Health Equity Measurement: Considerations for Selecting a Benchmark (SHVS Brief)

September 2023:

The following content is cross-posted from State Health & Value Strategies. 

Authors: Emily Zylla, Andrea Stewart, and Elizabeth Lukanen, SHADAC 

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As states look to advance health equity, they need ways to measure whether their efforts result in improvements. Benchmarking can be used to identify health disparities and establish a standard for evaluating efforts to address health inequities.

This issue brief summarizes the advantages and disadvantages of four common approaches to health equity benchmarking:

1) Using the best-performing group as a reference

2) Using the most socially advantaged group as a reference

3) Comparing against a population average 

4) Comparing against a set target or goal

Key Findings

• There is no single ideal benchmark for health equity measurement and it is important to weigh the advantages and disadvantages of each before selecting an approach.
• The rationale for selecting a benchmarking approach should be thoroughly explained and accompanied by detailed context and interpretation, acknowledging the role of societal inequality and structural racism in driving disparities to prevent the perception that individual subgroups carry responsibility for the observed disparities.

Conclusion

There is no universal “best” approach to selecting a benchmark for health equity measurement. Ultimately, careful and detailed documentation of benchmarking methodology and other choices made in health equity measurement, paired with a discussion of the root causes of inequities, connects the dots between disparate outcomes and the disparities in power and privilege in which they are rooted to maintain the focus on the goal of advancing health equity.

To read the brief in its entirety click here.

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About the Author/Grantee:

State Health and Value Strategies (SHVS) assists states in their efforts to transform health and healthcare by providing targeted technical assistance to state officials and agencies. The program is a grantee of the Robert Wood Johnson Foundation, led by staff at Princeton University’s School of Public and International Affairs. The program connects states with experts and peers to undertake healthcare transformation initiatives. By engaging state officials, the program provides lessons learned, highlights successful strategies and brings together states with experts in the field. Learn more at www.shvs.org.

This issue brief was prepared by Emily Zylla, Andrea Stewart, and Elizabeth Lukanen. The State Health Access Data Assistance Center (SHADAC) is an independent, multi-disciplinary health policy research center housed in the School of Public Health at the University of Minnesota with a focus on state policy. SHADAC produces rigorous, policy-driven analyses and translates its complex research findings into actionable information for states. Learn more at www.shadac.org.

Lukanen, Elizabeth
Planalp, Colin

Using Surveys to Monitor Coverage Transitions During the Unwinding of the Medicaid Continuous Coverage Requirement (Cross-Post)

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The following content is cross-posted from State Health & Value Strategies. 
Authors: Elizabeth Lukanen and Colin Planalp, SHADAC, and Kevin Caudill, GMMB

The unwinding of the Medicaid continuous coverage requirement represents the largest nationwide coverage transition since the Affordable Care Act. Not surprisingly, policymakers, advocates and the media are watching coverage transitions closely and many states have released Medicaid administrative data documenting their progress. While state and federal administrative data can quantify the number of successful Medicaid renewals and coverage terminations, they typically cannot provide details on what happens to people leaving Medicaid. For instance, are people gaining employer-sponsored insurance (ESI) upon leaving Medicaid coverage, or are they becoming uninsured? Those administrative data also are limited in their ability to tell us why patterns are occurring. For instance, among people who remained eligible for Medicaid coverage, why were some successfully renewed while others were not?

Individual-level surveys of people who were enrolled in Medicaid during the continuous coverage requirement can help to answer such questions. The federal government’s Household Pulse Survey, which the U.S. Census Bureau established during the COVID-19 pandemic, serves as one key example of how surveys can fill critical data gaps to answer questions during unique circumstances. Similarly, states may consider conducting their own survey of consumers.

