Data to Monitor the Unwinding of the Medicaid Continuous Coverage Requirement

July 2023:

On July 27, 2023, SHADAC Deputy Director Elizabeth Lukanen presented to the Protecting Immigrant Families Coalition, Medicaid Unwinding Task Force. This presentation included a brief overview of the potential coverage impacts of the unwinding of the Medicaid continuous coverage requirement, including variations by state and a review of actions states are taking to manage transitions and mitigate coverage loss.  It featured information on the type of data advocates and policymakers can use to monitor the unwinding – focusing on state-released data.

Click the image below to download the slide deck from this presentation.

Lukanen, Elizabeth
Zylla, Emily

Best Practices for Publicly Reporting State Unwinding Data (Cross-Post)

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

Original publication date: June 30, 2023.

The unwinding of the Medicaid continuous coverage requirement represents the largest nationwide coverage transition since the Affordable Care Act. With the restarting of eligibility redeterminations, millions of Medicaid enrollees are now at risk of losing their coverage and there is intense interest in monitoring the impact on coverage. To promote transparency, the Centers for Medicare & Medicaid Services (CMS) is requiring that states report the results of eligibility redeterminations and many states are making that data public. SHVS continues to monitor the states that are publicly reporting their unwinding data either in the form of data dashboards or static pdfs and the states posting copies of their required CMS Monthly Unwinding Data reports.

As advocates and researchers start to analyze unwinding data, it has become clear that it is difficult to compare different states for a variety of reasons. For example, states are initiating redeterminations and therefore disenrollments in different months and some states are staging redeterminations in a way that focuses on certain groups first, such as starting with people least likely to remain eligible. States are using a variety of different strategies to mitigate procedural terminations. States also use different terminology, definitions, population denominators, and timeframes on their reporting, which also makes it difficult to compare one state’s data to another.

In spite of data challenges, there are some best practices states can follow when reporting unwinding data.

• Release CMS Monthly Reports. While we typically don’t recommend releasing competing sources of data on the same topic, in this case, we recommend releasing CMS Monthly Reports alongside any state-specific data reporting to help satisfy calls from advocates and the media for comparable data across states. However, we recommend that states provide context about why the information may differ on state dashboards from CMS monthly reports. Kansas, for example, explains that data on their monthly unwinding reports is different from data on their dashboard because members move between reported categories.
   
• Timely release. Given the magnitude and scrutiny of unwinding coverage transitions, we recommend that states produce a data report that can be updated easily and frequently – at least monthly. We recommend prioritizing accuracy and timeliness over depth. And, if states are refreshing state unwinding data monthly, they should consider releasing it in tandem with the CMS Monthly Unwinding data reports.
   
• Prioritize key measures. Because timeliness of this data is so important, the report or dashboard needs to have enough data points to convey key information, but be limited enough to update quickly. In this case, we recommend focusing on measures that are already being reported (CMS Performance Indicators and indicators from the CMS Monthly Unwinding Data report). Key measures include:
  • Renewals initiated
  • Successful renewals
  • Ex-parte/passive renewals
  • Coverage terminations
  • Procedural terminations
  • Medicaid cases sent to the Marketplace
  • Call center volume
  • Number of terminations who reenroll in a specific period of time (e.g. 90 days)
     
• Publish disaggregated data. While required CMS data reporting includes very limited data disaggregation, there is a great interest in understanding who is being impacted by the unwinding. At a minimum, we recommend displaying data breakdowns by:
  • Program type
  • Age (children versus adults)
  • Race
  • Ethnicity
  • Language
  • Income
  • Geography (ZIP code is best, but by county or any other level lower than statewide is helpful)
     
