Key Findings
- State systems are unprepared for federal demands to implement a Medicaid work reporting requirement and other onerous changes. HR 1 (P.L. 119-21) requires states to implement complex work reporting and renewal policies just months after the Medicaid unwinding strained state eligibility systems. Warning signs – including long call center wait times, low rates of “ex parte” (automated) renewals, and long processing times for new applications – point to risks of widespread, avoidable coverage losses. Based on an analysis of eight Medicaid performance indicators, states most at risk of poor implementation which may lead to inappropriate coverage loss include Illinois, Missouri, Montana, North Dakota, New Mexico, Utah, and Wisconsin. More than half of states (29) have red flags for at least half of the eight metrics examined.
- Children will lose Medicaid and CHIP coverage despite not being the primary target of policy changes. The “One Big Beautiful Act” cuts federal funding for Medicaid and CHIP by nearly $1 trillion ($990 billion over 10 years). Since almost half of U.S. children are covered by Medicaid, states cannot shield them from harm. Child enrollment in Medicaid and CHIP grew from 35.2 million in February 2020 to a high of 42.3 million during the COVID-era enrollment protections but dropped to 37.3 million by April 2025. Enrollment declines for children are expected to continue for a variety of reasons, and pressure on state eligibility systems will make it slower and harder for eligible children to regain Medicaid coverage.
- When parents lose coverage, children are at greater risk. Many parents are enrolled through the ACA’s Medicaid adult expansion where eligibility thresholds are considerably higher (138% FPL or $36,777 for a family of three) than the restrictive limits of traditional parent coverage (37% FPL or $9,860). The Congressional Budget Office estimates that 6 million adults in the Medicaid expansion group will become uninsured as a result of work reporting requirements and more frequent renewals. Exemptions for parents of children under 14 may not work smoothly in practice, with as many 1.5 million children losing coverage either because of administrative errors or confusion over the changes. Additionally, families with uninsured parents face greater economic threats resulting from medical debt.
- Marketplace changes will add red tape and increase costs for families. HR 1 shortens the open enrollment period, eliminates auto-renewals, and imposes new administrative hurdles to access subsidized coverage through federal and state marketplaces. Marketplace enrollment doubled after enhanced premium tax credits were introduced in 2021. Unless Congress extends those subsidies before December 2025, Marketplace enrollees will face steep premium hikes with CBO estimating that 4.2 million will become uninsured. The changes to Marketplace policies will be particularly acute in the 10 non-expansion states that have a higher share of parents and adults enrolled in Marketplace plans since Medicaid is not an option. While not a primary source of coverage for children, child enrollment in the Marketplace has grown considerably in the past few years, nearly doubling to 2.1 million. All of these changes will put more pressure on state Medicaid and CHIP eligibility systems as families explore all options for coverage.
Introduction
On July 4, 2025, President Trump signed into law HR 1 (P.L. 119-21), the massive budget reconciliation bill that cuts more than $1 trillion from Medicaid and Marketplace health coverage. The law strips coverage from many lawfully residing immigrants, ties the hands of states to raise revenue to cover the state share of Medicaid, and specifically targets the Medicaid adult expansion enacted by the Affordable Care Act (ACA).
As was true with the Medicaid unwinding, how families fare as HR 1 provisions are implemented will vary enormously depending on where they live, the status of the state’s eligibility and enrollment processes, and how well the state handles the implementation. State Medicaid and CHIP policy choices matter, as does administrative capacity. And states will be further challenged by their own budget shortfalls resulting from restrictions on provider taxes and state-directed payments and other costs shifted to states resulting from HR 1.
States are just emerging from the unwinding of the pandemic-related Medicaid continuous enrollment provision when HR 1 presents a host of state budget impacts and new administrative hurdles for states. Designing, testing and implementing new technology to automatically check for compliance with work requirements or exemptions should be a multi-year project, but states have less than 16 months to prepare. Although HR 1 largely targets the adult expansion population, when state administrative capacity is stretched, all enrollees are affected. Confusion around changes, unrealistic timeframes for implementing major policy, and workloads that overwhelm staff all contribute to backlogs, stress, and human error. If states are already having trouble keeping up with their eligibility and enrollment administrative workload, adding work reporting, six-month renewals, and mandatory cost sharing requirements for expansion adults will only exacerbate the situation.