Motivation for Conducting a Medicaid Consumer Survey

Targeted surveys of people who have been enrolled in health coverage (referred to as “consumers” in this expert perspective), can be a relatively inexpensive and quick way for states to obtain information on coverage transitions and consumer experiences. In the context of unwinding, surveys would target Medicaid enrollees who recently went through the redetermination process. These surveys could be leveraged by officials in Medicaid or the Marketplace to:

• Better understand coverage transitions.
  • Did an enrollee transition to employer-sponsored coverage, some other source of coverage, or become uninsured?
  • Why did the enrollee exit Medicaid if they were still eligible?
  • If they were eligible for a qualified health plan (QHP) but didn’t enroll, why?
• Gather information on what messages and message strategies resonated with consumers.
• Assess what shopping, assistance and customer service tools were used.
• Educate people on tools, resources, or coverage options available to them.
• Serve as a final nudge to consumers that they need to take action to stay covered or transition to new coverage.
• Inform future research, such as longer targeted surveys, user experience testing or consumer focus groups.

Survey Mode

Given the dynamic nature of the unwinding, surveying consumers quickly is important. For this reason, states should consider short surveys that are distributed by email or text message using a convenience sample (i.e., Medicaid disenrollees for whom the state has contact information). For the sake of administrative ease, states could work with a web survey vendor that offers a user-friendly interface and (if possible) with whom they have an existing subscription or contract.

Many web-based vendors can send surveys via email or text. When sent via email, these surveys can typically be distributed in two ways: 1) consumers are sent a generic survey—the same survey link goes to everyone on the distribution list; 2) consumers are sent a unique survey link—a unique survey link is distributed individually to everyone on the distribution list. These options entail trade-offs. A benefit of a generic link is that it can be sent using the state’s existing communication platform. This avoids the need to import consumer contact information into the survey vendor platform, which might raise privacy and other legal concerns. Alternatively, a benefit of using a unique, individualized survey link is the ability to connect survey responses to state administrative data on the respondent, notably, characteristics (e.g. income, age, race, household type, etc.). This reduces the need to collect demographic data via the survey, can result in richer demographic detail about survey respondents, and provides insights into those who did not respond to the survey.  

Text or SMS surveys can also be distributed in two ways. One option is to send a “2-way” survey, where respondents text their replies to each question (best suited for a one question survey). The second option is to distribute a link to the survey which is sent to the consumer’s phone and can be opened in a mobile browser. During the unwinding, states are often focused on very short surveys. In some cases, they might ask a single question (typically focused on assessing coverage transitions) or other very brief surveys (3 to 10 questions). In some cases, states might attempt both—starting with a single question survey to assess coverage transition, followed up by a longer survey that captures information about the consumer experience. While there is wide concern that state Medicaid programs might not have up-to-date contact information for Medicaid enrollees, especially in a time-sensitive situation such as the unwinding, it is likely most practical to reach out to people using contact information already on file—often including a cell phone number or email address.

The primary benefits of web-based surveys sent via text or email are speed and cost. If a state has in-house expertise, funding, and can leverage an existing partnership (e.g., a state–university partnership) or an existing survey effort, they could also consider a more robust, mixed-methods survey that supplements a mailed survey (and online option) with interviews. For example, New Mexico recently fielded the New Mexico 2023 Office of the Superintendent of Insurance (OSI) Health Access Survey, commissioned by the New Mexico OSI and conducted by the University of New Mexico. This was a larger and sophisticated effort—a statewide survey of 1,900 adults, conducted by a survey firm in both English and Spanish using multiple modes (telephone and online). While the focus of the survey was broad, to better understand the opinions and attitudes New Mexicans have regarding health insurance, the state recognized the opportunity to use this vehicle to gain insights into unwinding. The survey found that residents were generally aware that pandemic funding for Medicaid was ending, but this awareness was lower for Latino/a, Native American, Spanish-speaking and lower-income New Mexicans, which highlighted the importance of targeted messaging and outreach.

Target Population and Timing

During the unwinding, states should focus on consumers who are scheduled to be redetermined for Medicaid. Logistically, states could consider sending the survey in waves, aligning with unwinding cohorts. If state systems allow them to target more granular groups, the state could send slightly different surveys to different groups. For example, if a state is targeting those who exited Medicaid and shopped for plans in the Marketplace, they could send slightly different questions to those who ultimately selected a plan than to those who did not select a plan.

