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Unwinding Watch: Tracking Medicaid Coverage as Pandemic Protections End

Our “Unwinding Watch” will highlight key developments as states resume determinations on people’s Medicaid eligibility. Previously, the pandemic-related “continuous coverage” requirement safeguarded this coverage for millions of people.

As of April 1, 2023, states may begin ending coverage for people found ineligible or whose redetermination can’t be completed for procedural reasons. This so-called “unwinding” process will last through May 2024; start dates for coverage losses vary by state.

States and consumer advocates prepared for this major event, but coverage losses are expected, even among people still eligible.

For more information, see our “End of the Pandemic-Era Medicaid Continuous Coverage Requirement” resource page.


May 30th: A survey of Medicaid enrollees, released by KFF last week, points to the need for enhanced outreach to help people either retain their coverage or to transition to other coverage that they might be eligible for.

Among KFF’s key findings:

  • Most Medicaid enrollees were not aware that states are now permitted to resume disenrolling people from Medicaid. This could mean that people are not focused on renewal notices that states are starting to send out and may not realize that action is required.
  • Nearly half of Medicaid enrollees say they have not previously been through the Medicaid renewal process, which was paused for three years. KFF points out that this group could be less likely to understand the importance of completing renewal forms to retain coverage.

These findings, coupled with early data revealing a high percentage of procedural terminations (which occur when someone doesn’t return renewal forms, for example; it does not mean they no longer meet eligibility criteria) underscore the need for the Centers on Medicare & Medicaid Services (CMS), states, and stakeholders to redouble efforts to communicate that current enrollees should watch their mail and take action, if needed, to renew their coverage.

CMS has posted various communication resources that states and stakeholders can use to communicate about eligibility determinations resuming. CBPP developed these community talking points. Other unwinding resources are also available from organizations such as Community Catalyst, Georgetown Center for Children and Families, and State Health and Values Strategies.

KFF also found that more than 4 in 10 people whose only coverage is Medicaid wouldn’t know where to look for other coverage if they lose Medicaid during unwinding or would end up uninsured. This also points to a need for increased education and outreach to help connect people to marketplace or employer sponsored coverage that could be available to them.

May 24: Data from early unwinding states give some reason for concern. Arkansas and Florida both terminated coverage for more than half of the enrollees for whom they completed renewals. The vast majority of those who lost coverage were terminated for procedural reasons ― meaning they didn’t submit the renewal form or other required documentation ― and not because they were determined to be no longer eligible for Medicaid. Both states said they prioritized initial redeterminations for enrollees they’ve identified as likely ineligible but had “protected” while the continuous coverage requirement was in effect. Indiana and Iowa similarly have very high rates of procedural terminations, while Arizona and Pennsylvania appear to be successfully renewing most of their enrollees.

More information is needed to fully understand these numbers. For example: will there be a spike in applications by eligible people who lost coverage and reapply? Are there stories of people not receiving notices or not being able to get through to call centers to complete their renewals? Such information would suggest that states need to increase their outreach efforts and scrutinize their operations to prevent high rates of procedural terminations. A high rate of procedural terminations might be less problematic in a state that also has a very high rate of ex parte (automated) renewals, because people who receive forms in the mail in those states are more likely to no longer be eligible and may choose to not return renewal forms. 

Organizations such as Florida Health Justice Project are documenting compelling stories of situations where people are falling through the cracks, because Florida hasn’t expanded Medicaid or due to poor communication by the state. How Florida and other states respond to stories and other data in their own states will be telling as unwinding unfolds over the next year.

May 12: The Centers for Medicare & Medicaid Services (CMS) recently launched its Enrollment Assistance Personnel (EAP) program, which will provide outreach and assistance for people no longer eligible for Medicaid who need help transitioning to ACA marketplace coverage. The program will operate in 23 counties across 12 states (Ariz., Fla., Ill., La., Mich., Mont., N.C., Okla., S.D., Tenn., Texas, and Utah), and CMS anticipates the program will begin in earnest in June.

