Introduction

At the end of March 2023, states began the process of redetermining eligibility for more than 90 million Medicaid enrollees after a three-year pause on disenrollment during the COVID-19 pandemic. By December 2023, Medicaid net enrollment had declined by more than 8 million people, including over 4 million children. While a drop in enrollment was expected, the most recent data indicate that thus far into the “unwinding,” as it’s commonly known, 70% of people losing coverage have been disenrolled for procedural or paperwork reasons, not because the state was able to verify that they were no longer eligible. This is particularly troubling for children since Medicaid is the primary source of health insurance for low-to-moderate income children. When the continuous enrollment protection was lifted, Medicaid covered more than half of the nation’s children (54%).

While some of those who were disenrolled have transitioned to employer-sponsored insurance or the marketplace, there is no doubt that many who have lost coverage remain eligible for Medicaid or the Children’s Health Insurance Program (CHIP), particularly children given that income eligibility levels are much higher for children than adults in all states. Federal researchers projected that nearly half (45%) of all individuals disenrolled from Medicaid during the unwinding would remain eligible. The risk of losing coverage while still eligible is higher for people of color but highest of all for children with an estimated three out of four children remaining eligible for Medicaid or CHIP. A recent KFF survey of adults who had been enrolled in Medicaid prior to April 2023 found one in five had been disenrolled from Medicaid at some point in 2023. Nearly half of (47%) of those who were disenrolled said they had re-enrolled but nearly a quarter (23%) said they were now uninsured.

During the unwinding, states clearly demonstrated their ability to intensify outreach, community-partner engagement, and consumer assistance strategies. Seizing this momentum and pivoting communications approaches and outreach messages to re-enrollment of eligible children and individuals should be a priority for states as the unwinding winds down.

To provide a snapshot of how states are engaged in non-unwinding related outreach and enrollment assistance, a CCF research team searched state websites to identify and inventory various strategies and resources that are available or linked online. There remain many questions about how states conduct outreach and support community-based assistance, such as whether states have dedicated outreach staff positions. Our goal in posting this point-in-time snapshot of state outreach efforts and resources is to offer states and stakeholders ideas and approaches employed in other states to ensure that all eligible children and families have access to the healthcare they need to thrive. No amount of online content can fully replace the need for consumer assistance through call centers and from community-based organizations, but states can do more to maximize online resources to advance the use of self-service options that promote enrollment and continuity of coverage.

Discussion

States have a statutory obligation to conduct outreach and assist eligible families and individuals with enrollment in both Medicaid  and CHIP. CHIP regulations highlight a broad range of outreach strategies that states may deploy including conducting public education and awareness campaigns, simplifying enrollment processes, and providing assistance directly to families and through community-based organizations. States are also required to “outstation” eligibility workers in federally qualified health centers and disproportionate share hospitals unless the Secretary approves an alternative plan that is an equally or more effective method. Despite federal statutory and regulatory requirements to conduct outreach and outstation eligibility workers, there are no benchmarks or standards to assess the adequacy of state strategies and resources.

To improve administrative efficiency and reduce the paperwork burden on eligibility workers and individuals, many states encourage the use of online tools for enrollment, account management, and renewal. Using these tools is not always intuitive, so self-help guides and how-to videos or tutorials are great ways to guide individuals through the process. However, not every applicant or enrollee has access to computers or stable connectivity, and states must provide individuals with options to apply for, report changes, or renew Medicaid and CHIP coverage through four modes: online, phone, mail, and in-person. For many people, particularly those with disabilities, language barriers, or limited computer literacy, in-person assistance through trusted community partners is often the best option.

As captured in CCF’s tracking of state unwinding strategies and policies, states dramatically boosted outreach, communications, and community partnerships given the large volume of materials, tools, and other resources created specifically for the unwinding. In comparison, this 50 state and DC scan found significantly less evidence of evergreen outreach resources and community partner engagement. Going forward, states should redirect their unwinding communications and assistance-related efforts to reconnect eligible disenrollees to Medicaid and CHIP. CMS should also redeploy the wide-ranging outreach and communications resources created for the unwinding to resonate with families and individuals who have lost coverage due to procedural reasons but are likely to remain eligible.