States should also carefully consider the timing of any consumer survey as they finalize their questions.  For example, questions about shopping and plan selection should happen fairly quickly, ideally within a couple of weeks of when consumers should have engaged in these activities. If a consumer can still submit redetermination paperwork or sign-up for a QHP, the questions and wording should make that clear and not imply the consumer has no option to take action. As mentioned above, given the nature of many states’ phased unwinding approach, states should consider sending surveys weekly or monthly based on renewal cohorts.

Questions of Interest

States considering consumer surveys related to the unwinding tend to be interested in a fairly narrow set of questions. They want to understand coverage transitions, specifically whether people enrolled in employer-sponsored or Marketplace coverage after leaving Medicaid, and the enrollee’s experience navigating the process. States might use these surveys to assess specific outreach methods (e.g. the impact of mailing campaigns to send people letters on colored paper). And for states with available customer service resources, they could use the survey to connect people with a customer service channel (for instance, asking respondents if they would like assistance with the application and enrollment process). By collecting demographic information along with these questions, states can also get a sense for whether there are population differences between those who successfully transitioned to another source of coverage and those who remain uninsured. 

Common survey question domains include:
(A list of sample questions is included at the end)

• Current coverage/coverage transitions
• Reasons/motivations to have or not have coverage
• Experience shopping for insurance
• Establish who shopped (if this cannot be identified using administrative data)
• Outreach and assistance
• Impacts of uninsurance
• Demographics
• Did an enrollee transition to employer-sponsored

As states consider what questions to ask, they should take care to tailor their surveys to the strengths and limitations of this data collection method. Surveys are good at collecting information on people’s experience and impressions, but they are less useful for collecting specific, detailed and nuanced information (e.g. specific information about ESI cost-sharing, specific detail on what programs consumers qualified for). 

Another best practice is to ask questions that only require the respondent to reflect on one concept at a time. For example, when constructing questions about the shopping process, avoid phrasing questions that conflate opinions about the shopping experience and plan choice, which could pose a challenge to respondents if they found the online interface easy to use but the plan options to be underwhelming, or vice versa.

Finally, states should consider the goals of the survey and tailor the questions to those goals. Especially in the unique circumstances of the unwinding, states may be looking for ways to make their redetermination processes more user-friendly for Medicaid in the near-term, so they can maximize the number of eligible individuals reenrolled in the program. In that case, states should prioritize questions that are likely to yield data that are actionable in the coming weeks or months, rather than years. Relatedly, states should take care in how they interpret survey data collected during the unwinding and temper their expectations for the generalizability of the survey findings into the future. Because the current circumstances are so unusual, it is possible that the experiences of Medicaid enrollees going through the redetermination process today may not resemble the experience of people going through the redetermination process in a couple of years. However, if states find these survey data useful, they could incorporate similar surveys even after the unwinding, as part of their ongoing, regular course of business.

Communications Best Practices

As states are developing survey instruments, it is important to also keep in mind the surrounding communications to potential respondents to maximize participation, reinforce validity, and mitigate against concern about scams. Below are some helpful tips that states should consider when developing communications to support consumer research. While these apply primarily to email, they can also be applied to other mediums such as text messages. 

Establish your tone/voice. The tone of your subject line and email should reflect your Marketplace or Medicaid agency brand. Reinforcing your role as an official program is key. Determine where you will fall on the spectrum of conversational (e.g. “A few minutes to share your feedback?”) versus professional (e.g. “We’d appreciate your feedback to help us serve you better.”)

Personalize as much as possible. Personalizing is more than a name; it’s reflecting the experience you want feedback on. For example: “How did we do with Medicaid/Marketplace enrollment?” or “Did you have all the enrollment information you needed?”

Talk about the benefits of completing the survey. Explain up front why their participation matters. For example: “Help us make Medicaid enrollment better” or “Your feedback will make Marketplace enrollment better.” Within the body of the email itself, briefly explain how their feedback will be used and express appreciation for their time and input.

Ask a question in the subject line.

Try to keep subject lines under 50 characters. This is so participants can get the full headline on their mobile device.

States should consider these recommendations as they develop customized messaging for survey communications. These steps can help states get the most helpful information from their survey efforts. Ultimately, communications should reflect the unique goals that each state will determine for its research effort so there is no one size fits all approach.

