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Across agencies, state health policy officials are in the midst of tremendous planning efforts to prepare for the end of the Medicaid continuous coverage requirement and the resumption of eligibility determination processes in Medicaid.

While the timing of this is uncertain because the requirement is tied to the COVID-19 public health emergency (PHE), states recognize that it is likely that the federal PHE declaration could end in the coming months. The Centers for Medicare and Medicaid Services (CMS) has issued a series of guidance documents for states related to unwinding PHE policies — most recently a state health official letter and new reporting templates released earlier this month — that have included specifics about reinstating disenrollments in Medicaid and strategies states can consider to minimize both churn and inappropriate coverage terminations.

On NASHP’s webinar earlier this month, three state officials each representing different health coverage programs — Medicaid (Colorado), CHIP (Utah), and a state-based marketplace (Massachusetts) — spoke about their programs’ current efforts to plan for the eventual end of the Medicaid continuous coverage requirement. While they shared unique perspectives from their various vantage points and state contexts, some of the common themes from the discussion are described below, along with state snapshots of their current key priorities.

State-Specific Unwinding Planning Efforts

Colorado: The state’s Medicaid agency is focusing on a range of strategies to ensure continuity of coverage once the continuous coverage requirement is no longer in effect. Their overarching priorities center on minimizing disruptions for enrollees and supporting their eligibility determination workforce, and they are focusing their efforts in the areas of system improvements and partner input to develop effective strategies. The agency is seeking to distribute their eligibility redetermination work evenly over the PHE unwinding period and is taking into consideration the needs of certain populations, such as individuals who will be covered under the American Rescue Plan Act’s (ARPA) extended postpartum coverage option that the state will be implementing and vulnerable populations such as homeless individuals. Additionally, the agency recently redesigned their renewal materials with the aim of improving communications with enrollees about actions that they will need to take to maintain coverage. State Medicaid officials also hold weekly meetings with their county-based eligibility determination sites and their state-based marketplace to review needed policy and system changes and assess communication plans.

Massachusetts: Officials from the state-based marketplace, the Health Connector, are working very closely with their Medicaid agency counterparts to strategize about policy and operational approaches, coordinate messaging efforts, and share general information. Health Connector staff are currently in the process of gaining a better understanding of the characteristics of the individuals currently enrolled in Medicaid who may become eligible for marketplace coverage when the Medicaid continuous coverage requirement ends. One advantage the state has is that their Medicaid and marketplace eligibility determination systems are integrated, which facilitates smoother transitions between coverage programs.

Utah: Officials from Utah’s CHIP agency are incorporating lessons learned from their experience last year when CMS informed the state that unlike Medicaid, the CHIP program should be conducting regular disenrollments for individuals determined ineligible during the PHE (CMS had previously approved the state’s request to implement a disenrollment freeze in CHIP). Although the CHIP program attempted to reach enrollees, because the process needed to be conducted quickly, 41 percent of the CHIP caseload was disenrolled. Reflecting on this experience to inform the upcoming changes in Medicaid, the state is strategizing on ways to better communicate with enrollees and examining their eligibility system data closely. Similar to Colorado, they are focusing on prioritizing certain populations based on a range of factors and are currently identifying Medicaid enrollees within their system who are either found to be ineligible or whose eligibility cannot be confirmed so that further action can be taken on these cases when the PHE ends. Additionally, the state plans to launch a dashboard that will be able to provide information to the public about the reasons individuals are disenrolled from Medicaid and whether they are transferred to other coverage programs, as well as information about call center volumes and other data points to provide a comprehensive picture of eligibility redetermination activity.

Key Strategies to Address Current and Anticipated Challenges

Broadly, all states are facing the challenges of uncertainty about when the PHE declaration will end, as well as the significant growth in Medicaid enrollment over the course of the pandemic which increases the volume of work that will need to be completed. There is the additional challenge that the enhanced federal Medicaid funding that states are currently receiving for complying with the Medicaid continuous coverage requirement will expire at the end of the quarter in which the PHE ends; but states’ work to unwind the requirement will take much longer.

