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In early 2023, states began final preparations for the end of the pandemic-related Medicaid continuous enrollment provision following passage of the Consolidated Appropriations Act (CAA) of 2023, which lifted the requirement effective March 31, 2023. During the three-year pause on Medicaid disenrollments, Medicaid and CHIP enrollment grew by 32% from 71.3 million to 94.1 million, resulting in the largest ever number of enrollees in Medicaid, which, along with enhanced subsidies in the Affordable Care Act (ACA) Marketplaces, contributed to the lowest ever uninsured rate. The CAA also extended and phased out the enhanced federal Medicaid matching funds that states received during the pandemic through the end of 2023. All states were expected to initiate their first month of renewals no later than April 2023, although some states did not process their first disenrollments until June or July.
The 22nd annual survey of state Medicaid and CHIP programs officials conducted by KFF and the Georgetown University Center for Children and Families in March 2024 presents a snapshot of actions states have taken to improve systems, processes, and communications during the unwinding, as well as key state Medicaid eligibility, enrollment, and renewal policies and procedures in place as of May 2024. The report focuses on policies for children, pregnant individuals, parents, and other non-elderly adults whose eligibility is based on Modified Adjusted Gross Income (MAGI) financial eligibility rules (information on policies for populations that qualify for Medicaid on the basis of age or disability—non-MAGI populations—is captured in a separate brief). Overall, 49 states and the District of Columbia responded to the survey, although response rates for specific questions varied (Florida was the only state that did not respond). For purposes of this report, the District of Columbia is counted as a state.
Key Takeaways
- All states report taking action to improve automated, also known as ex parte, renewal rates during the unwinding and plan to continue these strategies post unwinding. Forty-two states adopted 1902(e)(14)(A) waiver flexibilities to increase ex parte renewal rates for MAGI populations, while 39 states improved system rules and 22 states expanded the number of data sources they use to conduct ex parte reviews. In addition, 34 states process ex parte renewals on a mostly automated basis, which required system upgrades in some states. Among the 42 states that adopted 1902(e)(14)(A) waivers to increase ex parte rates for MAGI populations, allowing ex parte renewals for individuals with $0 income and with low income in some circumstances and using SNAP or TANF eligibility to confirm ongoing Medicaid eligibility were cited as the most useful waivers, and many states would like to make these permanent. CMS has extended the 1902(e)(14)(A) waivers through June 2025.
- All states made changes to simplify or streamline the renewal process and they want to keep many of the changes in place after the unwinding period ends. In addition to improving ex parte processes, some states also made more targeted changes to revise renewal notices (22 states), simplify the renewal form (10 states), and extend the time to respond to renewal notices (7 states) that should make it easier for enrollees to complete the renewal process in the future.
- States cite outreach to enrollees and engagement of health plans and community groups among the strategies that improved unwinding outcomes. States boosted direct outreach to enrollees through multiple modes, including text, email, and automated calls, and 37 states plan to maintain the enhanced outreach post unwinding. Additionally, over two-thirds (34) of states expect to continue engaging health plans and/or community-based organizations in the renewal process. States also note that these organizations played an important role in amplifying outreach and providing community-based assistance.
- Several states are taking steps to improve coverage for children and pregnancy, including by increasing eligibility levels, providing continuous eligibility, and eliminating premiums for children’s coverage. In 2024, two states increased eligibility levels for children and/or pregnancy coverage and eight states extended coverage to certain immigrant children and/or pregnant individuals, and three states did both. Eighteen states have eligibility levels above the median for both children (255% FPL) and pregnancy (210% FPL). Building on the experience of continuous enrollment, several states have adopted or are pursuing multi-year continuous eligibility for young children, and there has been widespread adoption of 12-month postpartum coverage. And since 2020, ten states have eliminated or are poised to eliminate premiums for children’s coverage.