Side Notes

CHIP versus Medicaid for Children

States have the option to use CHIP funding to cover uninsured children in Medicaid (known as M-CHIP), create a separate CHIP program, or use a combination of the two approaches. Children enrolled through M-CHIP receive all the benefits and protections required in Medicaid while separate CHIP programs have more flexibility regarding benefits, cost-sharing, and certain administrative policies. Approximately two-thirds of children funded by CHIP are enrolled in M-CHIP and were thus protected by the Medicaid continuous enrollment requirement. Although the continuous enrollment requirement did not apply to separate CHIP programs, some states also paused renewals for CHIP. Researchers projected that 57% of children losing Medicaid would be eligible for separate CHIP programs. Thus far in the unwinding, enrollment growth in separate CHIP programs only accounts for about 10% of children who have been disenrolled from Medicaid.

Fully Integrated State-based Marketplaces

Nearly half of the states (22) operate, or are in the process of transitioning to, a state-based health insurance marketplace (SBM), but of those only 10 states use integrated systems to determine eligibility for Medicaid and CHIP in addition to marketplace subsidies. Like private insurance, health insurance marketplaces are “marketing-driven,” and SBMs are more likely to broadly promote the continuum of public coverage options, including Medicaid and CHIP, under a single brand like Maryland Health Connection or HealthSource RI. Resources deployed by an integrated SBM are highlighted in blue in the state data tables.

Snapshot Summary

Results of the 50-state and DC scan are grouped as follows: primary agency and enrollment links; social media platforms; how-to videos; outreach resources; language supports and accessibility; and community-based assistance. A summary of federal resources is also included in our analysis, along with links to federal navigators and Connecting Kids to Coverage outreach grantees. 

State Agency Websites & Enrollment Resources

The scan starts with links to primary Medicaid, CHIP, and fully integrated SBM websites. Assessing the user-friendliness, accuracy, or thoroughness of websites is beyond the scope of this scan, but there are marked differences in how states present information and how easy their websites are to use. Almost all state websites (49 and DC) have an enrollment landing page that typically describes how individuals and families can submit Medicaid applications and may provide more information about what’s needed to apply.

Portal landing pages, where individuals begin the online application process, are generally linked from the enrollment landing page but can also be accessed directly. The online application is almost always embedded in an online account offering additional features for ongoing account management, such as uploading documents, reporting changes, or renewing coverage. Users must have an email address to set up an account, and may have to go through an identity verification process before proceeding. Not all potential applicants or enrollees have access to computers or stable connectivity, so “apps” for mobile devices can encourage online enrollment using a smartphone or tablet, which have the advantage of using device features like a camera to scan and upload documents while not requiring internet connectivity. A dozen states have also created mobile “apps” that can be downloaded to a smart device for ease of benefit management.

States must also provide individuals with options to apply by phone, mail, or in-person. Assessing state in-person and phone assistance is beyond the scope of this scan. However, we did look for paper application forms that can be printed and submitted by mail, and eventually found them in 49 states and DC, although it was challenging to locate them in a handful of states. Making it difficult to find the paper application form is potentially a way to discourage their use since most states prefer electronically submitted applications. This is not surprising since paper applications require additional administrative effort and can be prone to data-entry errors. However, mailing in a paper application may be the best or only option for some individuals, and is required under federal rules.

Social Media

Over 70% of adults ages 18–64 use at least one social media site, making it a cost-effective medium to reach large numbers of people, particularly younger people who are more likely to visit multiple social media sites. All states but one manage an account on at least one platform and most states manage multiple; the average is four. But states vary significantly in the frequency with which they post new content, and not all content is outreach focused. As Figure 1 shows, 47 states have a Facebook account, 47 states post on X (formerly Twitter), 41 states have a YouTube account, and 34 states use Instagram. Additionally, 25 states have other active social media accounts including Threads (14 states), Vimeo (10 states), with other mediums (four states), including Flickr, SoundCloud, Pinterest, and Blogspot. Of note, SBMs were more likely to have multiple social media accounts than Medicaid agencies; the average number of accounts for SBMs was 4.9 compared to 3.9 for Medicaid agencies.

