Under federal pressure, states work to boost Medicaid enrollment

By Alison Bennett / December 11, 2023

State Medicaid agencies, under intensifying federal scrutiny as millions of people lose coverage, say they are stepping up efforts to identify who should and shouldn't be enrolled as they continue eligibility redeterminations.

States have removed nearly 12 million people from Medicaid since April, when they began unwinding a pandemic-era continuous coverage policy that expired earlier this year, according to federal data compiled by KFF. More than 70% of disenrollments have been for procedural reasons, not because states determined the enrollees earn too much to qualify.

Federal officials have expressed alarm for months at the scale of the coverage losses and the huge percentage occurring for procedural reasons, such as state agencies being unable to locate beneficiaries.

In September, the Centers for Medicare and Medicaid Services ordered 30 states to halt redeterminations until they could show their systems weren't removing the wrong people. And last week, CMS issued a regulation asserting its right to financially penalize states that don't follow federal rules.

States are making major efforts to restore Medicaid coverage to beneficiaries after the disenrollments, including campaigns to find people and the creation of systems to determine who is eligible, experts and state officials said.

"States are pulling all the levers they can to help eligible folks connected to their coverage," said Lindsey Browning, director of Medicaid programming at the National Association of Medicaid Directors. "And if folks, for some reason, do get disconnected, they're trying to get them back."

While the federal government ramps up the pressure, states are working to contact beneficiaries and figure out the complexities of restoring them to the rolls. Often, they're coping with disenrollments that happened for procedural reasons.

One of the biggest challenges is simply locating and helping people who can reapply for coverage, Browning said. "States have been trying multiple modes of contact—advertising campaigns, phone calls—to really increase that response rate as much as possible," she said.

State Medicaid officials said that while the task has been difficult, they are experiencing success.

Arkansas Medicaid Director Janet Mann said her state's efforts ranged from launching an address update hotline to placing digital billboards in doctor's offices. The state hired more staff to seek out enrollees and reach out to providers and other stakeholders in schools, childcare facilities and libraries.

"We tried to use every piece of communication available to us, with texts, emails and electronic accounts, in addition to phone and email," she said.

The state's effort to restore coverage ended before Dec. 7. However, according to KFF data, as of Dec. 7, a substantial number of people remained disenrolled. The initial number of disenrolled people was about 427,000 while the number re-enrolled was about 298,000.

Medicaid officials in New York and Indiana also said finding people has been one of the biggest parts of the puzzle.

Indiana has taken an approach that involves many other agencies, Medicaid Director Cora Steinmetz said at meeting last month hosted by the Medicaid and Children's Health Insurance Program Payment and Access Commission, which advises Congress on policy.

"We really leveraged other state agency connections that were strengthened or forged during the pandemic period, and so we really embraced sort of a whole-of-government response to getting the word out," Steinmetz said.

The enrollees are served by other programs, such as workforce development and child services, which are trusted entities in communities, Steinmetz said.

In Indiana, 35% of enrollees were dropped from the rolls, but 65% of those were returned as of Dec. 7.

In New York, texting has proven to be a key asset, according to Medicaid Director Amir Bassiri. "We've seen the increase of the people who were texted go and complete their renewal, and that has increased each and every month we've done it," Bassiri said at last month's meeting.

"Overall, I think we've been very, very keen on looking at our data, stratifying all of the data by race, ethnicity, gender [and] language spoken to continue to refine and improve our continuous monitoring of renewal rates by population," Bassiri said.

Bassiri and Steinmetz said their states would like to see flexibilities in the Medicaid renewal process made permanent.

For example, New York has been able to help enrollees who became dually eligible for Medicaid and Medicare during the unwinding process and who may need long-term services and support, Bassiri said. For those who don't, the state is directing them to New York State of Health, its insurance exchange, he said.

As some states work to restore coverage, others have drawn criticism for ending Medicaid coverage inappropriately.

In August, the National Health Law Program and the Florida Health Justice Project filed a lawsuit challenging Florida's terminations of Medicaid benefits during the unwinding process. The lawsuit alleges beneficiaries were dropped from the rolls without adequate notice or due process.

On Capitol Hill, Texas Reps. Lloyd Doggett and Greg Casar led the state's Democratic congressional delegation in a letter to CMS Administrator Chiquita Brooks-LaSure in August that asked her to intervene and pause redeterminations in the state.

The lawmakers claimed Texas isn't meeting federal requirements and wrongly removed nearly 100,000 people from Medicaid, and urged corrective action to protect them from the loss of coverage.

According to the KFF data, Texas dropped 1.4 million enrollees from Medicaid coverage, more than any other state. As of Dec. 7, the state had restored about 760,000 people to its rolls.

Restoring Medicaid coverage continues to be an intense focus for federal regulators.

Last week, CMS published an interim final rule outlining its enforcement authority and potential penalties for violating federal standards during redeterminations, including threats of Medicaid funding cuts and fines.

It's significant to have CMS oversee the state process and step in to take enforcement actions as necessary, said MaryBeth Musumeci, a health policy professor at the George Washington University Milken Institute School of Public Health.

"The real question is going to be are there egregious enough cases where the agency is going to be actually stepping in?'" Musumeci said. "It's going to be important to take a look at what happens next, now that they've put this rule out."

The hope is that CMS will continue to partner with states on redetermination issues, Browning said.

"There's potential for federal policymakers to consider options for states to do continuous coverage for additional types of populations," she said. "There could be some additional conversations around whether there could be other optional pathways to offer those sorts of things to additional age groups and populations."

CMS should also spell out how long the regulatory allowances it offered states to facilitate redeterminations will last, Browning said.