Lukanen, Elizabeth
Zylla, Emily

Unwinding Ends, but States’ Reporting of Medicaid Renewal Data Continues (SHVS Cross-Post)

The following Expert Perspective (EP) is cross-posted from State Health & Value Strategies. Authors: Emily Zylla and Elizabeth Lukanen, SHADAC

Original posting date August 13, 2024. Find the original post here on the SHVS website.

States have resumed their regular processes for renewing individuals’ Medicaid and Children’s Health Insurance Program (CHIP) coverage due to the end of the continuous coverage requirement set in place during the COVID-19 pandemic. During this unwinding period, advocates, policymakers, and the media have been keenly interested in understanding how this work has impacted coverage for Medicaid enrollees.     

One key source of data has been the monthly Unwinding Data Reports that state Medicaid agencies were required to submit to the Centers for Medicare & Medicaid Services (CMS). These reports include indicators about activities related to eligibility renewals, call center operations, and transitions to Marketplace coverage; CMS began publicly reporting monthly snapshots of these data in August 2023. However, well before the federal government began reporting this unwinding data, many states began publishing their own state dashboards, publicly detailing their progress in restarting renewals.

The public release of renewal data, at both the federal and state level, has proven to be a valuable tool in understanding who lost Medicaid coverage and why during the unwinding. States have successfully used the data to both monitor renewal outcomes and adjust outreach and administrative enrollment policies. This data has also provided new transparency into state eligibility and enrollment processes that had previously been lacking.

CMS initially indicated it would report unwinding data only through June 2024 (the official end of the unwinding period). However, many states received CMS approval to extend timelines to complete their unwinding-related renewals. Subsequently, a May 30, 2024, State Health Official (SHO) letter announced that starting July 1, 2024, CMS will expect all states to continue to submit certain metrics contained in the Unwinding Data Report on an ongoing basis, now referred to as an “Eligibility Processing Report.” 

These reports will include monthly data on:

• Renewals initiated.
• Renewals due.
• Successful renewals, including the number renewed on an ex parte basis and through pre-populated renewal forms.
• Coverage terminations due to both ineligibility and procedural reasons.
• Pending renewals and renewal backlogs.
• Fair hearing requests pending for more than 90 days.

In the SHO letter CMS also explicitly encourages states to continue state-level transparency processes, including public dashboards that “can support ongoing state-level efforts to ensure timely processing of applications and renewals.”

States Publicizing Medicaid Renewal Data

During the unwinding period, the State Health Access Data Assistance Center (SHADAC) tracked which states were publicly reporting unwinding data (separate from their required CMS monthly report). Over the course of the official unwinding period, from April 2023 through June 2024, 45 state Medicaid agencies (including the District of Columbia) regularly published their own renewal data (reflected in the map above), either in an interactive dashboard or a static PDF format. Two states, Mississippi and West Virginia, made copies of their monthly CMS data unwinding reports available on their state websites, but did not publish any additional state-level renewal or unwinding data. Four states, Alabama, Florida, Hawaii, and Wyoming, did not publish any state-level data.

Although some states, such as Arkansas, Idaho, Montana, and Utah, have indicated that they will no longer be updating their state unwinding dashboards, the majority of states appear to be maintaining and posting regular data updates. Other states, such as Virginia, have indicated that they plan to incorporate some of the information from their unwinding dashboard into an ongoing dashboard to track enrollment as a whole. 

Medicaid Reporting Bright Spots

Given the time-lags and caveats of the CMS data, state-level dashboards and/or reports became valuable sources of timely, up-to-date information for states, policymakers, and other stakeholders, allowing them to better understand how the unwinding progressed. States that published their own data also had the ability to provide additional detail about definitions, varying timeframes, and state-specific context important for communicating the unique circumstances that they experienced during unwinding.

In addition, although CMS only required states to report data broken down by modified adjusted gross income (MAGI) and non-disability applications versus disability applications, many states were able to supplement their federal reporting with both state-specific data analysis and data broken down by eligibility group and other demographic characteristics (e.g., age, race, ethnicity, language, geography). These types of additional data breakdowns helped elucidate important trends about the disproportionate impact of the unwinding on groups that have been economically or socially marginalized.

