As We Unwind: What we are learning and how that is influencing change

The data that CMS will soon release on the nationwide process of redetermining the eligibility of all people served by Medicaid (the “unwinding”) is important and something from which Medicaid programs are learning a great deal, but it is also best understood to be a snapshot of a point in time and a continual work in progress. Medicaid programs are vigilant, dynamic, accountable and constantly learning, course correcting and adopting new strategies to ensure that people who are eligible for Medicaid remain covered and those who are no longer eligible transition successfully to other sources of health insurance coverage. We know this directly because we have just convened a meeting of state and territory teams that abundantly illustrated their continued commitment. Conclusions should not, therefore, be drawn based solely on where we started. And we urge all involved to reinforce that Medicaid will continue to be open to all eligible people, on a rolling basis, whether they are new to the program, are being reinstated or are becoming eligible again due to changes in their employment status or income.

Brief Background on Unwinding

Every state and territory U.S. Medicaid program knows this is an incredibly important year for the millions of folks served by Medicaid. Medicaid remains an essential mainstay of health care coverage and contributor to its members’ economic stability. Reducing administrative challenges in accessing and retaining that coverage is a shared federal, state/territory priority. Medicaid is also, by design, a program that elastically responds to the needs of people in difficult times of economic downturns, severe weather events and, yes, the experience that we just had with an unprecedented global pandemic. Its membership grew exponentially over the last several years, and Congress protected all those people from loss of coverage through early Spring of this year.

As the country moved on to an endemic approach to COVID-19, economic conditions improved and our nation achieved  a historically low rate of unemployment, it follows that some people who came onto the program are no longer eligible or have other health insurance coverage. Related, Medicaid Directors are acutely conscious of their obligation to ensure that the program is only serving people who meet its eligibility criteria. This is a bedrock obligation of the federal-state/territory partnership under which Medicaid operates and is especially important when Medicaid programs across the country are responding this year to a federal mandate to redetermine the eligibility of each and every person served by the program. This “unwinding” initiative is active across all states and territories, and in every sense of the word, it is a very dynamic process.

What we are learning and how we are responding

So, what are Medicaid leaders learning and how is that influencing change?

1. Despite super saturation of messaging cueing members to the need for renewal of their eligibility, many members are not responding.

The challenging reality is that people served by Medicaid often have very complex life circumstances. One or multiple jobs that leave them little flexibility to respond during work hours. Caregiving obligations for kids and aging parents challenge their time outside work. Health conditions and the stress of financial challenges hamper their ability to respond. States and territories have massively increased the volume of their outreach to members as well as the means they are using to engage, including texting and email as well as partnerships with community organizations that are trusted sources of information and support. All that said, many people are not responding to notices or other contacts. In the best possible scenario, people are not responding because they are aware they no longer qualify and already have alternate health insurance coverage through a marketplace plan or an employer. But undoubtedly there remain people who do not respond yet remain eligible. So, what are states and territories doing? They are:

• Reinforcing early-stage contacts with child care centers, pediatricians, clergy and others;
• Partnering with private sector partners such as Family Dollar stores and large chain pharmacies to help people understand the renewal process;
• Meeting regularly with a broad range of members, health care providers, stakeholders and advocates to learn from the lived experience of all involved;
• Making proactive outreach calls to prompt members who haven’t responded; and
• Using surveys, outbound calls, and other sources of data to understand why individuals may not be responding and whether they have other sources of coverage.

2. Messaging has had the effect of dramatically increasing the number of people attempting to contact their state or territory Medicaid program.

Given that unwinding affects every single one of the almost 87 million people served by Medicaid as of March of this year, the volume of renewals that must be processed by states and territories is unprecedented. Unsurprisingly, despite careful attention to staging the coverage groups that will be renewed at any given point in the year, the huge push of messaging about the process has tended to inspire many people to reach out to their Medicaid programs, most typically by contacting their call centers.

