Updated List of Flexibilities Highlight Variety of Approaches States Are Taking to Promote Continuity of Coverage During the Unwinding

To meet the unprecedented moment of the unwinding of the Medicaid continuous coverage protection, states have implemented a range of innovative policies to make the renewal process smoother for enrollees as well as state eligibility workers. One tool that states have increasingly used is Section 1902(e)(14)(A) waivers, or “e14s,” which we have written about previously in our Unwinding Wednesday blog series. CMS has continued to lean on the flexibilities offered by e14s as a key to ensuring eligible individuals remain enrolled in Medicaid, including unveiling new strategies in June specifically aimed at mitigating procedural disenrollments. Many, including us, have been eager to know more about what flexibilities states have taken up, and now we have new insights into that question – last week CMS quietly released a revamped version of its e14 landing page, complete with a map that provides detailed state-by-state information on what flexibilities states have adopted.

Just to recap, the last time we dug into where things stood with e14 waiver approvals, it was before the Consolidated Appropriations Act, which ended the continuous coverage protection, had even been enacted and there was not yet a date certain for the start of unwinding. At that time, 38 states had taken up flexibilities, for a total of 139 approved e14s. Fast forward a year later: all states except Florida have adopted at least one e14 waiver, with 360 approved waivers in total. And more than half of states have more than six approved flexibilities, though Tennessee tops the class with 15.

Before getting into the weeds of the specific flexibilities, note that the option to delay procedural terminations for 30 days so states can conduct additional outreach is not on the updated list of approved e14 waivers. This option is based on authority outside of section 1902(e)(14)(a) and therefore is not included on the list of e14 flexibilities.

Under the Medicaid statute, waivers are allowed through 1902(e)(14)(a) to “protect beneficiaries.” The flexibilities approved follow those guardrails by assisting states’ efforts to promote continuity of coverage, streamline the Medicaid renewal process, and help reduce procedural disenrollments. For example, strategies to increase ex parte renewal rates can improve the number of individuals renewed via ex parte, which can lessen bureaucratic hurdles eligible enrollees face to maintain coverage and the workload for state agency staff.

States have widely adopted the flexibilities allowing states to partner with managed care plans or use the National Change of Address and/or USPS database to update enrollee contact information (32 states and 37 states, respectively). These policies were especially important in the preparation and early days of the unwinding to ensure enrollees received important renewal information to stay enrolled in Medicaid. Many states have also adopted at least one of the strategies to increase ex parte renewal rates, which includes using SNAP eligibility to renew individuals. Though the flexibility to allow pharmacies and other community-based organizations to facilitate reinstatement of coverage for those procedurally disenrolled based on presumptive eligibility criteria was one that originally got a lot of attention from stakeholders, no states have adopted the option to date — the difficulty of standing up the infrastructure needed to implement the policy, including training qualified providers, is likely a significant barrier for most states.

In the release of new data on states’ adoption of e14 flexibilities, CMS published a detailed chart that included additional strategies beyond those in the June 2023 chart the agency had previously released. These new strategies include waiving the recording of telephonic signatures and using simplified renewal forms. Some states have also adopted strategies beyond those explicitly identified in the CMS chart, which can be found in the footnotes of the table.

It is too soon to tell whether the strategies states are adopting are translating to better unwinding renewal outcomes including fewer eligible individuals being disenrolled. After all, the devil is in the details, or rather, in the implementation of these policies. And the flexibilities are only effective if a state is willing to adopt these policies. But it is encouraging to see continued efforts to promote continuity of coverage which will hopefully remove some of the red tape Medicaid enrollees experience, help smooth the renewal process for state agencies and reduce the exceedingly high rates of procedural terminations. Let’s hope these efforts continue beyond the unwinding as well.

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