Biden Admin issues updated guidance tools re. ending continuous Medicaid enrollment as soon as the #PHE formally ends
In March 2020, Congress offered states additional Medicaid funding as long as they agreed to keep everyone enrolled in the program for the duration of the federal public health emergency, regardless of their eligibility status. As of January 2021, nearly 10 million had joined Medicaid or the Children’s Health Insurance Program (CHIP) during the pandemic, pushing enrollment to a record high of more than 80 million people. (Some independent analyses put the current total higher, closer to 90 million.)
The Biden administration has indicated the public health emergency will last at least through the end of 2021. Once it expires, states will once again be required to remove ineligible people from their rolls. While no national estimates exist for how many people currently enrolled in Medicaid are technically ineligible, a Tradeoffs survey of state Medicaid offices found that just nine states expect an estimated 1,450,877 of their current beneficiaries are ineligible and would lose coverage once the health emergency ends (see table below).
This suggests that nationwide, millions are likely to lose their coverage, which is in line with expert expectations that much of Medicaid’s growth during the pandemic is a result of the continuous enrollment requirements.
Last September, an analysis by Matthew Buettgens of the Urban Institute estimated that perhaps 15 million current Medicaid enrollees could be kicked off of the program as soon as the PHE officially ends, which would cause chaos, confusion and a massive backlog at various state and federal agencies if it happened all in one shot. As explained by Tricia Brooks of the Georgetown University Health Policy Institute:
Using Urban’s Health Insurance Policy Simulation Model (HIPSM), the study’s authors project that almost all of the 15 million will have a path to other coverage.
What about people who remain eligible for Medicaid or CHIP but experience a gap or a loss of coverage altogether due to any number of administrative barriers? Based on the well-documented, high prevalence of lapses in coverage among people eligible for Medicaid, more than 15 million children and adults are likely to lose Medicaid as states unwind the continuous eligibility provision in 2022. And, even for the 15 million, a path to coverage does not mean that everyone will successfully transition to a new source of insurance if it is unaffordable or difficult to enroll. One study conducted in 2016 after ACA implementation noted that 25 percent of Medicaid enrollees change coverage within one year and that most of these beneficiaries (55 percent) also experience a gap in coverage.
At the end of the PHE, states will be faced with processing an unprecedented volume of Medicaid redeterminations and changes in circumstances. The Urban Institute report draws attention to some of the risks that are likely to follow in 2022 (under the assumption that the PHE will end in 2021) as states reinstate the process of redetermining eligibility. It notes that the trajectory of Medicaid enrollment after the PHE is lifted and until the end of 2022, as well as the rate at which enrollment will change in individual states, is uncertain.
In many cases, renewal information may not reach people who have experienced housing instability, a problem among low-income populations that has been exacerbated by the pandemic. If states move too quickly to catch up on overdue renewals, they will overwhelm the capacity of eligibility workers to process paperwork and of call centers and consumer assisters to help individuals remain enrolled or transition to another source of insurance. And, although CMS guidance allows states a full twelve months to resume routine eligibility operations, there will be political and fiscal pressure for states to move more quickly to disenroll people. For example, in the 2022-23 Ohio budget, lawmakers have called for the Medicaid agency to complete overdue renewals within two months.
Earlier today, the Centers for Medicare & Medicaid issued updated guidance on how most of this should be handled whenever the PHE actually expires (whether it's extended again or not). Of course, different states will handle it differently and some aren't exactly known for working in good faith when it comes to Medicaid and other public health programs...
- Promoting Continuity of Coverage and Distributing Eligibility and Enrollment Workload in Medicaid, the Children’s Health Insurance Program (CHIP), and Basic Health Program (BHP) Upon Conclusion of the COVID-19 Public Health Emergency (PDF, 815.14 KB) (Posted 3/3/2022)
- Updated Guidance Related to Planning for the Resumption of Normal State Medicaid, Children’s Health Insurance Program (CHIP), and Basic Health Program (BHP) Operations Upon Conclusion of the COVID-19 Public Health Emergency (Posted 8/13/2021)
- State Health Office Letter: Planning for the Resumption of Normal State Medicaid, Children’s Health Insurance Program (CHIP), and Basic Health Program (BHP) Operations Upon Conclusion of the COVID-19 Public Health Emergency (Posted 12/22/2020)
Tools and Templates
- Medicaid and Children’s Health Insurance Program COVID-19 Health Emergency Eligibility and Enrollment Pending Actions Resolution Planning Tool (Posted 1/15/2021 and updated 3/3/2022)
- General Transition Planning Tool for Restoring Regular Medicaid and Children’s Health Insurance Program Operations after Conclusion of the Coronavirus Disease 2019 Public Health Emergency (Posted 1/15/2021)
- Program Integrity Considerations for Restoring State Medicaid and Children’s Health Insurance Program Operations Upon Conclusion of the COVID-19 Public Health Emergency
- Medicaid and CHIP Continuous Enrollment Unwinding – Toolkit (English (PDF, 1.61 MB)) (Spanish (PDF, 1.94 MB))
- Medicaid Unwinding Toolkit Graphics (ZIP, 4.62 MB)
- Consumer Research on Unwinding Phase I: Preventing Churn (PDF, 259.21 KB)
Other Guidance and Resources
- Overview of Strategic Approach to Engaging Managed Care Plans to Maximize Continuity of Coverage as States Resume Normal Eligibility and Enrollment Operations (Posted 12/8/2021 and updated 3/3/2022)
- Strategies States and U.S. Territories Can Adopt to Maintain Coverage of Eligible Individuals as they Return to Normal Operations (Posted 11/24/2021)
- Connecting Kids to Coverage: State Outreach, Enrollment and Retention Strategies issue brief (Posted 11/24/2021)
- Ensuring Continuity of Coverage and Preventing Inappropriate Terminations – Part 2 (Posted August 2021)
- Ensuring Continuity of Coverage and Preventing Inappropriate Terminations – Part 1 (Posted July 2021)
- CIB: Medicaid and Children’s Health Insurance Program (CHIP) Renewal Requirements (Posted 12/4/2020)
- CIB: Coordination of Eligibility and Enrollment between Medicaid, CHIP and the Federally Facilitated Marketplace (FFM or “Marketplace”) (Posted 7/25/2016)
CMCS Medicaid and CHIP All State Calls
- February 22, 2022 All-State Call Presentation: CMS Office of Communications consumer research on preventing churn during unwinding
- February 15, 2022 All-State Call Presentation: Sunsetting Medicaid and CHIP disaster relief SPAs and section 1135 waivers and options for disaster relief SPA provisions
- November 30, 2021 All-State Call Presentation: Strategies for retaining eligible individuals and engaging managed care plans
- August 19, 2021 All-State Call Presentation: Overview of August 2021 State Health Official Letter
- January 19, 2021 All-State Call Presentation: Overview of eligibility and enrollment provisions in December 2020 State Health Official Letter
- January 7, 2021 All-State Call Presentation: Overview of December 2020 State Health Official Letter
- June 16, 2020 All-State Call Presentation: Additional information on federal requirements for retaining Medicaid state plan flexibilities