In addition to having multiple accounts on the main social media platforms, New York’s Medicaid agency and integrated SBM are also unique for having Pinterest accounts, as well as a Flickr and a Snapchat account.

Outreach

Outreach Videos

Outreach videos provide individuals and families with program information that can be presented in a way to encourage them to apply. One quarter of states (14) post short informational videos, most often on YouTube. SBM states are more likely to post outreach videos; more than half of the fully integrated SBM states (6 of 10) have outreach videos that promote Medicaid and/or CHIP, while we found similar outreach videos on fewer than 1 in 5 of the remaining 41 state websites.

Kentucky’s integrated SBM, kynect, has a series of animated videos for general outreach that describe the kynect platform, review the various benefits available to residents, and promote KCHIP, the state’s CHIP program.

Child-Focused and Back-to-School Outreach

The enactment of CHIP in 1997 prompted a renewed focus on enrolling eligible children in CHIP, as well as Medicaid, with its statutory requirement for states to create awareness of all children’s coverage options and help families enroll. Outreach materials, including flyers or factsheets that can be printed or shared electronically, social media posts, sample emails or drop-in articles, were found on 20 state agency websites. A popular and recurring theme focused on back-to-school materials, a staple among outreach strategies given the highly effective collaborations between Medicaid or CHIP agencies, community organizations, and schools. Some states may use or adapt a back-to-school toolkit developed as part of the Connecting Kids to Coverage National Campaign, which is described in more detail below.

The New Hampshire Department of Health and Human Services created a flyer that prompts parents to check their child’s Medicaid status and ensure all paperwork is completed annually to avoid a gap in coverage. The flyer also connects parents with other resources in the case that their child is no longer eligible for Medicaid.

New York State of Health released a comprehensive back-to-school toolkit in 2023 for organizations, advocates, and providers to prompt parents to ensure their children remain enrolled if they are still eligible for coverage. While these resources were originally created to assist in lessening the impact of the Medicaid unwinding, they could easily be adapted as an evergreen resource that organizations can utilize annually. Many of the social media resources in this toolkit are already evergreen in nature, allowing for partners to use them this fall, even though the unwinding will be over.

Tennessee has created back-to-school flyer that links to a wellness road map for children in different age ranges for parents to keep up with recommended well child visits and immunizations.

Toolkits

Communication toolkits provide information and resources that can be used by healthcare providers, community-based organizations, and other Medicaid stakeholders to promote awareness of public coverage programs. Community-based partners are more likely to engage in outreach if states make it easier for them to do so by providing ready-to-use resources.

Toolkits typically contain a range of materials including flyers, postcards, fact sheets that can be shared electronically or printed, drop-in articles for newsletters or websites, and social media graphics and messaging. Some states translate these resources into common languages other than English or tailor them for specific venues such as schools, early education and childcare settings, faith-based organizations, and health care settings. Notably, only a quarter of states (13) have general communications toolkits while all 50 states and DC have unwinding-related communication materials or toolkits available online.

Colorado provides a toolkit of materials that can be used in a wide variety of settings to promote their Medicaid program, Health First Colorado. The materials include a bus ad, pre-recorded radio ads, posters, and member interviews, with many of the materials duplicated in Spanish.

Other Outreach

The scan found a mix of other outreach resources on 16 state websites. Most often, these were a general descriptive brochure on Medicaid. Posted materials also include application checklists or information on using the state’s enrollment portal and how to apply. 

Missouri and Tennessee post simple brochures and flyers to provide basic information about their Medicaid programs with simple steps for enrollment.

The scan of agency websites found that about two-thirds of states publish one or more newsletters or offer informational subscriptions or listservs. These are not included in the state tables since they are most often directed at providers, health plans, or other community partners, rather than individuals and families. Although not always outreach or enrollment related, ongoing communications keep partners up to date on Medicaid and CHIP and encourages them to stay engaged.

Frequently Asked Questions (FAQs)

Publishing answers to frequently asked questions (FAQs) is a great tool for addressing recurring questions about Medicaid and CHIP. Wide availability of FAQs can provide basic information such as income limits and how to apply that may encourage uninsured families or individuals to apply or re-enroll. Additionally, making it easy to find answers to common questions can reduce the number of calls to agency call centers, allowing staff to focus on more complex cases. Two-thirds of states (37) publish FAQ webpages and/or handouts with useful enrollment-related information; a few are focused on CHIP and a handful of states have multiple FAQs.

