Is the Great Medicaid Unwinding as ugly as feared? Let's take a look at some of the early numbers...
Wed, 05/17/2023 - 3:26pm
During the COVID pandemic emergency, Congress passed legislation which, among other things, required states to provide "continuous coverage" of people who enrolled in Medicaid or the CHIP program.
Normally Medicaid/CHIP enrollees have their eligibility statuses "redetermined" every month (or quarter in some states, I believe) to make sure they were still eligible for the program, but the Families First Coronavirus Response Act (FFCRA) stated that in order to receive increased federal funding of their Medicaid/CHIP programs, states couldn't kick anyone off as long as the public health emergency was in place (unless they died, moved out of state or asked to be disenrolled).
This requirement ended effective April 1st, 2023 via an omnibus bill passed back in December.
On paper, what should theoretically happen in a perfect world would be that state Medicaid agencies would start going over their Medicaid/CHIP enrollment lists, separate out those who may not be eligible for the programs any longer, review their current status to see if they are, contact the enrollees to provide further information as needed, and then either keep them enrolled in the program if they are or offer guidance as to their alternatives for healthcare coverage if they aren't.
Needless to say, we don't live in a perfect world. As Dylan Scott explained back at the end of March (just before the continuous coverage requirement ended):
...Over the past three years, under an emergency pandemic measure, states have stopped double-checking if people who are enrolled in Medicaid are still eligible for its coverage. If you were enrolled in Medicaid in March 2020, or if you became eligible at any point during the pandemic, you have remained eligible the entire time no matter what, even if your income later went up.
But in April, that will end — states will be re-checking every Medicaid enrollee’s eligibility, an enormous administrative undertaking that will put health insurance coverage for millions of Americans at risk.
The Biden administration estimates upward of 15 million people — one-sixth of the roughly 90 million Americans currently receiving Medicaid benefits — could lose coverage, a finding that independent analysts pretty much agree with. Those are coverage losses tantamount to a major economic downturn: By comparison, from 2007 to 2009, amid the worst economic downturn of most Americans’ lifetimes, an estimated 9 million Americans lost their insurance.
Some will lose coverage because they are no longer eligible due to a change in income or circumstance, such as a child turning 18. States are supposed to direct these people toward other insurance options, such as the Affordable Care Act marketplaces.
But many of the people who end up losing their benefits — even most, according to some projections — could be people who are actually still eligible for Medicaid but slip between the cracks of the system. People who have recently moved are one particular concern, as are children and people with disabilities.
In the real world, even if every state Medicaid agency were to do everything possible to do their jobs properly, the odds are high that many people will lose Medicaid coverage who aren't supposed to. Some people move. Some people don't answer phone calls from strangers, or assume that it's a scam if they do. Some people don't open their mail and throw it out or recycle it, or it gets lost in a pile of other papers. Some people don't speak English, or do so poorly. Some people are illiterate or can only read at a basic level.
In short, there's a dozen or more reasons why someone who should still be eligible for Medicaid/CHIP may end up being lost in the shuffle...and when you're talking about tens of millions of people total being "redetermined," that leaves an awful lot of folks who could still end up in that position...especially when they haven't had their statuses updated in over three years.
In addition, even many of those who legitimately aren't eligible for Medicaid/CHIP any longer will likely end up losing coverage because they may not understand what other options are available to them (such as subsidized ACA marketplace coverage or employer coverage). Again, three years is a long time to not have to deal with any of this stuff.
Many states are taking important measures to and doing everything they possibly can to minimize the fallout. For instance:
“Along with our partner Access Health CT and other key community stakeholders, we have been preparing for the public health emergency unwinding. Through extensive outreach and internal preparations, including adding more members to our benefits teams to meet the growing need that unwinding will generate, our priority is to make sure all communities throughout the state have access to the information and support they need to understand how the unwinding will affect them and their families,” said Andrea Barton-Reeves, Commissioner Designee for the CT Department of Social Services.
“We have been preparing for the Medicaid Unwinding for over a year and have collaborated with all departments to establish the most effective outreach and administrative plan to ensure that our most vulnerable populations are well-informed and avoid any coverage gaps,” said James Michel, Chief Executive Officer of Access Health CT.