Balancing workloads and providing training to address state workforce constraints: Although the majority of states have been conducting renewals during the PHE, there will still be a very sizeable amount of eligibility work for states to process during the unwinding period. State officials also mentioned additional concerns about the potential increased workload as people begin reapplying for coverage after being disenrolled or appeal eligibility decisions. Both Colorado and Utah cited challenges related to recruiting and training the large number of state eligibility determination workers that will be needed. In Colorado, the state oversees the Medicaid program, but it is administered at the county level. While the legislature allocated funding for the hiring of more eligibility workers, counties have reported that it has been difficult to find employees because many businesses in the private sector are offering higher wages. However, a centralized state-funded site has been added so that counties with excess eligibility determination work can redirect cases there, which state officials hope will help even out the workload. In Utah, about a third of the Medicaid and CHIP eligibility staff are new employees, and due to the continuous coverage requirement they lack experience with conducting disenrollments in Medicaid. The state is providing training to recently hired staff and seeking to ensure that the upcoming significant workload increase will be processed both efficiently and carefully, with a focus on helping Medicaid-eligible individuals remain enrolled or that those who qualify for other programs are smoothly transferred to other sources of coverage.

Leveraging partnerships to reduce enrollee communication barriers: All three state officials commented on the significant challenge of finding effective ways to communicate with enrollees about the impending changes, especially because many enrollees have not ever had to take action to maintain coverage and may be unfamiliar with the redetermination process. In Colorado, in addition to their revamped renewal packet, the agency is promoting their newly modernized online portal that state officials are working to ensure is user-friendly. They are also using text messaging and other communication tools to engage enrollees and collect updated contact information. Massachusetts is aiming to use best practices in communication with enrollees and is currently conducting focus group testing of messaging that can be used across agencies so that they are in sync and are using the same “song sheet.” Additionally, for individuals who no longer qualify for Medicaid but are eligible for qualified health plans, Massachusetts Health Connector staff are thinking through ways to inform individuals about how marketplace coverage differs from Medicaid in terms of factors such as cost, provider networks, and income change reporting requirements. In Utah’s CHIP program, premiums have been suspended during the pandemic and state officials are working to develop effective strategies to inform enrollees about the reinstatement of these charges once the PHE ends.

One essential element in improving enrollee communication methods and gathering updated enrollee contact information cited by all three states is the engagement of a range of partners, such as community-based organizations with well-established ties to underserved and vulnerable populations. In Massachusetts, the state legislature allocated $5 million in ARPA funding to Health Care for All (HCFA)—a grassroots organization with strong connections to many marginalized communities—to support outreach efforts to Medicaid enrollees, and the state’s health insurance marketplace and Medicaid agency are working in tandem with HCFA on these initiatives. In Utah, advocates are helping to ensure that notices are written in plain and clear language, and the state is also actively reaching out to tribal nations for their input on communication strategies. In Colorado, community-based partners are directly assisting with updating enrollee contact information and the state has frequent communication with advocacy organizations. All three states are also coordinating closely with health insurance carriers that may have more frequent communication with members enrolled in their plans to both collect updated enrollee contact information and communicate about the upcoming changes. For example, in Utah, managed care plans are conducting outreach calls to individuals, and the state will soon be able to share more detailed information about enrollees’ eligibility determinations with the plans.

Putting the Medicaid Continuous Coverage Requirement Unwinding in Context

State officials also emphasized that it is important for all stakeholders to keep in mind that the work of unwinding PHE policies and resuming normal eligibility determination operations in Medicaid will be occurring within the context of many other substantial changes, overlapping timelines, and unique state challenges. For example, in Utah, the state is making significant changes to their eligibility determination system, recently launched a new Medicaid Management Information System, and is in the process of merging their health and human services agencies. From the perspective of the state-based marketplaces, if the PHE ends in July 2022, that coincides with their efforts to prepare for the fall open enrollment season, which involves considerable system changes and could create outreach and communication challenges. A further complication is that if the enhanced marketplace subsidies currently available via ARPA are not extended by Congress, individuals transferring to the marketplace will face considerably higher costs. Additionally, each state’s unique characteristics, such as their Medicaid and marketplace coordination arrangements and eligibility system structures, will affect the resumption of regular Medicaid eligibility operations and the overall PHE unwinding process.

States appreciate CMS’ ongoing support, but also hope that the administration will provide them with ample notice about when the PHE will end as well as offer some flexibility on certain rules to facilitate the overall process for both individuals and programs. While the many impending policy and operational issues are daunting for states, they are continuing to actively prepare and are hopeful that with a common goal across state agencies, partners, and the federal government of ensuring that eligible individuals remain enrolled, efforts will be coordinated and coverage disruptions will be minimized.