On March 3, 2022, the Centers for Medicare & Medicaid Services (CMS) released a State Health Official (SHO) letter, “Promoting Continuity of Coverage and Distributing Eligibility and Enrollment Workload in Medicaid, the Children’s Health Insurance Program (CHIP), and Basic Health Program (BHP) Upon Conclusion of the COVID-19 Public Health Emergency.” The guidance lays out expectations, options and flexibilities for states as they develop their operational plans for resuming Medicaid redeterminations. Per CMS guidance, states are expected to adopt a “risk-based approach” when prioritizing pending eligibility and enrollment actions, which could be a:
- Time or age-based approach, which prioritizes cases based on the length of time the case has been pending
- Population-based approach, which prioritizes renewal actions based on characteristics of cohorts or populations that are likely to remain eligible, have become eligible for more expansive Medicaid benefits, or become ineligible for Medicaid and eligible for different coverage
- Hybrid approach, which combines the population and time-based approaches
- State-developed approach, which must meet the goals of maintaining coverage of eligible individuals, minimize the extent to which potentially ineligible individuals remain enrolled, achieve a sustainable renewal schedule and meet the 12-month unwinding timeline expectations.
Most states are pursuing a hybrid approach by planning for a time/age-based approach overall but layering on a population-based approach by flagging specific populations for earlier or later renewal.
State Medicaid agencies have (appropriately) been devoting their resources to planning their risk-based approaches, improving their overall renewal processes, strengthening communication, reducing returned mail, and leveraging their community-based organizations and Medicaid managed care plans for outreach and communication. In addition to these broad continuity-of-coverage strategies for all current Medicaid enrollees, states can consider additional targeted strategies to ensure continuity of coverage and care for sicker individuals with higher health care access needs.
Medicaid Strategies to Support Continuity of Coverage and Care for High-Need Enrollees
Identify enrolled populations who are likely to be at risk of harm if they lose or have gaps in coverage. Per CMS guidance, states may not prioritize populations for redetermination “based solely on the Medicaid eligibility group in which they are enrolled” and may not conduct a population-based redetermination approach that is discriminatory. CMS has confirmed, however, that states may develop specific unwinding approaches for individuals who are in a course of treatment for chronic or life-threatening diseas
Prioritize renewal for high-risk enrollees based on timing that mitigates risk of coverage loss and access gaps. Once states have identified high-risk enrollees, they can prioritize the timing for their redetermination with an eye to minimizing risk of coverage loss and access gaps, such as aligning the timing of renewals for people in the pregnancy/postpartum eligibility groups with implementation of extended postpartum coverage through the American Rescue Plan Act’s new state option.
Adopt special redetermination processes, including targeted communications, for high-risk enrollees. States can implement special redetermination processes, including noticing, aimed at helping high-risk enrollees retain coverage or transition seamlessly to new coverage, such as providing longer response time frames, following up with second requests for information and/or telephone outreach, and offering enhanced outreach and renewal assistance.
In states with State-Based Marketplaces (SBM), flag high-risk individuals being transferred to the Marketplace as requiring specialized assistance to ensure continuity of coverage and care. Medicaid agencies and Marketplaces in SBM states could collaborate to devise a system flag to identify individuals who have unique health needs that require specialized Marketplace and Navigator/assister support to ensure continuity of coverage, services, network providers or pharmaceuticals.
The end of the Medicaid continuous coverage guarantee is a looming and seismic health coverage event. All currently enrolled Medicaid individuals face a risk of coverage loss, including for procedural reasons, and a related gap in access to affordable health coverage. This risk is most acute and most likely to cause harm for people with serious health conditions that rely on continuous coverage to enable them to access care to treat chronic, debilitating and sometimes life-threatening conditions. Importantly, collaboration across Medicaid agencies, Marketplaces, and state insurance regulators will be essential to preserving access to coverage and care for these individuals.