As continuous enrollment provision ends, states begin Medicaid ‘unwinding’

Image of the United States topographical map with the word "Medicare" overlaying it.

By Susan Rupe

The Medicaid continuous enrollment provision expires at the end of March, meaning that millions of those who receive health coverage through Medicaid must have their eligibility redetermined or else lose coverage.

KFF estimates that enrollment in Medicaid and the Children’s Health Insurance Program will have grown by 23.3 million enrollees, to nearly 95 million, by the end of March, when the federal continuous enrollment provision expires. Starting April 1, states can resume disenrollments, which have been paused since February 2020. Millions of beneficiaries are expected to be disenrolled over the next year, including some who are no longer eligible for Medicaid and others who still qualify but lose coverage due to administrative paperwork problems.

This process of redetermining eligibility for millions of Medicaid beneficiaries is known as “the great unwinding” and it is already beginning in a few states.

States take steps to determine eligibility

KFF released the results of a survey that included steps the various states are taking to determine Medicaid eligibility. Those survey results were the subject of a webinar this week.

About half of the states – 23 – have begun the unwinding process, said Jennifer Tolbert, associate director, KFF Program on Medicaid and Uninsured. Twenty-eight states are scheduled to begin in April.

Most states expect to take between 12 and 14 months to complete the process, she said, with Texas reporting it expects to complete all Medicaid renewals in less than nine months.

More than half of the states – 27 – are flagging Medicaid enrollees who may no longer be eligible. But only 11 of those states are prioritizing the renewals of individuals who may no longer be eligible.

Fewer than one in five of the states are completing half of more of renewals using an automated process, she said.

States are taking steps to boost their staff capacity to handle the volume of work required during the unwinding period, Tolbert said. States are approving overtime for existing staff, hiring new workers, hiring contractors, bringing back retired workers temporarily, hiring temporary workers and borrowing staff from other agencies.

States face challenges

All states have taken steps to update enrollee mailing addresses ahead of the unwinding, Tolbert said. But states face challenges in reaching enrollees by mail. Some states are addressing these challenges by establishing an online change-of-address form, requesting that managed care organizations contact enrollees, or conducting data matches with the U.S. Postal Service.

But states are persisting in their efforts to reach enrollees, said Tricia Brooks, research professor with the Georgetown University Center for Children and Families. About two-thirds of the states reported they plan to follow up with additional mailings, text messages, emails and phone calls to notify enrollees of their redetermination.

In addition, more than half of the states have established online portals for application assisters or community partners, she said.

Looking ahead, Brooks said, the impact of the unwinding will vary across states. These impacts will be driven by differences in systems capabilities, communications strategies, staff capacity and adopting operational policies that make it easier for people to stay enrolled.

Even with all the steps states are taking to promoting continuous coverage, millions are expected to lose coverage, she said. Close monitoring of the unwinding processes across states can help identify problems early when actions can be taken to reduce coverage losses.

Children, people of color impacted

“We know that many of those on Medicaid who are disenrolled should have a path to enroll in other coverage, such as ACA coverage or workplace coverage,” Tolbert said. “But we expect disenrollments for procedural reasons to be high. This will disproportionately impact children and people of color.”

The Centers for Medicare and Medicaid Services’ primary goal through the great unwinding “is that people who are eligible retain coverage,” said Jennifer Stephens, CMS policy advisor.

“We want to ensure that smooth transitions occur for those no longer eligible for Medicaid as they move on to other coverage, such as marketplace plans,” she said.

Stephens said CMS is conducting outreach and engagement “on what to expect, what needs to be done now and what needs to be done on an ongoing basis for people to keep their coverage or transition into some other type of coverage.”

Susan Rupe is managing editor for InsuranceNewsNet. She formerly served as communications director for an insurance agents' association and was an award-winning newspaper reporter and editor. Contact her at [email protected]. Follow her on Twitter @INNsusan.