23 Million Unenrolled: 11 Insights from the Medicaid Unwinding

New Kaiser Family Foundation research reports state challenges and some successes despite mass disenrollment.

During the pandemic, CMS allowed states to use Section 1902(e)(14)(A) waivers to keep members continuously enrolled in Medicaid. These waivers offered financial protection to vulnerable individuals and softened administrative burdens for states by suspending enrollment eligibility verification and renewal.

Most of those continuous enrollment provisions ended March 31, 2023, after which state Medicaid programs began their unwinding process: once again verifying eligibility and disenrolling those who no longer meet requirements or haven’t provided the necessary information to prove that they do. The unwinding has resulted in nearly 23 million people losing their Medicaid coverage since April 2023.

States have conducted this unwinding in multiple ways, reporting diverse process challenges — as well as improvements, despite the devastating coverage losses. These changes will have an impact on Medicaid eligibility, enrollment, and renewal for years to come. Below are the top insights from a June 20 Kaiser Family Foundation webinar based on new research.

1. More Medicaid members could be disenrolled as the unwinding continues.

States have focused on enrollment renewals throughout 2024 with completion expected by July 2024 and based on the following timetables:

• Before/During March 2024: 5 states
• April 2024: 12 states
• May 2024: 15 states
• June 2024: 8 states
• After June 2024 or In Development: 11 states

2. Medicaid workforce challenges impacted enrollment renewals in more than 25 states.

Medicaid is one of the many healthcare employers that have been affected by workforce challenges. States reported significant to moderate impact in the following areas among Medicaid eligibility staff.

• Vacancy challenges in 32 states
• Recruiting and retention challenges in 29 states
• Training challenges in 27 states

3. States will continue many of their new renewal processes after the unwinding.

There are some upsides the unwinding — ranging from new partnerships to more member-focused activities (e.g., outreach, update and access options, paperwork and response timeframes). They include the “ex parte” process, which allows states to automate Medicaid renewal by using multiple data sources:

• Improved Ex Parte Renewal: All 50 states
• Increased Member Renewal Outreach: 37 states
• Partnered with MCOs and Community Organizations: 34 states
• Gave Members New Ways to Update Their Contact Information: 27 states
• Improved Member Online Portals: 26 states

In addition, 22 states updated their renewal notices and another 15 either simplified their renewal forms or game members longer to respond.

4. States want the federal government to make some 1902(e)(14)(A) waiver provisions permanent.

X waivers allowed states to use information from other sources to update Medicaid member contact and renewal information. Two of these waiver strategies — using updated contact information from either the National Change Of Address database/US Postal Service or from MCOs — are now permanent thanks to the Medicaid Eligibility and Enrollment Rule.

Some 34 and 29 states, respectively, used these waiver strategies to update member information, in addition to:

• Ex Parte Renewal for Members with $0 Income: 29 states
• Ex Parte Renewal for Members with Low Income: 17 states
• Renewal Based on SNAP/TANF Eligibility: 25 states

At least some states (15) want to continue working with MCOs to support member renewals.

5. Automation helped most states increase ex parte renewals.

Ex parte decreases paperwork and workload volume for State Medicaid agencies. In addition to allowing states to use additional data sources to verify eligibility, it has promoted further automation of the process:

• Most of Ex Parte Automated: 34 states
• Ex Parte Both Manual and Automated: 14 states
• Ex Parte Still Mostly Manual: 2 states

6. Improved enrollee and stakeholder engagement were states’ top successes.

When asked to list their top three successes from the Medicaid unwinding, 24 states reported that enrollee outreach and communication improved and 18 reported the same with stakeholders. Other successes tapered off from there but included:

• Increased Ex Parte Rates or Systems Automation: Reported by 11 states
• Better Data Reporting: 9 states
• More Streamlined Renewal Processes: 6 states

7. Federal guidance uncertainties and workforce issues were states’ leading challenges.

Nearly half of states (22) reported that either changing or unclear federal guidelines made the unwinding process difficult. Once again, workforce was a top issue (20 states), followed by an associated challenge: workload (18 states).

Some state successes have been challenges for others, including the need to upgrade their enrollment systems (14 states) due to existing limitations (13 states).

8. Most states have now aligned Medicaid eligibility with other programs.

The majority of states now align their renewal processes for their Medicaid and Seniors and People with Disabilities programs. Those processes include not requiring in-person renewal interviews, a 90-day reconsideration period after a procedural disenrollment, 30 days to respond to renewal notice, and providing pre-populated renewal forms.

States have also aligned their Medicaid and CHIP eligibility systems to other programs as well:

• SNAP (food assistance for families with low incomes): 28 states
• TANF (income assistance for families with low incomes): 28 states
• Child Care Subsidy Programs: 15 states

9. States are also building bridge between their Medicaid and CHIP programs.

Some states (28) manage their Medicaid and Children’s Health Insurance Programs (CHIP) separately. Of these, 21 are now automatically transferring children to CHIP when the ex parte review confirms eligibility.

10. State eligibility expansions have helped offset disenrollment.

During the past year, 13 states expanded Medicaid eligibility for three populations:

• Children: 2 states
• Pregnant persons: 7 states
• Combined: 4 states

11. Continued premium breaks have been another positive.

During the unwinding, some states suspended premium payments in their CHIP programs. Now many plan to continue those practices, with nine states eliminating CHIP premiums permanently and another four keeping them suspended.