California’s Medicaid agency provides an FAQ page that answers questions about their Medicaid program, Medi-Cal, as well as their SBM, Covered California. The webpage also answers additional questions specific to families and immigration status.

Screening Tools

Screeners are simple online tools that allow an individual to input basic eligibility information such as income and citizenship/immigration status to see if they or their family members are eligible for Medicaid or CHIP. Having a sense of eligibility can often motivate individuals to take the next step to apply for coverage. More than half of states (29) have screeners on state websites that can be accessed without first creating an online account.

Maine provides an easy prescreening tool consisting of eight questions, four of which are a simple “Yes / No” response, to test eligibility for Medicaid, SNAP, and TANF.

How-To Videos

To improve administrative efficiency and reduce the paperwork burden on eligibility workers and individuals, many states encourage the use of online tools for enrollment, account management, and renewal. However, these options are not always intuitive and self-help guides, step-by-step instructions, and how-to videos or tutorials are great tools to help individuals help themselves through the process.

In particular, states are making strides in offering online tutorials or how-to videos. These video tools are generally short but guide users through various steps in the application and enrollment process. Half of the states have videos on how to create an account through the state enrollment portal (27 states) and/or apply (28 states), while some states include both processes in one video. Notably, only 11 states have evergreen online tutorials describing the annual renewal process, while more than twice as many states (27) created unwinding-specific renewal videos. Unwinding-specific renewal videos can be easily converted to evergreen tutorials by removing references to the unwinding.

Michigan provides a helpful, nearly four-minute-long video on YouTube that touches on all aspects of using the states’ portal, MI Bridges, which is accessible using a computer, tablet, or smartphone. The animated clip includes captions to make it easier to follow the audio content for those with impaired hearing. 

The Oklahoma Health Care Authority has a series of how-to videos segmented in to short, digestible clips, including eight separate videos for each step of enrolling in SoonerCare online and a 1:34 minute-long video on how to reset your password on your online account.

Language Supports and Accessibility

Under federal civil rights laws, including Title VI of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act, states have obligations to ensure that individuals have meaningful access to Medicaid and all federally-funded programs. The importance of language access in Medicaid cannot be overstated; an adult in a household with Medicaid enrollees is more than twice as likely to have limited English proficiency than an adult in a non-Medicaid adult household. Sixteen percent (16%) of Medicaid adult enrollees speak English “less than very well” compared to 7% of adults in non-Medicaid households. The difference is even larger for children: nearly a quarter of children (23%) enrolled in Medicaid who have a parent that speaks English “less than very well.”

Getting a clear understanding of which languages are supported proved to be the most challenging aspect of this project. Application portals could not be fully assessed for language and accessibility supports in this scan since most require setting up an account using personal information. Identifying translated materials that may be available yielded varying results. At best, the resources included in this tab are an incomplete list of language or accessibility supports offered by states. However, our findings do suggest that this is an area in need of improvement both in terms of the availability of supports and ease of use. The National Immigration Law Center has published a helpful analysis of language access that includes useful tips for states.

Language Supports

In two-thirds of the states (33 states and DC), agency websites offer some ability to view some or all pages of the website in ‘one or more’ languages with wide variation across the states. Most states (29) use Google Translate (GT) for translation; 16 of those provide access to more than 100 languages, while 13 states using GT either limit the number of languages available or access to more languages using GT is not clear or intuitive. This is particularly true if a multi-step process if required, such as adding the GT widget to your browser toolbar. Of other states that offer translation, but do not use GT, the average number of languages offered for full website translation is approximately six.

While all states must also provide oral translation, not all state websites denote the languages in which telephonic translation services are offered. Thirty-two (32) states made this designation clear with an average of 15 languages being made available. Some states also use “other” language support tools including audio readers or chatbots that are available in multiple languages.

The front page of the Arizona Medicaid agency website shows 15 language options in blue that provide instructions on accessing translation services in the preferred language.

