Unwinding Wednesday #3: State Plans Provide a Glimpse into Unwinding Process

This week in our Unwinding Wednesday blog series, we unpack an element of our 50-state Unwinding Tracker that has been a top issue since discussions about the end of the continuous enrollment protection began: state unwinding plans.  In the initial December 2020 guidance, CMS advised states to develop and document a comprehensive plan for eligibility and enrollment operations post-public health emergency. However, there is no requirement for states to submit the plan to CMS, unless the agency requests it for monitoring or compliance, and there is no public reporting requirement.

Advocates and other stakeholders, including Georgetown CCF, have encouraged states to collaborate with stakeholders in developing their plans as doing so will improve state unwinding plans and engage partners who can amplify key messages and assist individuals with renewals or transitions to other sources of coverage. We have also advocated for states to publicly release unwinding plans and update the plans on a timely basis. By understanding state unwinding plans, stakeholders are in a better position to support or supplement those efforts.

So far, we have found twenty states that have posted at least a summary of their unwinding plan, which is the category with the second fewest states meeting the standard in the six elements we are tracking. This is actually fairly encouraging progress as there were no states that had posted a public unwinding plan or summary early this year. The documents posted provide insight into how states are preparing for the unwinding and challenges they are working through to help maximize continuity of coverage.

Within the posted plans, there is wide variation on where states are in the planning process and the scope of information provided. Almost all state plans provide details of their current and future communications strategies; in fact, for some states the only posted information is on communications plans, like Tennessee which has phase one of its four-phase strategy which focuses on updating contact information. Many states also specify the timeline for restarting normal operations – unwinding-related ex parte renewals will be initiated and the earliest dates for terminations based on that start date – based on the three timeline options CMS laid out in its March 2022 guidance. Only two states (CA and NV) have posted their full comprehensive plans rather than a PowerPoint or summary version of their plan.

States’ proposed timelines for restarting routine operations, if included, begin up to two months before the month in which the PHE ends. For example, Michigan’s plan includes a hypothetical calendar for when each month’s renewals would begin if the PHE ended in October (the public health emergency is expected to be renewed in October since the Biden administration has said it will give states 60-day notice before declaring the end to the PHE).

More importantly, the unwinding plans provide information on how states are planning to prioritize renewals once the PHE ends. The approaches are as different as each state Medicaid program (spoiler: very different). Take Utah, for example  – the state is planning to prioritize cases where a renewal could not be completed during the PHE by first reviewing individuals with known eligibility issues followed by individuals who did not complete their review (with additional criteria for prioritization) and then emergency-only services programs. Georgia, on the other hand, is utilizing a “state-developed approach,” the fourth in the risk-based approaches CMS provided in its December 2020 guidance, which includes deprioritizing pregnant women and Katie Beckett children to ensure the longest possible eligibility period. Many states are planning to align renewals with SNAP and/or keep renewal dates the same for those who were successfully renewed during the PHE.

States plan to use a range of methods to conduct outreach or provide assistance for the renewal process when ex parte (automated) renewal cannot be completed and the individual is required to submit additional information. Some states plan to use colored paper or envelopes for renewals so they stand out, while others are leveraging health plans by providing MCOs with a list of redeterminations requiring beneficiary action. Oregon is adding a “call back option” to its customer service line to support individuals completing renewals and also help with call center capacity as well as launching a new platform to enable email processing of questions from beneficiaries.

As we have previously noted, the end of the public health emergency also means the end of many temporary disaster relief flexibilities. A number of state unwinding plans address these flexibilities including which flexibilities the state intends to make permanent or terminate and how the state plans to notify beneficiaries and providers of changes. Oklahoma’s plan goes well-beyond other states, listing every authorized disaster-related flexibility and what the state is planning to do with each flexibility post-PHE.

A final item to note is the inclusion of estimates of the number or percentage of individuals to be disenrolled at the end of the PHE. Six states include these estimates ranging from 300,000 in Oregon to almost 3 million in Texas. Additionally, some plans provide an indication of the scale of procedural disenrollments we may see. For example, Arizona estimates 300,000 individuals are at risk of losing coverage for procedural reasons.

It is great to see states being transparent with what they are planning for the unwinding. However, some plans are still lacking important specifics and many plans have not been updated in months, with some of them nearly a year old. We encourage you to read through your state’s unwinding plan to see where the state could be encouraged to do more. If your state is one of the 30 that has not posted its plan, push your state to release it.

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