The Medicaid Unwinding Process at the Halfway Mark: How Can MCH Advocates Address the Current Challenges to Ensure Continuity of Coverage for Children and Families?
November 03, 2023

Stacy Collins, Associate Director, Health Systems Transformation, AMCHP

At the pandemic’s end, nearly 95 million people nationally were enrolled in Medicaid, and federal rules required all enrollees to be redetermined for eligibility. Six months into the process, few MCH advocates would describe their state’s Medicaid “unwinding” efforts as functioning smoothly.  In most states, the process is hampered by confusing communication to beneficiaries, procedural errors, and inadequate Medicaid agency staffing, among other issues. This is leading to a significant loss of health insurance coverage throughout the country.  As of the time of this writing, net Medicaid enrollment losses have exceeded five million for all enrollees, two million of whom are children.   

In the Medicaid unwinding process, three problems currently stand out: 

Continued high rates of procedural terminations 

More than 70% of people who have been disenrolled from Medicaid lost coverage due to administrative errors such as missing renewal notices, filing paperwork incorrectly, or other mistakes unrelated to a legitimate eligibility determination. Renewal notices are often confusing, and many people are unaware they lost their coverage until told by a pharmacy or doctor’s office when seeking care. Children have been especially impacted by the failure to minimize unnecessary coverage losses due to procedural reasons.  

Uncertainty about transitions to alternative sources of coverage

The Children’s Health Insurance Program (CHIP) and the ACA Marketplace are two likely sources of coverage for children and families deemed ineligible for Medicaid. However, based on the national rate of Medicaid disenrollment, there has been no proportional growth in CHIP and Marketplace enrollment.  There is no national data that indicates what type of insurance children are receiving after Medicaid termination and how many of them are becoming uninsured or experiencing gaps in coverage.  Because of their higher income eligibility threshold, children are more likely than adults to remain eligible for Medicaid. High Medicaid termination rates for children – coupled with low CHIP enrollment rates – suggest that at a minimum, thousands of children are now uninsured.  

Lack of transparency in the redetermination appeals process

Federal rules allow individuals to appeal their Medicaid terminations, and states must inform people about their appeal rights in termination notices. Appeals are required to be completed within 90 days, but compliance with these rules varies widely across states. With continued coverage losses, state Medicaid offices have received an onslaught of appeals. The process is often frustrating, with individuals and families receiving confusing information and getting minimal assistance from understaffed call centers.  Many states are hiring additional staff to manage the backlog of appeals cases. The federal government has offered states more time to hear cases, but only 24 states have extended the 90-day appeals time frame.  Coverage suspension during the appeals process is a major concern for families of children with children with special health care needs, for whom disruptions in care can seriously impact their health and well-being.   


What can MCH advocates do to improve the redetermination process for children and families? 

Encourage states to slow down the redetermination process and deprioritize children. 

For months, the Centers for Medicare and Medicaid Services (CMS) has expressed concern that many states are rushing through the process and making mistakes due to the rapid pace of redetermination.  In September, CMS identified 30 states that had incorrectly used household income to determine eligibility, which resulted in 500,000 former Medicaid beneficiaries, mostly children, having their coverage reinstated. Health departments should encourage states to use the full 14 months allowed by federal rules to initiate and complete all renewals.  It is also important that children with special health care needs be among the last population groups to undergo redetermination.  Ideally, states should halt all child disenrollment until 2024, when the 12-month continuous Medicaid coverage provision for children goes into effect.  

Encourage data transparency for children and pregnant and postpartum individuals.

Currently, only 20 states release redetermination data specific to children, three states are releasing redetermination data on pregnant individuals, and no states are releasing information on postpartum individuals. The lack of disaggregated data exacerbates the challenge of determining what sources of coverage – if any – people acquire after losing Medicaid.  Assessing the impact of redetermination and tailoring solutions requires data on each MCH population. 

Make the case for eliminating CHIP premiums and enrollment fees. 

Many families transitioning their children from Medicaid to CHIP are unaware that they must pay premiums, and that not doing so can result in loss of coverage. States can promote continuity of coverage for children disenrolling from Medicaid by waiving CHIP premiums, enrollment fees, and copayments, either permanently or for the duration of the unwinding process. Eight states (AZ, DE, GA, IA, MD, VT, WV, and WI) have waived premiums through the end of the year or the end of the unwinding, and six states (CA, CO, IL, ME, NC, and NJ) are eliminating premiums and enrollment fees completely. MCH advocates in the remaining 24 states with separate CHIP programs should emphasize the importance of eliminating CHIP-associated costs for families, which are a barrier to continuous coverage for children. 

Spread the word about the availability of subsidized Marketplace plans and ACA open enrollment season.

Marketplace plans are a backstop for people losing Medicaid coverage. Many former Medicaid beneficiaries are eligible for fully or partially subsidized Marketplace plans (most states offer both family and child-only coverage). But information about these options – and assistance with enrollment – is not readily available to all families.  States must reduce administrative barriers to transitioning to Marketplace coverage when Medicaid is no longer an option. Some states have implemented promising approaches. New Mexico covers the first month’s premium for many enrollees switching from Medicaid to Marketplace coverage and the state employs an active media campaign using calls, texts, and emails to urge consumers to enroll in plans if they have lost or are at risk of losing their Medicaid coverage. Rhode Island and California automatically enroll certain people into Marketplace coverage after they have been disenrolled from Medicaid.  The Marketplace annual open enrollment season runs from November 1st to January 16th. The Biden administration has also created a special enrollment period (April 2023 – July 2024) for people losing Medicaid coverage due to redetermination. State health departments should heavily promote both Marketplace enrollment opportunities.  

Encourage states’ use of ex parte data in the redetermination process.

For all Medicaid renewals, federal rules require states to attempt verification of eligibility through existing (“ex parte”) data sources (e.g., TANF, SNAP, WIC) before sending paper renewal notices to enrollees. Ex-parte data systems can simplify the Medicaid renewal process for families, and despite recent state database problems, ex-parte data collection should be prioritized. Ex-parte renewals free up Medicaid eligibility worker time, and some observations show a correlation between high ex-parte renewal rates and lower procedural disenrollment rates.  

Reduce procedural terminations and promote understanding of the appeals process through direct engagement with consumers.

The continued loss of Medicaid coverage due to procedural errors is unacceptable and preventable. In many parts of the country, the support system to help families navigate the complicated process of renewing Medicaid coverage is inadequate or non-existent. There is a continued need for both public education and direct engagement with Medicaid beneficiaries. Health departments can encourage their employees, grantees, and contractors to learn the state’s redetermination and appeals processes. Interpreting confusing redetermination notices, explaining to consumers how they should update their contact information, and supporting robust community navigator programs are all actions that can reduce the rate of procedural terminations.  Understanding the appeals process – and how to impart this information to consumers – is especially important.  Knowing which legal aid organizations in the state can assist former Medicaid enrollees with their appeals actions is also critical. 

It may take years before the impact of the Medicaid unwinding process is fully understood. But we can safely predict that, in the absence of immediate efforts to stop the nationwide coverage loss, the health of millions of children, pregnant people, and families will be at risk. In the remaining months of the unwinding, state health departments and other MCH advocates should do all they can to mitigate the harm to MCH populations. 


Medicaid redetermination resources: