Unwinding of Medicaid Continuous Enrollment: Key Themes from the Field

During the COVID-19 pandemic, states kept people continuously enrolled in Medicaid in exchange for enhanced federal funding. With the end of continuous enrollment on March 31, 2023, states are required to complete an eligibility renewal for all Medicaid and CHIP enrollees by May 2024 – a process commonly referred to as “unwinding.” KFF survey data show that despite outreach, as of early November more than one-third (36%) of Medicaid enrollees had heard nothing at all about unwinding. As of January 2024, states had renewal outcomes for more than four in ten enrollees with over 14 million people disenrolled and more than 27 million reenrolled in Medicaid coverage. In December 2023, growing concern over loss of Medicaid coverage for children prompted federal officials to issue additional guidance with strategies to protect coverage and to write letters to nine states with large declines in Medicaid child enrollment, urging them to take up additional policy options to prevent disenrollments due to paperwork, or procedural, issues.

Data are important to help monitor how unwinding is going across states, but trackers and dashboards only tell part of the unwinding story. Medicaid eligibility is complex, and outcomes are the result of federal and state policy decisions but also the result of how those policies are implemented and how well eligibility and other systems work. This brief examines the perspectives of state officials and others involved in the unwinding process. KFF worked with PerryUndem to conduct interviews with representatives from Medicaid managed care plans, primary care associations, legal aid and other advocacy organizations, and navigator organizations in four states: Arizona, Florida, Indiana and Pennsylvania. In addition, the report draws on broader state input from interviews with Medicaid officials as part of the 23rd annual budget survey of Medicaid officials conducted by KFF and Health Management Associates (HMA) from June to September 2023 (early in the unwinding process). The brief provides information on outreach and engagement, renewal processes and coverage transitions, providing lessons for the ongoing unwinding process, as well as for how to conduct more effective Medicaid renewals generally in the future. Key takeaways include the following:

Communication and Engagement

States have used an array of outreach strategies and partnered with multiple entities involved in unwinding to reach Medicaid enrollees. All states reported using traditional communication campaigns with mailers and paid advertising, and some states have added text messaging and targeted outreach to certain populations, including users of long-term services and supports and people with limited English proficiency. To encourage consistent messaging and information, all four study states have developed toolkits for partner organizations that included printable and digital materials. Study states credited new strategies to update contact information, such as using the National Change of Address database and accepting updated contact information from managed care organizations (MCOs), with reductions in returned mail. While enhanced outreach efforts were generally viewed as positive, some participants said enrollees have been overwhelmed by the volume of contact they have received and, in some cases, unclear messages have led to confusion.

State engagement with those involved with unwinding was described as a positive aspect of unwinding, and feedback loops have helped identify early problems. Many states, including three of the study states, increased engagement and coordination with others involved in unwinding, holding regular meetings to provide updates and review data. In the study states, participants noted these meetings have provided an opportunity to create feedback loops to alert states to potential problems and build relationships in the process. In contrast, limited state engagement and communication contributed to more reports of problems with the unwinding process and frustration among groups involved with the unwinding.

Renewal Processes

The volume of renewals, systems issues, and staffing shortages have posed significant challenges to states. Across many states, older systems that require manual workarounds to meet federal requirements have exacerbated staffing shortages and negatively impact the processing of renewals. While systems are generally working well in Arizona and Indiana, Pennsylvania’s system was not designed to conduct ex parte renewals for a large number of Medicaid enrollees, increasing the burden on eligibility staff to manually process most renewals. Study state officials noted that staffing shortages and inexperienced staff have contributed to backlogs and disenrollments of people who are likely still eligible early in the process; these states responded with additional training and other efforts to increase staff.

States have taken steps to streamline renewal processes and increase ex parte, or automated, renewals. As of January 2024, all study states except Florida had adopted a range of 1902(e)(14) waivers and other flexibilities to increase ex parte rates and streamline renewals. Guidance from CMS in December 2023 announced these waivers will be available through the end of 2024 unless approved for a longer duration. A number of states, including Indiana, have also taken steps to increase ex parte renewals for people who qualify on the basis of disability or over age 65, referred to as non-MAGI populations. When asked about the most helpful flexibilities, states most often pointed to those allowing use of Supplemental Nutrition Access Program (SNAP) data to renew Medicaid, streamlining renewals for those with no and low income, and waiving the asset limit test. Officials in the study states have prioritized ex parte renewals, both automated and manual, as a strategy for reducing procedural disenrollments.

All four study states have increased the number of communication touch points with enrollees. In an effort to improve response rates, study states increased the number of enrollee contacts during the renewal process. For example, Pennsylvania went from sending one mailer ahead of the renewal notice to adding 11 enrollee contacts. States have also expanded communication modes to include emails, texts, and phone calls in addition to mailed notices.

Participants in all four study states reported that Medicaid renewal and termination notices can be difficult to understand. Participants described a variety of problems with notices, from lack of clarity on what actions or documentation are needed for renewal to misleading or incorrect information. Issues with notices were most acute in Florida where advocates have filed a lawsuit, contending notices are confusing, fail to explain why individuals lost Medicaid coverage, and sometimes include incorrect information.

Participants reported challenges getting through to call centers when enrollees needed assistance with their renewals, particularly for people with limited English proficiency. According to study participants, call center wait times are often long and it can be difficult to connect with someone able to assist with complicated cases. Advocates noted wait times were longer for those requesting a language other than English. These problems were echoed by state officials in a number of states.

Coverage Transitions

Some individuals who are disenrolled from Medicaid for procedural reasons are reenrolling after a gap in coverage. While most states are not reporting data on the number of people reenrolling in Medicaid, two study states (Arizona and Pennsylvania) are reporting these data. In Arizona, about half of people who complete their renewal during the 90-day reconsideration period have their coverage reinstated. States have increased communication with people procedurally disenrolled who may be eligible – Arizona and Pennsylvania send letters following disenrollment to let people know they still have time to regain their coverage without completing a new application. Participants noted that when process and systems issues result in disenrollment, it can undermine peoples’ trust in the system and can discourage them from completing their renewal or reapplying.

While children in some states are seamlessly transitioning to CHIP, in other states children are experiencing gaps in coverage. When children in Arizona and Indiana are found to be ineligible for Medicaid, the states automatically enroll them in CHIP, if eligible, without any action required from the family. Participants reported that challenges and glitches with a recent change in Pennsylvania to integrate the CHIP eligibility system with Medicaid have led to some children losing coverage. While information for children determined ineligible for Medicaid is automatically transferred to CHIP, slow processing times may lead to gaps in coverage for some children.

Participants reported that even with enhanced Marketplace premiums, affordability remains a barrier to enrollment. Respondents generally said that account transfers to the Marketplace were happening as expected; however, the number of people disenrolled from Medicaid who enroll in Marketplace coverage remains low in all study states. Participants said that for some people, the deductibles and cost sharing are too high. They also noted that not everyone is aware that Marketplace coverage is an option.

As states continue processing renewals for the more than half of enrollees whose eligibility must be still redetermined, the perspectives of state officials and others involved in unwinding provide valuable insights into what is working well and where there are challenges and room for improvement. States can make changes in the near term to help enrollees maintain Medicaid or transition to other coverage during the unwinding period, but they can also apply the lessons learned to make longer-term improvements to Medicaid renewal processes.