1 Year Later: How Has the Unwinding of Medicaid Continuous Enrollment Gone?

For about three years during the Covid-19 pandemic, a continuous enrollment provision was in place that prevented states from disenrolling Medicaid beneficiaries, regardless of whether or not they were still eligible for coverage.

But about a year ago, this continuous enrollment provision ended. States had to begin the process of redetermining members’ eligibility at a time when a record high of about 94 million people were enrolled in Medicaid. As of March 26, 19.2 million people have been disenrolled from Medicaid while 40.6 million people have had their coverage renewed, according to KFF (an independent source for health policy research previously known as Kaiser Family Foundation). There are 34.3 million people awaiting a renewal of Medicaid coverage. Disenrollment rates vary widely by state, ranging from 57% in Utah to 12% in Maine.

How have states handled the end of the continuous enrollment provision and the transition back to the typical renewal process? Experts said that while some things have gone well like outreach campaigns to members, improvement is needed in the systems states use to check eligibility and enroll members.

“We’re all aware of the historic challenges with eligibility and enrollment systems and thus Medicaid health plans anticipated, but the events of the past year have confirmed that the eligibility and enrollment systems for Medicaid greatly need to be modernized,” said Anna Dunbar-Hester, vice president of Medicaid policy at AHIP, in an email.

What the numbers show

Many experts didn’t expect that as many as 19.2 million people would find themselves disenrolled from Medicaid when the pandemic emergency ended.

For instance, The Health and Human Services projected that 15 million people would lose Medicaid or Children’s Health Insurance Program coverage. A report from the Urban Institute predicted that 18 million would lose coverage. And that number is only going to increase because not all states have completed the unwinding yet, though most states will likely wrap up in the summer. Some states are expected to go beyond that, according to Bradley Corallo, a senior policy analyst with KFF’s Program on Medicaid and the Uninsured.

The biggest question that remains is what this means for health coverage nationally, especially uninsured rates, Corallo said.

“Even though more people are getting disenrolled than we expected, are those people finding new coverage while they’re on the ACA marketplace? Are they re-enrolling in Medicaid?” he said in an interview. “Those things are still to be determined, but to me, the big question is, what’s happening to the people who lost coverage and are they finding coverage elsewhere or re-enrolling?”

He added that it’s going to take time to “get the whole picture.”

Of the disenrollments, 70% were for procedural reasons, meaning the enrollee didn’t complete the renewal process. This can happen when states don’t have updated contact information or the beneficiary doesn’t finish the renewal packets in time. Like general disenrollment rates, procedural disenrollment rates vary by state, from as many as 93% of overall disenrollments in Nevada and New Mexico to as low as 22% in Maine.

Procedural disenrollments can be worrying because some of the people removed from coverage could still be eligible. But not all procedural disenrollments are a bad thing, noted Louise Norris, a health policy analyst for healthinsurance.org. For some people, it might just mean that they obtained coverage elsewhere and don’t need Medicaid anymore and therefore, ignored the Medicaid renewal notice. But when procedural disenrollment rates are unusually high, like in Nevada and New Mexico, that’s when it’s a little bit concerning since some of them are likely still eligible.

What’s gone well and what hasn’t?

Parts of the unwinding process have gone well, while others have been rocky, experts said. When asked what’s gone well, Corallo said there have been some effective outreach campaigns from state Medicaid agencies via paid media, text messages and chatbots. Medicaid agencies have also partnered with community-based organizations to get the word out to people about the need to renew their coverage and how to do so.  

Dunbar-Hester said there have been high levels of transitions from Medicaid to Marketplace coverage. Through November 2023, about 2.3 million people transitioned from Medicaid to a private Marketplace plan, according to healthinsurance.org.

There has also been an increase in ex parte (or automatic) renewals, though there were some issues in the beginning, according to Norris. States are required to first try an ex parte renewal, in which they check available data to determine if a member is still eligible for coverage and automatically renew them if so. If that fails, they send a renewal form. According to KFF’s data, 59% of people who kept their coverage were renewed via the ex parte process.

“When this whole thing started a year ago, I think about half of the states had problems with their automatic renewal process,” Norris said. “They’ve been working with CMS, working internally in the states to improve that and we definitely have seen an uptick over time in the percentage of renewals that are done automatically.”

Dunbar-Hester echoed Norris’ comments on the ex parte process.

“Ex parte renewal, which is the requirement for states to first attempt to renew eligibility through available data matching, is an extremely valuable tool, and we are grateful for all the difficult work states have done, with the support of CMS, to improve state systems so more of the regular renewal process can be automated and fewer people fall through the cracks,” she said. “We view it as the single most important tool for improving the system long term, and urge states to continue to make improvements. State performance on this varies greatly.”

The automatic renewal process needs further fine-tuning but so does the process that people face when trying to renew coverage. KFF focus groups showed that while many of those who successfully renewed their coverage thought the process was “quick and easy,” some faced barriers. For example, some complained that the notices for renewing coverage contained “legalese” that was difficult to understand, and several said that they received the notices very close to the deadline for renewing.  Of those who were disenrolled, many experienced communication problems, such as not receiving a notice from the state about renewing coverage. Some weren’t aware they lost coverage until they tried to refill a prescription.

Spanish speakers faced additional challenges. In September, civil rights groups (including UnidosUS) filed a complaint with the Office of Civil Rights —part of Health and Human Services — alleging that Florida was using discriminatory practices in their Medicaid redetermination process. The organizations argued that Spanish speakers faced significantly longer wait times than English speakers at Florida’s Medicaid call center (two hours and 22 minutes for the average Spanish-language caller, versus 36 minutes for the average English-language caller, according to UnidosUS). An updated report released in March showed that 80% of calls were dropped for English speakers and 82% were dropped for Spanish speakers. Dropped calls weren’t an issue when UnidosUS did its initial report. For those who were able to connect with a live person, however, there was a significant narrowing of the gap between the two groups. The average wait time for an English-language caller was 66 minutes, versus 47 minutes for a Spanish-language caller. UnidosUS contends that the call times improved because the dropped calls weren’t recorded as completed calls. 

Jared Nordlund, UnidosUS Florida political director, believes that nothing came out of the complaint they filed in September. 

“There have got to be easy changes that we can be doing, whether they need access to more Spanish speakers or whatever,” he said.

What’s ahead?

There are still about 34.3 million renewals remaining of the total 94 million Medicaid members, according to KFF. While more than 19 million people have been disenrolled from coverage, the Medicaid population won’t decrease by that much, Corallo noted. There are always people newly enrolling in Medicaid, and some of those who were disenrolled will eventually re-enroll. However, how this process has affected the uninsurance rate is still unknown.

Once the unwinding process is complete, states will resume the typical process that existed before the Covid-19 pandemic in which eligibility is checked every year.

“For a lot of states, I think it will get more manageable because they will no longer have that backlog,” Norris said.

Dunbar-Hester added that the end of the continuous enrollment provision has taught some valuable lessons.

“Wherever Medicaid rolls finally settle, it is burdensome for all stakeholders, including states and Medicaid enrollees, to process 70-95 million people’s renewal each year through a largely paper process,” she said. “The amount of regular coverage loss based not on a change in eligibility, but on a failure of the system to work, has caused gaps in coverage and care, as well as financial stress and instability, for far too long.”

There seems to be an acknowledgment on the part of the Centers for Medicare and Medicaid Services that the re-enrollment process has been tough for people. CMS announced Thursday that it is extending a temporary special enrollment period to help those who are no longer eligible for Medicaid or CHIP transition to Marketplace coverage. The transition period is being extended from July 31 to November 30.

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