The Medicaid Unwinding: Expectations and Estimations

Written by Sarah Scarborough

The pandemic tested Medicaid and health departments across the nation. Health systems were overwhelmed with a large influx of patients and demand for healthcare coverage. Congress passed the Families First Coronavirus Response Act (FFCRA)^[1] in response to this outcry which ensured patients could assess healthcare services during the COVID-19 health emergency period (PHE) as needed.^[2] With the emergency period over, Congress is ending continuous enrollment through the Consolidated Appropriations Act (CAA).^[3] States must “unwind” the additional services and programs provided during the health emergency period and resume annual Medicaid eligibility reviews.^[4] Within a specified amount of time, States are to submit a renewal redistribution plan to the Center for Medicaid and Medicare Services (CMS) and provide monthly progress reports and unenrollment data.^[5] The full effects of this transition are undetermined, but the expectation is procedural issues coupled with stricter eligibility requirements will increase healthcare coverage uninsurance rates.

The FFCRA allowed Medicaid Programs to keep enrollees signed on regardless of income changes or family size^[6] and granted states a 6.2 % point increase in the Federal Medical Assistance Percentage (FMAP).^[7] Because continuous enrollment is ending and the increased FMAP is phasing out, Medicaid offices must review every enrollee and determine their eligibility using the enrollee’s most current and confirmed information. Enrollees must also receive a 10-day notice of termination before losing coverage, and those who lose coverage have 90 days to contact the Medicaid office and submit renewal paperwork.^[8] This sizeable task marks the largest healthcare coverage transition since the opening enrollment of the Affordable Care Act (ACA).^[9] States are likely to receive unprecedented amounts of renewals and applications. With the coverage of millions at stake, CMS will require all states to submit a renewal redistribution plan compliant with federal regulations with progress reports per CMS guidelines. Failure to accomplish these requirements during the designated time will be penalized by regular FMAP reduction and fines.^[10]

Since the unwinding encompasses such a large administrative burden, CMS is temporarily allowing states to pursue support strategies through the Section 1902(e)(14)(A) Waiver.^[11] These strategies enable states to:

Renew coverage based on SNAP and/or TANF eligibility.
Allow for renewals of those who have had zero income confirmed within the past year or whose assets cannot be verified through the asset verification system (AVS).
Partner with managed care organizations (MCOs) and enrollment brokers to update enrollee contact information.
Use the National Change of Address (NCOA) database or the US postal service (USPS) to update enrollee contact information.
Extend automatic enrollment in MCO plans up to 120 days.
Extend the timeframe for fair hearing requests.

While these strategies can possibly reduce procedural unenrollment, there will still be many who will lose healthcare coverage through Medicaid. The Kaiser Family Foundation (KFF) estimates this period could result in 7.8 to 24.4 million people becoming uninsured.^[12] As of May this year, 30 states have posted their renewal redistribution plan.^[13] During this time, collecting data and ensuring the availability of information will be crucial. State reports and unenrollment data will be publicly available.^[14] Along with this information transparency, some states and nonprofit organizations (SHADAC, KFF, and the Robert Wood Johnson Foundation) will use online dashboards to track and display this data.

While states review strategies to approach this task as efficiently and timely as possible, there are also those monitoring the social consequences of this process. Strategies to minimize healthcare coverage gaps and losses are underway. CMS recommends involving partnerships with CMOs, community health centers, and other community-based organizations to promote effective information collection and dispersal.^[15] Other strategies propose creating Marketplace assister programs to direct the unenrolled into possible Marketplace coverage options.^[16] While the full effect of the unwinding is unpredictable and uninsurance rates will increase, hopefully, strategies such as those listed above, along with the tools and aids provided by CMS, will prevent a drastic increase in uninsurance rates.

To view Mississippi’s Medicaid Operational Unwinding Plan, click here.
To view Mississippi Medicaid’s FAQs and communications toolkit, click here.
To view Mississippi Medicaid’s Renewal Distribution Report, click here.