As the unwinding comes to an end, there is a lot to learn from state experiences during the past year. States made numerous policy and systems changes to improve the renewal process and they plan to maintain many of those changes. Additionally, the Eligibility and Enrollment final rule CMS issued earlier this year simplifies many eligibility and enrollment processes for Medicaid and CHIP by eliminating certain enrollment barriers in CHIP; facilitating transitions between coverage programs; and aligning enrollment and renewal requirements for most individuals in Medicaid. It makes some temporary policy changes permanent and will require additional changes over the next 36 months. CMS has also extended 1902(e)(14)(A) waivers through June 2025 while it continues to assess whether any waivers can be made permanent under other authority. Collectively, these changes to renewal and ex parte processes as well as eligibility expansions mean that the return to “routine” operations will not mean return to pre-pandemic operations. The impact these changes may have on continuity of coverage and churn and on overall Medicaid enrollment will be seen over the coming years.
Detailed Summary
The Unwinding and Post-Unwinding
The timeline for completing all unwinding-related renewals has been extended beyond June 2024 in at least ten states. On May 31, 2024, CMS released preliminary estimates of when states will complete unwinding renewals. While most states are expected to complete renewals by June, Illinois, Kentucky, Michigan, New Jersey, and Wisconsin will finish in July while Alaska, District of Columbia, Hawaii, North Carolina, and South Carolina will finish in August or later. New York’s completion month is still under development. Although it had been expected that all states would complete the unwinding by June 2024, some states voluntarily pushed out the deadline for returning renewals by a month or more to conduct targeted outreach and give enrollees more time to return renewal forms. Other states were required to pause disenrollments to correct a system glitch or address another issue that was uncovered during the unwinding.
Most states (41) have frontline eligibility staff vacancies while somewhat fewer states (32) report call center staff vacancies. Workforce challenges in most states have had a significant or moderate impact on the states’ ability to manage application and renewal workloads. Approximately two-thirds of states report moderate to significant impacts related to eligibility staff vacancies, recruitment, training, and retention. However, states report that the impact of workforce issues on call centers has been more modest.
All but four states are interested in maintaining flexibilities that have been most useful to simplifying renewal processes. Nearly all states adopted at least one 1902(e)(14)(A) waiver and most states would like to make some of the waivers permanent. Topping the list were two waivers CMS has already made permanent through the recently finalized Eligibility and Enrollment Rule – accepting updated contact information from Medicaid health plans, the USPS National Change of Address Database (NCOA) and/or mail returned with an in-state forwarding address from the USPS without further verification. States are also interested in continuing to enroll or renew individuals based on SNAP and/or TANF eligibility (25 states) and to renew coverage when no income data is reported (29 states) or reported income is below the poverty level (17 states). Given the positive impact some strategies have had on renewal outcomes, CMS has extended their use through June 2025 while the agency determines which can be implemented on a longstanding basis under other authorities. Additionally, certain 1902(e)(14)(A) waivers will need to be maintained as mitigation strategies in states with processes that do not fully comply with federal renewal requirements.
Most states (41) report they plan to continue improved communication with enrollees and/or engagement of health plans and community groups. States cite communications and the involvement of health community organizations as strategies that improved unwinding outcomes, including increased outreach to enrollees (37 states) and engaging health plans in the renewal process (31 states). Half of the states cited providing new ways for enrollees to update contact information (27 states); engaging community-based organizations in the renewal process (26 states); and maintaining enhanced online account functionality (26 states) as changes they intend to keep.
Data reporting has been important for monitoring the unwinding, and while half of states were uncertain about continuing to post renewal data or had planned to stop reporting, new guidance from CMS continues state monthly renewal outcome reporting. The CAA requires states to report renewal data and requires CMS to make the data public but only through June 2024. While data posted by CMS lag by 2-to-3 months, most states (42) post their own renewal-related data on a timelier basis. At the time of the survey, 15 states confirmed that they will continue reporting these data after the unwinding period ends, while 22 states were uncertain, and five states responded that they would not continue posting the data. However, on May 30, 2024, CMS issued new guidance stating that states are expected to continue reporting renewal monthly outcome data and encouraging states to maintain data dashboards or other timelier posting of data.
