How States Can Prepare for 2023 Medicaid Redeterminations

Priorities before the redetermination process begins

Brooks named two overarching priorities for Medicaid agencies in the pre-redetermination period.

First, they should focus on updating enrollee mailing addresses.

“It’s been as many as three years since enrollees have had contact with Medicaid in some states. And with the continuous coverage protection in place, some states have not been in regular communication,” Brooks said.

Given the lack of contact, updating beneficiary information is crucial. The pandemic pushed people out of the urban areas and into non-metro areas, away from cities with escalating prices and into more affordable housing options, Freddie Mac researchers found.

In 2021, Americans were far less likely to move, with only 8.4 percent of Americans reporting a move compared to 11.0 percent in 2017, according to the Freddie Mac report. But they were more likely to change metro areas. More than a quarter of all moves that year were to a new metro area or non-metro area.

These affordability-driven address changes could result in Medicaid beneficiaries failing to hear about their impending disenrollment.

It’s been as many as three years since enrollees have had contact with Medicaid in some states. And with the continuous coverage protection in place, some states have not been in regular communication.

AHCCCS submitted for a federal eligibility-related flexibility to partner with the United States Postal Service (USPS) National Change of Address (NCOA) program to update Medicaid beneficiaries’ contact data. Additionally, in the first part of the agency’s two-phase communications campaign, the agency has been contacting members to remind them to update their information on the agency’s website.

The agency has also implemented strategies to pursue beneficiaries when mailed materials are returned to the agency, indicating an address change.

As the agency attempts to remind beneficiaries to update their information, AHCCCS uses both broad and targeted methods of communicating with beneficiaries. For more widespread awareness, the Medicaid agency publishes information on social media, public forums, website content, and newsletters.

Its targeted efforts involve connecting with beneficiaries through robocalls, text messaging, and other direct forms of contact. The agency also published messaging toolkits in 2021 that help the health plan and its stakeholder partners to provide consistent information.

Second, Medicaid agencies should communicate the state’s redetermination plan to stakeholders.

Medicaid agencies cannot tackle redetermination alone. The task of communicating with beneficiaries is an all-hands-on-deck undertaking with a variety of partners.

“Medicaid stakeholders, including managed care plans, health care providers, consumer advocates, navigators and assisters, legal aid service organizations, and policy shops, particularly frontline organizations that have face-to-face interactions with Medicaid enrollees, can amplify and supplement communications with enrollees, conduct outreach, and assist enrollees is states work in collaboration with stakeholders,” Brooks explained.

AHCCCS indicated that, while the public health emergency unwinding project plan has AHCCCS’s logo and name at the top, the agency did not expect this to be a solo mission.

“We rely heavily on our stakeholders: community partners, CBOs, advocacy organizations, local business, other state agencies, and legislators to use these toolkits to spread awareness of the upcoming Medicaid renewal process,” the agency spokesperson explained.

In addition to updating enrollee information, Medicaid programs need to test and implement any required systems changes and ascertain whether they are ready to collect the necessary data.

Priorities during the redetermination process

During redetermination, monitoring performance data will be key, Brooks indicated.

Performance data will tell Medicaid agencies whether the process is clear to beneficiaries and whether the agencies’ goals are being achieved.

Brooks suggested that Medicaid agencies pay attention to call center wait times as a key performance metric. Call centers can be important touchpoints with beneficiaries. To prevent widespread coverage loss at the end of the public health emergency, one Medicaid agency redesigned its call center script to request updated information.

Another meaningful performance metric that Medicaid agencies should track is the number of individuals that have been disenrolled for factors not related to eligibility. If high numbers of beneficiaries are being enrolled for administrative reasons, Brooks recommended pausing and evaluating the state’s redetermination plan.

AHCCCS indicated in its project plan that it anticipates around half of the approximately 600,000 Arizonans who are disenrolled from Medicaid during redeterminations will be factually ineligible for Medicaid. The remainder may be disenrolled due to a failure to respond to agency requests for updated enrollee information.

In addition to measuring performance, Medicaid agencies should track their progress and assess their redetermination process by inviting feedback from their partners and stakeholders who are face-to-face with beneficiaries.