• Provide context and transparency. As noted above, there are many reasons that the data reported by different states might be difficult to compare. We strongly encourage states to use their reporting vehicle to contextualize and explain various measures. This includes:
  • Document data revisions. We anticipate that states may be asked by CMS to make various adjustments retroactively to their data. States do not need to wait until data is final to post it publicly. They can address this by including revision dates when new data are posted. And wherever possible, maintain an archive of older data for comparability.
  • Include both proportions and counts. Proportions are especially useful to help make comparisons across states on measures like procedural denials, but counts are critical for understanding the denominators being used and to get a sense for the magnitude of impacts within states.
  • Include data labels, definitions, and context. Provide clear data labels, establish defined date ranges for data being displayed, add data refresh dates (as needed), describe population numerators and denominators if relevant (including exclusions such as pending cases). If the format allows, link to information that can help contextualize the information. This might include the state’s unwinding timeline, information about how redeterminations are being staged or any analysis or reaction to the results to date. For example, California posts their plan for prioritizing and distributing renewals on the same page as their unwinding data. Kentucky also has a webpage dedicated to unwinding that includes the state’s unwinding dashboard (the Kentucky Medicaid Renewals Data Snapshot), their required CMS unwinding reports and materials from monthly stakeholder sessions that provide a summary of the federal requirements, state goals and activities and their progress to-date.

Related SHVS Expert Perspectives:

• Using Surveys to Monitor Coverage Transitions During the Unwinding of the Medicaid Continuous Coverage Requirement

• State Dashboards to Monitor the Unwinding of the Medicaid Continuous Coverage Requirement 

• State-Based Marketplace Transition Data During the Unwinding

• States Reporting of Medicaid Unwinding Reinstatement Data

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

Reporting Requirements Related to Unwinding Medicaid Continuous Coverage: Considerations for Medicaid and the Marketplace (State Health & Value Strategies Expert Perspective Cross-Post)

The following content is cross-posted from State Health & Value Strategies. 
Original publication date: February 9, 2023.
Authors: Elizabeth Lukanen, Emily Zylla, SHADAC

The Families First Coronavirus Response Act implemented a Medicaid continuous enrollment requirement which was enacted to preserve coverage during the COVID-19 public health emergency and has resulted in a sharp increase in enrollment. Since February 2020, enrollment in Medicaid and the Children's Health Insurance Program (CHIP) has increased by 20.2 million enrollees. When the unwinding of the Medicaid continuous coverage requirement begins, it will represent the largest nationwide coverage transition since the Affordable Care Act. As states restart eligibility redeterminations, millions of Medicaid enrollees will transition to other coverage and some will become uninsured. Now that the details and timing associated with the unwinding of the Medicaid continuous enrollment requirement have been established by the Consolidated Appropriations Act, 2023 (CAA), states can start refining and implementing long laid plans to restart eligibility redeterminations and return to routine eligibility and enrollment operations.

As part of this process, states will be required to closely track and monitor the impacts of the resumption of eligibility redeterminations and disenrollments and to make that data public. The Centers for Medicare and Medicaid Services’ (CMS) commitment to transparency is mirrored by calls from advocates and researchers eager to see how progress is being made as people enrolled in Medicaid have their eligibility redetermined. This expert perspective outlines the relevant reporting requirements that were included in the CAA and the corresponding reporting guidance provided by CMS in its January 2023 State Health Official letter, and presents considerations for state officials as they fulfill their federal obligations and address calls from advocates and others for transparency.

Reporting Requirements During Unwinding

The Consolidated Appropriations Act, 2023 established a set of reporting requirements related to unwinding that will, for the first time, be made publicly available by CMS. Box 1 provides an overview of the CAA required reporting indicators. CMS believes that all of the measures overlap with indicators Medicaid/CHIP agencies and state-based marketplaces (SBMs) are currently required to report, including as part of: the monthly Unwinding Data Report (outlined in a March 2022 State Health Officer letter and detailed in subsequent Data Specifications; through existing Performance Indicators and T-MSIS submissions; or via existing SBM Priority Metrics.ⁱ Therefore, CMS does not anticipate that states or SBMs will need to submit a separate report (or additional reporting) to comply with the new CAA requirements. Additionally, CMS plans to report on behalf of states that use the federal eligibility and enrollment platform (FFM states) as well as SBMs on the federal platform (SBM-FP states).

