CMS Spotlights State Strategies for Protecting Continuity of Health Coverage when PHE Lifts

As planning for the eventual unwinding of the COVID-19 related Medicaid continuous coverage protection continues, CMS has made significant efforts to provide additional tools and flexibilities to smooth the process for states and promote continuity of coverage. One such effort is allowing states to request time-limited waivers, authorized under Section 1902(e)(14)(A), to assist Medicaid agencies as they return to routine operations once the continuous coverage protection ends. Last week, CMS released data on the first wave of approvals of these temporary waivers which allow states to implement targeted strategies that can streamline the renewal process for states and promote continuity of coverage.

In its March 2022 guidance, CMS outlined five specific strategies that states may request under (e)(14) waiver authority: (1) renewal based on SNAP eligibility; (2) ex parte renewal for individuals with no income; (3) streamlining asset verification; (4) utilizing managed care organizations to update beneficiary contact information; and (5) extending timeframes for fair hearings. The agency also indicated it would consider other unwinding-specific strategies if they protect enrollees from inappropriate termination of coverage.

Not quite half of the states have taken advantage of flexibility offered through (e)(14) waivers. CMS has approved 61 waivers for 20 states so far. Seven types of waivers have been approved – the five strategies detailed in the March 2022 guidance and two additional strategies (using National Change of Address or USPS to update beneficiary contact information and extending the timeframe for automatic re-enrollment into MCO plans). CMS also listed another option – to delay the resumption of premiums until a full redetermination is completed – but no state has yet received approval for that strategy.

Most of the states with approved waivers have adopted the flexibility to use MCOs to help update contact information (14 states), as well as the renewal strategy for enrollees with zero income (14 states). Only a handful have adopted the strategies to renew beneficiaries based on SNAP eligibility (6 states), use the NCOA and/or USPS returned mail to update contact information (7 states), or extend fair hearing timelines (6 states). Kentucky has the most approved (e)(14) waivers with seven approved while Alabama is the only state to have a waiver outside of the waiver options that CMS has listed, which would allow renewals based on TANF eligibility, similar to the SNAP strategy.

The release of the (e)(14) waiver approvals is the first state-specific information CMS has published on state unwinding plans. CMS should be commended for this transparency. But, as my colleague Tricia Brooks has written, there is a critical need to share more data, especially states’ required unwinding data reports and call center statistics, so the agency and stakeholders can monitor the impact of the unwinding process.

The real story in the list of approved waivers, however, is what is NOT there. While twenty states have approved waivers, over half of states have yet to do so. And more than a dozen of the states that do have (e)(14) waivers have adopted three or fewer of the flexibilities. A number of the available waivers, like those to use trusted third-party sources to help update beneficiary contact information, should be no-brainers for states; these flexibilities would have potentially big rewards in mitigating coverage losses. As we have previously highlighted, having updated enrollee contact information is going to be essential to helping children and their families maintain coverage so they are not disenrolled for procedural reasons despite still being eligible.

Florida, Georgia, and Texas – three of six states we identified as most at risk of children losing health coverage – have no approved waivers. Adopting some of the flexibilities provided by CMS would go a long way to assist the continuity of coverage and access to care for children.

With so much at stake when the continuous coverage protection is lifted, states should take advantage of all available strategies to make the unwinding process smoother. Hopefully greater awareness of what other states are doing with the information on approved (e)(14)’s will prompt more states to adopt these flexibilities to promote continuity of coverage at the end of the PHE.

Allie Gardner
Allexa Gardner is a Research Associate at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.

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