Ensuring Continuity in Healthcare Coverage While Medicaid Unwinds

January 30, 2024 | Madison Hluchan, Orobosa Idehen

During the COVID-19 Public Health Emergency (PHE), Congress passed the Families First Coronavirus Response Act to ensure that individuals enrolled in Medicaid would remain covered throughout the duration of the PHE regardless of changes in circumstance that would normally impact their eligibility, such as income. This provision contributed to a substantial increase in Medicaid enrollment and a noticeable decline in the uninsured rate. However, in March 2023 the Consolidated Appropriations Act decoupled the Medicaid continuous enrollment provision from the PHE, requiring states to begin their redetermination processes with coverage termination allowed beginning April 2023. States were given approximately 12 months to complete these redeterminations.

Kaiser Family Foundation (KFF) reported that, as of Jan. 2024, over 14 million Medicaid enrollees have been disenrolled across 50 states and D.C., underscoring the complexity of the redetermination process. It also demonstrates the need for collaborative, cross-agency strategies and alignment between state and territorial health agencies (S/THAs) and the health and social service system to help people navigate coverage transitions. By partnering with their Medicaid agencies, aligning policies, and embracing innovation, states can support smoother transitions for their population, preserving Medicaid’s vital support for those in need.

S/THA Strategies to Support Continuity of Coverage

This new loss of coverage poses numerous downstream impacts to public health. S/THAs play a crucial role in mitigating these risks by directing Medicaid enrollees to resources for renewing or transitioning coverage. For instance, Health Resources and Services Administration’s (HRSA) HIV/AIDS Bureau suggests strategies for Ryan White HIV/AIDS Programs to assist in the unwinding, including:

• Collaboration with state Medicaid agencies.
• Educating clients about renewal procedures.
• Bolstering staff capacity for engagement and enrollment
• Assisting eligible clients in exploring alternative coverage options.

Similarly, this joint HRSA/Centers for Medicare & Medicaid services (CMS) letter suggests that state maternal and child health leaders work with their Medicaid counterparts to better assist individuals to understand and respond to the Medicaid eligibility review process, while also highlighting the opportunities for states to expend Title V Block Grant funds for these efforts.

CMS has also outlined strategies for various stakeholder groups to better assist individuals in the unwinding process, including the recommendation for states to leverage use of Temporary 1902(e)(14)(A) waivers. These waivers grant states the opportunity to adopt strategies such as renewing coverage based on Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) eligibility. For the seven of our state and territorial health officials (S/THOs) that have statutory oversight over SNAP, this is an option for active collaboration and influence. As for the six S/THOs with statutory oversight over Medicaid, and the 16 who work within the same umbrella agency as their Medicaid department, there are more opportunities for direct impact on innovative approaches to redetermination.

It is also important to note that S/THAs have the opportunity to connect individuals most likely to be impacted by the unwinding with trusted community partners—such as community-based organizations, community health workers, Indian healthcare providers, and tribal enrollment assisters—to access the resources and coverage they need.

State Approaches

When considering priorities and efforts of other states, the National Association of Medicaid Directors surveyed state and territorial Medicaid directors on unwinding outreach strategies and received responses for 34 Medicaid programs. Findings show that pre-unwinding, 61% of programs lacked renewal outreach funding; now, all surveyed programs allocate funding for outreach, highlighting its importance during the unwinding period. However, further need for sustainability of these efforts within states offers an opportunity for continued collaboration.

Examples of innovative approaches to outreach and collaboration include:

• Automated tools, such as Nevada's address update support, Minnesota, and Rhode Island's renewal lookup assistance.
• A live chat feature available to residents renewing coverage in Arizona.
• Communication toolkits, like North Carolina’s comprehensive unwinding toolkit, which includes communication tools for various Medicaid stakeholders to spread awareness.
• Stakeholder convenings to discuss strategy, review data, and troubleshoot issues, as seen in Kentucky and the District of Columbia.
• Video tutorials of the renewal process coordinated in Missouri and New Mexico.

While only a few S/THOs have statutory oversight over their state’s Medicaid program, the sphere of influence and insight into communities most impacted provide ample opportunity for S/THAs to provide meaningful interventions during the unwinding period. As states consider their processes for Medicaid redetermination, it’s important to recognize the valuable role public health plays in outreach, collaboration, and education of the public. It is also important to consider opportunities for continued partnership with between state public health and Medicaid agencies as both work to ensure equitable access to care.