States were prohibited from disenrolling Medicaid enrollees during the COVID-19 Public Health Emergency. The process of restarting and completing annual redeterminations for all Medicaid enrollees was deemed ‘unwinding’ and initiated by the Consolidated Appropriations Act enacted in December of 2023 (CAA, 2023).

To comply with provisions in the CAA, 2023, the Centers for Medicare and Medicaid Services (CMS) implemented state-level reporting of Medicaid application and redetermination outcomes. CMS is using this data to facilitate technical assistance for states and monitor compliance with federal renewal and fair hearing requirements. In a State Health Official Letter issued on May 30, regarding “Continuation of Certain Medicaid and CHIP Eligibility Processing Data Reporting” (SHO# 24-002), CMS announced the ongoing collection of some data from the already familiar “Unwinding Data Report.” The final submission of metrics in the Unwinding Data Report (UDR) will be submitted for the period ending June 30, 2024.

The SHO outlines that the new reporting will be called the Eligibility Processing Data Report and require monthly submission of a limited subset of data from the UDR. Because this is state level reporting, providers will be unaffected, though ongoing monitoring of state timeliness and appeal rights by CMS may result in states working to improve Medicaid renewal processes for individuals. Read more on the reporting transition for states in the full SHO# 24-002.

Medicaid unwinding has exposed vulnerabilities in state processes for determining and redetermining Medicaid eligibility. In response, the Center for Medicare and Medicaid Services (CMS) has released an informational bulletin and related slide deck outlining obligations and prohibited activities as states conduct renewals. These resources represent a comprehensive compendium to assist states in understanding how eligibility processes must comply with federal requirements.

The deck includes case examples of how states should adjudicate or pend termination notices in particular cases. If you’re a provider and seeing significant challenges with participants, residents, or staff losing Medicaid coverage, consider reaching out to your local county office of eligibility to understand how you can support them.

More information about Medicaid unwinding, including communication resources are available here.

Included in the Consolidated Appropriations Act of 2023 were provisions that allowed states to resume Medicaid eligibility terminations in April of 2023, along with data reporting requirements. The Centers for Medicare & Medicaid Services (CMS) has used these data or failure to report these data to determine that states are unjustly terminating thousands of individuals from Medicaid for administrative or paperwork reasons. In response, CMS released an interim final rule on December 4 codifying CMS’ ability to enforce state compliance by: imposing corrective action plans, levying fines, suspending procedural disenrollments, or decreasing a states’ federal financial participation (FMAP). These steps could be taken for a multitude of reasons including failure of a state to: submit required reporting, comply with corrective action plan submission, or follow actions outlined in an approved corrective action plan. The rule was effective December 6 and can be reviewed here.

While most individuals on waitlists for home and community-based services (HCBS) do have access to state plan services like personal care, more specialized services like adult day or assisted living wouldn’t be available to someone living in a state with a limited number of waiver slots.

States use a number of authorities to offer HCBS as alternatives to nursing homes, including 1915(c) authorities which allow them to target specific populations based on needs, available services, and diagnoses, among others. Additionally, 1915(c) authorities allow states to place caps on the number of individuals served to assist with state budget planning, leading to waitlists if demand outpaces approved slots.

In a recent survey of states, KFF gathered data on waitlists for HCBS. In a November 29 article, “A Look at Waiting Lists for Medicaid Home- and Community-Based Services from 2016 to 2023,” KFF outlined its findings, which used expanded terminology from simply “waiting lists” to include catchall terminology that states may use to skirt reporting or change public perception.

KFF found more than 692,000 people are on waiting lists across the country, with the majority of those individuals residing in states that complete no eligibility pre-screening for placement on the list. Similarly, about 73% of people on waiting lists are seeking services through ID/D or autism-specific waiver programs. Approximately 170,000 individuals were on waitlists for services through aging or physical disability waivers, with about 100,000 of those people residing in either Florida, Texas, or Maryland.

See the full data analysis and more information on KFF’s website.

As states struggle through more than 93 million Medicaid eligibility redeterminations following the pandemic pause on disenrollments, processing for other benefits has stalled and caused many to lose supplemental nutrition assistance (SNAP). KFF published an article, “Medicaid ‘Unwinding’ Makes Other Public Assistance Harder to Get,” outlining cases in Missouri and Montana, and noting that the huge influx of work imposed by Medicaid unwinding is causing problems for residents in every state.