Interpreting the Results

This type of consumer survey can be very useful to gather information on consumers’ experiences, identify areas where they are struggling with the process and which resources or outreach methods are resonating. In this case, it can also be useful for gaining some insights into coverage transitions outside of Medicaid or the Marketplace. That said, it will rely on a convenience sample, it is likely to have a low response rate and the results will not be representative of the target population as a whole. When interpreting the results, these limitations should be considered. States shouldn’t assume that survey results collected using a convenience sample during the unwinding represent everyone who experiences the Medicaid redetermination process. For example, consumers’ experiences might be different during a more typical renewal period and might be different for those who did not respond to the survey.

Agency Coordination

States considering these surveys should work closely with their legal, marketing, customer service and other relevant teams. Support and guidance from a legal team can be critical as states consider specific details about how the surveys are sent and distributed. For example, can the state send text messages to consumers and with what limitations? Can the state upload consumer contact information into survey vendor platforms for the purposes of distributing a survey? Involving the marketing and public relations team is also a good idea as they can ensure the terminology is consistent and that messages are aligned with what is being sent regarding redeterminations. And it is important to let customer service teams know when these surveys are going out, particularly if they are designed to spur final action or are directing enrollees to specific supports.

Sample Questions

A list of sample survey questions can be downloaded using the link below. The sample questions can be customized and used by states interested in conducting a consumer survey during the unwinding.

SHVS_Sample Consumer Unwinding Survey

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

Considerations from SHADAC: Proposed Revisions to Federal Standards for Collecting Race/Ethnicity Data

Response from SHADAC

The State Health Access Data Assistance Center (SHADAC) is a health policy research center within the University of Minnesota School of Public Health. We provide technical assistance (TA) to states in the areas of data use and analysis to support policy. The below comments are based on SHADAC’s specific experience supporting states as they address challenges related to the collection of data on race, ethnicity, language, disability, sexual orientation, and gender identity via the Medicaid application.

SHADAC was thrilled to see the revised OMB standards related to the collection of race and ethnicity. The proposed revisions align with available evidence, are consistent with the changes made by leading states, and most importantly, explicitly state that these standards should serve as a minimum baseline with a call to collect and provide more granular data. However, while these standards are specifically named as minimum reporting categories for data collection throughout the Federal Government, if adopted, they are likely to shape data collection and reporting across all sectors, including the states with whom we work that collect race/ethnicity data through the Medicaid application process.

State Medicaid programs have the flexibility to develop their own applications and race and ethnicity questions as long as they meet CMS-established reporting requirements (which follow current OMB guidance). Although many states follow the application model that CMS developed in 2013, our research has found 65 different variations in how these data are collected across all states and modes (e.g., paper, online). Once collected, this information is used in a wide variety of ways: to support state analysis and operation; in reporting to CMS; and to feed into the T-MSIS, which in turn is released as the research-ready T-MSIS data files used by researchers studying Medicaid program health outcomes, health equity, and administrative accountability.

Given the role OMB standards play in shaping state data collection approaches and the obvious impact and reach of these data, we respectfully submit our comments aimed at supporting the adoption of a revised set of standards.

Cross Program and Agency Alignment

Guidance needs to include detail on how any revisions will filter through data collection and reporting across all sectors that impact states/federal interactions. Will all federal agencies adopt the proposed new standards on the same timeline?

For example, all Food and Nutrition Services (FNS) state agencies are currently required to collect race and ethnicity according to prescribed specifications: race and ethnicity must be collected using a two-question format (ethnicity must be collected before race), and the minimum categories must align with OMB standards. Therefore, states with a combined Medicaid/SNAP application currently cannot offer a combined race/ethnicity question even though the most current evidence shows that is the preferred approach. States will want to know whether the adoption of the new proposed OMB standard allowing for a combined race/ethnicity question will supersede the existing FNS guidance on how to collect this information. Or will states that want to pursue a combined question on their combined Medicaid/SNAP application have to wait for updated FNS guidance to be released?

