States Using Unwinding Lessons To Improve Medicaid: KFF

Dive Brief:

• Most states are done unwinding Medicaid, and are thinking about how lessons learned during the process can permanently improve enrollment and renewal in the safety-net insurance program, according to new research.
• The unwinding has helped states expand Medicaid eligibility to more people, and make changes to streamline administration and outreach, found a new survey of state Medicaid officials by health policy think tank KFF.
• All but four states say they want to permanently retain waiver flexibilities from the federal government, including automatic renewals and using more up-to-date information from health plans to contact enrollees.

Dive Insight:

During the pandemic, states agreed not to kick any beneficiaries off Medicaid in return for more generous federal funding. As a result, Medicaid enrollment snowballed to roughly one in four Americans. However, states resumed checking beneficiaries’ eligibility for Medicaid last spring, and have removed an estimated 23 million people from the program since.

Redeterminations have not been easy for the states for a number of reasons, including the sheer size of the task, a lack of resources at Medicaid agencies, shifting federal guidance and difficulty contacting enrollees to determine eligibility.

As a result, the process has dragged. Though all states were expected to complete redeterminations this month, at least ten states are still working toward completion, according to the KFF.

In addition, redeterminations have been dogged by high levels of improper disenrollments, when people are removed from coverage despite still being eligible.

Unwinding has been “high stakes” for states, the CMS and patients, said Robin Rudowitz, the director of the KFF’s Program on Medicaid and the Uninsured, during a Thursday webinar discussing the survey.

Yet state Medicaid programs say they’re emerging from redeterminations stronger for it.

“It wasn’t easy. But I thought overall, with the tools and workflow that we brought to this job, it went very well,” said Patrick Beatty, the deputy director of the Ohio Department of Medicaid, during the webinar.

One key factor has been improvement in automated renewal processes, called “ex parte renewals,” wherein states use existing data to verify whether an enrollee is eligible. Ex parte renewals have been found to cut back on paperwork and lower improper terminations.

All states took action to improve ex parte renewal rates during the unwinding, and plan to continue those strategies after, according to the survey. Forty-two states used CMS waivers to increase automated renewal rates, such as allowing automated renewals for people with no income or using eligibility for other government assistance programs to confirm Medicaid eligibility.

Prior to the pandemic, every single Medicaid renewal in North Carolina needed to go through a physical employee, creating a time-intensive and largely decentralized system, according to Emma Sandoe, deputy director of medicaid policy in the North Carolina Department of Health Benefits.

“Now we’ve really modernized our eligibility system,” Sandoe said during the webinar. “Now we have a lot more of the renewals as well as the applications going straight through our computer systems so our eligibility workers are able to focus more on those complex cases and the individual back-and-forth with Medicaid beneficiaries.”

States have also turned to more outreach methods, including email and text, which have also been a big help, according to the survey.

Many states started text messaging their enrollees for the first time during redeterminations, which really improved outreach, said Jessica Stephens, senior policy advisor in CMS’ Medicaid division, during the webinar. Lost or misdelivered physical mail has been a driver of improper disenrollments.

Thirty-seven states plan to maintain these outreach strategies, according to the survey. And, more than two-thirds of states plan to continue engaging health plans in the renewal process.

As for coverage, this year alone two states increased eligibility levels for children or for pregnancy coverage, while eight states extended coverage to some immigrant children or pregnant individuals — and three states did both, the survey found.

The CMS recently extended its unwinding waiver flexibilities through June 2025 as regulators assess what waivers can and should be made permanent. All states but Florida have used at least one waiver during redeterminations.

In addition, a CMS rule earlier this year included many changes requested by state agencies, including allowing states to accept contact information from Medicaid health plans and use U.S. Postal Service addresses.

“There are so many lessons… that we’re seeking to embed in the fabric of Medicaid and renewals moving forward,” Stephens said, adding later: “We’re working with states to get to the finish line — which is not a finish line, because renewals are forever.”