^[1]Congress.gov. (2020). Text – H.R.6201 – 116th Congress (2019-2020): Families First Coronavirus Response Act.
^[2] U.S. Department of Health and Human Services. (2023). COVID-19 public health emergency (PHE).
^[3] Congress.gov. (2022). Text – H.R.2617 – 117th Congress (2021-2022): Consolidated Appropriations Act, 2023.
^[4] Health Reform, Beyond the Basics. (2023). FAQ, Unwinding Medicaid continuous coverage.
^[5] Gottlich, V. (2023). Public health emergency “Unwinding:” Changes to Medicaid enrollment and eligibility.
^[6] Health Reform, Beyond the Basics. (2023). FAQ, Unwinding Medicaid continuous coverage.
^[7] Musumeci, M. (2020). Key questions about the new increase in federal Medicaid matching funds for COVID-19.
^[8] Health Reform, Beyond the Basics. (2023). FAQ, Unwinding Medicaid continuous coverage.
^[9] Medicaid.gov. Unwinding and returning to regular operations after COVID-19. (2023).
^[10] Lukanen, E., Zylla, E. (2023). Reporting requirements related to unwinding medicaid continuous coverage: considerations for medicaid and the marketplace.
^[11] Medicaid.gov. (2023) Covid-19 PHE unwinding section 1902(e)(14)(a) waiver approvals.
^[12] Tolbert, J. and Ammula, M. (2023). 10 things to know about the unwinding of the Medicaid continuous enrollment provision.
^[13] Ibid
^[14] Lukanen, E., Zylla, E. (2023). Reporting requirements related to unwinding medicaid continuous coverage: considerations for medicaid and the marketplace.
^[15] Centers for Medicare and Medicaid Services (CMS). (2023). Strategic approaches to engaging managed care plans to maximize continuity of coverage as states resume normal eligibility and enrollment operations: January 2023 update.
^[16] Tolbert, J. and Ammula, M. (2023). 10 things to know about the unwinding of the Medicaid continuous enrollment provision.

REFERENCES

Centers for Medicare and Medicaid Services (CMS). (2023). Strategic approaches to engaging managed care plans to maximize continuity of coverage as states resume normal eligibility and enrollment operations: January 2023 update. https://www.medicaid.gov/resources-for-states/downloads/health-plan-strategy.pdf

Congress.gov. (2020). Text – H.R.6201 – 116th Congress (2019-2020): Families First Coronavirus Response Act. https://www.congress.gov/bill/116th-congress/house-bill/6201/text

Congress.gov. (2022). Text – H.R.2617 – 117th Congress (2021-2022): Consolidated Appropriations Act, 2023. https://www.congress.gov/bill/117th-congress/house-bill/2617

Gottlich, V. (2023). Public health emergency “Unwinding:” Changes to medicaid enrollment and eligibility. Administration for Community Living. https://acl.gov/news-and-events/acl-blog/public-health-emergency-unwinding-changes-medicaid-enrollment-and

Health Reform, Beyond the Basics. (2023). FAQ, Unwinding Medicaid continuous coverage. https://www.healthreformbeyondthebasics.org/wp-content/uploads/2023/01/FAQ-Unwinding-Medicaid-Continuous-Coverage.pdf

Lukanen, E., Zylla, E. (2023). Reporting requirements related to unwinding medicaid continuous coverage: considerations for medicaid and the marketplace. https://www.shvs.org/reporting-requirements-related-to-unwinding-medicaid-continuous-coverage-considerations-for-medicaid-and-the-marketplace/

Musumeci, M. (2020). Key questions about the new increase in federal Medicaid matching funds for COVID-19. Kaiser Family Foundation. https://www.kff.org/coronavirus-covid-19/issue-brief/key-questions-about-the-new-increase-in-federal-medicaid-matching-funds-for-covid-19/

Medicaid.gov. (2023) Covid-19 PHE unwinding section 1902(e)(14)(a) waiver approvals. https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-and-returning-regular-operations-after-covid-19/covid-19-phe-unwinding-section-1902e14a-waiver-approvals/index.html

Medicaid.gov. Unwinding and returning to regular operations after COVID-19. (2023). Medicaid. https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-and-returning-regular-operations-after-covid-19/index.html

Tolbert, J. and Ammula, M. (2023). 10 things to know about the unwinding of the Medicaid continuous enrollment provision. Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/

U.S. Department of Health and Human Services. (2023). COVID-19 public health emergency (PHE). https://www.hhs.gov/coronavirus/covid-19-public-health-emergency/index.html

The Center for Mississippi Health Policy is an independent, non-partisan, non-profit organization that provides objective information to inform health policy decisions.