The EAP program, run by private contractor Cognosante, will supplement existing Navigators and enrollment assisters in these counties, conducting direct outreach, providing ACA marketplace application and enrollment assistance, and referring people to other organizations and resources when appropriate. In some states, Cognosante may also sub-contract with existing assister organizations.

CMS requires that EAP staff receive training at the same level as Navigators and observe the same consumer protections, including protection of personally identifiable information and a requirement to provide unbiased information about ACA marketplace plans. Like Navigators, EAP staff can’t recommend a specific marketplace plan and don’t receive commissions from health insurance companies.

May 1st: A second group of 14 states have begun their first terminations of Medicaid coverage as part of unwinding the continuous coverage provision. Some enrollees in Connecticut, Florida, Indiana, Iowa, Kansas, Nebraska, New Mexico, Ohio, Oklahoma, Pennsylvania, Utah, Virginia, West Virginia, and Wyoming lost Medicaid coverage for the first time in over three years effective May 1. Arizona, Arkansas, Idaho, New Hampshire, and South Dakota terminated coverage for additional enrollees in May after beginning terminations in April.

We can expect to see data trickling in over the next couple of weeks that will begin to give an indication of outcomes in the first 19 states that started terminating coverage in April or May. States must submit reports to the Centers for Medicare & Medicaid Services (CMS) by May 8, and some of them will likely publicly post those reports after submitting them, as West Virginia has begun doing for prior months. Other states have dashboards with detailed unwinding data that may soon reflect April activity, including Iowa, Pennsylvania, Utah, and Virginia. And we expect CMS to begin releasing data on ex parte renewal rates and call center wait times across states sometime in June.

April 26: People who are no longer eligible for Medicaid following a redetermination may be eligible for Affordable Care Act (ACA) marketplace coverage with premium tax credits, but only if they do not currently have an offer of employer-sponsored insurance (ESI) that is considered affordable (employee share of premiums does not exceed 9.12 percent of income in 2023).

An estimated 3.8 million people losing Medicaid eligibility have ESI or an affordable offer of ESI, but they will need to act quickly to transition to ESI. Employers must provide people losing Medicaid or CHIP at least 60 days following loss of coverage to enroll in ESI (although they have the option to provide more time). If people miss this window, they qualify for the Unwinding Special Enrollment Period and can enroll in ACA marketplace coverage any time before July 31, 2024, but they do not qualify for premium tax credits or cost-sharing reductions to lower the cost of coverage and care.

For more information on helping people losing Medicaid/CHIP transition to ESI, see our FAQ: Transitioning from Medicaid to Employer-Sponsored Insurance.

April 5th: A letter from the U.S. Department of Health and Human Services Office for Civil Rights (OCR) reminds state health officials of their obligations to provide people with limited English proficiency (LEP) and people with disabilities meaningful language access and effective communications to ensure those who remain eligible maintain access to coverage during unwinding.

Under long-standing anti-discrimination laws, all individuals must have an equal opportunity to participate in federally funded health programs, including Medicaid. This means states must provide communications to people with disabilities that are as effective as their communications with all other groups, and they must take reasonable steps to provide meaningful language access to people with LEP.

OCR’s letter provides examples of best practices and offers to provide technical assistance to states.

April 1st: States can resume Medicaid coverage terminations as of April 1. Five states — Arizona, Arkansas, Idaho, New Hampshire, and South Dakota — have done so.

Unwinding enrollment data for these five states are pending. All states must submit reports with redetermination data each month to the U.S. Department of Health and Human Services.

The data will be made publicly available in the coming months and will include metrics such as the number of procedural terminations, rates of renewals conducted ex parte (that is, automatically), and state call center wait times. The reports will help stakeholders monitor states’ unwinding activities in this crucial period.

The month of a state’s first terminations depends on when they initiated the unwinding process. From here, we expect about 14 states to have their first set of terminations in May, 22 states in June, and nine states in July.