The Maine Department of Health and Human Services (DHHS) announced today the launch of a Special Enrollment Period (SEP) through CoverME.gov, Maine’s Health Insurance Marketplace, to help Maine people transitioning from MaineCare coverage after the COVID-19 pandemic explore affordable health insurance options and avoid gaps in coverage. The Special Enrollment Period began on April 15, 2023, and will continue through July 31, 2024, allowing Maine individuals found no longer eligible for MaineCare to apply for plans through CoverME.gov outside of the annual Open Enrollment Period.
To assist those who are no longer eligible for NJ FamilyCare and qualify for coverage through Get Covered New Jersey, the department has established an extended Special Enrollment Period to allow these individuals 120 days to sign up for coverage. The Special Enrollment Period also provides flexibilities that create a streamlined transition between the programs, and offers consumers the option of having an earlier effective date of coverage to avoid coverage gaps. Consumers will have 120 days to enroll and have the option of coverage taking effect 60 days earlier. Consumers should enroll within 60 days of losing coverage to avoid a gap in coverage.
As the state unwinds from the federal public health emergency, the Division of Welfare and Supportive Services (DWSS) has begun the reevaluation of all Medicaid enrollments for the first time since 2020 during which you may lose coverage under Medicaid. In April, the first wave of recipients received their renewal packets in the mail. Those who did not respond or who no longer qualify based on income or other factors will lose their benefits starting June 1, 2023. Nevada Health Link is available as the go-to resource to help people stay insured.
The DWSS is working with the state-based health insurance marketplace Nevada Health Link to transfer individuals who were not renewed into Medicaid to help them find a plan to keep them insured. Nevadans who exceed the income limits to receive Medicaid benefits may be eligible for tax credits, or subsidies through Nevada Health Link. Additionally, those who do not respond to their renewal packet in the mail can contact DWSS to reapply for Medicaid or visit NevadaHealthLink.com to seek new coverage options. This unwinding process will take place through June 2024.
Some clients will be automatically renewed based on the most recent information already on file with the state. If the state does not have enough information on file, clients will need to take action to complete the renewal process to stay insured.
- If clients are auto renewed, they will get a notification saying their health coverage was renewed. For most, health coverage will be renewed for 12 months. The requirement will continue for clients to report any changes within 30 days.
- If clients are not auto renewed, they will get a renewal notice in the mail. They must respond to complete their renewal by the 60-day deadline. If at the end of 60 days the client hasn’t responded, the state will send a notice informing them their Apple Health benefits are ending.
...The Bridge Health Program, as it is called, would be available to individuals making under 200% of the federal poverty level...Those above 200% of poverty will still be eligible for coverage on the health insurance marketplace.
...The path the task force decided to take — with input from the Centers for Medicare and Medicaid Services — was to create a basic health plan utilizing a federal program known as the 1331 waiver. It's named for the section of the 2010 Affordable Care Act that authorized it.
...The program's biggest target, at least initially, is individuals who have remained on OHP during the coronavirus pandemic despite no longer qualifying.
...The Oregon Health Authority estimates as many as 300,000 Oregonians could lose OHP insurance after the public health emergency ends.
Of that number, state officials estimate the bridge program could enroll an estimated 55,000 people in 2023.
It is critical to ensure that as many Michiganders as possible maintain health insurance coverage during this process. Therefore, we need to continue to utilize all the resources of state government to make people aware of the reinstated requirements. This includes apprising them of how to renew their eligibility and giving them information about other alternatives, including employer-sponsored health insurance.
Section 1 of article 5 of the Michigan Constitution of 1963 vests the executive power of the State of Michigan in the governor.
Section 8 of article 5 of the Michigan Constitution of 1963 places each principal department under the supervision of the governor.
Acting under the Michigan Constitution of 1963 and Michigan law, I order the following:
New York Attorney General Letitia James and Acting Department of Health (DOH) Commissioner Dr. James McDonald today warned New Yorkers about a new scam targeting New Yorkers enrolled in public health insurance programs and provided important tips to protect consumers. For the first time since March 2020, people enrolled in Medicaid, Child Health Plus and the Essential Plan will have to renew their health insurance coverage. Attorney General James and Acting Commissioner Dr. McDonald are urging New Yorkers to be vigilant in light of reports of scammers deceptively calling people and asking them to pay hundreds of dollars to maintain their health insurance.