How can we assess whether state Medicaid eligibility enterprises are ready to tackle additional administrative tasks mandated by HR 1? While the 41 states that have implemented the adult expansion, plus Georgia and Wisconsin, will have the heaviest lift with work reporting requirements, all states will have new administrative tasks and may make other changes to deal with budget shortfalls and changes to immigrant eligibility. Although we don’t have all the data that would paint a complete picture, we do have certain Medicaid performance indicators that reflect the status of state performance on various aspects of the eligibility and enrollment processes. These metrics are published monthly by the federal Centers for Medicare and Medicaid Services based on data reported by the states and include call center wait times; call abandonment rates; applications processed in over 30 days; the overall renewal rate; the ex parte renewal rate; the share of enrollees disenrolled at renewal; the procedural disenrollment rate; and the share of pending renewals. The metrics are described in more detail below.
The analysis of state performance metrics is displayed in national maps for the most recent quarter (January – March 2025) broken into four quartiles with the top quartile reflecting the highest performing states. To smooth out monthly anomalies in state workload and allow for tracking these metrics over time, we are averaging the monthly data over a quarter. Each metric will be updated for the most recent quarter in our new State Readiness for HR 1 Tracker. Data from prior quarters starting in January 2024 are also available on our tracker.
Each state gets a red flag if its performance on any metric is in the bottom two quartiles as an indication or warning that the state may be encountering systems issue or difficulty in managing the workload. The higher the number of red flags, the greater the likelihood the state will have additional challenges in administrating eligibility and enrollment and assisting applicants and enrollees. Illinois, Missouri and Montana top the list with seven red flags, followed by North Dakota, New Mexico, Utah and Wisconsin with six red flags. Over half (29 states) have red flags on at least half of the eight metrics.
Medicaid Performance Indicators
States are required to report performance on 12 primary eligibility and enrollment measures that are disaggregated into more than 80 sub-measures. However, only a handful of these measures are published routinely on a 50-state basis. Background on the Medicaid performance indicators is explained below. For this analysis, we examined the eight measures below which are reflected in these national maps.
Average Call Wait Times: Call center wait times are the average amount of time an enrollee is on hold waiting for assistance. Long wait times means states are unable to adequately serve enrollees and applicants who need assistance. Since most call centers are only available during normal business hours, people who work jobs with limited flexibility may have difficulty getting the help they need to stay enrolled.
In the first quarter of 2025, call wait times ranged from a high of 57 minutes in Missouri to a low of less than a minute in the District of Columbia, Kansas, Mississippi, North Carolina, and Tennessee. A quarter of the states have call wait times over 14 minutes; the national median was 7 minutes.
Average Call Abandonment Rate: Callers encountering long wait times may be unable to stay on hold. When call volume is high and wait times long, phone systems can also be overloaded and inadvertently drop calls. High abandonment rates indicate a call center is unable to adequately manage the need for assistance, leaving enrollees without the answers they need to complete their application or renewal.
In the first quarter of 2025, the call abandonment rate ranged from a high of 52.4% in Missouri to a low of .1% in Tennessee. More than 20% of the calls to Medicaid call centers were dropped or abandoned in a quarter of the states; the national median was 9.7%
Application Processing Times: The timeliness standard for processing most Medicaid applications is 45 days or less. Like ex parte renewals, states can ping data sources to verify eligibility automatically in real time (within 24 hours) upon application, but some states have yet to change their workflows and enhance their systems to rely on available data. A higher share of applications over 30 days suggests that the state may have a backlog or requires additional paperwork that takes extra time for enrollees to submit and states to process.
In the first quarter of 2025, the share of applications taking more than 30 days to process ranged from a high of 72.2% in Virginia to a low of 0% in Minnesota, Oklahoma, and Oregon. In one quarter of states, 26.7% of applications take longer than 30 days to process.
Overall Renewal Rate: The overall renewal rate reflects the share of enrollees with a renewal due who retained coverage. A higher overall renewal rate means fewer eligible individuals are likely to lose coverage at renewal due to missing paperwork or other administrative barriers.
In the first quarter 2025, the overall renewal rate ranged from a low of 23.2% in Nebraska to a high of 99.1% in Rhode Island. A quarter of the states had overall renewal rates of less than 61.2%; the national median was 75.9%.
Ex Parte (Automated) Renewals: States are first required to attempt to confirm ongoing eligibility at renewal through reliable data sources without requesting information from the enrollee. This process, known as “ex parte,” accesses income and other data available to the state through quarterly wage reports, tax filings, unemployment compensation, the Social Security Administration, and other third-party sources. If the data confirm that an individual continues to be eligible, coverage is automatically renewed.
In the first quarter 2025, the ex parte renewal rate ranged from a low of 9.6% in Texas to a high of 99.0% in Rhode Island. Ex parte rates were less than 37.9% in states in the bottom quartile; the national median was 52.6%.
