In This Report:
Executive Summary
In early 2023, states began final preparations for the end of the pandemic-related Medicaid continuous enrollment provision following passage of the Consolidated Appropriations Act (CAA) of 2023, which lifted the requirement effective March 31, 2023. During the three-year pause on Medicaid disenrollments, Medicaid and CHIP enrollment grew by 32% from 71.3 million to 94.1 million, resulting in the largest ever number of enrollees in Medicaid, which, along with enhanced subsidies in the Affordable Care Act (ACA) Marketplaces, contributed to the lowest ever uninsured rate. The CAA also extended and phased out the enhanced federal Medicaid matching funds that states received during the pandemic through the end of 2023. All states were expected to initiate their first month of renewals no later than April 2023, although some states did not process their first disenrollments until June or July.
The 22nd annual survey of state Medicaid and CHIP programs officials conducted by KFF and the Georgetown University Center for Children and Families in March 2024 presents a snapshot of actions states have taken to improve systems, processes, and communications during the unwinding, as well as key state Medicaid eligibility, enrollment, and renewal policies and procedures in place as of May 2024. The report focuses on policies for children, pregnant individuals, parents, and other non-elderly adults whose eligibility is based on Modified Adjusted Gross Income (MAGI) financial eligibility rules (information on policies for populations that qualify for Medicaid on the basis of age or disability—non-MAGI populations—is captured in a separate brief). Overall, 49 states and the District of Columbia responded to the survey, although response rates for specific questions varied (Florida was the only state that did not respond). For purposes of this report, the District of Columbia is counted as a state.
Key Takeaways
- All states report taking action to improve automated, also known as ex parte, renewal rates during unwinding and plan to continue these strategies post unwinding. Forty-two states adopted 1902(e)(14)(A) waiver flexibilities to increase ex parte renewal rates for MAGI populations, while 39 states improved system rules and 22 states expanded the number of data sources they use to conduct ex parte reviews. In addition, 34 states process ex parte renewals on a mostly automated basis, which required system upgrades in some states. Among the 42 states that adopted 1902(e)(14)(A) waivers to increase ex parte rates for MAGI populations, allowing for ex parte renewals for individuals with $0 income and with low income in some circumstances and using SNAP or TANF eligibility to confirm ongoing Medicaid eligibility were cited as the most useful waivers, and many states would like to make these permanent. CMS has extended the 1902(e)(14)(A) waivers through June 2025.
- All states made changes to simplify or streamline the renewal process and they want to keep many of the changes in place after the unwinding period ends. In addition to improving ex parte processes, some states also made more targeted changes to revise renewal notices (22 states), simplify the renewal form (10 states), and extend the time to respond to renewal notices (7 states) that should make it easier for enrollees to complete the renewal process in the future.
- States cite outreach to enrollees and engagement of health plans and community groups among the strategies that improved unwinding outcomes. States boosted direct outreach to enrollees through multiple modes, including text, email, and automated calls, and 37 states plan to maintain the enhanced outreach post unwinding. Additionally, over two-thirds (34) of states expect to continue engaging health plans and/or community-based organizations in the renewal process. States also noted that these organizations played an important role in amplifying outreach and providing community-based assistance.
- Several states are taking steps to improve coverage for children and pregnancy, including by increasing eligibility levels, providing continuous eligibility, and eliminating premiums for children’s coverage. In 2024, five states increased eligibility levels for children and/or pregnancy coverage and eight states extended coverage to certain immigrant children and/or pregnant individuals. Eighteen states have eligibility levels above the median for both children (255% FPL) and pregnancy (210% FPL). Building on the experience of continuous enrollment, several states have adopted or are pursuing multi-year continuous eligibility for young children, and there has been widespread adoption of 12-month postpartum coverage. And since 2020, ten states have eliminated or are poised to eliminate premiums for children’s coverage.
As the unwinding comes to an end, there is a lot to learn from state experiences during the past year. States made numerous policy and systems changes to improve the renewal process and they plan to maintain many of those changes. Additionally, the Eligibility and Enrollment final rule CMS issued earlier this year simplifies many eligibility and enrollment processes for Medicaid and CHIP by eliminating certain enrollment barriers in CHIP; facilitating transitions between coverage programs; and aligning enrollment and renewal requirements for most individuals in Medicaid. It makes some temporary policy changes permanent and will require additional changes over the next 36 months. CMS has also extended 1902(e)(14)(A) waivers through June 2025 while it continues to assess whether any waivers can be made permanent under other authority. Collectively, these changes to renewal and ex parte processes as well as eligibility expansions mean that the return to “routine” operations will not mean return to pre-pandemic operations. The impact these changes may have on continuity of coverage and churn and on overall Medicaid enrollment will be seen over the coming years.