Medicaid Unwinding: plans, challenges, and tools

Brandy Davis
Fellow, Medicaid Policy
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October 2, 2023
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During the Public Health Emergency (PHE), the Families First Coronavirus Response Act (FFCRA) provided states enhanced federal funding if states agreed not to disenroll members from Medicaid. With the end of the public health emergency, also came the end of the enhanced federal funding that FFCRA provided. States are now returning to enrollment as it existed prior to the public health emergency in a process known as “Medicaid Unwinding.”

Ending pandemic-expanded Medicaid coverage

Ohio resumed its regular Medicaid eligibility operations on February 1, 2023. This marked the end of the continuous coverage provision that prevented the disenrollment of members from Medicaid, even if they were found ineligible, due to the COVID-19 pandemic. In December 2022, President Biden signed the Consolidated Appropriations Act (CAA) 2023, which delinks the continuous coverage provision from the PHE effective March 31, 2023. Ohio received approximately $5.1 billion in enhanced federal matching funds (eFMAP) through December 2023. Ohio returned to normal eligibility operations on February 1, 2023, and disenrollment began in April 2023.

 Starting April 1, 2023, Ohio began the process of re-determining Medicaid eligibility for all its members.

Starting April 1, 2023, Ohio began the process of re-determining Medicaid eligibility for all its members. Those found ineligible would be disenrolled from the program. It is crucial for Medicaid members to keep their contact information up-to-date and respond to any requests for information, including renewal packets. The unwinding of Medicaid back to the traditional enrollment process is resulting in mass disenrollments nationwide. Ohio's unwinding process will occur over a 12-month period. Some renewals will be automatic or ex parte, based on data comparisons, while others will require members to work with their County Department of Job and Family Services (CDJFS) to complete the process manually. Children under the age of 19 will retain coverage for twelve months from their initial eligibility determination or most recent renewal.

Procedures and paperwork issues could jeopardize coverage

In Ohio, the average call center wait time was 4 minutes and the average call abandonment rate was 3 percent. Sixteen percent of enrollees were terminated for what is referred to as procedural reasons or because of paperwork issues.

 Sixteen percent of enrollees were terminated for what is referred to as procedural reasons or because of paperwork issues.

The Department of Health and Human Services (HHS) previously sent letters to Governors to encourage adoption of automatic renewal strategies. These federally-authorized strategies include redetermining Medicaid financial eligibility when SNAP (Supplemental Nutrition Assistance Program) or TANF (Temporary Assistance for Needy Families) gross assets are below income limits or renewing Medicaid eligibility for individuals with income at or below 100 percent Federal Poverty Level, who did not return any data through the automatic (or ex parte) data retrieval process, promote continuity of coverage. Federal authority even allows automatic reenrollment into a Medicaid managed care plan up to 120 days after loss of Medicaid.

From episodic to continuous coverage…and back again?

Prior to the changes in enrollment that existed during the public health emergency, there was an episodic nature to how people accessed Medicaid coverage. A patient could need care at varying access points. That need could vary from critical care in a hospital setting to acute care at a federally qualified health center. This episodic enrollment and cyclic termination did not foster the continuity of coverage that promotes healthier patients. The continuous coverage provided through the public health emergency and CAA was the first of its kind.

 The continuity of coverage that the public health emergency allowed Medicaid to provide is no longer guaranteed.

While the details surrounding patients disenrolled from Medicaid are not yet able to paint a picture of how they are faring after loss of coverage, the expectation is that some patients will transition into the Marketplace. Just as the Marketplace has changed a lot since it launched on October 1, 2013, so has the coverage it offers. The cost-sharing and copayments associated with Marketplace coverage make the coverage less accessible for many individuals is simply not as comprehensive as Medicaid coverage. The association between higher cost-sharing and inaccessibility of care for lower income individuals is a trend that extends to all types of cost-sharing plans. The continuity of coverage that the public health emergency allowed Medicaid to provide is no longer guaranteed. Patients will choose between paying what some view as a minimal copay or cost-share and making decisions that have more immediate impacts on their households.

