When watching a baseball game, we rely on the scoreboard to keep track of the score, strikes, balls, outs, etc. But unfortunately, it’s not quite that simple when it comes to keeping up with the Medicaid continuous coverage winddown. So far, we have very little data available to monitor the unwinding. CCF is posting state enrollment data as it becomes available and this blog discusses some of the key points to keep in mind as you assess what is happening to Medicaid enrollees in your state.
Let’s start with monthly enrollment data because that’s the data most-commonly posted by states (and that’s what CCF is tracking). Any change in enrollment from month to month is the net result of people who are newly enrolled and people who are disenrolled. If enrollment is declining, the actual number of people disenrolled is higher than the net decline in enrollment. Unfortunately, most states don’t post how many people were newly enrolled although some post the number of applications processed.
Even if we have a total disenrollment number, more information is needed to determine if the termination was procedural or due to ineligibility. We know that enrollment in Medicaid will shrink during the unwinding because some people who got a raise may no longer be eligible and some people will have gotten a better job with health insurance. But these aren’t the only reasons people will lose Medicaid. Children aging out of Medicaid or CHIP (particularly in non-expansion states), as well as people who turned 65 and became eligible for Medicare during the public health emergency, may lose eligibility. Individuals who have exhausted their 60-day or 12-month postpartum period and don’t qualify for the lower income eligibility guidelines for parents, expansion adults or for any other eligibility group will also be disenrolled.
What we are mainly concerned about is the share of people who are disenrolled for procedural reasons, but even that number must be put into context. As noted in my recent blog on procedural reasons, people who obtained employer coverage or who know their income is over the Medicaid limit may choose not to respond to the renewal request. Those counts will be included in procedural disenrollments.
State renewal reports (also called renewal distribution plans) can help in assessing available data. These reports, if publicly available, are linked in CCF’s 50-state unwinding tracker and provide important details about how a state is prioritizing renewals. For example, if a state has been flagging people who appeared to be over income limits, and prioritizing those renewals, we would expect a higher number to be disenrolled because they are no longer eligible. Of course, it’s important for the state to do a complete renewal based on current data since income fluctuates significantly among lower-income populations.
So what data points are warning signs that the unwinding may not be going well?
It’s been said before but call center statistics are the canary in the coalmine because it means that people are not able to get answers to questions or access the assistance they need in completing the renewal. When call volume goes up, so do average call wait times unless the state has excess call center capacity. But that’s probably not the case since so many states report staff vacancy rates of greater than 10 percent. And vendors in states that contract out their call centers have the same hiring challenges encountered by states and private employers. Not surprisingly, when call wait times increase, so do call abandonment rates. Most low-wage workers are not employed in the types of jobs that allow you to remain on hold while multi-tasking at your desk. And it’s not unusual for phone systems to disconnect callers when the call volume overloads the system.
Other warning signs include data that suggest the state is backlogged in its work. Increases in application processing times and growing delays in processing fair hearing requests signify that staff lacks the capacity to manage the workload. And when staff is overwhelmed, errors are likely to occur, which only compounds the problem.
While not all procedural disenrollments represent people who remain eligible, as noted above, if large numbers of people are losing coverage for procedural reasons, it is important for states to hit the pause button to reassess their policies and procedures. For example, states could do more on the communications front to ensure that people understand what they need to do to renew their coverage. Or states could provide more than 30 days for enrollees to return renewal forms or submit documentation and do more to follow-up with individuals using multiple modes of communications who must take action to retain coverage.
Monitoring social channels and participating in feedback loops with frontline organizations are critical ways for states to gather intel from the field about how the unwinding is impacting real people. Moreover, these insights can tell us more about early impact before problems show up in the data. Stakeholders should work together to compare notes about the impact of the unwinding in the state and urge the state to take stock of their findings and take action to address recurring problems or system issues.
Except for social monitoring and intel from the field, states are required to report data to CMS, and CMS is required to publicly post the data. But it is unclear when CMS will begin posting the data and how much of a lag time there will be before new data is added. In the meantime, some states are posting data or sharing the data reports submitted to CMS. Stay tuned for next week’s Unwinding Wednesday blog when Allie Gardner takes a closer look at states leading the way on transparency by creating public-facing unwinding data dashboards.
[Editor’s Note: This is the 28th blog in the Unwinding Wednesday series. For more information, visit our PHE Unwinding resource page where you’ll find other blogs in this series, reports, webinars and the 50-state tracker.]