Although there is no new data reporting being required, the indicators that states report will be made public for the first time; in addition, there are new enforcement provisions and penalties for noncompliance. Reporting and enforcement provisions released as part of the CAA start on page 3,859, and more detail is available in a CMCS Informational Bulletin from January 5, 2023 (“Key Dates Related to the Medicaid Continuous Enrollment Condition Provisions in the Consolidated Appropriations Act, 2023”) which also revises due dates for existing unwinding reports such as the Renewal Distribution Planⁱⁱ (due February 1, 2023 for states initiating renewals in February or February 15, 2023 for all other states ) and the Baseline Unwinding Report (due the eighth day of the month in the month that the state initiates renewals). Additional reporting requirement information is also available beginning on page 17 of the January 2023 SHO letter.  

Reporting Timeline

Although CMS expects states will be able to meet the reporting requirements outlined above through existing reports and tools, the timing of certain state reporting may need to change in order to meet the requirements of the CAA. See Box 2 for an overall reporting timeline. All states will now have to submit monthly unwinding data reports from April 1, 2023 through June 30, 2024. This means that states who initiate their first batch of renewals in February 2022 will now have to submit monthly unwinding data for a period that exceeds 14 months.

*Reporting overlaps with requirements in the CAA.
Note: Should the eighth calendar day fall on a weekend or holiday, states may submit by the next business day.

Enforcement and Penalty

To assure transparency and timely reporting, the CAA includes penalties for states that do not meet the reporting requirements (Box 3). Most notably, if a state does not report the required data starting in July 2023, it will face a reduction in the state’s Federal Medical Assistance Percentage (FMAP) by .25 percentage points for each quarter in which the state fails to satisfy the reporting requirements (up to a maximum of one percentage point). The full set of penalties associated with non-compliance are summarized below and were presented in a State Health and Value Strategies webinar, “Omnibus Unwinding Provisions and Implications for States.”

*Procedural terminations occur when potentially eligible individuals fail to respond to a state Medicaid/CHIP agency’s request for additional information as part of the redetermination process.

Consideration for Unwinding Reporting Requirements for States

As states prepare for the unwinding of the continuous coverage requirement and the implementation of new required reporting activities, they should consider ways to demonstrate and communicate progress with key partners. The following strategies will ensure transparency to stakeholders, who will be critical in supporting coverage retention for eligible enrollees, while also keeping policymakers informed about the success of this transition. 

Coordination Between Medicaid and Marketplaces. The reporting requirements in the CAA include measures from both Medicaid and the marketplace. At a minimum, state Medicaid agencies will want to coordinate with their state-based marketplace (SBM) or the federally facilitated marketplace (FFM) on metrics that affect both groups, such as call center data or information on the number and outcomes of electronic transfers. For states in which the same agency operates its Medicaid program and the SBM, there may be fewer barriers to coordinating the data, but all states should align to operationalize how and when the data are shared with the public. Pre-planning and coordination in advance of the first report can help streamline staff effort and reduce confusion.

Sharing Relevant Information Publicly. The CAA clearly states that metrics submitted to monitor eligibility redeterminations will be made publicly available. Details on how and when these data will be shared with the public are forthcoming, but states should expect this and consider releasing their own communications to ensure accurate interpretation of their data and to provide context about their successes and challenges. This could include measures required for the unwinding as well as Performance Indicator data that could help serve as an early warning sign as to how applicants and enrollees are faring on renewals and redeterminations. States will likely face requests for information from advocates and researchers who have already called for increased transparency. By publishing information on retention and disenrollment, successful transitions to new coverage, and changes to the numbers and rates of uninsured, states can meet these information needs in an organized and timely way while also controlling their data and message. Some states, such as Utah, are considering publishing new Medicaid enrollment and retention dashboards that would track this type of data in more easily digestible, visually appealing ways, and we encourage states to explore that possibility. SHVS will continue to monitor state activities in this area and will plan additional programming or publications as public dashboards become available.

