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Notes on the unwinding: urgent focus now; long-term benefit ongoing

As the unwinding unfolds, Medicaid programs are focused on ongoing challenges that can create long term improvements for Medicaid members.


This is an intense time for all of us who care deeply about the Medicaid program and the millions of folks it serves. The unwinding is fully in earnest and the experiences and data that are emerging from the first four months both reveal important cautionary notes – notably, our mutual concern about loss of coverage to children who remain Medicaid eligible – and also actionable opportunities for state and territory Medicaid leaders and the Centers for Medicare and Medicaid Services.

Medicaid leaders are maintaining urgent focus on this work right now because all of us want to do everything possible to retain coverage for all eligible people. We also, however, recognize the reality that some of those eligible people are losing benefits and will need to be restored to coverage through reconsideration, presumptive eligibility by a Federally Qualified Health Center or hospital, or even a new application. While that last option isn’t ideal, it is a fail-safe that Medicaid remains open on a rolling basis to all eligible folks. This is why describing the unwind as a cliff off which people will necessarily fall is neither fair nor accurate.

It’s also notable that changes in state/territory operations as well as action by the federal government will both have great potential to permanently improve how members experience the eligibility process. Systems changes and adoption of tech tools in states and territories will help people to know more about their eligibility status, to get connected to the program and to remain covered.  And at the federal level, we are poised to know much more than we have known historically about where people are in the continuum of coverage options – Medicaid, marketplace and employer-sponsored insurance – with the first-ever release of consolidated coverage data, which is expected sometime in September. At too long last, that will help us to tell a more complete story about this recalibration of the system that is occurring as a result of unwinding and understand the ultimate national rate of health insurance coverage.

What member-centered changes are happening right now that have long term potential to benefit Medicaid members?

Programs are:

  • Examining data on procedural terminations to assess which members have appropriately left the program due to ineligibility or other sources of coverage, and which members may remain eligible and require more outreach and/or reinstatement of eligibility;
  • Investing in portals and apps through which members can update their own address changes, access their renewal dates, and/or understand the status of their coverage;
  • Sharing rosters of renewal dates with health care providers, so that providers can help cue their patients that renewals are occurring and help to prevent loss of coverage;
  • Improving call center capacity by refining the triage function of integrated response systems (i.e., call centers that support SNAP, Medicaid, and other human services) and implementing call-back functions and other technology that will make it easier for Medicaid members to get needed information; and
  • Striving to increase the rate of people renewed through the ex parte (passive or automatic) process, through which programs use all available data to renew Medicaid coverage before seeking more information from members themselves. 

How did we get here?

The intensity, rapid cycle and unique constraints of the pandemic inspired lots of important work by Medicaid leaders to more directly connect with their membership and gain the benefit of their lived experience with the program, partner with providers and community leaders, and preserve access to care through a broad array of flexibilities. This work, which was done with and by partners across the country, has influenced the way in which Medicaid Directors across states and territories think about and have been approaching systems change. A specific example of this during the unwinding is that several Medicaid programs have developed journey maps to better educate their staff and key partners about member experience with eligibility redeterminations.

There has never been a point in the program’s history that rivals the breadth and scope of outreach efforts to cue members to the unwinding and try to meet them where they are in the process. NAMD was able to capture this very real point in a recent member survey that found, for example, nearly 100 percent of the states responding put dedicated budget to statewide advertising and outreach campaigns aimed to help Medicaid members navigate the unwinding. That was up from just over 61 percent of those responding in previous years. While these efforts remain an important area of focus, Medicaid leaders are also acutely aware that no matter what mode or medium of communication, there remain people who are not aware of the implications of renewal, struggle with English literacy, face complex life circumstances that are crowding out attention to deadlines, or simply do not respond. That is not a surprise. Historic data on the churn experienced across Medicaid programs is clear. It is a reality that we all have to continue to try to address because no single barrier has created this issue and no single solution will solve it. This is why ALL hands on deck continues to be an appropriate call to action.

While we all aspire to implement simple and straightforward systems that enable peoples’ needs, it is also a reality that in the best of all times, the machineries that support the Medicaid program – call centers, Eligibility Management and Medicaid Management Information Systems, policy and procedural frameworks – are complicated, challenging to pivot and require significant state and federal investment. Each state has its own structure, and must navigate complex obligations related to systems standards, procurement, resourcing the state share of costs, and often staged and incremental implementation.

Critics may reasonably ask why, some years out, states continue to work to fulfill all of the Affordable Care Act eligibility standards, including, but not limited to, obligations to conduct ex parte or passive renewals. Having served as a director, I can tell you that this is in no way a failure of will or support for people served by the program. Medicaid Directors are compelled by a common interest in meeting these standards, both a means of ensuring that eligible individuals retain coverage, but also because it will be more efficient and cost-effective to operate that way. What does in fact influence the pace of progress, however, is the high cost and technical challenges of moving these systemic changes through the pipeline, especially considering having to layer new requirements over a substantial array of other obligations that predate unwinding. That said, state leaders are unwaveringly focused continuing to move this work forward.

All Medicaid leaders understand the current moment as an opportunity to innovate and improve how they do business. That is evidenced by all the work that has already occurred and by strategies that continue to be rolled out. This process is dynamic, and it is still unfolding. And it wouldn’t be happening without the partnership and collaboration of countless committee parties – CMS, sister state departments,  and the thousands of health care providers, community-based organizations and advocates that are pushing us all to do more and better. Medicaid programs across the country are not letting a good challenge go to waste. And as our partners in this effort, we know that you won’t either.

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