What Have We Learned from the Medicaid Unwinding Redetermination Process?

What is the Medicaid Unwinding Redetermination Process?

The Medicaid Unwinding involves reassessing the eligibility of Medicaid enrollees who remained continuously eligible during the COVID-19 Public Health Emergency (PHE), ensuring that those who qualify continue to receive benefits while identifying those who no longer meet the eligibility criteria. During the PHE, officially initiated on January 31, 2020, Congress passed the Families First Coronavirus Response Act (FFCRA) of 2020. In exchange for additional federal funding, the FFCRA required state Medicaid programs to keep people enrolled. Once the PHE ended, states were permitted to begin re-assessing Medicaid enrollees’ eligibility for the program and disenrolling people starting on April 1, 2023. Since then, more than 20 million people have been disenrolled.

What is the Current Status of Medicaid Unwinding?

According to the Kaiser Family Foundation (KFF) Medicaid Enrollment and Unwinding Tracker , in March 2023, there were 94 million people enrolled in Medicaid/CHIP (Children’s Health Insurance Program). As of June 2024, based on data reported on state websites:

• 49.6M (53%) have had their coverage renewed (i.e., they met eligibility requirements to remain on Medicaid/CHIP).
• 60% of those whose coverage was renewed did so on an ex parte basis, which means it occurred automatically using available data sources, rather than sending a renewal form through the mail to request information and documentation from the enrollee (i.e., auto-renewal).
• 22.8M (24%) have lost their Medicaid coverage (i.e., disenrolled).
• 69% of this total were disenrolled due to procedural issues. Reasons included outdated contact information, language barriers, and missed deadlines to return paperwork.
• 21.8M (23%) are still pending.

Data reported by the Centers for Medicare and Medicaid Services (CMS), which may differ from the state-reported data due to timing, show that:

• 37% of Medicaid enrollees renewed ex parte (i.e., auto-renewal).
• 23% renewed via completion of a renewal form.
• 19% were terminated due to procedural reasons.
• 8% were found ineligible.
• 12% of renewals are still in process.

State results vary widely. For example, disenrollment rates range from 56% (Utah) to 13% (Maine). Most states completed their processes by the end of May. About 13 states are scheduled to finish in June and July, with only a few continuing beyond this timeframe.

Key Challenges & Lessons Learned Unwinding has come with its share of challenges . For example, the large volume of renewals and incomplete, outdated, and inaccurate information about enrollees caused delays and complications. Staffing shortages added to the difficulty, and data systems and communication channels were strained. CMS requested some states to pause, and others extended their completion timeframe. An information bulletin from the Centers for Medicaid & CHIP Services (CMCS) in March 2024 reiterated:

CMS strongly encourages all states to review their renewal processes, including standard operating procedures, renewal forms, and notices, and to test the renewal logic in eligibility systems to confirm that processes and systems are compliant with these existing federal requirements.

Incomplete and limited data have also created challenges in understanding the full impact of the unwinding process. The process has affected millions of Medicaid/CHIP beneficiaries. Findings from this Kaiser Family Fund Survey highlight the human impact. Read the full report for details:

• About one in five enrollees say they were disenrolled from Medicaid coverage at some point in 2023, and about 23% of those who were disenrolled remain uninsured.
• Newly uninsured adults indicated that costs were the reason for not getting another form of health coverage.
• Most pre-unwinding enrollees who tried to renew their Medicaid coverage experienced problems.
• About half of enrollees said they heard only a little or nothing at all about Medicaid renewal.
• 70% of enrollees remember receiving some information about Medicaid renewal.

New CMS Rules

In response to the challenges and lessons learned, CMS published a final rule on April 2, 2024, titled Medicaid Program; Streamlining the Medicaid, Children's Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes . As the title suggests, the purpose of the rule is to simplify the eligibility, enrollment, and renewal processes for Medicaid and CHIP to help eligible individuals enroll and retain Medicaid/CHIP and Basic Health Program benefits. This resource from Sellers Dorsey provides a detailed overview of the new CMS rule. Some key provisions designed to address the redetermination challenges faced post-PHE include:

• Defining what eligibility information/documentation is to be maintained by the state.
• Establishing minimum standards for states to complete a timely determination of beneficiary eligibility at application, renewal, and when there is a change in circumstances.
• Minimum timelines and protections for determination and redetermination of eligibility for applicants and at renewals:
• At least 15 calendar days for new applicants to return needed information.
• At least 30 calendar days for beneficiaries to return information required for renewal.
• At least a 90-day reconsideration period for procedural terminations due to a failure to respond to requests for information
• Guidance for responding to updated address information for in-state and out-of-state address changes when mail is returned with no forwarding address, and identifies “reliable data sources” that no longer require beneficiary verification.
• Allowing CHIP beneficiaries to re-enroll without a lock-out period when a family fails to pay a CHIP premium or enrollment fee.

Moving Forward

The Medicaid unwinding process has been a significant undertaking that affected millions of Medicaid/CHIP beneficiaries – some of the most vulnerable populations. More data will be needed in the coming months to determine the impact of unwinding on healthcare coverage and access. The new CMS rule represents progress toward applying the lessons learned from the unwinding process to innovative and modernized approaches to the Medicaid and CHIP eligibility process. Several provisions within the new rule became effective on June 3, 2024, like allowing MCOs to collect updated contact information for enrollees and providing that information to the state. As states navigate the final stages of unwinding, ongoing collaboration between state agencies, MCOs, providers, community-based organizations, and federal entities will be crucial. The goal is to create a more resilient and responsive Medicaid system that can adapt to changing circumstances and continue to provide essential healthcare coverage to those in need.?

Michael S. Barr, MD, MBA, MACP, FRCP

Sr. Director, Population Health Improvement

The Population Health Alliance (PHA) is committed to Quality and Continuity of Care.?Our key priorities are advancing value-based care, improving consumer engagement, and addressing social determinants and health equity.

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