Consider Reporting Data That Is Disaggregated Beyond What CMS Requires. The CMS guidance does not require states to report data disaggregated any further than by modified adjusted gross income and non-disability applications versus disability applications. Data broken down by various population characteristics (e.g., age, race/ethnicity, income, gender, language, or program type) or geographic areas make it easier to understand the disproportionate impact enrollment and renewal policies have on groups that have been economically and socially marginalized. States can prioritize the monitoring and reporting of disaggregated data even though CMS has not required it. At a minimum, we recommend displaying data breakdowns by program type, age, race, ethnicity, and geography (ZIP code is best, but county or region is also helpful). States should also consider additional breakdowns as the data is available, such as by language, income, and disability status. Data reported in this way would help improve the transparency, accountability, and equity of the Medicaid program.

Consider the Guidelines a “Floor” and Expand Monitoring Measures to Get Better Insights Into Unwinding. The reporting requirements and resources from CMS set the minimum amount of reporting that all 50 states should produce. For states with the bandwidth and resources, additional analysis could include an in-depth study of churn during this period or for specific groups, or an evaluation of outreach and enrollment strategies designed to identify what worked to keep people enrolled (e.g., color letter campaigns, assister training, ad campaigns, etc.). States could also assess coverage transitions and reasons for and consequences of disenrollment by fielding a disenrollment survey. This could provide quantitative and qualitative data that could be used to understand both enrollees’ experiences navigating Medicaid processes as well as the consequences of disenrollment.

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

Issue Brief: Unwinding the Medicaid Continuous Coverage Requirement - Transitioning to Employer-Sponsored Coverage (State Health & Value Strategies Cross-Post)

The following content is cross-posted from State Health and Value Strategies, published on January 19, 2023.
Authors: Elizabeth Lukanen and Robert Hest, SHADAC

Medicaid and the Children’s Health Insurance Program (CHIP) have played a key role in the response to the COVID-19 pandemic, providing a vital source of health coverage for millions of people. The Families First Coronavirus Response Act (FFCRA) implemented a continuous coverage requirement in Medicaid, coupled with an increase in federal payments to states. The requirement has prevented states from disenrolling Medicaid enrollees, except in limited circumstances, allowing millions of Americans continued access to healthcare services during the pandemic.

Enrollment in Medicaid and CHIP has grown sharply since February 2020, with more than 20 million enrollees added to state rosters as of September 2022. Continuous coverage can also likely be credited for the decrease in the number of people who were uninsured in 2021, down to 8.6% from a pre-pandemic level of 9.2% in 2019. This was driven by a 1.4 percentage point increase in public coverage in 2021, to 36.8% from 35.4% in 2019. These trends were mirrored across states, with 28 states experiencing significant decreases in their rates of uninsurance. Meanwhile, 36 states saw rising rates of public coverage with none seeing a decline in public coverage.

When the unwinding of the Medicaid continuous coverage requirement begins, states will restart eligibility redeterminations, and millions of Medicaid enrollees will be at risk of losing their coverage. Estimates vary, but most approximate that in the range of 15 million to 18 million people will lose Medicaid coverage, with some portion exiting because they are no longer eligible, some losing coverage due to administrative challenges despite continued eligibility, and some transitioning to another source of coverage. While much attention has been paid to how states can approach the unwinding of the continuous coverage requirement to prioritize the retention of Medicaid coverage and transitions to marketplace coverage, less attention has been paid to the role of employer-sponsored insurance.

To get a sense for the size of the group that might have employer-sponsored coverage as an option, this issue brief discusses the proportion of individuals with an offer of employer-sponsored coverage by income and state, and the proportion of those offers that are considered affordable based on premium cost. The issue brief also discusses the importance of a Medicaid disenrollment survey to monitor the coverage transitions associated with the unwinding.

A companion issue brief, Helping Consumers Navigate Medicaid, the Marketplace, and Employer Coverage, discusses how state Medicaid agencies, state-based marketplaces, labor departments, and employers can play critical roles in helping people understand and navigate their employer coverage options.