Several states also reported how many individuals were reinstated in Medicaid after a termination, thus providing a more complete story about what happened to individuals after they were disenrolled from Medicaid.

Among state Medicaid agencies’ unwinding dashboards or reports, several stood out.

Indiana Family and Social Services Administration – Medicaid Renewals and Outcomes Dashboard

Indiana’s dashboard provided a highly visual and interactive interface for the user. Renewal outcome data was filterable by geography, race and ethnicity, gender, age, program type, and managed care entity. Renewal outcomes were displayed both as total counts and percentages.

Kentucky Cabinet for Health and Family Services – Medicaid Unwinding Demographic Reports

Kentucky was one of the earliest reporters of state-level unwinding data, publishing data snapshots beginning in April 2023. Kentucky additionally began publishing Data Demographic Reports on a monthly basis beginning in September 2023, which provided breakdowns by race, ethnicity, age, gender, and county of residence, of Medicaid renewals, pending cases, and terminated cases.

Massachusetts Executive Office of Health and Human Services – MassHealth Eligibility Redetermination Dashboard

Massachusetts’ dashboard, updated on a monthly basis, provided data on member renewals and departures, filterable by age, program type, disability status, and whether the member resides in a “priority community” (i.e., one of the top 15 towns or cities where the most MassHealth members were at risk of losing coverage). Massachusetts also reported the number of terminated members who re-enrolled in Medicaid after a specific period of time.

Nevada Department of Health and Human Services – Monitoring Medicaid Enrollments, Disenrollments, and Renewals in Nevada Dashboard

Nevada’s dashboard displayed historical enrollment data both prior to and during the public health emergency (PHE). It also contained detailed metrics of the demographic characteristics for individuals disenrolled from Medicaid, including a comparison of the distribution of the disenrolled population versus the enrolled population. This visual display of differences between the two groups made it especially clear to see how disenrollments were affecting certain demographic groups more than others. 

Oregon Department of Human Services – Medical Redeterminations Dashboard

Oregon’s dashboard displayed the number of renewals due each month as well as the number of renewals that were completed, initiated, or not started. The dashboard also presented data disaggregated by written language, gender identity, race and ethnicity, age, disability status, housing status, county, and reason for closure. Oregon also published a separate dashboard for call center data, including a daily average customer service score.

State-Based Marketplace Reporting

State-Based Marketplaces (SBMs) also played a significant role during the unwinding by coordinating with Medicaid agencies and using a number of different strategies to ensure a smooth transition for people who no longer qualified for Medicaid and were eligible for a qualified health plan (QHP) offered through the Marketplace. Given this, policymakers, advocates, and the media have also been keenly interested in unwinding data on the outcomes of transitions from Medicaid to the Marketplace.

By the end of the unwinding, 16 of the 19 states that operate an SBM had reported some data on Marketplace transition outcomes (see Table 1 below). In some states, this information was reported by the SBM itself, and in other states, Marketplace transition outcomes were included within the state’s Medicaid renewals dashboard. In 11 states, this meant ongoing reporting as part of a formal and easy to find data dashboard or data repository. In five states, Colorado, Idaho, Kentucky, Maine, and Washington, data was reported less consistently – examples include reporting as a part of SBM board meeting minutes or administrative documents, or as a part of a one-time or sporadic release of information. Three SBMs, the District of Columbia, New Mexico and Virginia, did not publicly report Marketplace transition data. Virginia, however, launched its SBM on November 1, 2023 and while the state was using the Federally-Facilitated Marketplace (FFM) at the beginning of the unwinding, CMS was responsible for the states’ reporting of transition data.

Table 1. Reporting of State-Based Marketplace Transition Data

Generally, reporting of SBM data was more limited and less consistent across states than Medicaid reporting. All of the states listed in the table above reported enrollment in a QHP by people no longer enrolled in Medicaid. Only one SBM, Idaho, reported a conversion rate (i.e., Marketplace enrollment among those disenrolled from Medicaid) and about half of the SBM states reported elements allowing for this calculation (however, it is important to note that often these data points were hard to find). Six SBM states reported information about whether transitioners received premium assistance, and only two states, California and Washington, reported transitioner demographics. 

