that state, require a corrective action plan, and even reduce the state’s federal match rate for each quarter it is out of compliance.
There is broad concern that children are losing their Medicaid coverage despite still being eligible. Generally, children are eligible at higher income levels than are other covered groups. If parents or caregivers believe they are no longer eligible, they may fail to submit renewal materials even though this could impact their children’s coverage. This is a true in both expansion and nonexpansion states, but of particular concern in nonexpansion states where Medicaid eligibility levels for parents and caregivers are so low (e.g., 28% of the federal poverty level in Mississippi or $6,960 in annual household income for a family of three).
Promising Strategies to Help Beneficiaries Retain Insurance Coverage
State Medicaid agencies are taking proactive steps to improve outreach to enrollees with the goal of increasing renewal responses and connections to other sources of coverage. For instance:
- Arizona has a live chat feature to help Medicaid enrollees renew coverage
- Missouri and New Mexico offer videos explaining the renewal process and steps people should take to retain coverage
- Kentucky and the District of Columbia have regular meetings with stakeholders to review data, discuss outreach strategies, troubleshoot issues, and clarify messages
- Massachusetts has created an outreach toolkit with materials available in multiple languages. The state’s Medicaid agency, MassHealth, is collaborating with the Massachusetts Health Connector and Health Care for All to target 15 priority communities with high Medicaid enrollment for outreach about renewals and affordable state marketplace options for people no longer eligible for Medicaid.
Conclusion
Almost all states have now started terminating Medicaid coverage for people no longer eligible. While they have had three years to prepare for this undertaking, it is a monumental effort that requires clear communication and engagement of health plans, providers, and other stakeholders to ensure Medicaid enrollees understand what is happening and what steps they need to take. CMS is continuing to offer states new flexibilities; it will be up to states to take advantage of these options to keep people appropriately covered by Medicaid or connected to other affordable sources of coverage.
