Millions Are At Risk Of Losing Medicaid Coverage When The COVID-19 Public Health Emergency Ends
As part of week three of Medicaid Awareness Month, Protect Our Care is examining the consequences of ending the COVID-19 public health emergency, which could result in millions of people losing Medicaid coverage if states fail to act. Today, more than one in four Americans have health coverage through Medicaid or the Children’s Health Insurance Program (CHIP), making these programs undeniable pillars of the American health care system. During the COVID-19 pandemic, President Biden and Democrats in Congress have made historic investments to secure and expand Medicaid during a time of grave public health risks, sudden job loss, and economic upheaval. Thanks to their continued commitment to protecting health coverage access, 2022 saw more than 85 million Americans receiving their coverage through Medicaid or CHIP.
As America seeks a return to normal, it’s likely the public health emergency will end this summer. When that happens, for the first time in more than two years, all states will need to redetermine the eligibility for most people with Medicaid. This process — called the “PHE unwinding” — could result in more than 16 million people losing their Medicaid coverage, including more than six million children. It is imperative that Americans who continue to qualify for Medicaid coverage are not kicked off due to administrative hurdles and Americans who are no longer eligible are connected with affordable, quality coverage — not left to fall through the cracks. Far too many states who have been historically hostile to Medicaid care more about saving money than they care about peoples’ lives. Medicaid terminations prior to the COVID-19 pandemic have shown several states hostile to Medicaid have previously removed hundreds of thousands of Medicaid recipients due to administrative barriers and temporary income increases. It is essential that history not repeat itself, with the health of millions at risk.
President Biden has already taken the bold step of establishing an open enrollment period (OEP) for individuals with incomes below 150 percent of the federal poverty level that will continue until the end of 2022. This will ease the transition for Americans who are no longer eligible for Medicaid and ensure they have access to the coverage they need. States must also do everything within their power to protect the coverage of their residents, and respond to the worries and concerns of families. It is essential states follow the Centers for Medicare and Medicaid Services’ guidance to promote continuous coverage, and have a clear and proactive plan to implement every tool at their disposal, in order to protect millions of vulnerable Americans from losing their care.
Medicaid Landscape
Over 85 Million Americans Rely On Medicaid & CHIP. Nearly 15 million Americans were able to enroll in Medicaid during the COVID-19 pandemic, bringing the total of individuals covered by Medicaid and CHIP to more than 85 million, or one in four Americans. The pandemic has revealed the essential nature of the Medicaid program during America’s worst public health emergency. Since February 2020, there has been a 21 percent total increase in Medicaid and CHIP enrollment.
How The Pandemic Transformed Medicaid
Medicaid Served As A Lifeline During The Pandemic. Millions of Americans lost their jobs, and subsequently, their health coverage during the pandemic. The Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security Act (CARES) requires states to provide enrollees with continuous Medicaid coverage until the federal public health emergency (PHE) ends. The federal government provided additional funding to states during this period to support the increase of enrollees, which surged by 14.8 million over the course of the pandemic. Additionally, states streamlined their enrollment processes, allowing individuals to access their coverage as quickly as possible.
What’s At Stake When The Public Health Emergency Ends
Millions May Lose Coverage. In the 20 states able to report on potential Medicaid disenrollment, it is estimated that 13 percent of Medicaid recipients will be disenrolled at the end of the PHE. The majority of states report that a change in income will be the overwhelming reason people lose Medicaid coverage. However, many states have also indicated that missing documentation, incomplete renewals, or other administrative barriers are likely to be a primary reason for loss of coverage.
Restarting Medicaid Churn. The continuous coverage requirement in place during the PHE, has halted Medicaid churn — when enrollees are dis- and re-enrolled in Medicaid coverage over a short period of time. Churn happens for a number of reasons, including administrative barriers during the renewal or eligibility process. Churn can also occur when Medicaid recipients have brief periods of income fluctuation, which is common for enrollees. Most Medicaid recipients who are physically able to work are employed, frequently in low-wage, unpredictable sectors where their hours and income can adjust from month to month. The continuous coverage requirement protected these individuals from the constant cycle of gaining and losing coverage.
How States Can Prevent Coverage Loss
Renew Based On SNAP Eligibility. CMS’ unwinding guidance allows states to automatically renew Medicaid eligibility for non-elderly beneficiaries who receive SNAP. Nearly all SNAP beneficiaries, 97 percent, qualify for Medicaid. States would protect millions from losing coverage and reduce administrative burdens by renewing Medicaid eligibility based on SNAP enrollment.
Promote Coverage Through Waivers. States can opt to provide continuous coverage for a full year to adult Medicaid enrollees by submitting a Section 1115 waiver to CMS. This would allow individuals to undergo the eligibility determination process only once during a 12 month period, promoting coverage and lessening the administrative burden for states. CMS has also encouraged states to pursue Section 1902(e)(14) waivers, which would protect beneficiaries’ coverage, while allowing states with large administrative loads flexibility to process renewals.
Establish Plan To Promote Continuous Coverage. As of March 2022, only 27 states have developed their required plans for outstanding Medicaid eligibility and renewal when the PHE ends. While states are required to follow elements of CMS’ unwinding guidelines, they also have broad authority over this process. What states ultimately decide could mean the difference between smooth transitions and continuous health coverage and mass Medicaid disenrollment and spiking uninsurance rates.
Suspend Data Matching As Eligibility Tool. Electronic data matches — from a variety of data sources used to verify eligibility — are used to identify Medicaid enrollees for priority action who may lose their eligibility when the PHE ends. In practice, data matching can result in inaccurate information that causes states to begin the disenrollment process, even when the enrollee maintains eligibility. If the individual in question doesn’t follow up with the state when notified, they are likely to lose coverage due to this administrative error. Despite the recommendation from CMS that states suspend use of periodic data matching during the unwinding process, 15 states have indicated they will proceed with this practice and 16 states have yet to determine if they will move forward with electronic data matching. States that do utilize this tool are expected to see reduced coverage and increased churn.
Lengthen The Redetermination Process. CMS gives states 12 months to initiate and 14 months to complete the backlog of Medicaid redeterminations, which review enrollee eligibility at the end of the PHE. The longer the redetermination process, the more time states have to reach out to enrollees to confirm eligibility or assist in the transition process to another form of coverage. Currently, 41 states plan to take 9 to 12 months to conduct the redetermination process, four states plan to take six to nine months, and three states plan to take three to six months.
Follow Up With Enrollees. States are not required to follow up with Medicaid recipients during the redetermination process, they only need to send a renewal form and a termination notice if the enrollee does not respond. This is not adequate to ensure continuous coverage for millions of Americans. Currently 41 states plan on sending reminders and only 25 states plan on reaching out a minimum of two times. States can increase continuous coverage rates by allocating resources to reach out to enrollees multiple times and using multiple methods, such as mail, phone, text, and email.
Update Enrollee Contact Information. Because states are not required to do anything other than mail a renewal form and termination notice, it is essential that enrollee’s addresses are updated and correct. Currently, 46 states are planning on taking some form of action to update mailing addresses prior to the expiration of the PHE, but four states still have no plan to perform this critical service. Only 35 states have a plan to follow up when enrollee mail is returned to sender.
Increasing Staff Capacity. To complete the redetermination process in a timely manner that ensures continuous coverage, states will need additional resources. Currently, 30 states plan to increase staffing towards the end of the PHE, with 21 states planning to approve overtime work, 15 states planning to hire new workers, and 12 states intending to hire contract workers.
More information on Medicaid Awareness Month can be found here.