Along with this data reported by SBMs, CMS also released state Marketplace enrollment transition data. These data included information on consumers who:

• Were transferred to or applied for Marketplace coverage.
• Were eligible for a QHP or Basic Health Plan (BHP) coverage (disaggregated by those eligible for financial assistance).
• Had a QHP selection or BHP enrollment.

CMS data was reported differently for FFM states that use HealthCare.gov, and for SBM states with an integrated system versus those who transfer accounts between Medicaid and the Marketplace.

While CMS data offered a somewhat parallel view of progress in all states, it was released at a lag (compared with state reported data) and comparability was complicated by data concerns and cautions regarding state comparisons, differences in how states managed changes to ex parte renewals, and potential confusion regarding the use of different denominators. Although CMS is requiring states to report ongoing Medicaid enrollment and renewal metrics beyond the unwinding period, the May 2024 SHO letter indicated that states will no longer have to report SBM transitions starting June 30, 2024, or once the state has completed all unwinding-related renewals (whichever is later).

SBM Reporting Bright Spots

While most SBM states offered transparency regarding unwinding transitions by releasing outcomes data beyond required CMS reporting, variation in how data were reported, their specific definitions, reporting timelines, and disaggregation made it very difficult to compare similar measures across states.

That said, like the Medicaid unwinding dashboards, individual SBM reporting allowed states to present the most current data available in the context of their broader unwinding efforts – controlling the narrative and storyline. In other words, states could report more quickly, and they could present Marketplace and Medicaid data together offering a holistic view of the impact of the unwinding. States could also publish disaggregated data, beyond the requirements, such as transitioner race/ethnicity and geography. States were also able to provide more detail on the metrics being released, providing clear data labels and definitions, methodologies and documenting data revisions. Among the SBM states reporting robust Marketplace transition data, several stood out.

Covered California Medi-Cal Transitioner Profile

California provided detailed data on Californians who transitioned from Medi-Cal to Covered California (the state’s official health insurance Marketplace) in the form of an Excel file. The Excel file has multiple tabs and contains counts, percentages, and detailed methodological and definitional information. It starts with a tab containing summary information on transitions by month (called “key performance indicators”). The tabs that follow contain detailed demographic information for: individuals who lost Medi-Cal and who were eligible for Covered California; those who lost Medi-Cal, were eligible for Covered California, and received an automatic plan selection; and those who effectuated QHP coverage. Demographic data available for those categories includes:

• Age
• Gender (including transgender identification)
• Income
• Race and ethnicity (in combination and separately)
• Written language
• Service channel used (i.e., Certified Insurance Agent, Certified Enrollment Counselor)
• Geography (i.e., region, county)
• Financial assistance

Pennsylvania Medicaid Continuous Coverage Unwinding Data Tracker

Pennsylvania had one of the earliest unwinding dashboards featuring Marketplace renewal outcome metrics. The dashboard presented side-by-side renewal outcome metrics for Medicaid and the Marketplace, providing a holistic view of coverage transitions across the state. In addition, the state provided information on the outcomes of transitions to Pennie (the state’s official health insurance Marketplace) by county and ZIP code. 

Washington Keeping People Covered During the Medicaid Unwind: Data Snapshot Reports

Washington released robust data snapshots in October 2023 and January 2024 (each available as a PDF). These reports started with summary information (called “data top lines”), a personalized coverage transition example illustrating an individual’s cost under a QHP, and detailed information on coverage transitions such as the geographic distribution, carrier transitions, receipt of financial assistance, and demographics of transitioners (i.e., age, sex, race, and ethnicity). Washington provided both counts and percentages for most data points and provides a detailed appendix with information on data sources and definitions.

