Unwinding Update: Different vantage points, shared goals

Last week I had the opportunity to join Dan Tsai of the Center for Medicaid and CHIP Services and Allison Orris of the Center for Budget and Policy Priorities in discussing the current state of Medicaid unwinding – the challenges, the good news, and implications for the future – with the Medicaid and CHIP Payment and Access Commission (MACPAC). While we come from different vantage points, what remains most striking is the strength of our mutual commitment to our primary constituents – each and every person in the nation who is eligible for Medicaid and CHIP.  Taking a page from CMCS’ central message, all hands truly are on deck towards ensuring that Medicaid and CHIP eligible people have smooth access to and can readily retain their coverage.

State and territory Medicaid staff are central to this effort and remain actively and dynamically at work. This includes learning from unwinding data and experience, issue spotting and responding to feedback from members and partners, and proactively collaborating with both federal partners and the myriad entities – managed care organizations, health care providers, community-based organizations, and advocates – that are essential to achieving that shared goal. This is where we started and where we will end. We are strongest when we are clear-eyed about the challenges that we are collectively facing, acknowledge that this is shared work in progress of unprecedented scope and scale, and support and elevate Medicaid leaders in this hard and worthy work.

The Challenges

Given the great variability of circumstances for individuals and families served by Medicaid,  the complexity of rules that govern program eligibility, and differences in the state and territory systems that support enrollment, issue spotting and course correction is difficult for states, territories, and the federal government. At the federal and state levels, we are also balancing among competing, costly operational and systems priorities that require time and resources to pivot. Another challenge is the difficulty of unpacking and interpreting procedural terminations. All of us are urgently compelled to intervene when otherwise eligible people – especially children – lose coverage. Medicaid leaders are acutely aware that people served by the program have complex lives and may require multiple contacts and extra support to complete the eligibility renewal process.  Another aspect of procedural terminations, however, undoubtedly includes people who qualified for and remained covered by Medicaid during the pandemic but are no longer eligible. These folks may already other coverage or may need help connecting with other options. While more than forty states and territories are publishing data dashboards and reports that are helping to provide more detail on procedural terminations, until we have more detailed national data on migration to Medicare, the marketplace and employer-sponsored insurance– early indicators of which are expected to be released by the federal government this month – we will be hampered in telling a more complete story of what is actually happening.

The Good News

It is remarkable how much unwinding of the continuous coverage requirement has elevated public consciousness of the primacy of Medicaid’s role in both health care coverage and economic security for individuals, families, and communities. Medicaid worked exactly as intended during the pandemic, when countless people faced loss of access to health care and epidemic rates of job loss. Unwinding has also raised collective consciousness about longstanding opportunities for states and territories, but also the federal government, to streamline connections to the Medicaid program and improve continuity of coverage. Improved transparency of data, both at the national level through CMCS’ publication of core indicators and through detailed dashboards at the state level, is a central good that has emerged from unwinding. Finally, unwinding has activated state and territory Medicaid leaders and their teams to pay close attention to each and every interval to promote coverage continuity for eligible people, from ex parte through reconsideration and even restoration of coverage through presumptive eligibility, where despite multiple modes of contact, a member has not responded to renewal inquiries. We can never say it too many times: Medicaid, unlike private insurance, always remains open to all eligible people.  On each of these points, states and territories, CMCS and national advocates remain fully aligned.

What may be less publicly visible is the extent to which states and territories have been unwaveringly tenacious in their unwinding efforts, constantly working in close partnership with both their peers and CMCS to identify issues and offer solutions. Specifically, states are taking unprecedented steps to remove barriers, reach and renew families, and support reinstatement or reenrollment of eligible people if they do lose their coverage. NAMD is a proud convenor and collaborator in this work, bringing together active affinity groups of Medicaid peers – among them, directors, eligibility leads, chief financial officers and communications leads – for active sharing of emerging issues and practical examples of tactics and strategies. NAMD and its member directors also regularly and candidly compare notes and strategies with CMCS leadership and other important federal partners (the United States Digital Service and the Administration for Community Living, just to name two important examples) and have been very privileged to partner with State Health & Value Strategies (SHVS) in important, ongoing technical assistance.