The Massachusetts Medicaid website homepage has a chat virtual assistant available in 19 languages.

The Oregon Health Plan has an application guide in 13 different languages on its website.

Accessibility

Over 10% of Medicaid enrollees are covered under a disability category, and about half of individuals eligible for both Medicaid and Medicare (known as dual eligibles) have at least one limitation in daily activities. While in-person assistance may be the best way to help some individuals, accessibility tools, such as audio readout options, widgets allowing for the user to easily select the font size or color contrast, or dyslexia-friendly text, can help those with visual or auditory impairments use the state’s web resources. The scan found 20 states with evidence of accessibility supports.

Combining language support and accessibility, the Indiana Medicaid agency homepage includes an accessibility widget that is available in 19 languages. The homepage also includes an embedded screen reader and they make available large print outreach flyers.

Community-Based Assistance

Many types of community partners serve a critical role in educating clients and patients and referring them to additional resources. A formalized community-based assistance program extends the state’s reach by providing enrollment assistance through trusted organizations that serve children and families in local communities. While many Medicaid enrollees can maneuver online enrollment tools, abundant research points to the important role community-based outreach and enrollment assistance play in connecting eligible children, families, and low-income adults to health coverage, particularly those who need individual assistance. Community health centers and hospitals are important sources of assistance, and often fulfill state outstationing requirements noted above when people are accessing health care. However, navigators and other application assisters can assist individuals in enrolling coverage before they need care.

States can support community-based assisters and navigators by creating online tools to facilitate enrollment; providing assisters with training and support materials; offering direct access to senior eligibility workers to help resolve problems; and participating in ongoing feedback loops where the state, assisters, and other stakeholders exchange information and collaborate on ways to make Medicaid stronger and more efficient.

State Assistance Programs

Based on state agency website searches, slightly more than half of states (29 and DC) have assistance programs. This aligns largely with the number of states reporting that they have online portals for application assisters and community partners to submit facilitated applications and enrollment. Assister organizations vary across states but may also include social service agencies, community action programs, and schools, as well as health care providers. Detailed information about what types of organizations can be community assisters, the training they may receive, and whether they receive compensation is not generally available on state websites.

Illinois’ Medicaid agency trains HFS Application Agents, typically community-based organizations like faith-based organizations, day care centers, unions, and medical providers, to help families apply for All Kids, FamilyCare, and Moms & Babies.

Assister Locator Tools

An online tool to locate an assister helps connect individuals with personalized assistance in or near their community. Assister locator tools provide a list of assisters, or better still, a search function to identify resource in a specific geographic area or zip code. The scan includes assister locator tools on state websites separately from external assister locators, which are often posted by navigator organizations.

Connecticut’s integrated SBM, AccessHealthCT, has a locator tool that allows users to select a zip code and city name, as well as the mile radius within which they would like to find a service. Users may also select their preferred language for assistance. 

The North Carolina Navigator Consortium is an independent statewide network of health insurance navigators serving all 100 counties in the state, and the only federally-funded navigator to do so.

Navigator Programs

Navigators help individuals enroll in health coverage in all states. While these assistance programs were created specifically to assist with enrollment in health insurance marketplace plans, navigators facilitate enrollment in Medicaid and CHIP since there must be a seamless process to coordinate coverage across the continuum of public health insurance options. State-based marketplaces must fund their own navigator programs but the federal government awards funding through cooperative agreements to navigators in states that use HealthCare.gov as the state marketplace (known as FFM states). The 2023-2024 federal navigator awards, totaling $98.6 million, fund the work of 57 navigator organizations in 31 states.

Connecting Kids to Coverage Grantees

Since 2009, Congress has appropriated funding for a campaign to connect eligible children to coverage. The most recent 3-year grants were awarded in 2022; 43 organizations in 23 states received grants averaging $1.27 million. The award summaries provide an overview of each project, often including a description of the target population and strategies and/or settings for outreach activities. Common communication strategies use social media, phone calls, text messages, postcards, and media campaigns for Spanish-language radio and television, while settings often include schools, churches, health clinics, hospitals, Head Start centers, street festivals, and COVID-19 testing and vaccination sites. Additionally, specific outreach personnel may be noted in project descriptions, such as community health workers, health navigators, application assisters, or parent mentors.