Conclusion

Timely, accessible, state-level data on Medicaid renewal outcomes will continue to be important for understanding the impact of various policies on Medicaid enrollees, even after the unwinding period ends. Given the ongoing reporting requirement from CMS, and states’ success setting up these new public reporting capabilities, there is hope that states will continue to make detailed disenrollment, renewal, call center, and Marketplace transition data publicly available on an ongoing basis.

Stewart, Andrea
Research Fellow

p 612-624-4850
e astewart@umn.edu

2023 NHIS Full-Year Health Insurance Estimates Early Release: Decreasing Uninsured Rates Overall and for Certain Groups of Nonelderly Adults

Hest, Robert
Liu, Grace
Theis, Lindsey

Tracking Health Insurance Coverage During the Unwinding: Monthly Data from the Household Pulse Survey

This update was posted on October 4, 2024 and uses data from the October 2024 release of the Household Pulse Survey, collected August 20 - September 16, 2024. 

Important Note: This will be the final data release from the Household Pulse Survey, and the final update of this SHADAC product. Moving forward, the U.S. Census Bureau will be launching a similar study with a longitudinal design called the Household Trends and Outlook Pulse Survey (HTOPS) in January 2025. You can read more about this study here. 

Introduction

The unwinding of the Medicaid continuous coverage requirement represents the largest nationwide coverage transition since the Affordable Care Act. Since February 2020, enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) has increased by 23 million enrollees and analysis indicates that as many as 15 million individuals will exit Medicaid to other coverage or become uninsured. This blog uses data from the U.S. Census Bureau’s Household Pulse Survey (HPS) to track trends in adult health insurance coverage rates as states “unwind” the Medicaid continuous coverage requirement and restart standard redetermination procedures.

Given the intense interest from policymakers and the media in monitoring coverage transitions during the unwinding, many states have released Medicaid administrative data showing their progress, with some State-based Marketplaces also reporting transition data. Though administrative data can show the number of successful Medicaid renewals and coverage terminations along with transitions to Marketplace coverage, they cannot provide information on transitions to other sources of coverage, such as employer-sponsored insurance or provide an estimate of changing rates of uninsured individuals. 

As states continue the process of redetermining beneficiaries’ Medicaid eligibility, this resource will help track transitions in coverage. Specifically, it will present rates of primary source of health insurance coverage by type (Employer/Military, Direct Purchase, Medicaid/CHIP) and rates of no insurance as they are observed in the HPS. Estimates will be presented at the state and national level by selected individual and geographic characteristics. The survey does not include children, so the analysis is limited to adults 18 and older.

This blog will be updated on a monthly basis as new HPS data are released and compare the latest monthly coverage estimates (reference above in the subtitle) to estimates from March 2023, the last month before the unwinding began.

Highlighted Findings

Limited to statistically significant changes at the 95% confidence level.

• Compared to March 2023, ESI/Military coverage fell 1.6 percentage points (PP) to 52.1% among all adults in September. This decrease was reflected across several groups: 
  • Adults age 65 or older (2.4PP)
  • White, non-Hispanic adults (2.1PP)
  • Adults living in Medicaid expansion states (1.7PP)
• The uninsurance rate overall did not change significantly. While uninsurance rates among adults age 65 or older fell 1.1PP, significant increases were seen in the following groups:
  • Adults age 18 - 64 (1.2PP)
  • White, non-Hispanic adults (1.1PP)
  • Adults with prior year household incomes of $50,000 - $74,999.
• Rates of any Medicaid fell 4.2PP among adults with prior year household incomes of $50,000 - $74,999. Rates among all adults held steady at 18.0%.
• The rate of Direct Purchase coverage increased in adults with prior year household incomes of $50,000 - $74,999.
• There were few meaningful changes in rates of Medicaid/CHIP as a primary source of coverage.
  

Select a coverage type from the orange box on the right in the dashboard below to filter the visualizations. 

Methods and Data

This analysis uses public use microdata from the Household Pulse Survey (HPS), a monthly, nationally representative, quick-turnaround survey that collects data on topics including household demographics, education, employment, food sufficiency, financial spending, housing security, and physical and mental health, in addition to current health insurance coverage.

