States Can Help Eligible Immigrants Keep Medicaid Coverage at PHE’s End

People who are immigrants and their families, who often face the brunt of complex eligibility processes that make it difficult to enroll and stay enrolled in health coverage, may be at greater risk of coverage loss when the COVID-19 public health emergency (PHE) ends. Millions of people have been enrolled in Medicaid without interruption during the PHE, but when it ends — possibly later this year or in early 2023 — states will resume Medicaid renewals. This massive renewal of eligibility for the over 80 million Medicaid enrollees will be a large undertaking for state Medicaid agencies and many people will be at risk of losing their Medicaid coverage. But massive coverage losses aren’t inevitable. States have time to prepare and should act now to ensure that eligible people, including immigrants and their families, stay covered.

The 2020 Families First Coronavirus Response Act’s “continuous coverage” requirement prohibits states from ending coverage for most enrollees during the PHE in exchange for enhanced Medicaid funding. Once the PHE ends, states will have to review the eligibility of everyone enrolled in Medicaid, a process referred to as “unwinding” the continuous coverage requirement.

Eligible enrollees could lose coverage if they don’t receive a notice to renew or don’t return requested documents on time. Others could become uninsured if they are no longer eligible for Medicaid and fall into a coverage gap because their incomes are below the poverty line and their state has refused to expand Medicaid, or if they can’t successfully navigate the process to enroll in coverage through the Affordable Care Act (ACA) marketplaces.

Medicaid is a vital source of support for people who are immigrants and their families. But these groups face barriers that make it harder for them to gain access to coverage and could lead to coverage losses during the unwinding process. Enrollment barriers to health coverage include inequitable language access in outreach and application processes, complex eligibility rules, and burdensome processes.

Many people may also experience what is referred to as the “chilling effect,” meaning they fear that accessing benefits may result in someone in their family being denied the ability to obtain an immigration status to come to the U.S. or could change their status if they are already here. The chilling effect was exacerbated by the Trump Administration’s harsh anti-immigration policies and rhetoric including radically changing the “public charge” policy. The Biden Administration reversed this policy, but many people remain fearful about accessing public benefits, including Medicaid.

As states plan for the end of the PHE, they can ensure their unwinding plan responds to barriers that disproportionately impact people who are immigrants and their families. Many of the flexibilities, streamlining strategies, and best practices that the Centers for Medicare & Medicaid Services and others have promoted will improve the renewal experience for all enrollees, including immigrants. Such practices include:

• Partnering with trusted groups that have expertise in serving people who are immigrants. State agencies should partner with local organizations including community-based organizations, health centers, and other groups that provide direct services to immigrants. These groups often have existing strategies and channels to communicate with people who are immigrants and have cultivated their trust through ongoing engagement. These groups can play a critical role in building awareness about unwinding, the importance of responding to renewal paperwork when it arrives, and where people can get help with the renewal process.
• Using inclusive outreach and communications. States and trusted groups should raise awareness about the unwinding using targeted outreach and multiple modalities including mailed notices, text messages, and email to encourage enrollees to update their contact information and submit renewal paperwork to stay enrolled. However, agency communications can be confusing and difficult to understand, particularly for people who are immigrants and those with limited English proficiency. States should work with trusted groups to gather feedback on their materials to ensure they are clear and should translate them into multiple languages to meet the needs of the people they serve. Messaging should emphasize that Medicaid enrollment — except for the use of Medicaid to pay for long-term care in an institution like a nursing home — will not negatively impact people seeking an immigration status. Messages should also reassure enrollees that their information will be kept private and be used only to redetermine their eligibility. Agencies should also ensure that their staff meet clients’ language needs when handling calls and inquiries, and that interpretation services are available when needed.
• Streamlining renewals and related eligibility verification processes. States should maximize the opportunity to use data available through existing electronic sources to re-determine eligibility without requiring action from the enrollee (known as an ex parte renewal). To the extent states must gather additional information from enrollees, they should use pre-populated forms and only request information that is subject to change. Many factors such as citizenship and Social Security numbers are not subject to change and should not be asked about on renewal forms.
• Supporting successful transitions to the ACA marketplaces for people no longer eligible for Medicaid. Some people will no longer be eligible for Medicaid coverage at the end of the PHE but will be eligible for subsidized coverage through the ACA marketplaces. Agencies can streamline transitions to the marketplaces by conducting proactive outreach in collaboration with navigators and assister groups who serve communities with large numbers of immigrants and providing notices in multiple languages that specify where people can go for help in their preferred language. Messaging can also reinforce that marketplace coverage will not negatively impact people seeking an immigration status.