Opportunities to Improve Guidance on Phasing out the Public Health Emergency Continuous Eligibility Provision

In December 2020, the Trump administration issued guidance on unwinding the Medicaid continuous eligibility provision associated with the COVID-19 public health emergency (PHE). There are a number of opportunities for the Biden administration or Congress to strengthen requirements for states to ensure that eligible Medicaid enrollees do not lose coverage at the end of the PHE. The goal should be to take steps to resume normal operations in an orderly fashion without overwhelming Medicaid agencies so that all enrollees who remain eligible stay covered – not to purge the rolls as fast as possible.

Give states a full year to catch up on overdue renewals and changes in circumstances. The current guidance requires states to be up-to-date on the processing of all applications within four months and acting on renewals, post-enrollment verifications, and changes in circumstances within six months. If states were given a full year to resume normal operations, they would be better able to stagger the workload to avoid overwhelming call centers and consumer assistance resources and to avoid future peaks in administrative workloads.

Require states to review eligibility for any enrollee flagged for disenrollment due to procedural (non-eligibility) reasons. The December guidance allows states to establish a six-month lookback period and proceed with disenrolling any beneficiary who did not respond to a request for information, as well as those who were determined ineligible, in the six months prior to the end of the PHE. Beyond creating the public health crisis, the pandemic and its swift lockdown took a toll on low-income families and Medicaid agencies alike. Beneficiaries report receiving conflicting and confusing notices about their Medicaid coverage leading to confusion about actions required to maintain coverage. Unless states have clear evidence of ineligibility, they should be required to conduct a fresh review of eligibility.

Eliminate the lookback period on determinations of ineligibility or limit it to three months. 
After pausing normal operations at the beginning of the pandemic lockdown, states were encouraged by CMS to resume processing renewals and changes in circumstances to extent they could using electronic data to verify eligibility. This means states may be keeping lists of “pending adverse actions” (or what amounts to a disenrollment waiting list) for individuals who have been determined ineligible or who did not respond to a request for information although they must provide continuous coverage until the end of the PHE. In its December guidance, CMS indicated that it would allow states to move forward with those disenrollments, with a final notice, if the action was taken in the final six months of the PHE – in other words, a lookback period of six months. But those actions are likely based on income data that is at least three to six months old. For example, if the PHE were to end in January, the lookback period would start August 2021 (next month). In August, states will be basing their determinations on income data from the first quarter of 2021. We should not disenroll people in February 2022 based on income data that will then be a year old. Ideally states should redetermine eligibility before disenrolling most beneficiaries (with a few exceptions – like someone aging out of coverage). At the very least, the lookback period should be limited to disenrolling individuals determined ineligible in the final three months of the PHE.

States should not be able to disenroll beneficiaries based on a single piece of returned mail. Less than half of the states take steps to locate beneficiaries before terminating coverage even though there are numerous ways for states to update mailing addresses and to offer simple tools for beneficiaries to report address changes. Some states interpret current regulations to allow them to disenroll someone based solely on returned mail. The regulation waives the minimum required 10-day advance notice of adverse action if “the beneficiary’s whereabouts are unknown and the post office returns agency mail directed to him indicating no forwarding address.” In the short term, CMS should issue guidance and provide technical assistance on best practices and reliable data sources in keeping mailing addresses up-to-date.  A statutory change would help assure that eligible individuals do not lose coverage due to red tape.

CMS should align the response time for requests for information with the 30-day period required for renewals. When states identify a change in circumstance that requires information from the beneficiary, they frequently allow only 10 days for a response and send only a single notice. Between issues with the U.S. Postal Service, unstable housing, and difficulty obtaining documents needed to prove eligibility, 10 days is insufficient. Text, phone, email, and online accounts are cost-effective ways to remind enrollees when action is needed. Additionally, states should provide a 90-day reconsideration period without requiring a new application if documents are received after the deadline, as is required for renewals.

Ensure that State Eligibility and Enrollment Operational Plans are publicly available. States are required to develop a risk-based plan for resuming normal eligibility and enrollment operations that prioritizes action on individuals most likely to no longer be eligible. While CMS has created a planning tool template, states are not required to use it or submit it to CMS for review or approval. CMS has encouraged states to engage stakeholders in the planning process, but there is no requirement for public input. States should be required to engage stakeholders, create an opportunity for public comment, and share their plans broadly so that stakeholders and beneficiaries know what to expect.

Report key performance indicator data in real-time for monitoring the unwinding of the PHE. Since 2014, states have been required to report a number of performance indicators as a condition of enhanced federal funding (90%) for state eligibility systems. Although these data are submitted to CMS on a monthly basis, few indicators have been publicly reported – namely application volume and enrollment on a monthly basis, as well as two annual reports on application processing times. But the indicators are much more robust and include call center performance data, as well as determinations stratified as “ineligibility established” or “eligibility could not be established.” Assessing the share of disenrollments due to procedural (non-eligibility related) reasons, compared to determinations of ineligibility, can be an early indicator of eligible beneficiaries losing coverage. Monitoring call center volume, wait times, and abandonment rates are an early indication of whether consumer assistance capacity is being overwhelmed by demand. It should be a priority for CMS and states to publicly report these data and other key indicators promptly.

Will the unwinding be a tsunami or manageable wave? Low-income and racially-diverse families have experienced a disproportionate impact from COVID-19, and due to their low incomes and lack of access to job-based insurance are more likely to rely on Medicaid for health coverage. As the nation continues to control and recover from the pandemic, the very least we can do is take extra steps to sure that eligible children and families retain health coverage after the public health emergency.


Webinar Series: Unwinding the COVID-19 Medicaid Continuous Eligibility Provision

Tricia Brooks is a Research Professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.