The reality of state call centers is that many handle multiple functions, not just for Medicaid but for a range of programs such as SNAP (food stamps) and other financial assistance for families. Inquiries from callers are also often complicated and require research to resolve – these calls are often not cookie cutter, script-based encounters. Despite planning in advance, making systems improvements and contracting for additional call center staff, states and territories are experiencing extraordinarily high call volume related to unwinding. It is therefore not surprising that the initial cross-state and territory data that CMS will release is likely to illustrate the reality of long call wait times and high rates of people opting out of phone system queues. As is the case with outreach, states and territories are continuing, on a rapid-cycle basis, to innovate and adapt new strategies to address those challenges. Just a few examples include:

• Automated tools to support members in updating their addresses (e.g., Nevada) and help members look up when their renewals will occur (e.g. Minnesota, Rhode Island);
• Sharing rosters of renewal rates with health care providers such as primary care physicians and health centers (e.g., Indiana), so that clinicians can remind patients about renewal;
• Partnerships with their state-based marketplaces (e.g., New York and Pennsylvania) to ensure that eligibility platforms that integrate Medicaid and marketplace eligibility determinations are working smoothly and well;
• Use of staff, integrated voice response systems or chatbots (e.g., Colorado and Oregon) to triage calls as they come in, so that people can be appropriately directed;
• Use of a “pizza tracker”-type apps (under development) to help people understand the status of their application and redetermination without needing to contact a call center; and
• Call-back functions (many states) that ensure that people don’t have to wait for lengthy periods on the phone.

3. Every state and territory wants to streamline and modernize the process of conducting renewals, notably through increasing the percentage of renewals that can be completed without obtaining new information from members (the “ex parte” process).

State and territories strongly support means of streamlining the Medicaid eligibility and renewal process to reduce administrative burden for members. A key example of this is that the federal government has required programs to use best efforts to determine and renew eligibility by using data, such as information on income, that can be obtained from existing sources instead of asking members. It has been a work in progress for all states to fulfill these “ex parte” requirements. A typical historical starting point  centered on systems and processes to renew coverage for families. By contrast, it has been less typical to have used this process for other coverage groups, such as older adults and people with disabilities. Medicaid programs acknowledge the need to increase the incidence of renewals conducted by ex parte and appreciate the support of the federal government’s US Digital Service, which is working with a group of states on rapid cycle,  “sandbox” solutions to help enable higher rates of this kind of renewal through scalable technology improvements.

4. Key indicators of how unwinding is going will not be linear and will have to be reconciled on a rolling basis.

We acknowledge that the key indicators that CMS will release are an important means of starting to understand how the unwinding is going. This includes, but is not limited to, data points that help to describe access to and experience with state call centers, rates of renewals, and rates of people losing Medicaid coverage. CMS’ approach will also helpfully include other vital aspects of this story, such as new application activity and means of comparing current experience with historical data on migration on and off the program. All of that said, the data CMS will release is now three months old and states have been hard at work addressing the early challenges identified above through new and refined strategies.

We can also expect that month over month, this data won’t be linear. Not only will adjustments be made to reflect people being restored to coverage, but new people are continually applying for Medicaid coverage and that activity will have to be reflected as well. Related, while we are grateful to see CMS publishing some early indication of how many people are transitioning to marketplace coverage, it won’t be until later this year that this information will be more specific and complete and that there will be a means to report how many people have gained employer-sponsored insurance. All of that commends caution in drawing conclusions about the overall picture of things.

The bottom line is that states and territories remain hard at work on this process. They are learning and gaining discernment from data, but also from the experience of members, providers, and advocates. We all share the goals of retaining coverage for all who are eligible, correcting for unintended administrative errors, adopting, and scaling new strategies and remaining alert until the very last person’s renewal has been completed. This story is still in its early chapters, but Medicaid programs are determined to ensure that it carries through to its best possible end.