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Medicaid enrollment spiked during the pandemic; but when the public health emergency (PHE) ends, certain pandemic era protections -- including a freeze on involuntary disenrollment -- will go with it.

Public policy experts concerned over the potential for not only huge coverage losses -- for perhaps 15 million individuals, including at least 6.7 million children -- but also disruptions in care, stressed the importance of states taking a thoughtful approach to redetermining Medicaid eligibility for beneficiaries.

However, when the public health emergency ends -- although no one knows when that will be -- states will resume the process of redeterminations, deciding who will remain eligible for the program. Some experts fear the program will revert to the pre-pandemic status quo.

Because Medicaid rolls have grown steadily over the last 2 years, "we could see the largest migration of people away from Medicaid ever, and appropriately so," said Matt Salo, executive director for the National Association of Medicaid Directors, given that millions of people will no longer meet eligibility criteria and will have to decide on a different form of coverage.

"Trying to make sure that this is done carefully, thoughtfully, humanely, but also efficiently is really important," Salo said.

He told 麻豆传媒 that state Medicaid directors are keeping these concerns front-of-mind. "The end of the continuous coverage requirements is clearly the number one priority for our members across the country."

The Numbers

Approximately 9 million Americans enrolled in Medicaid from February 2020 to January 2021, according to a from the Urban Institute. Medicaid and the Children's Health Insurance Program (CHIP) together grew to 83.6 million, an increase of 12.4 million, from February 2020 to July 2021, according to the .

These increases were spurred in part by pandemic-related job losses, the majority of which occurred from March to June 2020, and by a continuous coverage provision in the . That Act banned states from disenrolling people involuntarily from Medicaid and also temporarily increased the federal government's share of Medicaid spending or federal medical assistance percentage, noted the Urban Institute.

Policy experts found that the continuous coverage protections helped enrollees avoid the coverage gaps and "churn" that have long been a feature of the program. The U.S. Department of Health and Human Services Assistant Secretary for Planning and Evaluation stressed in that disruptions in coverage can lead to "periods of uninsurance, delayed care and less preventive care for beneficiaries."

The Urban Institute projects that after the PHE expires.

The historic rise in enrollment in Medicaid during the pandemic has been particularly beneficial for children, said Joan Alker, executive director and co-founder of the Center for Children and Families and a research professor at the Georgetown University McCourt School of Public Policy in Washington, D.C. Currently, half of the children in the country are covered by Medicaid.

Like Collins, Alker is very concerned about the potential for coverage losses. Her "conservative estimate" is that about are at risk of losing coverage during this process, she told 麻豆传媒.

And children are especially at risk in certain states, including Delaware, Florida, Georgia, Missouri, Nevada, and Texas, according to Alker and Georgetown colleague Trish Brooks, MBA.

'Going to Be Complicated'

For Sara Collins, PhD, vice president of healthcare coverage and access at the Commonwealth Fund, "what's really important is that states take a longer period of time to do this and don't do it abruptly," she said.

Pre-pandemic, the average enrollee spent only about 10 months in the program. Some states look to redetermine eligibility every 12 months, but others do more frequent checks of fluctuations in income among enrollees, she said.

Collins expressed concern that, as states resume the redetermination processes, some will be "more aggressive" than others. The anticipated decline in the federal matching funds may incentivize them to speed up the process, which could mean more mistakes.

If so, many people will lose coverage or experience gaps in coverage, either for procedural reasons, such as not submitting paperwork quickly enough, or because their incomes are too high and they aren't able to enroll in another plan through the marketplace or their employer quickly enough, she noted.

A letter may be lost in the mail or an enrollee may have moved and not updated their address with the state, resulting in renewal paperwork that isn't completed and subsequent disenrollment, noted Alker.

For context, one large managed care organization (MCO), Molina Healthcare, said that it currently lacks contact information for about 40% of its members, Alker noted. These organizations contract with state Medicaid agencies and operate on a capitated, or per-member, per-month delivery system.

"Obtaining contact information is critical to get ahead of these problems," she said.

Salo agreed that there will be financial pressure for states to "right-size" their programs quickly but said he believes that Medicaid programs are "leaning into" a more "thoughtful" and slower approach, given the high stakes.

"This is going to be complicated. This is going to be hard, but this is really important," he said.

There are two clear goals: "Making sure that people who are still eligible remain on the program with as little turmoil [and] as little bureaucracy as possible, but then also making sure that for people who are no longer eligible ... we transition them off the program in the proper way," he said.

In the majority of states that leverage managed care, Medicaid programs are working with MCOs as well as community-based organizations and provider groups to ensure that the process goes as smoothly as possible, Salo said.

States must consider different ways to reach enrollees who may have moved -- by direct mail, phone, text, or other means -- and find ways to makes sure enrollees provide the right information to state programs to complete the process.

Of course, the other wrinkle to this is the uncertainty around when the PHE will end.

The PHE is slated to extend until mid-April. But the Biden administration has not yet given the promised 60 days notice of termination, so Alker anticipates that the PHE will be extended another 90 days until at least July. Still, no one knows for sure.

A Little Help Please, Providers

Whenever that notice is given and the PHE does expire, Alker anticipates clinicians will be the first to notice it.

"They're going to be be on the front lines of this, because a lot of people aren't going to know they've been disenrolled. And so they're going to bring their child to the doctor, and the child's not going to have any coverage," she said.

Healthcare teams, for their part, can help by communicating the importance of maintaining coverage to their patients, Collins said. They must warn patients that they will, at some point, be asked to submit information about their income to gauge whether they are still eligible to participate in Medicaid, and they must stress the importance of submitting that information quickly.

For those participants whose incomes are too high to remain in the program, it's important to point them to the Affordable Care Act's marketplaces and to patient navigators, who can help them choose plans through either state-run websites or the federal website, healthcare.gov, Collins said.

CMS guidance allows states a full 12 months to complete the redetermination process; whether states choose to adopt a shorter time frame is up to individual states.

Federal policy changes that aim to guard against coverage losses are in the works but have not been signed into law yet, Collins noted.

One provision of the House-passed Build Back Better legislation could help by slowly phasing out the 6.2% bump in federal matching dollars as well as establishing disenrollment standards, under which states could only redetermine eligibility for one-twelfth of participants each month. The Senate version of the bill would also similarly phase-down enrollment, Collins said.

Another component of the Build Back Better Act would make people in so-called non-expansion states (states that did not expand their Medicaid programs to include coverage for people whose incomes are 138% of the federal poverty level or below) eligible for coverage on the healthcare marketplaces if their incomes are below 100% of the federal poverty level.

However, none of these protections will go into effect unless the legislation is passed, and look dim of late.

Some 13 states provide continuous eligibility for children, regardless of changes in their families' circumstances, Collins noted.

Real-time sharing of state-level data will be important to tracking how the redetermination process plays out, said Alker.

Some states provide "reason codes" that explain why people are disenrolling. If a lot of children are disenrolling for procedural reasons rather than aging out of the program, for example, that raises flags. Some states also track call center statistics for their help lines.

"If the wait times are getting long, that's a clear canary in the coal mine that there's not enough help for people trying to get through this process," Alker said.

If a lot of children and families are losing coverage, states have the option to "press the pause button," on this process, she said. "It's really in the governor's lap."

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