Similarly, existing guidance requires states to share data (including demographic data like race and ethnicity) with health plan carriers via a federally standardized 834 template. States cannot make changes to existing data fields on this form—any changes made currently result in enrollment transaction failures. If OMB standards are updated, how and when will changes be made to the 834 file form to align with these new changes? 

Finally, the revisions have implications for state data reporting of race and ethnicity into the Transformed Medicaid Statistical Information System (T-MSIS). If approved, states will need guidance on how to transition to a single data element (combined race and ethnicity). They will need to understand how to streamline or roll-up more granular data and more write-in data and how to manage the likely increase in people who report more than one race.

Data Granularity

The revised guidance rightfully acknowledges the challenges associated with collecting more granular data. If the final guidance recommends the inclusion of an open text response option for each detailed category, states will need detailed, individual guidance on how best to manage those data. While most states prioritize granularity, they simply don’t have the staff time or, in some cases, the expertise to develop the thoughtful and detailed cleaning and coding procedures required to process a large volume of write-in data. In addition, many current IT systems don’t have the functionality to collect and store a large volume of write-in data.

One way to support this would be to develop or enhance an existing hierarchy that includes a long and diverse list of racial and ethnic categories, such as the Centers for Disease Control Race Category and Ethnicity Groupings. Another way to support the use and reporting of disaggregated data is to provide technical support and guidance around data use standards. This could include standards around recency, maximum “refusal to answer” thresholds, data missingness thresholds, and sample size thresholds that guide suppression of publication.

Technical Assistance

States need direct technical assistance (TA) to support the successful implementation of revised standards. This will need to go beyond documentation and guidance. To do this well, states should have access to experts who can provide practical, hands-on advice that is responsive to their specific needs. The type of assistance needed will vary. States with sophisticated analytic teams may seek advice on how to bridge race and ethnicity data collected under one method with data collected under a revised method. Other states may need more fundamental support to implement the expanded race/ethnicity option in a way that is the least disruptive to their current data collection structure.

We would also recommend that any TA effort include a forum for states to discuss implementation challenges with their peers and serve as a repository for promising practices. States will face different challenges but always appreciate having a forum to discuss problems and solutions with other state officials. In addition, there is limited research on best ways to collect data on race and ethnicity and even less on operational considerations for collecting this information in an administrative context like a Medicaid application. Technical assistance should encourage and support the evaluation of systems’ improvements and serve as a clearinghouse for sharing key findings.

To build trust with the enrollees from whom this data is being collected, states would also benefit from technical assistance or model training materials on the best ways to communicate why this data is being collected and how it is being used (e.g., TA on effective forms of community engagement, Navigator or assister training, or instructional language scripts for frontline workers.)  

Funding

Questions that collect race and ethnicity data within the Medicaid application are embedded in many other complex and multifaceted questions about topics such as employment, income, household composition, etc. The systems that collect and house this information vary in their age, technical capacity, and purpose. Almost uniformly, they are complex and expensive to change, both in terms of data collection but also data transfer, reporting, and sharing. Ideally, states can access new dedicated funding or receive clear guidance on how existing federal money can be used to make necessary IT and systems changes.

The funding associated with this effort should also be flexible. It should support direct costs like system modifications but also priorities such as stakeholder engagement, instructional language development, and training—all of which are critical to successfully implementing the revised data collection guidance.

Urgency of Additional Guidance

While we are encouraged to see revised standards related to race and ethnicity data collection, we want to stress the urgency of revised guidance related to data collection on sexual orientation, gender identity, primary language, and disability. The current standards on sex are woefully inadequate, to the point of causing harm to people who identify as belonging to a sexual or gender minority population. Standards around disability and language are similarly lacking. Given the intersectionality of these concepts as they relate to identity, it’s important to make progress on updating standards for all areas, not just one. In addition, if states are to make significant investments to modify application wording as well as data systems and reporting structures to improve the collation of race and ethnicity, it makes sense to do this with the knowledge and understanding of timing for future changes regarding sexual orientation, gender identity, primary language, and disability. At the best, these timelines could be aligned, and at the least, states should have visibility to when those revisions are likely to be released.

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.