As state workers are reassigned to prioritize Medicaid eligibility, SNAP and other services are experiencing delays in application processing and call times. LeadingAge highlights this issue for members, especially affordable housing members and others serving those with low incomes, and reminds that you can support staff by contacting your county human services agency or local elected officials.

The Kaiser Family Foundation (KFF) on November 14 released two reports outlining national trends in Medicaid enrollment and spending and post-pandemic policies and changes to Medicaid programs across states. The research finds states are struggling with forecasting and budgeting as Medicaid unwinding is stripping many enrollees from state Medicaid roles. Speakers on a webinar addressing the reports cited workforce challenges as limiting factors in service continuity and expansion. Overall, the pandemic has caused significant shifts in state Medicaid programs and spending, while adding stressors on states related to trending and innovation. The full webinar recording is available here.

In an August 21 email, the Department of Housing and Urban Development (HUD) reminded multifamily housing owners and operators that states have been recertifying their Medicaid and Children’s Health Insurance Program (CHIP) rolls for the first time since the start of the pandemic, and that this information will be used to decide which individuals still qualify for Medicaid. Because Medicaid is a state-run program, HUD told owners and operators it is essential that people update their contact information and renew their eligibility this year to remain covered.

Owners can remind residents to make sure they are checking their mail for a letter about whether they must complete a renewal verification form (and to complete the renewal form right away if they got one). The timeline for these verifications varies by state; owners and operators can check here to learn more about the reverification process in every state.

The administrative process of assessing ongoing Medicaid eligibility was paused during the COVID public health emergency. As states have begun the unwinding process of annual eligibility renewals for all enrollees, Centers for Medicare & Medicaid Services (CMS) has been reviewing data submitted by states on call wait times, administrative disenrollment, and slow state processing times.

Until recently, CMS has not made state-level communications public. Each state received a letter from CMS outlining areas of concern, which can be reviewed here. More insight on CMS oversight of unwinding is available in this Politico article. Politico analysis points to mounting pressure both on states that seem to be dragging their feet and on states that are quickly dis-enrolling large numbers of Medicaid enrollees.

The Department of Health and Human Services (HHS) is hosting a series of webinars on Medicaid unwinding for special populations. On August 17, the webinar session is focused specifically on older adults and will provide strategies to reach out to diverse communities and audiences to share information about Medicaid and CHIP renewals. Each webinar will also include a “train-the-trainer” presentation, during which CMS will walk-through a set of downloadable slides for educating others about Medicaid and CHIP renewals.

Register here to receive a Zoom link; all sessions run from 3-4 p.m. ET at the dates below.

• Thursday, August 3: Reaching Asian American, Native Hawaiian and Pacific Islander (AANHPI) Populations
• Tuesday, August 8: Reaching Hispanic and Latino Populations
• Thursday, August 10: Reaching Black American Populations
• Thursday, August 17: Reaching Aging and Disability Populations
• Thursday, August 24: Reaching Rural Populations

Centers for Medicare & Medicaid Services (CMS) operationalized reporting of aggregate data on Medicaid unwinding and returning to regular operations after COVID-19. As states complete renewal processes for 93 million current Medicaid enrollees across the country, they must maintain and report to CMS accurate records about activities related to eligibility renewals and other issues in order to continue collecting additional federal matching funds.

CMS committed to public reporting of this information and has launched their data reporting initiative. The data and analysis are from April 2023, the first month in which states could issue terminations. Monthly updates are anticipated. The data illustrate that of those individuals terminated from coverage, more than 79% were for procedural reasons, leaving less than 21% of terminations for ineligibility. Review the CMS data reporting here.

As states resume normal Medicaid eligibility renewals following the break during the pandemic, more than 1.5 million people have lost Medicaid coverage. The numbers of disenrollment compared to renewals varies vastly across states because of state’s variable plans in executing redeterminations. Centers for Medicare & Medicaid Services has limited ability to intervene in states eligibility redetermination processes, though has required submission of state-level data and is monitoring disenrollment.

Review the KFF analysis on unwinding here.

Following the pause in annual Medicaid renewals brought on by the pandemic, states are undergoing efforts to determine eligibility for all 93 million individuals before July of 2024. Some states have reported procedural or paperwork-related terminations for more than 80% of completed determinations. The Centers for Medicare & Medicaid Services (CMS) paused the process in a number of states after reviewing the submitted data so they can work through issues where states haven’t met CMS requirements.

