Policy Update

Updates on Medicaid Continuous Enrollment Unwinding[1]

Liz Coronado

Picayune Rancheria of the Chukchansi Indians

Senior Policy Advisor

With the passage of the Consolidated Appropriations Act, 2023 at the end of last year, Congress set an end date for the Medicaid continuous enrollment condition to March 31, 2023.[2] Since April 1, 2023, some states have resumed routine Medicaid renewals and eligibility and enrollment efforts.  Each state must report monthly data to the Centers for Medicare and Medicaid Services (CMS), which is then compiled and publicly released.  However, the released data on monthly renewal trends provided by CMS is delayed by many months and not provided in real-time.[3]   

According to recent data compiled by the Kaiser Family Foundation (KFF), almost 7 million people have been disenrolled from Medicaid and CHIP since unwinding efforts started earlier this year.[4] KFF has found that 73% of the people disenrolled from Medicaid were disenrolled for procedural reasons such as failure to respond to notices for renewal. In the Northwest, 89% of all disenrolled Medicaid beneficiaries in Washington were due to procedural reasons, and 73% in Idaho.[5] These are appalling numbers of disenrolled Medicaid beneficiaries nationally after having many years of record-high Medicaid enrollment through the COVID-19 pandemic. We currently lack data on how unwinding has impacted American Indian and Alaska Native loss of coverage.  

The Tribal Self-Governance Advisory Committee is coordinating a Tribal-specific data survey to share with the Centers for Medicare and Medicaid Services to show the impact on Tribes and Tribal health programs.  

State Medicaid Agencies' Compliance with Automatic Renewal Federal Requirements

On August 30, 2023, CMS issued a State Medicaid Director letter to all 50 states to remind Medicaid directors of their obligations to conduct renewals in compliance with federal regulations.[6] CMS has discovered that there were system and operational issues affecting over 30 states, resulting in eligible Medicaid beneficiaries being improperly disenrolled.[7] CMS clarifies that states must make redeterminations of eligibility based upon reliable information the state already has access to without requiring additional information from the individual through ex parte renewals (emphasis added).[8]  This system-wide issue most commonly impacts children in households with at least one adult enrolled in Medicaid and other eligible individuals in a household where additional documentation is needed to verify eligibility for other household members.[9]  States were disenrolling all household members, including children, even though they had access to reliable information for eligibility for some members through an ex parte renewal in violation of federal law.[10]  

Washington and Idaho were identified as part of the 30 states that could not conduct automatic renewals at the individual level consistent with federal law.[11]  CMS has required all 30 states to pause procedural terminations for those individuals impacted by the systemic issues identified above until the state agencies can ensure all eligible people are not improperly terminated.[12]  Additionally, the states must reinstate those individuals who were improperly disenrolled from Medicaid and fix their systems and processes to comply with federal law.[13]         

Continuous Enrollment for Children under 19

Effective January 1, 2024, states must provide 12 months of continuous enrollment for children under 19 in Medicaid and Children’s Health Insurance Program.[14]   States may terminate eligibility for children under 19 during their 12-month continuous enrollment period for the following limited circumstances for children: who reach age 19; cease to be state residents; request a voluntary termination of eligibility; the agency determines that eligibility was erroneously granted because of error, fraud, abuse, or perjury; or child is deceased.[15] States must submit a State Plan Amendment if their current state plan specifies a continuous enrollment period for children under 19 that does not comply with the Consolidated Appropriations Act 2023 provisions.[16]  

States are not limited to providing only a 12-month continuous enrollment period for children under 19.[17] States may submit a section 1115 demonstration authority waiver to CMS to request a longer continuous enrollment period.  Oregon became the first state in the country to maintain eligibility for children from birth to age six and for two-year periods for children ages six and up.[18]  Washington has followed suit and submitted an 1115 demonstration authority waiver to CMS on July 27, 2023, requesting approval to maintain coverage for children from birth to six years of age.[19]     

Sources  

[1] See Health News and Notes, April 2023, for more detailed information on Medicaid continuous enrollment.  

[2] See Consolidated Approps Act 2023, Pub. L. No. 117-328. 

[3] CMS has reported in their July 2023 data release that 5.5 million Medicaid and CHIP beneficiaries have lost coverage nationally.  See CMS July 2023 Medicaid and CHIP Enrollment Snapshot, available at https://www.medicaid.gov/sites/default/files/2023-10/july-2023-national-summary-renewal-outcomes.pdf.  

[4] Kaiser Family Foundation, Medicaid Enrollment and Unwinding Tracker (Oct. 2, 2023) (available at Medicaid Enrollment and Unwinding Tracker | KFF).  

[5] Oregon was not listed in Kaiser Family Foundation data.  See Id.

[6] See Ctrs. for Medicare & Medicaid Services, State Medicaid Director Letter (Aug. 30, 2023) (available at Requirements to Conduct Medicaid and CHIP Renewal at the Individual Level).  

[7] Id.

[8] Id.

[9] Id.

[10] Id.

[11] Preliminary Overview of State Assessments Re Compliance with Medicaid & CHIP Automatic Renewal Requirements at the Individual Level (Sep. 21, 2023) (available at State Compliance with Medicaid Renewal Requirements at Individual Level).  

[12] See Ctrs. for Medicare & Medicaid Services, State Medicaid Director Letter (Aug. 30, 2023) (available at Requirements to Conduct Medicaid and CHIP Renewal at the Individual Level).  

[13] Id.

[14] See Consolidated Appropriations Act 2023, Pub. L. No. 117-328, 136 Stat. 5940.

[15] See Ctrs. for Medicare & Medicaid Services, State Health Official Letter No. 23-004 (Sep. 29, 2023) (available at SHO 23-004 Continous Eligibility (medicaid.gov)).  

[16] Id. 

[17] Id.

[18] See Letter from Chiquita Brooks-LaSure, Adm’r, Ctrs. for Medicare & Medicaid Services, to Dana Hittle, Interim Medicaid Director, Oregon Health Authority (Sep. 28, 2022) (available at https://www.oregon.gov/oha/HSD/Medicaid-Policy/Documents/2022-2027-1115-Demonstration-Approval.pdf). 

[19] See Letter from Charissa Fotinos, Medicaid & Behavioral Health Medical Director, Health Care Authority, to Dan Tsai, Deputy Adm’r & Director, Ctrs. for Medicare & Medicaid Services (Jul. 27, 2023) (available at wa-medicaid-transformation-jul-2023-amnd-pa.pdf).