Unwinding Wednesday #12: More States Are Taking Advantage of Flexibilities Aimed at Mitigating Gaps in Coverage during Unwinding

A few months ago, we wrote about new data from CMS on approvals of time-limited waivers, or (e)(14) waivers, that states may adopt to smooth the unwinding process and mitigate unnecessary gaps in coverage. Only 20 states had been approved for these temporary waivers at the time the data was initially released. Since then, the number of states with (e)(14) waiver approvals has almost doubled (now totaling 38 states) with more than twice the number of approved waivers in August (139 compared to 61).

Take-up of (e)(14) waivers was a concern when the data were first published – both in the number of states and the number of waivers each state had adopted. Not only do the majority of states now have approved waivers, but also, of the states with waivers, over half have four or more approved. And five of the six states we had identified as being most at risk of children losing health coverage earlier this year have adopted (e)(14)s – Florida is, unsurprisingly, the only one of our “high-risk” states with no approved waivers. While these waivers are by no means a guarantee that eligible children will maintain health coverage, they are a signal that these states have their eyes on the ball and are working to promote continuity of coverage at the end of the PHE.

Another development we’ve seen in the data on (e)(14) approvals is the expansion of the types of waivers approved. In addition to the eight strategies initially posted in August, CMS has approved waivers for two more flexibilities – allowing renewals based on TANF eligibility and utilizing enrollment brokers to update beneficiary contact information – in the same vein of strategies using managed care plans or USPS data. This means states can use additional existing data for renewals and leverage partnerships with reliable third parties to help with the all-important task of updating beneficiary contact information. These additional strategies show that CMS is open to considering other unwinding-specific strategies outside of those detailed in its March 2022 guidance, and states are learning from other states. For example, Alabama’s waiver to allow renewals based on TANF eligibility was originally approved under the ”other” category and now two more states have adopted that waiver.

Unsurprisingly, the waivers that have been adopted by the most states are those that will assist in updating contact information prior to the unwinding. Almost two thirds of the states with approved (e)(14)s have taken up the flexibilities to use MCOs to help update contact information (27) or use the NCOA database and/or USPS returned mail to update contact info (24). Strategies to simplify the renewal process are also popular among states with approved waivers as half of them adopted the flexibility to renew eligibility for enrollees with zero income under certain conditions or streamline asset verification. These waivers will help states prepare for the end of the PHE as well as ease the burden on Medicaid agency staff during the unwinding.

CMS’s timely and transparent reporting on the approved (e)(14) data should be applauded. Data will be essential to help monitor the unwinding process; however, it is also incredibly important to monitor before the unwinding starts. Information, such as which states have adopted temporary waivers or what states’ plans for the unwinding are, give stakeholders an opportunity to identify where their states have adopted policies that will help mitigate coverage losses and where they could take additional steps to do so. It would be great if CMS would commit to releasing state performance indicator and supplemental unwinding data in the same timely manner as it has with the (e)(14) approvals.

For the thirteen states without any (e)(14) waivers, there is still time to adopt these flexibilities. As CMS explained in its recent FAQs, states can request a retroactive effective date for the waivers, allowing implementation of key strategies, like those relating to updating beneficiary contact information, to begin before official approval. With the presumed extension of the PHE likely to be extended until April 2023, states should continue to plan, evaluate, and adopt policies that will help preserve coverage for eligible enrollees once the continuous enrollment protection is lifted.

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