The national campaign maintains an online Outreach Tool Library of nearly 2,000 sample materials to reach families eligible for Medicaid and CHIP. The library includes social media images, posters, tear-pads, videos, radio PSA scripts, and coloring pages relating to eligibility and enrollment, as well as vaccinations, maternal health, dental care, mental health, and renewal reminders. Often the materials are available in both English and Spanish and can be customized with the name(s) and logo(s) of the organizations utilizing them. The site includes webinars and videos where lessons-learned and promising practices are shared. And last, but not least, the site provides a locator that provides links to information about Medicaid in each state, where to apply, and other resources.

Conclusion

As the unwinding concludes, maintaining improvements to renewal processes and communications should be a priority for states. But it is also imperative that states reinvigorate their outreach efforts to reconnect eligible children and families with coverage. During the unwinding, states significantly boosted direct outreach to enrollees and engagement of community partners, including health care providers and health plans, in an all-hands-on-deck approach. States should seize this momentum and refresh their communications approaches and outreach messages to resonate with families whose children were procedurally disenrolled. Reconnecting eligible kids and adults to coverage is essential to reducing gaps in access to health care and avoiding the risk of more kids and adults becoming uninsured.

Methodology

State Medicaid and CHIP agency and fully integrated SBM websites, when applicable, were scanned for a variety of public tools, resources, and materials pertaining to outreach and consumer assistance. Searches were conducted within state websites, and through web-based searches, using a variety of terms. The intent was to be thorough and as accurate as possible, but it was often challenging to find common items or resources that should be readily available on state websites, such as paper applications. Assessing language supports and accessibility was particularly challenging, so the scan is limited to information that could be confirmed. Given these factors, and the fact that state websites continually evolve, we have done our best to offer a robust collection of resources and links that can be used to stimulate further development of public education and outreach tools, and assistance programs, to maximize and stabilize coverage for children and low-income families.

Category Methodology

Social Media

State agency use of YouTube, Facebook, X (formerly Twitter), or Instagram accounts, as well as less common sites such as Threads, SoundCloud or Vimeo, was documented. LinkedIn was not included as Medicaid-related posts are typically directed toward health professionals or policy experts, rather than toward potential enrollees.

Outreach

State agency websites were scanned for outreach materials or efforts directed at potential enrollees or community partners, who assist in creating public awareness of public coverage options. In addition to general outreach resources, we separately identified child-focused outreach, including back-to-school. Health-related back-to-school materials that were not specific to Medicaid or CHIP enrollment are not included (e.g., a toolkit only featuring vaccination reminders).

How-To Videos

YouTube accounts for state Medicaid agencies or integrated SBMs were searched for instructional or promotional videos related to online portal/account creation, how to complete an application, how to complete an annual renewal, and the need to complete a renewal during the unwinding period. If YouTube accounts did not yield results, a Google search was performed to capture videos that may be present on other platforms, such as Vimeo or Facebook.

Language Supports & Accessibility

Websites were assessed for the number of languages into which translation was available. An asterisk is used to denote when Google Translate was identified as the translation source. A similar process was used for determining the number of languages used in benefits portals. Google Translate was often deployed via the Google Translate widget, meaning that once a language other than English is selected, a separate widget appears at the top of the window for translating into a language available on the Google platform. Paper applications translated into languages other than English were included when found. Finally, we noted when chatbots, audio readouts, and other accessibility supports were prominently available.

Community-Based Assistance

State-operated assistance programs to support individuals to apply for coverage were included in the scan, and locator tools are linked, if available. Links to organizations current federal navigator grants and SBM navigator programs were included for applicable states. Finally, Connecting Kids to Coverage outreach and enrollment grantees were linked to the most recent awardees.

State Data Tables

Note: We recognize that our scan might have missed a resource in your state. If you have materials that should be added to the scan, please send an email with the subject line “Outreach Scan Update” to childhealth@georgetown.edu by June 30, 2024. In the email, please include a link that we can use to verify the information you send. After June 30, 2024, no additional updates will be made to these state data tables.