Total Disenrollment: Lower disenrollment rates mean more eligible people are retaining coverage while high disenrollment rates create “churn” and gaps in coverage when eligible individuals lose coverage at renewal and re-enroll within a short period of time. Churn impacts health care access for enrollees and creates more administrative work and unnecessary costs for states and health plans to disenroll and re-enroll an eligible individual.
In the first quarter of 2025, the total disenrollment rate ranged from a high of 42.8% in South Dakota to a low of 1.4% in Rhode Island. The total disenrollment rate was greater than 26.3% in the bottom quartile of states; the national median was 16.4%.
Procedural Disenrollments: Procedural disenrollments occur when the state lacks information needed to determine eligibility at renewal, not because the enrollee was determined ineligible. On average, over two-thirds of individuals losing coverage at renewal are disenrolled for procedural reasons. Research has shown that many people who are disenrolled for procedural reasons re-enroll in a short period of time, creating gaps in coverage and additional administrative burden for states and health plans. States are also unable to fully measure quality when individuals have gaps in enrollment.
In the first quarter of 2025, the total share of disenrollments for procedural reasons ranged from a high of 94.4% in Missouri to a low of 0% in Rhode Island. More than a quarter of states had procedural disenrollment rates of greater than 80.3%; the national median was 72.3%.
Pending Renewals: When a state has received renewal information from an enrollee that has not been processed by the end of the month, it is reported as pending. A high share of pending renewals suggests that a state may be experiencing system issues or backlogs of unfinished work.
In the first quarter of 2025, the share of pending renewals ranged from a high of 71.4% in Nebraska to a low of 0% in Minnesota, Nevada, and Rhode Island. The pending renewal rate was greater than 12.9% in states in the bottom quartile; the national median was 4.8%.
State Readiness for HR 1 Online Data Tracker
In addition to the national maps, we have trended state performance on these metrics starting with the first quarter 2024 with a new State Readiness for HR 1 Tracker. In the state charts, we show how the state compares to the national median. Please note that not all states had completed the unwinding in 2024, so the first two quarters of data may include a state’s unwinding experience.
State Strategies to Reduce the Negative Impacts of HR 1
Strategies for improving state eligibility and enrollment processes revolve around leveraging technology and strengthening consumer support.
Using technology to make data-driven eligibility determinations increases state efficiency, lowers administrative costs, improves accuracy, and simplifies the application and renewal processes for enrollees. States can maximize the use of technology by:
- Increasing the share of ex parte renewals by accessing additional data sources and making system improvements will lower the share of enrollees losing coverage due to procedural reasons.
- Using technology to automatically determine if an adult in the expansion population complies with or is exempt from work reporting requirements is critical to avoid unnecessary loss of coverage. Automating straightforward tasks like using an income proxy of 80 hours at the federal minimum wage (currently $580 per month) or exempting parents with dependent children under age 14 will free up staff time to deal with more complex situations.
- Working with managed care plans and providers may help identify innovative ways to ease the administrative burden on enrollees with disabilities, mental health or substance use disorders, medically frail, and other circumstances that will be more challenging for states to automate.
Adding staff capacity can always help states manage increased administrative workloads, but pressures on state budgets will likely limit this option. However, states should apply the lessons learned during the unwinding about communications, consumer support, and extending reach through community partnerships. These include:
- Boosting touch points with enrollees prior to and during the renewal period using multiple modes of communication is critical.
- Improving the readability of notices, which has been a longstanding problem in Medicaid, and supplementing information with online FAQs and social media will help applicants and enrollees understand the changes and what they need to do.
- Providing self-help tools such as online tutorials or step-by-step instructions on how to apply and renew coverage reduces the demand for consumer assistance.
- Engaging health plans, providers, and community partners to reinforce state communications and assist individuals with applications or renewals extends the state’s reach into the community through trusted messengers.
- Extending call center hours can provide access to consumer assistance for individuals who work jobs with limited flexibility.
Conclusion
States struggling to manage their eligibility and enrollment administrative processes will have greater challenges as provisions of HR 1 come into effect. Given the fast-tracking of work reporting requirements and semi-annual renewals for Medicaid expansion adults, expansion states have little spare time and resources to improve their processes as they shift focus to implementing HR 1 provisions. With implementation deadlines looming, states may be pressured to issue no-bid contracts to IT contractors resulting in enormous taxpayer expense. Without swift improvements in administrative readiness, HR 1 will deepen state challenges, increase costs, and leave millions of children and families at risk of losing health coverage.