CMS did not name states as their support and collaboration continues. KFF maintains a tracker with disenrollment data; More than three million individuals have seen their Medicaid coverage terminated as of July 19.

The Department of Health and Human Services Secretary Xavier Becerra urged governors to review their state’s Medicaid unwinding plans in a June 12 letter. As states begin their return to normal Medicaid operations and require completion of Medicaid eligibility paperwork (unwinding) for the first time since the beginning of the pandemic, more than a million Americans have seen their Medicaid coverage terminated.

While the details and differences among states are major drivers of this massive loss of coverage, Secretary Becerra urges states to review all of their procedures and consider ways in which processes can be optimized, or additional federal flexibilities can be sought, to limit coverage loss. Medicaid unwinding began in March 2023, and is anticipated to conclude by July 2024.

Over the upcoming year, projections indicate upwards of 15 million people could lose access to health care—with children, older adults, and individuals with physical disabilities at the highest risk.

LeadingAge recommends talking to staff and residents early and often about the need to heed eligibility renewal information received via mail, text, or phone call from your state Medicaid agency. If individuals miss their window to return their eligibility paper work, urge them to complete and return it as quickly as possibly or complete a new Medicaid application.

If you’re not sure how to begin the conversation or what is at risk, consider reviewing the CMS communications toolkit for assistance with starting the conversation, materials translated into other languages, or collateral for posting around your community. If you have questions, consider reviewing your state’s Medicaid unwinding plan, or reach out to Georgia Goodman.

Centers for Medicare & Medicaid Services (CMS) released a June 7 memo outlining communication messaging and strategies for PACE organizations and Medicare Advantage (MA) dual eligible special needs plans (D-SNPs) to use with enrollees as states complete Medicaid eligibility determinations. As a result of the COVID public health emergency, states could draw down enhanced federal financial participation in their Medicaid programs in exchange for meeting specific requirements.

One of the requirements prohibited states from disenrolling Medicaid participants except in very limited instances. Therefore, states were unable to conduct eligibility redeterminations with the intent of disenrolling individuals during the pandemic. The omnibus bill, passed by congress in December 2022, outlined when and how states could restart annual eligibility redeterminations and disenrollment (also known as ‘Unwinding’).

The memo outlines the background, how deemed Medicaid eligibility is effected, and how organizations can communicate with enrollees about unwinding in compliance with marketing rules.

Centers for Medicare & Medicaid Services (CMS) clarifies a number of provisions relating to states’ required actions and treatment of different populations through Medicaid Unwinding in a Frequently Asked Questions (FAQs) document. These clarifications outline a number of requirements, including (in Q18) when states (with 1634 agreements) can use State Data Exchanges to complete ex parte renewals for Medicaid Enrollees receiving social security income (SSI). Ex parte renewals allow states to use available data from a variety of sources including the Social Security Administration (SSA) to confirm that a current enrollee has not had a change in income and would remain eligible for Medicaid.

Loss of Medicaid coverage is estimated to effect upwards of 15 million Americans. Many of those individuals will lose coverage because they didn’t know they needed to complete paperwork, or didn’t receive their packets to complete because of a change of address. To help current enrollees understand what is happening, the Department of Health and Human Services continues to update their communications toolkit.

Members can use the toolkit to have conversations with staff about termination of Medicaid coverage for themselves or their children. Many reports indicate children are most at risk of losing coverage with parents not understanding they have been terminated until seeking care from a pediatrician or filling a prescription at the pharmacy. Help keep your staff and the community avoid these stresses and remain covered by using the toolkit and helping to educate about the ongoing process.

The end of Medicaid continuous coverage provisions will mean loss of health insurance for millions of Americans- possibly residents in your community or staff supporting your operations, or children of your staff. Of those likely to lose coverage, many will result from administrative failures, not from changes to eligibility- meaning people will be disenrolled for data errors or failure to fill out their paperwork, not because they now earn too much money or have come into a windfall of assets.

Kaiser Family foundation has released a map to help people understand when their state will begin disenrolling individuals. Imbedded within the description is a Google document including links to each states’ websites and national data trending tables, along with state level breakouts.

