The Urban Institute and Georgetown CCF have released a new report highlighting ways to improve the Medicaid/CHIP redetermination process for children emanating from key lessons learned during the unwinding of the Medicaid continuous coverage protection. These insights are based on interviews of representatives in 8 state Medicaid agencies, offering a unique perspective directly from the individuals responsible for planning and facilitating their state’s unwinding. To support our understanding of states’ efforts to mitigate coverage losses among eligible children, stakeholders in each of these states (i.e., provider and health plan representatives, consumer advocates, policy experts, and others) were also interviewed.

The eight states included in the report — Alabama, Connecticut, Illinois, Maryland, North Carolina, Ohio, Tennessee, and Washington – were selected based on the state’s relatively low enrollment declines for children as of early 2024 and/or being identified as having adopted practices or having potential lessons on how to support the successful retention of children in Medicaid/CHIP. This study sought to parse out the effects of the unwinding on children since limited research has been done focused specifically on kids; however, as described more below, efforts to retain coverage directly targeted at children were few and far between. But because children represent a large share of the Medicaid population, many of the policies and strategies implemented by states had consequences for children’s coverage.

Some of the notable findings from our interviews with states include:

• There were very few approaches implemented specifically with children in mind, particularly due to the enormous workload state agencies faced. But long-standing policies adopted prior to the unwinding designed to facilitate and maintain children’s coverage, like adoption of Express Lane Eligibility (ELE) and 12-month continuous eligibility, helped protect against unnecessary coverage losses.

• Prior improvements to and investments in state enrollment systems was a thread throughout state interviews. Systems updates in some of the study states were driven by previous compliance issues identified years before the unwinding, which allowed their systems to be more efficient and contributed to state readiness for the unwinding. 

• High-performing ex parte systems were cited in numerous interviews as being critical to managing the unwinding and helping safeguard children’s coverage. State officials in one state noted that the implementation of a “renewal receipt bot” that referred individuals who did not return their renewal packets to county workers for processing if data showed the person was very likely eligible significantly reduced procedural terminations. Many of the state officials interviewed also pointed to the use of Section 1902(e)(14)(A) waivers to improve ex parte rates – with some, such as the zero income and SNAP strategies, being noted as particularly effective.

• State officials emphasized efforts to engage stakeholders early in their planning for unwinding (as early as 18 months before) as well as in disseminating messaging about redeterminations once they began. Several states leveraged partnerships with coalitions of stakeholders and other trusted organizations to help inform communications strategies and to provide feedback on how the unwinding was unfolding. State coordination with managed care organizations (MCOs), including providing lists of individuals with upcoming renewal dates to MCOs to facilitate targeted outreach, was also incredibly valuable in communicating with Medicaid enrollees about redeterminations.  

One key theme across state agency official interviews was the importance of CMS leadership and oversight during the unwinding.  According to interviews, CMS provided important resources and additional tools throughout the unwinding. And a few states specifically noted appreciation for the technical assistance and regular communications CMS provided. Yet, the unwinding has also highlighted that more federal enforcement is needed to ensure compliance and improvement of state eligibility policies and systems to protect children’s coverage, as detailed in an accompanying Health Affairs blog.

The new report uses the lessons learned from unwinding, including from the perspectives shared in the state and stakeholder interviews, to identify recommendations for federal and state policymakers  to improve the redetermination process for children enrolled in Medicaid/CHIP. We found that while no single strategy is a “silver bullet” to ensuring all eligible children maintain coverage, continual efforts to improve eligibility processes and systems and a  strong commitment to policies that support continuous coverage are necessary to protect children’s coverage.