A terrific example of this is that in July, states, territories, CMCS, and SHVS technical assistance experts joined together for an intensive two-day unwinding summit. The aim was to have deep and transparent conversation about unwinding issues, challenges, and best practices – around member engagement and communications, discerning and analyzing unwinding data, and specific interventions including use of call center technologies to better support members who need additional help. That is exactly what we all experienced, and there is no substitute for having been together in one big room to compare notes and to learn from one another.

Evidencing many other aspects of the intensity and constancy of state and territory actions on unwinding, SHVS also produces States of Unwinding: How State Officials are Innovating to Support Coverage, which is regularly refreshed with capsules of best practice. These span from continued creativity around outreach and engagement to means of supporting people who need extra help in understanding their eligibility status. The strategies also reflect efforts to protect particularly vulnerable people and to follow up with people who have experienced a procedural termination. See just a few important examples below:

• Kentucky: Kynect Benefits, the state’s single-stop website for state benefit programs, created a back-to-school flier to inform families who are enrolled in Medicaid or CHIP coverage that their renewal letter will be coming soon and the actions they need to take to remain covered. The flier, which is also available in Spanish, includes contact information and a QR code directing individuals to more information about the unwinding.
• West Virginia: The state’s Medicaid enrollment website now allows individuals to search for community partners to help them enroll. The West Virginia Department of Health and Human Resources has upgraded search features on WV Path, the enrollment and eligibility website for Medicaid, SNAP, and cash assistance applicants and enrollees. Now users can search for “Community Partners,” organizations and individuals who help West Virginians enroll in benefit programs, by county.
• Michigan: The Michigan Department of Health and Human Services (MDHHS) is extending the renewal of enrollees undergoing life-saving treatment through May 2024 to ensure these enrollees can keep their healthcare coverage and complete their treatment. The extension for those receiving life-saving treatment applies to enrollees undergoing chemotherapy, radiation, immunotherapy infusions or dialysis who are not able to be renewed through ex parte and do not have other comprehensive health insurance coverage, like Medicare.
• Maine: The state is calling MaineCare member households who did not return their renewal paperwork in a given month. As a result of such calls, over 1,200 households initiated or completed their June renewal, and over 500 requested to close their MaineCare coverage for reasons such as having other insurance or no longer being a resident of Maine.

Looking to the Future

As we near the mid-point of the unwinding process, all of us are interested in what the ongoing work of unwinding will look like and which current measures, strategies, and learning should be adopted permanently. Across the country, unwinding will continue to reflect an active and continuous cycle of examining data and experiences of people enrolled in Medicaid and CHIP and responding with interventions. This is not a static undertaking. States and territories are actively assessing which of the waiver-based flexibilities offered by CMS are most probative of continued coverage for eligible people and need to know, as soon as feasible, which authorities CMCS will permit Medicaid programs to retain permanently. Medicaid programs will also need firm commitments from CMCS and systems vendors to develop and implement broad, scalable technology solutions, replacing the more state-by-state, first-dollar approach that has typically been taken historically. All will benefit from routinizing release of national data that illustrates the migration to and from Medicaid and other sources of coverage and supports more of a continuum approach that reflects peoples’ changeable employment and income. Finally, and most foundationally, Medicaid leaders are committed to embedding direct means of hearing and responding to members’ experience with eligibility processes. When we met with states and territories for the unwinding summit, one of the most important and material aspects was hearing from members of the Colorado Medicaid Member Experience Advisory Council. As member Samantha Fields said, “we look at state data and say, that’s my life you’re talking about.”

When we talk frankly but also proactively and constructively about experience with the unwinding and how to keep improving it, we are “talking about peoples’ lives”; that is, their health, well-being and economic security. At the end of the day, this is what continues to motivate and inspire all of us – states, territories, CMCS and advocates.