In addition, the Centers for Medicare and Medicaid Services has launched a Special Enrollment Period lasting sixteen months specifically for those caught up by the Medicaid Unwinding process in states with ACA exchanges hosted via HealthCare.Gov:
Today, CMS is announcing a Marketplace Special Enrollment Period (SEP) for qualified individuals and their families who lose Medicaid or CHIP coverage due to the end of the continuous enrollment condition, also known as “unwinding.” This SEP, hereinafter referred to as the “Unwinding SEP,” will allow individuals and families in Marketplaces served by HealthCare.gov to enroll in Marketplace health insurance coverage outside of the annual open enrollment period. CMS will update HealthCare.gov so that Marketplace-eligible consumers who submit a new application or update an existing application between March 31, 20233 and July 31, 2024; and attest to a last date of Medicaid or CHIP coverage within the same time period, are eligible for an Unwinding SEP. Consumers who are eligible for the Unwinding SEP will have 60 days after they submit their application to select a Marketplace plan with coverage that starts the first day of the month after they select a plan.
Even with all of this, many will still fall through the cracks...and at the same time, there are other states which aren't exactly bending over backwards to help minimize coverage losses.
With that in mind, it's time to take a look at the initial numbers from some of the states which have started their redeterminations...and so far it's not pretty. Most of this data comes from Joan Alker, Executive Director of the Center for Children & Families at the Georgetown University Health Policy Institute:
NEW: Arkansas has just released data on Medicaid terminations for 1st 2 months. 40% losing coverage are kids - very big 18% parents, 39% expansion group, A whopping 85% are procedural denials. This is exactly what we have feared.
...More from Arkansas from data reported to CMS. 52% of those for whom renewals initiated lost coverage = 65,742 Of those only 7,223 were transferred to the Marketplace.
NEW: data from another "A" state - Arizona that went out early on Medicaid unwinding.
Looks much better than Arkansas. 65% retained coverage 17% lost coverage (Arkansas 52% lost coverage) 17% still in process
UTAH (via Stacy Stanford):
As of April 30th, Utah Medicaid has disenrolled 35,103 members as part of the continuous eligibility unwinding
Another 15k covid-only cases are set to be closed this week There are 510k total cases to be reviewed over the next 11 months
Idaho is providing less data than they did for the 1st month of Medicaid unwinding.
The latest numbers indicate: 48,005 processed 18,980 eligible = 40% retaining coverage 29,025 ineligible = 60% losing coverage
NEW: Medicaid unwinding data from New Hampshire
Total enrollment decline from March to April: 10.8% 27,217 people inc. 6,814 children/youth
Eligibility groups w/ biggest % drop: Expansion adults 17% Postpartum women 15% Foster care/youth aging out 10%
Medicaid unwinding data from Virginia as of May 1
11% of cases redetermined were dropped = 21,529
Of whom: 40% adults/parents 27% children 13% seniors (seems high) 9% people w/ disabilities 7% limited benefit groups 4% postpartum group
New: South Dakota unwind data - 10% of enrollees lost their coverage in April including 1,747 who will become eligible for Medicaid expansion on July 1. It didn't have to be this way as I have said before. State could have sequenced to keep them on.
NEW: 1st mo of Medicaid unwind data from Florida
250k people lost coverage
54% termination rate (Kids, parents, young adults b/c FL hasnt expanded Medicaid)
Of those losing only 18% were found ineligible; 82% lost for red tape reasons My blog
I'm not trying to do a comprehensive tally here; for one thing, data is only available for 8 states so far; for another, the data from those states is a mish-mash, clearly broken out in some but only partial in others, and some only include percentages instead of hard numbers.
Even so, you can already see that at least 258,000 people have lost Medicaid coverage due to paperwork/clerical issues in just Arkansas and Florida alone...in just the first two months of the unwinding process.
For what it's worth, Arkansas and Florida combined have (or had, as of last September) around 6.47 million Medicaid enrollees between them, so that's already 4% of the total enrollees in those states which have already lost coverage even though many of them are likely still eligible. If that rate were to apply nationally, it would be roughly 3.8 million people...and again, that's in just the first two months of the process.
Again, of course, the numbers and percentages vary widely from state to state. Stay tuned...
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