The survey has a typical monthly sample size of 60,000 to 80,000 U.S. adults and is designed to produce state-level (and a select number of metropolitan-level) estimates of the civilian noninstitutionalized adult population. The survey does not include children (those age 17 or younger).

As of January 2024, data is collected for approximately four weeks each month from adults age 18 or older via a short, online survey and is released on a monthly basis. Prior to this, data was collected for approximately two weeks each month and released on a monthly basis. Readers should keep in mind that the HPS emphasis on producing near-real-time data comes with the tradeoff of lower levels of data quality compared with “gold standard” surveys such as the American Community Survey (ACS).

These data quality issues include very low response rates (e.g., 6.7% response rate in the March 2023 survey), underrepresentation of harder-to-reach groups (e.g., adults with lower levels of education, young adults), a lack of editing and imputation for most variables, and likely some degree of nonresponse bias. For these reasons, HPS estimates should be treated with a greater degree of caution than estimates from other federal surveys.

Further, like other surveys, the HPS relies on respondents’ self-reporting their coverage, which is often associated with known biases such as the Medicaid Undercount and reflects respondents’ (sometimes imperfect) knowledge of their own coverage rather than the reality reflected in administrative data sources. 

The HPS’ health insurance coverage measure is similar to that used in the ACS and asks respondents: “Are you currently covered by any of the following types of health insurance or health coverage plans?” Respondents are allowed to select “Yes” or “No” from among the following coverage types:

1.  “Insurance through a current or former employer or union (through yourself or another family member)”; 
2.  “Insurance purchased directly from an insurance company, including marketplace coverage (through yourself or another family member)”;
3.  “Medicare, for people 65 and older, or people with certain disabilities”;
4.  “Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability”;
5.  “TRICARE or other military health care”;
6.  “VA (including those who have ever used or enrolled for VA health care)”;
7.  “Indian Health Service”; or 
8.  “Other”

The response options for employer coverage [1], TRICARE [5], and VA [6] were combined into one Employer/Military coverage category, and respondents were considered uninsured if they didn’t affirmatively report any coverage under options 1-6.

SHADAC’s primary source of coverage hierarchy was applied to determine which payer was likely primary when a respondent reported multiple sources of coverage (see SHADAC brief for more information).

For example, the hierarchy would classify a respondent reporting both Medicaid/CHIP coverage and Employer/Military coverage as having Employer/Military as a primary source of coverage, as Employer coverage typically acts as the primary payer for individuals with Employer and Medicaid coverage.

Estimates with a relative standard error (standard error divided by the percentage estimate) of 30% or greater, based on an unweighted denominator count of less than 50, based on an unweighted numerator count of less than five, or with a weighted estimate of exactly 0% or 100% were considered statistically unreliable and were suppressed.

Two-sided t-tests (95% confidence level) were used to assess statistically significant differences between the most recent data month and the baseline month (i.e., March). A lack of statistically significant difference does not affirmatively establish that there was no significant difference but rather that the data presented here are not sufficient to show a significant difference.

Lukanen, Elizabeth
Stewart, Andrea

2023 NHIS Early Release: Estimates from Quarter 3 (July to September) Hold Steady

The National Center for Health Statistics (NCHS) has released quarterly estimates of health insurance coverage beginning in July 2022 through September 2023 from the National Health Interview Survey (NHIS) as part of the NHIS Early Release Program. Each quarter covers a three-month span, and this blog specifically looks at survey data from the most recent quarter (Q3 - July to September 2023) and notes any differences compared to the same time period in 2022.

Between Q3 of 2022 and Q3 of 2023, rates of uninsurance, public coverage, and private coverage for adults (age 18-64) remained mostly unchanged. There was a small increase in the rate of public coverage for all ages and a small decrease in the rate of uninsurance overall, but these changes were not statistically significant.