The Department of Health and Human Services released one pagers for employers who may have employees losing Medicaid coverage. These resources are available in both English and Spanish. Loss of coverage would apply mostly to low wage and part-time positions, or those that have recently joined your team that were previously unemployed.

The resources urge employers to communicate early and often with staff about Medicaid eligibility redeterminations and what loss of coverage could mean. Employers should understand that loss of Medicaid coverage would count as a qualifying life event, making an employee eligible for a special enrollment period outside of your benefits annual open enrollment (assuming the person is otherwise eligible, per your policies).

The Medicaid and Chip Payment Advisory Commission (MACPAC) is monitoring state activities related to the end of continuous Medicaid coverage. Commissioners voiced support for elevation of best practices, including small changes to call center processes that share wait times or add call-back options. Materials from the full meeting are available here.

Read the full bulletin for more details and information.

In this member-only offering on the LeadingAge LearningHub, Georgia Goodman highlights the importance of educating team members, older adults, and their families about changes to Medicaid coverage and eligibility. Maintaining health insurance for eligible individuals and members of their families increases participation in the workforce and improves mental health. This short video covers the basics of unwinding and offers providers insight into beginning the conversation about Medicaid coverage and associated risks of coverage loss with staff and clients.

Log in to watch-  Medicaid Unwinding: The End of Continuous Coverage Requirements

Kaiser Family Foundation (KFF), released a report outlining activities and timelines states will be undertaking during the upcoming 15 months. During the COVID-19 pandemic, states were prohibited from disenrolling Medicaid enrollees in exchange for acceptance of additional federal financial support for states’ Medicaid programs. Through the three-year prohibition from dis-enrollments, Medicaid roles swelled by approximately 30%. Reminder that all enrollees historically underwent annual eligibility redeterminations for Medicaid; this is the restart of that process. For some individuals dually eligible for Medicare and Medicaid, loss of Medicaid coverage may be costly as they lose access to copay and cost sharing programs. Early and often communication about the threats of losing Medicaid will help people understand messages from trusted sources and be more likely to pay adequate attention to mail from their states’ Medicaid agency. KFF reviewed their findings in a webinar. The recording is available here.

The Medicaid and Chip Payment Advisory Committee (MACPAC) meeting on March 2 covered efforts from Centers for Medicare & Medicaid Services (CMS) to monitor state’s progress and activities through the 14-month eligibility determination process recently started for all enrollees. Metrics being assessed—such as call volumes, wait times, bounce rates, returned approved and denied applications—will help states and CMS determine how course corrections may be required to reallocate or hire additional staff to support unwinding.

• Advocates and members of the committee expressed concern about beneficiary confusion. Concurrently underway in some states include contracting transitions between ACOs or MCOs through normal procurement timelines.
• Receipt of multiple correspondence about Medicaid, with limited understanding at the enrollee level of the program, is causing some consumers to seek help, while others discard materials because they don’t understand what is required.
• More updates and ongoing reports to come at the April Meeting.

Kaiser Family Foundation (KFF) released an analysis of affected Medicaid enrollees from the sunset of continuous enrollment provisions. The brief indicates that about 5% of the 23 million newly eligible enrollees are over the age of 65 or have a disability, while one third of total new enrollments occurred in five large states: Texas, California, Illinois, Florida, and New York.

Within the article, Appendix 1 breaks down enrollment increases between February 2020 and March 2023 by state and age/program. KFF continues to estimate that between 5 and 14 million enrollees will lose coverage, while referencing Department of Health and Human Services (HHS) estimates of 15 million people to lose Medicaid coverage through the redetermination unwinding.

As states work through their Medicaid unwinding efforts, some states have submitted waiver requests to CMS to enable different flexibilities. Options for states were initially outlined in March of 2022 in the State Health Official (SHO) letter #22-001. Under Section 1902(e)(14)(A), states can extend timeframes, involve additional organizations and their data, and use other social service program renewals to determine Medicaid eligibility for a limited period of time. To undertake any of these flexibilities, states must discuss their desire to implement one or more of these flexibilities. CMS has approved 163 waivers in 43 states (as of 3/20/23) and posted a table of approved waivers here.

As of February 24, CMS released a table outlining the initiation timeframe for each state for Medicaid unwinding. The table shows the first month in which notices will be mailed to participants and the first month any participant will be procedurally disenrolled from Medicaid.