Tools to navigate the Medicaid renewal process

Ohio Department of Medicaid (ODM) has provided resources and tools to help both members and stakeholders navigate the renewal process and understand the impact of the changes. There are FAQs, contact information and support available to assist members in maintaining their coverage. Data indicates an increase in uninsured patients in Ohio since the end of the Public Health Emergency (PHE). This highlights the importance of Medicaid members taking action to maintain their healthcare coverage. Ohio's efforts to prepare for the unwinding of Medicaid eligibility procedures following the COVID-19 Public Health Emergency (PHE) have been extensive.

Ohio’s unwinding plan will rely on analytics, accuracy, and communication

Ohio's plan for unwinding its Medicaid procedures following the COVID-19 Public Health Emergency (PHE) include several key components:

  1. Identifying Likely Ineligible Individuals: Ohio will use a data analytics vendor to identify individuals enrolled in Medicaid who are deemed "likely ineligible." These cases will be prioritized for processing when the PHE ends.
  2. Timely Processing: The state aims to complete the redetermination of eligibility for individuals deemed likely ineligible within 90 days of the end of the PHE.
  3. Compliance with Federal Guidelines: Ohio will work to align its unwinding efforts with federal guidelines, ensuring that eligibility determinations are made in compliance with regulations.
  4. Balancing Priorities: The state acknowledges the importance of balancing the processing of likely ineligible cases with other priorities, including new applications, changes in circumstances and federal corrective action plans.
  5. Effective Communication: Ohio planned a comprehensive communications strategy to keep stakeholders, including Medicaid beneficiaries, counties, advocacy organizations, providers and legislators, informed about the unwinding process. This includes identifying key messages, communication mechanisms and timelines.ODM continues to rely on data analytics to evaluate and prioritize cases, ensuring that the eligibility reviews are based on the most up-to-date information. ODM will conduct audits of its unwinding efforts and submit reports to public officials, as required by state law. ODM's plan focuses on efficiently and accurately redetermining Medicaid eligibility for individuals while maintaining compliance with federal guidelines and communicating effectively with all stakeholders involved in the process.

Public Health Emergency (PHE) impacts on Medicaid caseload

Medicaid's caseload increased by about 760,000 individuals (27.3%) since February 2020. Approximately 41% of newly enrolled individuals during this time are children, and 12% are newborns. Ohio estimates that the caseload increase peaked at 800,000 by May 2023 and expects to reduce it by approximately 220,000 individuals over eighteen months.

Regulations governing Ohio's return to normal eligibility operations

Ohio must adhere to federal requirements in place before the Consolidated Appropriations Act, 2023 (CAA) and new reporting requirements in the CAA. Ohio is working within two federal corrective action plans (CAP) put in place in 2020 to address application backlog and audit findings. The 134th General Assembly passed House Bill 110, which contained provisions directing certain aspects of Ohio's unwinding operations.

Unwinding challenges at the county-level

Ohio Department of Job and Family Services offices handle multiple programs, including Medicaid, SNAP, TANF and childcare. Ohio's county-level eligibility offices face challenges, including outdated enrollee contact information, eligibility workers' lack of experience processing renewals without continuous eligibility and staffing shortages.

Ohio's automation efforts

ODM has made efforts to automate and streamline processes, including improvements to IT systems. A third-party vendor (Public Consulting Group) assists in identifying "likely ineligibles," allowing counties to prioritize cases. ODM has provided additional resources to county partners. ODM has conducted outreach and communication efforts.

Resumption of routine eligibility operations

Eligibility determinations must follow federal procedural requirements, including processing no more than 1/9th of the caseload each month, using data not older than three months and notifying individuals at least twice. Termination occurs at the end of the month following the determination that an individual is no longer eligible.

Comprehensive member outreach and transition

ODM developed a partner packet with key messages, including updating contact information, responding to requests for information and transitioning to other coverage if no longer eligible. Individuals who are no longer eligible may be eligible for other coverage through their employer or the federally facilitated marketplace. Ohio offers assistance through insurance navigators and the website

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