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Millions of People Could Lose Medicaid Starting in April

In 2 weeks, states will begin unwinding pandemic's continuous enrollment provisions

Due to pandemic-related continuous enrollment provisions, Medicaid rosters surged to over 90 million enrollees. On April 1, for the first time in 3 years, states will begin unwinding those provisions and disenrolling individuals no longer eligible for the program.

While a majority of states have taken numerous steps to prevent those still eligible for coverage from losing it for procedural reasons -- such as renewal letters being sent to a wrong address -- experts and lawmakers who spoke on panels at America's Health Insurance Plans 2023 Medicare, Medicaid, Duals & Commercial Markets Forum on Thursday remain concerned.

Arkansas state representative Deborah Ferguson (D-51), who is a dentist, said her biggest concern is for people with chronic conditions who "go from Medicaid to employer insurance or Affordable Care Act insurance ... are they going to have to get another prior authorization for treatment, are they going to have to get another prior authorization for medicine, is the formulary going to be different ... Are they going to have this huge gap in care that's really going to create problems?"

Typically, Medicaid processes renewals on an annual basis. Due to provisions in the Families First Coronavirus Response Act and the Coronavirus Aid, Relief, and Economic Security Act, states were required to maintain continuous enrollment for all Medicaid enrollees until the end of the public health emergency (PHE) and in return were granted a 6.2-percentage point bump in their Federal Medical Assistance Percentage. (For each dollar the state spends on Medicaid, the federal government provides a match rate that changes year to year.)

As a result of these provisions, Medicaid and the Children's Health Insurance Program (CHIP) will have increased by 30% or 23.3 million people by March 31, according to estimates from the Kaiser Family Foundation (KFF).

Beginning on April 1, all 92 million enrollees will be up for renewal and the increased federal assistance will go away.

This change comes as a result of a provision in the Consolidated Appropriations Act, passed in December 2022, which decoupled the continuous enrollment provision from the PHE, and named March 31 as the end of the continuous enrollment period.

While Anne Marie Costello, MPH, deputy director for CMS's Center for Medicaid and CHIP Services, said she's impressed with the "tremendous investment" by states to reach enrollees, she noted that processing renewals for 92 million people over a period of 12 to 14 months is an "insurmountable task."

And it's a task that state agencies face while struggling to retain their workforce, like most other industries, she added.

Joan Alker, MPhil, executive director and co-founder of the Georgetown University Center for Children and Families in Washington, D.C., said she found some of the findings from a KFF report based on a national survey released Thursday "reassuring."

However, "I don't see that there's any way that we're not going to lose millions of people," she said, noting "the potential for hundreds of thousands, if not millions, of children to lose their coverage when they're still eligible."

In the survey, over one-third of reporting states indicated that about 18% of Medicaid enrollees will be dropped from the program when the continuous enrollment period ends -- with projections ranging from 7% to 33%.

More than half of states plan to wait until April to begin implementing the "unwinding process," while another 15 states said they would begin in March, and another eight states planned to begin in February.

As for the intended duration of renewals, 43 states intend to use the full 12 to 14 months to complete the renewal process, five states plan to take 9 to 12 months, and one state aims to finish in less than 9 months. Two states declined to respond.

Stretching the workload over a long period can help states balance the volume of renewals, but would also increase state spending, noted Tricia Brooks, MBA, a senior fellow at the Georgetown University Center for Children and Families and lead author of the KFF report, and her co-authors.

Other findings from the report include:

  • About half of states have flagged individuals who they suspect are no longer eligible or who have not responded to renewal requests

  • In 16 of 26 states that responded, eligibility worker vacancy rates are higher than 10%, and higher than 20% in seven of the 16

  • Forty-three states use an ex parte renewal process (which leverages state wage or unemployment compensation data prior to asking an enrollee to complete a form or submit information)

  • Approximately 34 states are searching for updated information through the Supplemental Nutrition Assistance Program (SNAP) and other programs; 33 states are asking Medicaid Managed Care Organizations to contact enrollees; and 13 states launched an online change-of-address form

  • A majority of states (40) will attempt to contact enrollees when mail is returned

All 50 states and the District of Columbia have taken action to update enrollee contact information, Brooks and co-authors noted.

CMS issued guidance for states in 2021 detailing recommendations for responding to returned mail. In addition, all states are required to "make a good faith attempt to contact an enrollee through at least two modalities prior to disenrolling when mail is returned," the authors wrote.

Alker said she worries that adults in non-Medicaid expansion states (states that have not extended eligibility to all adults up to 138% of the federal poverty level) will become ineligible for Medicaid because their incomes disqualify them. These adults will fall into the "coverage gap," meaning they lack an affordable insurance option.

This coverage gap has always been a significant problem, but the loss of insurance for children is a new problem, Alker told Mississippi Today in a recent interview ahead of the panel.

Approximately 15 to 18 million people are still expected to lose coverage during the renewal process, and HHS has estimated that about 6.8 million might still be eligible.

Reporter: Shannon Firth has been reporting on health policy as MedPage Today's Washington correspondent since 2014. She is also a member of the site's Enterprise & Investigative Reporting team.


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