How One Medicaid Program May Prevent Coverage Loss Post-COVID

The Massachusetts Medicaid program can use a variety of strategies that it might implement in order to reduce coverage loss after the public health emergency lifts, according to a brief from the Blue Cross Massachusetts Foundation, Massachusetts Medicaid Policy Institute, and Manatt.

MassHealth enrollment grew by over 431,000 enrollees from February 2020 to February 2022. This represented a nearly 25 percent increase over the course of two years.

For context, prior to the pandemic, MassHealth saw single-digit shifts in enrollment in the two-year timeframe spanning 2016 to 2018, according to an analysis of Massachusetts healthcare coverage enrollment conducted by the Center for Health Information and Analysis.

Like many states, MassHealth is preparing for the end of the public health emergency and the changes that this will bring to Medicaid processes, specifically redetermination processes.

The Medicaid program faces a widespread problem. Medicaid enrollment spiked during the pandemic while coverage redeterminations were put on hold. Redetermination processes regularly result in temporary coverage loss for enrollees who are still eligible for Medicaid coverage.

When redeterminations resume after the public health emergency lifts, experts are concerned that MassHealth—and Medicaid programs like it—will see massive, unnecessary coverage losses due to what are called “administrative” or “procedural” terminations. 

This type of coverage loss occurs when an individual is still eligible for coverage but does not turn in the appropriate paperwork to prove that she is still eligible for coverage. A tenth of all enrollees in Medicaid or in the Children’s Health Insurance Program (CHIP) face an administrative termination and are re-enrolled in under a year.

In Massachusetts specifically, only 10 to 15 percent of Medicaid members who must submit paperwork for the redetermination process actually do so. This can be the result of enrollees’ confusion regarding what is required of them.

The last coverage redeterminations took place approximately two years ago, which means that MassHealth’s enrollee information is likely outdated. As a result, MassHealth may have to send out more paper notices seeking redetermination information.

In order to prevent unnecessary loss of coverage for individuals who remain eligible for Medicaid coverage after the public health emergency ends, MassHealth will pursue five primary mitigation strategies alongside six additional steps that could help maintain coverage.

First among the four primary methods, the state will leverage community-level outreach. 

The state legislature has dedicated $5 million to an outreach campaign with Health Care For All (HCFA) Massachusetts. The funds will be used to activate community partners to educate eligible individuals about redetermination, support an ethnic media campaign, and canvas communities with a high risk of coverage loss.

Second, the state will make changes to its renewal verification process. MassHealth will work to increase the number of individuals eligible for “ex-parte” redetermination—a type of redetermination that lacks the need for paperwork updates and which tends to have lower rates of coverage loss. For example, the state will boost the income reasonable compatibility threshold.

Third, the state will partner with its managed care organizations and accountable care organizations (ACOs) in order to ensure that enrollees are aware of the redetermination process and to support the state in connecting with enrollees.

Fourth, the state will activate a communications strategy that involves revising its call center scripts to incorporate requesting updated information, nudging people to respond to redetermination information requests through social media, and improving its linguistic and cultural competency in communications. 

Also, the renewal process information requests will arrive in blue envelopes to make them visually noticeable.

Finally, MassHealth is hiring more caseworkers in order to process appeals and redeterminations more quickly.

On top of these five strategies, the state will establish a year-long plan for the redetermination process, organizing the population of redeterminations by order of need. MassHealth will also be more proactive about updating contact information when their notices are returned. 

The Medicaid program will offer guidance to its managed care organization and ACO partners and will offer strong oversight including, potentially, a public-facing dashboard that would offer transparency on enrollment and disenrollment data. The state may institute a disenrollment rate “circuit breaker” if the disenrollment rate starts to surge too high.

MassHealth will transfer disenrolled individuals to Health Connector—Massachusett’s Affordable Care Act marketplace—to see if they can easily receive coverage there.

On the horizon, MassHealth plans to implement a text messaging strategy that may allow members to more conveniently update information.

On the federal level, the proposed Build Back Better Act sought to reduce Medicaid enrollment churn by boosting postpartum and childhood coverage.

Separate studies indicate that continuous coverage through the Affordable Care Act marketplace may be tied to higher care utilization for certain populations.