Background on Performance Indicators
In September 2013, CMS published an initial list of 12 performance indicators that states were expected to report beginning in the quarter before implementation of the Affordable Care Act’s eligibility and enrollment changes in January 2014. CMS described the initial data elements as “the most critical to measuring the outcomes of Medicaid and CHIP eligibility enrollment process, as well as those elements that states are most likely planning to collect internally.” Less than a year later, the agency published a more robust performance indicator data dictionary featuring the 12 metrics disaggregated into more than 80 sub-measures. The data provides states, stakeholders, and the Centers for Medicare & Medicaid Services (CMS) a common understanding of eligibility and enrollment processes within and across all states and all populations.
In 2018, CMS began releasing an annual report on state application processing times but none of the other indicators were published until states were preparing for the unwinding of the pandemic-related Medicaid continuous enrollment provision. In December 2020, CMS put states on notice that it was developing a template for states to submit data demonstrating state progress in resuming normal operations at the end of the COVID public health emergency. The template included most of the measures that Congress required of states as the freeze on disenrollment was lifted in the Consolidated Appropriations Act (CAA) of 2023. The CAA also required CMS to publish the data through unwinding. Although unwinding was largely completed last summer, the agency has continued to post a limited set of performance indicator data monthly on data.Medicaid.gov. Our ability to update the data in our State Readiness for HR 1 Tracker will depend on CMS continuing to report these performance indicators going forward.
Methods
Data Sources: This report from the Georgetown University Center for Children and Families (CCF) uses two administrative datasets from the Centers for Medicare & Medicaid Services (CMS): the State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data and the State Medicaid and CHIP Eligibility Processing Data. Data reflect CMS-defined reporting periods available as of the access date. Footnotes on state reporting are included in the data set.
Note: While the 41 states that have implemented the adult expansion, plus Georgia and Wisconsin, will have the heaviest lift with work reporting requirements, all states will have new administrative tasks and may make other changes to deal with budget shortfalls and changes to immigrant eligibility. To see how states compare to the national median on each of the performance indicators, please see our State Readiness for HR 1 Tracker.
Handling of Missing and Zero Values: Missing values (blank) are excluded from all calculations and do not contribute to numerators or denominators. Monthly shares are computed as numerator divided by denominator when the denominator is greater than zero and the numerator is reported; if denominator is zero, then monthly share is reported as missing; if numerator is zero, then monthly share is reported as zero. Months with zero volume (numerator = 0 and denominator = 0) are treated as missing for the purpose of averaging monthly shares within a quarter. Quarterly averages are the simple mean of available monthly shares within the quarter. If all months are missing, the quarterly value is set to missing.
Definitions
- Call center wait times are the average amount of time an enrollee is on hold waiting for assistance.
- Abandonment rate is the percentage of calls in which an enrollee disconnects before reaching assistance.
- Share of applications that took longer than 30 days to process is the percentage of Medicaid and CHIP applications with a final determination made more than 30 days after submission, using MAGI rules. States report application timeliness for children, parents, pregnancy, and expansion adults in 5 buckets: within 24 hours; 1-7 days; 8-30 days; 31-45 days; and over 45 days. For this metric, we have combined state data for the last two timeframes to report applications processed in more than 30 days.
- Share of enrollees whose coverage was renewed is the percentage of Medicaid and CHIP beneficiaries due for renewal who successfully retained coverage. It is calculated as the number of beneficiaries whose coverage was renewed divided by the total number of beneficiaries with a renewal due.
- Share of enrollees renewed via ex parte is the percentage of Medicaid and CHIP beneficiaries due for renewal in the reporting period who were successfully renewed and retained on coverage through the ex parte process.
- Share of enrollees disenrolled at renewal is the percentage of Medicaid and CHIP beneficiaries due for renewal who lost coverage at the time of renewal. It is calculated as the number of beneficiaries disenrolled at renewal divided by the total number of beneficiaries with a renewal due.
- Share of disenrollees who lost coverage for procedural reasons is the percentage of Medicaid and CHIP beneficiaries disenrolled at renewal whose coverage ended due to procedural reasons. It is calculated as the number of beneficiaries disenrolled for procedural reasons divided by the total number of beneficiaries disenrolled at renewal.
- Share of pending renewals is the percentage of Medicaid and CHIP beneficiaries due for renewal whose renewals were due in the reporting period but were not completed by the end of the reporting period. It is calculated as the number of beneficiaries with a pending renewal divided by the total number of beneficiaries with a renewal due.