To support communications efforts during the unwinding, SHVS has also produced sample messaging for state departments of labor to share with the employer community which explains the unwinding and coverage options for employees.

Zylla, Emily
Senior Research Fellow

p 612-624-4802
e ezylla@umn.edu

Expert Perspective and Issue Brief: Tracking the Data on Medicaid’s Continuous Coverage Unwinding (State Health & Value Strategies Cross-Post)

The following content is cross-posted from State Health and Value Strategies published on January 21, 2022.
Authors: Emily Zylla, Elizabeth Lukanen, and Lindsey Theis, SHADAC

Medicaid and Children’s Health Insurance Plan (CHIP) programs have played a key role in the response to the COVID-19 pandemic, providing a vital source of health coverage for millions of people. However, when the Families First Coronavirus Response Act (FFCRA) Medicaid “continuous coverage” requirement is discontinued states will restart eligibility redeterminations, and millions of Medicaid enrollees will be at risk of losing their coverageⁱ.

A lack of publicly available data on Medicaid enrollment, renewal, and disenrollment makes it difficult to understand exactly who is losing Medicaid coverage and for what reasons. Publishing timely data in an easy-to-digest, visually appealing way would help improve the transparency, accountability, and equity of the Medicaid program. It would inform key stakeholders, including state staff, policymakers, and advocates, allowing them to more fully understand the impacts of Medicaid policy changes on enrollees’ access, and give them an opportunity to modify or implement intervention strategies as needed. States already collect a significant amount of data that could inform their success in enrolling and retaining eligible individuals in Medicaid. Many advocates and researchers have been calling for increased transparency around this data in order to better understand the barriers and challenges individuals face when trying to enroll in or maintain coverage.   

One effective way to monitor this dynamic issue is by creating and publishing a Medicaid enrollment and retention dashboard. A typical data dashboard is designed to organize complex data in an easy-to-digest visual format, thus allowing the audience to easily interpret key trends and patterns at a glance. A new issue brief examines the current status of Medicaid enrollment and retention data collection, summarizes potential forthcoming reporting requirements, and describes some of the best practices when developing a data dashboard to display this type of information.

The issue brief lays out a phased set of priority measures and provides a model enrollment and retention dashboard template that states can use to monitor both the short-term impacts of phasing out public health emergency (PHE) protections and continuous coverage requirements, as well as longer-term enrollment and retention trends.

State Medicaid Enrollment and Retention Dashboard – Measurement Priorities
Priority 1 – Use currently reported data: Start with the data that are already collected and submitted to the Centers for Medicare & Medicaid Services (CMS) under the 11 Medicaid performance topics.

Priority 2 – Track reasons for disenrollment: Include measures in the proposed Build Back Better Act (BBB) legislative language that address the reasons why people are being disenrolled.

Priority 3 – Monitor coverage transitions: Add measures to address issues of transitions between programs and churn—the moving in and out of coverage—that frequently occurs in Medicaid and CHIP.

Priority 4 – Explore reasons for and consequences of disenrollment: Field disenrollment surveys that could provide quantitative and qualitative data that could be used to understand both the enrollee’s experience navigating Medicaid processes as well as the consequences of disenrollment.

Regardless of the measures highlighted, an overarching goal of any Medicaid enrollment and retention dashboard should be a focus on displaying disaggregated data. Providing data broken down by various population characteristics (e.g., age, race/ethnicity, income, gender, language, or program type) or geographic areas (urban, rural) will make it easier to understand the potentially disproportionate impact of administrative enrollment and renewal policies on communities of color, persons with lower incomes, and other populations that face disparities. Access to this type of granular data provides stakeholders an opportunity to take action in order to minimize needless loss of coverage.   

Designing an easy-to-understand dashboard that is accessible to all interested stakeholders—state or county program staff, navigators or enrollment assisters, and advocates—will highlight the early warning signs of large numbers of people losing Medicaid coverage. States should start small, using data dashboard best practices and as they gain experience publicly reporting this data, consider adding additional measures over time.