Unwinding Wednesday #10: FAQs Provide Additional Clarity on State Options Before and During the Unwinding

Over the past two years, CMS has published a wealth of resources designed to aid states in the unwinding process. These documents, which provide guidance and lay out flexibilities available to states, are available on a single landing page on Medicaid.gov. In our tenth installment of Unwinding Wednesday, we are highlighting a recent addition to these resources – a set of frequently asked questions specific to the unwinding. This is the first set of FAQs released since 2020, and it provide answers to a comprehensive list of questions that will be helpful as states prepare for the end of the continuous enrollment protection.

There’s a lot in the FAQs (38 detailed questions/answers total) including some general information and reiteration of what has been stated in CMS guidance, so we won’t unpack everything here. But we do want to dig into some of the questions which provide clarity on state opportunities as well as responsibilities both before and during the unwinding.

(e)(14) Waivers 

As we have explained in previous blogs, CMS has provided states the opportunity to apply for time-limited 1902(e)(14)(a) waivers to help ease the operational burdens that many states will be facing after the end of the PHE. To date, CMS has now approved 107 (e)(14) waivers for 34 states (the number of waivers has almost doubled since the first release of the data).

In the FAQs, CMS dives deeper into the details of the (e)(14)s than the March 2022 guidance ­to explain the types of waivers the agency will consider approving and some operational specifics that will be important for implementation. For example, states can request a retroactive effective date for a waiver so implementation can begin prior to CMS approval; this allows states to get a head start modifying their unwinding plans and adjusting their systems rather than having to wait for CMS authorization. We were also pleased to see the responses regarding waivers that are relevant to the Children’s Health Insurance Program (CHIP) such as those related to managed care plans and strategies to update contact information can be applied to the program.

Resumption of Premiums

Resumption of premiums is something we have been worried about as states return to routine operations. Medicaid members have not been terminated from coverage for non-payment of premiums during the PHE and some states have taken further steps to suspend premiums in Medicaid and/or CHIP through disaster SPAs. The FAQs detail how premiums may be reinstated at the end of the PHE and options states have to reestablish them. These are:

  • Resume suspended premiums in Medicaid and/or CHIP in the same manner as before. Without taking the actions listed below, states are required to reinstate charging premiums when their disaster state plan amendments (SPAs) expire at the end of the PHE. States must complete a redetermination before reimposing premiums for individuals who have not had one in the last twelve months. Premium amounts must remain the same or lower than those assessed on January 1, 2020 until the quarter the PHE ends.
  • Delay resuming premiums in Medicaid and/or CHIP beyond the end of the PHE. This can be done by extending an existing CHIP disaster SPA or submitting a new Medicaid or CHIP SPA.
  • Delay resuming premiums in Medicaid at the end of the PHE until a full renewal is completed. States must request (e)(14) waiver authority to stagger the resumption of premiums since premiums generally cannot be charged to a subset of Medicaid enrollees under the state plan.
  • Delay resuming premiums in CHIP at the end of the PHE until a full renewal is completed. Prior “evergreen” disaster SPAs can be activated or a new unwinding-specific disaster SPA can be submitted to do this.

Premium resumption will also be staggered based on when individuals’ last renewal was completed – if a renewal has not been completed in the last 12 months, one must be completed before reimposing premiums but they may be restarted immediately after the PHE if a renewal has been completed in the last 12 months. Delaying premiums should be a no-brainer to help alleviate additional operational/system stress state agencies will likely face during the unwinding. Not to mention continuing to suspend premiums would help smooth the transition from Medicaid to CHIP, reducing gaps in coverage for children. Or better yet, states could eliminate their premium requirements entirely and remove a hurdle for children to stay covered when the PHE ends.

Use of Contractors for Administrative Functions

Additionally, CMS makes clear that states can use contractors for certain administrative functions, which can help ease the burden on state agency staff. Contractors can perform functions that do not require individual discretion in evaluating eligibility such as staffing call centers, providing IT support, and performing data entry. In January 2022, twelve states indicated that they planned to hire contractors to help increase eligibility staff capacity. As states face large staff vacancy rates, they should explore this opportunity to reduce the workload on existing staff and ensure a smooth unwinding process. But careful oversight is needed to avoid issues; remember what happened in Missouri disenrolling individuals based on information provided by Lexis-Nexis that inaccurately flagged enrollees when an individual with the same name lived in another state.

Administrative Claiming for Outreach

A final thing to highlight is the last question in the FAQs which details how states can use administrative matching funds for unwinding-related outreach and advertising. Both Medicaid and CHIP allow states to claim federal funds for outreach efforts (50 percent for Medicaid and regular enhanced FMAP for CHIP); these funds can be used for a variety of outreach for the unwinding including paid marketing campaigns. States can combine outreach/advertising efforts for Medicaid and CHIP but, according to the FAQs, states will have to develop a method for assigning costs for these efforts in order to appropriately claim matching funds and meet programmatic requirements, including adhering to the 10 percent cap on administrative expenses in CHIP. States should take advantage of these available funds to maximize the reach of their outreach efforts and help families navigate through these unprecedented times.

It is great to see new FAQs after a year or so hiatus, especially addressing some key questions that have arisen from CMS guidances and as states are planning for the unwinding.

[Editor’s Note: For more information, visit our PHE Unwinding resource page where you’ll find other blogs in this series, reports, and the 50-state tracker.]