One-third of states (16) plan to resume periodic data checks that can lead to churn for low-wage earners. With continuous eligibility no longer in effect (except for children and pregnancy coverage), states may opt to conduct periodic data checks to identify potential changes in income or circumstances that could affect eligibility. Periodic data checks can exacerbate churn since low-income wage earners experience frequent fluctuations in income during the year. And, although states have the option to push out renewal dates for 12 months if ongoing eligibility is confirmed through a mid-year data check, only 3 of the 16 states plan to do so. Additionally, 7 of the 16 states provide only ten days for enrollees to respond to a request for information following a periodic data check although known delays in mail delivery can make it challenging for enrollees to submit information before coverage is terminated. Beginning in June 2027, in accordance with the Eligibility and Enrollment rule, states will be required to provide 30 days for enrollees to respond to requests for information, which aligns with the current rule for renewals.
Lessons Learned
States cited changing or unclear federal guidance, workforce issues, and the sheer volume of work as the top three challenges they faced during the unwinding. Other challenges centered on systems issues—the need to make systems changes and/or upgrades quickly to respond to the changing landscape or to implement new renewal flexibilities and fix limitations or problems with existing systems that hindered states’ ability to process renewals efficiently. States also noted difficulties engaging enrollees in the renewal process and communicating effectively about the renewal requirements and process.
Despite the challenges states faced, they made many changes to simplify and improve the renewal process, including improved outreach and enrollee communication, improved engagement with stakeholders and community organizations, and increased ex parte renewal rates. States also noted improved systems automation and building the infrastructure for data reporting and transparency as significant accomplishments in addition to streamlined renewal processes.
Systems and Online Tools
Most system improvements have been focused on increasing state ex parte renewal processes. Using reliable data to verify ongoing eligibility at renewal, known as ex parte or automated renewals, decreases the paperwork burden on states and enrollees while reducing gaps in coverage and extra work associated with re-enrollment of eligible people losing coverage for procedural reasons. All states have taken steps in the past two years to increase ex parte rates that include expanding data sources used for ex parte reviews and improving other system rules. In addition, 42 states reported adopting one or more 1902(e)(14)(A) waivers to improve ex parte rates for MAGI populations. Flexibilities allowed during the unwinding have helped states increase ex parte renewals rates and improve overall renewal outcomes.
Nearly all states (49) have online accounts with similar features but there are differences in requirements for setting up accounts and resetting passwords. Online accounts are a first step in applying for coverage since no state offers the ability to apply online without an account. Most online accounts provide a range of features for individuals, including checking their application status, viewing notices, reporting changes, renewing coverage, and uploading scanned or electronic verification documents. These accounts must be secure to protect personal information, and more than half of states (29) require new users to go through an identity verification process before setting up an account. In the 28 states that require multi-factor authentication, this security measure is required to set up an account in 25 states, to reset the password in 22 states, and every time the account is accessed in 13 states. The process for resetting the account password varies as well; users can reset passwords online by answering security questions (32 states) or through a link sent via email or text (33 states). In 29 states, users may contact the Medicaid call center to reset the password.
Eligibility and Enrollment Policies
Several states have expanded eligibility for children and pregnancy coverage, and two states newly adopted the Medicaid expansion in 2023. Arizona, Maine, and North Dakota expanded child eligibility levels over the past year while the median eligibility level remained unchanged. The median income eligibility for pregnancy coverage rose from 207% to 210% FPL with expansions in North Dakota, Nevada, and Tennessee. Several states newly waived the five-year waiting period for Medicaid and CHIP coverage for lawfully residing immigrant children and pregnant people (Georgia and New Hampshire) and for just pregnant people (North Dakota, Nevada, and Rhode Island). Adults with income up to 138% FPL are now eligible for Medicaid expansion in North Carolina and South Dakota.
Several states have made changes to children’s Medicaid and CHIP coverage. As of January 2024, all states are now required to keep children continuously enrolled for a full year with limited exceptions. However, 13 states are seeking to provide continuous eligibility beyond 12 months for young children. Additionally, since 2020, eight states (California, Colorado, Illinois, Maine, Maryland, Michigan, New Jersey, North Carolina) have eliminated their premiums or enrollment fees for children; Utah will eliminate premiums in July and Delaware has a pending request with CMS to eliminate premiums in its CHIP program. In the Eligibility and Enrollment regulation CMS made several changes to CHIP, including prohibiting new waiting and lock-out periods and requiring states with existing waiting and lock-out periods to eliminate them by June 2025.
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