By Suzanne Wikle

With the end of pandemic-era protections for people insured by Medicaid, we’re learning more about states’ outcomes for Medicaid renewals. Since states were barred from disenrolling virtually any Medicaid recipient for over three years, enrollment reached record highs and the rate of people lacking health insurance hit record lows. But as of April 2023, states were allowed to disenroll people who either didn’t complete the renewal process or were no longer eligible. Currently, more than 6 million people have lost Medicaid coverage, and that number will increase.

The disenrollment fallout is tragic on a personal level; on a systemic level, it is both enlightening and highly concerning. Requirements for states to submit certain renewal data to the Centers for Medicare and Medicaid Services (CMS) and CMS’s hypervigilance in monitoring state performance have put a spotlight on Medicaid renewals, illuminating issues that either go against the spirit of the law or outwardly violate it. CMS issued a document in July that outlined areas of noncompliance for each state, but many of these problems have likely been happening for nearly a decade—ever since Affordable Care Act rules updated state requirements for Medicaid application and renewal processes. Examples include:

Non-compliant renewal pathways.

Regulations require that people be able to submit renewals in person, by mail, via phone, or online. Not all states are complying with either the letter or spirit of this law. Twenty states have a mitigation plan with CMS to enhance the availability and accessibility of renewal pathways. Mississippi didn’t offer an online pathway for renewals, and only when pushed by CMS with unwinding did the state provide an online option, albeit one that is a stopgap measure. Several states were not attempting ex parte renewals for elderly and disabled populations as required. And while other states may technically offer all four pathways, they have unnecessary barriers. Some require an appointment for a telephonic renewal or don’t allow telephonic signatures, so people still must receive a mailed form, sign it, and return it. Prior to unwinding, Texas didn’t mail renewal forms to people; rather, it mailed letters directing people to find renewal forms through Texas’s online portal.

Incorrect ex parte process.

The first step for all Medicaid renewals is an attempt by the state to renew cases ex parte. States must use existing data to see if an individual is still eligible, and if so, renew that person’s Medicaid without any action needed by the individual. During the unwinding process it became apparent that some states are renewing entire households at once via ex parte, rather than individuals. Although this may seem like just a technical issue, this error results in people – primarily children – losing coverage because income eligibility limits for children are often higher than for adults. In those instances, children should be automatically renewed even if their parent(s) need to complete a paper renewal form. On August 30, CMS issued a letter to states outlining this issue and providing states with four options to come into compliance. As a result, 30 states reported conducting ex parte reviews incorrectly, and CMS is therefore requiring that 500,000 people have their Medicaid coverage reinstated. In addition to the household/individual issue, unwinding data has shown that ex parte rates vary widely across states, with some reporting fewer than 15 percent of cases renewed ex parte. It’s critical to understand what’s holding certain states back from more ex parte success to reduce administrative burdens and make the renewal process more equitable across states.

Improper coverage terminations.

States are required to give at least 10 days’ notice before disenrolling someone from Medicaid and may not disenroll anyone while completed renewal paperwork is pending with the state. Advocates in multiple states have reported hearing about people being disenrolled without receiving any notices, without ever receiving renewal paperwork, or after paperwork has been returned to the state but not processed. Kansas temporarily halted disenrollments due to mail delays contributing to improper disenrollments and changed its renewal timelines to come into compliance.

What’s next?

Now that these shortcomings have been identified, advocates, state agencies, and CMS must do better. Advocates are now able to see how many people are successfully renewed, how many renewals are done ex parte, and how many people are disenrolled, including for procedural reasons. Although the data isn’t perfect—for example, only a few states included racial, ethnic, or age breakdowns—it provides enough information to see where states need to examine their policies and practices to retain more eligible people in Medicaid.

While the magnitude of the task of “unwinding” from the pandemic-era continuous coverage provision may account for some poor outcomes, the reality is that many of these are systemic issues that will persist if not corrected. This includes ensuring that eligibility systems are properly programmed to follow policy and law; that notices are clear and available in multiple languages; and that state agencies and call centers are adequately staffed.

As the body that oversees Medicaid in states, CMS will play a critical role going forward. Its ability to hold states accountable through measures like pausing terminations or reducing federal Medicaid payments is mostly time-limited during the unwinding process. But CMS can do more to clarify policy, which will help state agencies and advocates know where to look for solutions. An example of this can be found in the individual-versus-household ex parte renewal process mentioned earlier. Laying out clear expectations that states must follow for this process would help minimize disruption and harm. More ex parte guidance about the acceptable age of data used in the process, how to handle people enrolled in multiple benefit programs, and outlining expectations for people who are elderly and disabled are needed. CMS can also push for continued data reporting and transparency after unwinding ends, continued state flexibilities during unwinding, and continued monitoring of states, as well as provide technical assistance as needed.

The Medicaid unwinding process shows how important Medicaid is for tens of millions of people and creates a roadmap for improving the program. It’s up to all of us to make sure the spotlight on Medicaid doesn’t fade away before systemic issues are fixed.