Figure 1: Health Insurance Coverage Rates by Type (Adults Age 18-64), Q3 2022 vs. Q3 2023

Theis, Lindsey
Lukanen, Elizabeth
Zylla, Emily

State-Based Marketplace Transition Data During the Unwinding (Cross-Post)

The following content is cross-posted from State Health & Value Strategies. Authors: Elizabeth Lukanen, Emily Zylla, and Lindsey Theis, SHADAC

This expert perspective (EP) will be updated by SHADAC experts as additional dashboards/reports go live. Please visit the State Health & Values Strategies webpage for the most recent version of this EP.

Original publication date: August 16, 2023. Updated: January 11, 2024.

As the unwinding of the Medicaid continuous coverage requirement progresses, SHVS is closely monitoring state reporting on the impacts of redeterminations and disenrollments. There is intense interest in data that monitors transitions between Medicaid and Marketplace coverage and, more importantly, the outcomes of those transitions.  (Virginia, which would be the 19^th State-Based Marketplace, launched on November 1, 2023. Virginia is not included in the total number of SBMs since it was not operating as an SBM from the beginning of the unwinding.)

The Centers for Medicare & Medicaid Services (CMS) continues to release required state data reporting metrics. In December, CMS released a new batch of data which included information on Marketplace enrollment transition data as of September 2023. CMS also continued to point to the increase in Marketplace enrollment (an increase of 1.5 million people between March and September 2023) as a signal of strong transition rates. CMS continues to report slightly different data for states that use HealthCare.gov compared to SBMs. And among SBMs, for states with an integrated system versus those who transfer accounts between Medicaid and the Marketplace. Broadly, these data include:

• Consumers who were transferred to or applied for Marketplace coverage.
• Consumers who were eligible for a QHP or Basic Health Plan (BHP) coverage (disaggregated by those eligible for financial assistance).
• Consumers with a QHP selection or BHP enrollment.

In all cases, CMS provides both counts and percentages. Among SBM states without an integrated system, CMS provides two percentage calculations – one where the denominator is applications and one where the denominator is account transfers. This distinction is important, because using the much larger account transfers number as a denominator makes the successful rate of transitions to QHP coverage seem much smaller. While the presentation of the CMS data is clear and the availability of counts and percentages is useful, it could leave room for misinterpreting the denominator.

Data reporting and interpretation have been complicated by several factors causing delays in renewal processing and changes to states’ timelines. First, the announcement from CMS on August 30, 2023 that 29 states and the District of Columbia had been making ex parte renewal determinations on a household, rather than an individual level, as regulations require. This included 16 of the 18 SBMs (California and Rhode Island were in compliance). This caused some states to pause procedural terminations, reinstate coverage, and/or implement temporary extensions for renewal. Second, CMS offered states the option of delaying procedural disenrollments while they conduct targeted renewal outreach. To date, 15 states have opted to take advantage of this flexibility. 

Given the ongoing data concerns and cautions regarding state comparisons, differences in how states are managing changes to ex parte renewals and potential confusion regarding the use of different denominators, it is more important than ever for SBMs to release their own data.

SHADAC will continue to update this expert perspective as more states publish their unwinding data
 

State-Based Marketplace Reporting Marketplace Transition Outcome Data
 

Note: In some cases, SBMs publish Marketplace transition outcome data in administrative documents (e.g., board meeting minutes and legislative reports). Because these data are more difficult to access, they are not represented in the map above.  

Variation in State Reporting

To date, 12 of the 18 SBMs that use their own eligibility platform are reporting outcomes for individuals who exited Medicaid and were transitioned to the Marketplace. While most of these states continue to update their data frequently, three states haven’t released updated data since October 2023. In summary:

• Seven states are reporting whether individuals were eligible for a QHP.
• 11 states are reporting whether individuals selected a plan.
• Five states are reporting enrollment and/or eligibility broken down by whether the individual received financial assistance (e.g., advance premium tax credit or cost-sharing reduction payments).
• Three states are reporting on the demographics of people transitioning from Medicaid to Marketplace coverage.
• One state, Idaho, reports having completed its redeterminations.

Select Data Highlights
In addition to general information on transition outcomes, most of the states reporting outcome measures are providing additional information of interest, though this detail differs by state. Select data highlights are provided on the SHVS Expert Perspective .