During the unwinding of the COVID-related freeze on disenrollments in Medicaid, states were required to renew health insurance for all 94 million enrollees. The focus on Medicaid renewal processes during the unwinding revealed their complexity and inefficiencies in the system. With states facing an unprecedented volume of work and eligibility worker shortages, CMS provided new options to streamline enrollment and renewal processes, emphasizing automation and the use of reliable data sources to increase accuracy and efficiency. States broadly adopted these strategies, and many emerged from the unwinding with more efficient processes by maximizing the use of technology to verify income, reduce returned mail, and improve communications with enrollees.
Medicaid agencies are now turning their attention to ensuring that state policy aligns with new and existing federal requirements. At the same time, there is significant uncertainty about how potential changes to federal Medicaid financing and policy under consideration by Congress and the Administration will impact states and Medicaid enrollees in the future. Congress is debating cuts to Medicaid of $880 billion or more over ten years, citing a desire to curtail spending to help pay for tax cuts and address “fraud, waste, and abuse”. While several proposals would fundamentally restructure who is covered by the program and how it is financed, repeal of regulations finalized in the last administration, and specifically the Eligibility and Enrollment rule (E&E rule) finalized in June 2024, are also under consideration.
Key Takeaways
- Building on strategies adopted during the unwinding, most states are continuing to implement policies to increase ex parte, or administrative, renewal rates. During the unwinding period, states employed new approaches to using data and automation to streamline processes for verifying eligibility. Over two-thirds of states plan to continue or newly adopt at least one strategy to facilitate ex parte renewals. While 29 states report that over half of ex parte renewal rates are conducted automatically by their systems, the share of eligibility determinations at application that are automated and conducted in real-time (within 24 hours) lag. Close to half of states say they cannot conduct automated real-time eligibility determinations on new applications or report that less than 10% of these eligibility determinations are automated.
- States increasingly rely on data from trusted sources to automate manual tasks and improve accuracy of Medicaid eligibility, enrollment, and renewal processes. By advancing the use of information from other programs such as SNAP and TANF, states have improved the accuracy of income verification while reducing administrative burden associated with mailing renewal forms and manually processing information submitted by mail or phone. At the same time, periodic checks of income data sources coupled with limited time for enrollees to respond to information requests can increase procedural disenrollments and churn.
- States have incorporated new strategies for updating contact information and communicating with enrollees into routine operations. Access to the US Postal Service National Change of Address (NCOA) Database and other program data allows states to routinely update mailing addresses, tackling the longstanding problem of returned mail. Nearly all states proactively check available data sources for updated contact information or accept updated addresses from managed care plans or providers. To increase renewal response rates, states contact enrollees multiple times before and after sending renewal notices using multiple modes including email and text. States have also enhanced online tools–online accounts and mobile apps–to provide additional ways to communicate with enrollees and to give enrollees the ability to more easily manage their coverage.
- Continuing a trend over the past few years, two states increased income eligibility for pregnancy coverage. Alaska and Washington state expanded income eligibility for pregnancy and Colorado adopted the From Conception to the End of Pregnancy coverage option in CHIP. Since 2023, five states (Alaska, Nevada, North Dakota, Tennessee, and Washington) have increased pregnancy eligibility levels, but one state (Iowa) is seeking approval to reduce pregnancy income eligibility. At the same time, half of the ten non-expansion states base parent eligibility on a dollar threshold that erodes over time with inflation. As a result, the federal poverty level equivalence declines. As of January 2025, four states experienced declines in parent eligibility: in Florida from 27% to 26% FPL, in Georgia from 30% to 29% FPL, and in Wyoming from 45% to 44% FPL. BTW, Texas has the lowest parent eligibility at 15% FPL, or $333 per month, for a single parent with 2 kids.
- States have taken steps to remove administrative barriers to enrollment and renewal for children and seniors and people with disabilities (non-MAGI groups). Almost all states with separate CHIP programs have eliminated required periods of uninsurance (waiting periods) and lock-out periods following nonpayment of premiums, both of which contribute to gaps in coverage. The E&E rule requires states to phase out waiting and lock-out periods by June 2025 (Table 1). Two states (Utah and Delaware) permanently eliminated CHIP premiums in 2024, and premiums remain temporarily or indefinitely suspended in Arizona and Vermont while Georgia reinstated CHIP premiums after pausing them during the COVID pandemic. All states have taken steps to align non-MAGI renewal rules with those in place for MAGI groups such as conducting annual renewals, eliminating in-person interviews, and giving enrollees more than 10 days to respond to requests for information. The E&E rule requires states to align non-MAGI renewal policies by June 2027.
The survey report includes additional analysis, numerous figures and graphics, and 28 50-state tables with details. The 2025 and prior year reports and tables can be found here.