“Whenever major system changes and processes are introduced, there will inevitably be glitches,” Brooks said. “Hearing from the field, particularly from navigators and enrollment counselors in community health centers and hospitals who work directly with Medicaid enrollees and understand their state’s processes, can help the state identify issues and recurring problems in need of attention.”

AHCCCS indicated that performance monitoring is a priority at AHCCCS as well.

“We will be monitoring the progress closely to ensure that no eligible Arizonans are inadvertently disenrolled,” the AHCCCS spokesperson said.

Hearing from the field, particularly from navigators and enrollment counselors in community health centers and hospitals who work directly with Medicaid enrollees and understand their state’s processes, can help the state identify issues and recurring problems in need of attention.

The summary of the state’s project plan concludes by mentioning the federal monitoring requirements. States must report to CMS on their progress with pending applications and their caseload and disposition of renewals.

Priorities after the redetermination process

With millions of beneficiaries expected to lose Medicaid coverage on April 1, 2023, Brooks indicated that outreach and public education should be top priorities for states, post-redetermination. However, she noted that, historically, some states have failed to prioritize outreach appropriately.

“Consumer education is critical to ensuring that individuals are not inappropriately disenrolled from coverage when normal eligibility determination operations resume,” a post from the National Academy for State Health Policy (NASHP) emphasized.

“Some states are taking added steps to ensure that notices are distinct from communications sent throughout the pandemic and convey the appropriate level of urgency, while also meeting readability standards for their consumers. Some states have engaged community perspectives in drafting communications such as member advisory groups to ensure that messages are effective to help with disseminating communications.”

The NASHP post indicated that beneficiaries who ended up in Medicaid coverage during the tumultuous pandemic may be unaware of Medicaid renewal processes.

The redetermination process will undoubtedly leave a large population of disenrolled individuals uninsured.

Between 2016 and 2019, nearly two-thirds of disenrolled Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries were uninsured at some point in the first year after disenrollment, a Kaiser Family Foundation (KFF) brief found. Of these, 17 percent were uninsured for at least a full year.

The brief noted that eligibility could change due to income shifts or other factors, but it could also be due to administrative challenges. The loss of coverage—even when it is temporary—can cause disruptions in care as patients have to transition to a different doctor covered under their replacement health plan.

Regardless of the cause for disenrollment, millions of Americans may find themselves with no insurance and a lot of questions after the redetermination. It is up to Medicaid agencies and their partners to ensure that these individuals have access to the appropriate information about alternative coverage options.

Resources for the redetermination process

In the face of this challenging mission, Medicaid agencies can turn to a number of resources for support.

First, Brooks pointed Medicaid staff toward the CMS unwinding page. The page includes guidance from the federal agency stretching back to December 2020 such as guidance on COVID-19 public health emergency unwinding frequently asked questions, distributing the eligibility and enrollment workload, and preparing to resume normal processes.

The page also offers templates for communications. There is a toolkit available in seven languages, a four-page refresher on implementing changes to Medicaid Enterprise Systems, guidance on coordinating Medicaid and Affordable Care Act marketplace enrollment efforts, a partner education webinar, and more.

Also, Georgetown University Health Policy Institute Center for Children and Families has an unwinding page as well, with resources extending back to October 2020. One of the resources offers a communications toolkit, graphics and materials for providers, and state-specific renewal flyers. The Center has been publishing an “Unwinding Wednesday” blog post series that covers unwinding updates and recommendations.

Lastly, Brooks noted that the State Health and Values Strategies Initiative (SHVS) had created an unwinding resource page with topic-specific resources that cover health equity, data and information technology, eligibility and enrollment policy and operations, consumer communications and outreach, oversight and monitoring, Medicaid and Marketplace integration, and federal resources.

The Federal Communications Commission has also issued guidance on state and federal agencies’ ability to use automated calls and texts regarding public payer enrollment.

“As you can see, there really is no shortage of resources for states,” Brooks said.

AHCCCS expressed a sense of readiness, now that the start date for redeterminations has been established.

“We have been preparing on all fronts—financially, operationally, programmatically—for two years, ready to implement the change at a moment's notice every time there was the possibility that the PHE would end,” the agency spokesperson said.

“While the work will be a big lift, and the prospect of so many Arizonans becoming ineligible is daunting, we appreciate the certainty and are ready to implement our plan.”