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Public Health Emergency “Unwinding:” Changes to Medicaid Enrollment and Eligibility

March 22, 2023
Vicki Gottlich, Deputy Administrator for Policy and Evaluation

See also:  "Unwinding" of Policy Changes due to the COVID-19 Pandemic

At the beginning of the COVID-19 pandemic, significant changes were made to Medicaid enrollment and eligibility rules to promote continuous health insurance coverage. These changes are ending. As a result, many older people and people with disabilities are at risk of losing their Medicaid coverage. Disabled people and older adults who are enrolled in Medicaid need to be aware of these changes and how they may be affected, so they can take the actions needed to maintain their health insurance coverage.

As trusted community partners and effective messengers, the aging and disability networks have a critical role to play in ensuring millions of low-income older adults, people with disabilities, their families and caregivers retain health coverage.

Background

The Families First Coronavirus Response Act (FFCRA), which was signed into law on March 18, 2020, provided states with increased federal funding for Medicaid. To receive the increased funding, states were required to keep people continuously enrolled in Medicaid, even if they had a change in eligibility (such as an increase in income or a change in “categorical eligibility,” such as age or disability status, that might otherwise disqualify them or make them eligible for Medicaid under a different category).

Initially, this “continuous enrollment” provision was set to last through the end of the public health emergency, which has been extended several times and is set to expire on May 11, 2023. However, the Consolidated Appropriations Act passed in December 2022 separated the end of the continuous enrollment provision from the PHE. States must begin the process for reviewing Medicaid eligibility by April of this year, and they have 14 months to complete it. States may begin disenrolling people who no longer qualify starting April 1, 2023. Many states have already begun the process of notifying Medicaid beneficiaries that their eligibility will be reviewed.

This return to normal operations and the end of pandemic-specific Medicaid policies has been dubbed the “unwinding period.” As a result of this unwinding, up to 15 million people total and ten percent of those eligible on the basis of age or disability stand to lose their Medicaid coverage over the next year. However, many of these people may be eligible for other coverage through Medicare or the Marketplace established by the Affordable Care Act.

In addition, many people who remain eligible for coverage could be disenrolled if they do not complete and return the necessary materials to “recertify” their eligibility.

What do the aging and disability networks need to know?

1) Medicaid beneficiaries should make sure their contact information is current with the Medicaid agency, check their mail, and fill out all forms quickly.

It is critical that state Medicaid agencies have the correct address, phone number and email on file for each beneficiary so communications get to the right place on time. Urge people with Medicaid to contact their state Medicaid agency to verify that their information is accurate and up to date. The state will mail letters about coverage letting people know if they need to complete a Medicaid renewal form. Beneficiaries may also hear from their Medicaid managed care plan, social service provider, or health care provider with reminders, updates, and information.

If a beneficiary receives a form, they should fill it out and return it right away to help avoid a gap in coverage. Most Medicaid beneficiaries will have 30 days to return their redetermination to the state once they receive it. For others, including people eligible based on age or disability, the state must allow for a “reasonable period of time.” This timeframe will vary state by state and will be clearly stated on the letter.

Actions for the aging and disability networks

  • Work with state Medicaid agencies to assist their state in reaching underserved and hard-to-reach populations
  • Routinely ask the people they serve whether they have Medicaid, whether their contact information is up-to-date, and whether they have received information from Medicaid about a review of their Medicaid eligibility
  • Assist people in updating their information

2) All renewal forms and notices must be accessible to people with limited English proficiency and people with disabilities.

Federal law requires all Medicaid renewal information be provided in plain language and in a way that is accessible to people with limited English proficiency and to those with disabilities. All information from the Medicaid agency should be available in multiple languages and with free oral translation. States should provide appropriate auxiliary aids and services for people with disabilities at no cost. This could include sign language interpretation and materials in braille or other accessible alternative formats.

Actions for the aging and disability networks

  • Educate state Medicaid agencies about local needs for materials in alternate formats/languages
  • Assist people with requesting information in other formats or languages

3) Many people will be able to retain Medicaid or will have other coverage options through the Marketplace.

State Medicaid agencies will work to ensure as many people as possible are able to retain or find new coverage. For example, states will automatically assess individuals for all categories of Medicaid using information they have on file so even if their life circumstances have changed, they may still be eligible. This is called an “ex parte” renewal. (If the Medicaid agency does not enough information to determine eligibility, they will send a renewal form.)

Additionally, many people no longer eligible for Medicaid can enroll in a Marketplace plan; and 4 out of 5 will pay less than $10 for coverage. The Medicaid agency is required to transmit eligibility information directly to the Marketplace. The Centers for Medicare & Medicaid Services (CMS) has created a special enrollment period to allow people who lose Medicaid coverage because of unwinding to pick a Marketplace plan outside of regular enrollment periods. This unwinding SEP will allow people who submit a new application or update an existing application between March 31, 2023 and July 31, 2024 to pick a new plan that will start the next month.

4) People with Medicaid who became eligible for Medicare may have enrollment problems

People who become eligible for Medicare during the pandemic may have decided not to enroll, thinking they did not need it because they were covered by Medicaid. Now they may be outside a Medicare enrollment. However, many will be eligible for a Special Enrollment Period (SEP) based on the termination of their Medicaid. This SEP will allow them to enroll in Medicare and have coverage begin either the next month or retroactive to the month Medicaid coverage ends.

In addition, some people with both Medicare and Medicaid may lose Medicaid and thus no longer be eligible for their Medicare Advantage plan (also called Dual Eligible Special Needs Plans or D-SNPs). Beneficiaries in these types of situations will need special counseling, including information on Medicare enrollment periods, penalties, and Medicare Advantage plan options.

State Health Insurance and Assistance Programs (SHIPs) provide people eligible for Medicare with information and counseling about their health insurance options and can help people navigate these issues.

5) If someone disagrees with their state Medicaid agency’s decision to disenroll them or change their Medicaid coverage, they can appeal.

If a Medicaid beneficiary believes their benefits were terminated or their eligibility was reduced due to an error, they have the right to an appeal, also called a “fair hearing.” The notice of termination will have information about how to file an appeal. In general, individuals can keep their Medicaid coverage while this hearing is pending. For example, someone who believes the Medicaid agency did not correctly assess their income or disability status can appeal their state’s decision.

People over the age of 60 may want to contact the Eldercare Locator for referral to a free legal services program funded under the Older Americans Act. Similarly, people with disabilities may be able to receive assistance from local legal aid organizations, including Protection and Advocacy systems. The Disability Information and Access Line (DIAL) can help make referrals to these services.

6) CMS and ACL have a number of other helpful resources available

  • Medicaid.gov has a webpage devoted to the unwinding with resources for beneficiaries and community-based organizations that support them. It includes: .
    • A list of all state Medicaid agencies
    • State timelines for initiating unwinding-related renewals
    • A communications toolkit, which can help our networks as they assist beneficiaries. (These resources also are available in languages other than English – they are posted about halfway down this page.)
    • A new fact sheet on the waivers, flexibilities and the transition forward from the COVID-19 PHE
  • The Disability Information and Access Line (DIAL) and the Eldercare Locator can help connect people with disabilities and older adults to resources available in their area.

Last modified on 05/09/2023


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