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An Overview of CMS Continuous Enrollment Condition Unwinding Webinar and Key Resources for Medicaid Stakeholders and Providers 03.27.2023

In March 2020, the Families First Coronavirus Response Act established the “continuous enrollment condition,” which provided states with extra federal Medicaid funding in exchange for maintaining enrollments for all Medicaid-enrolled individuals throughout the public health emergency (PHE). Many states implemented comparable policies that had a similar impact on the Children’s Health Insurance Program (CHIP). Up until the passage of the Consolidated Appropriations Act 2023 (CAA, 2023), the ending of the continuous enrollment condition was linked with the ending of the PHE. When the CAA, 2023, was passed, the continuous enrollment condition end date was decoupled from the ending of the PHE and will now end on March 31, 2023. When the continuous enrollment condition ends, 15 million or more enrollees could lose their Medicaid or CHIP coverage. The Biden Administration has signaled that it intends to end the PHE on May 11, 2023.[1]

Since May 2022, the Centers for Medicare & Medicaid Services (CMS) has held monthly calls to provide resources and updates regarding the unwinding of the continuous enrollment condition. This document summarizes CMS’s monthly calls and resources CMS has provided to guide states and other stakeholders through the process. Summaries from May 2022 – December 2022 reflect the initial continuous enrollment condition’s dependence on the end of the PHE. The January 2023 summary and beyond reflect the continuous enrollment condition end date of March 31, 2023.

Highlights of these webinars include:

  • CMS is committed to communication and engagement with state Medicaid agencies and other organizations serving beneficiaries, and strongly encourages use of its various resources and toolkits.
  • The unwinding will create a heavy burden on states as they address the large volume of pending renewals, likelihood of outdated mailing addresses and contact information, and workforce shortages.
  • Obtaining updated contact information; launching outreach and communication plans; and engaging with community partners, health plans, and the provider community will help states to better manage the unwinding.
  • Coverage losses will disproportionately impact Black and Latinx children.
  • Consumers can sign up for Marketplace coverage as soon as they know their Medicaid coverage is ending, rather than waiting until they have lost coverage.
  • December research indicated that many people are not aware of the upcoming re-determinations or potential re-enrollment requirements. Some minority groups will require targeted outreach.
  • Effective HealthCare.gov outreach to people who no longer have Medicaid should address plans’ affordability with specific dollar messaging as well as mention plan quality and the services covered.
  • gov is offering an additional “Unwinding” Special Enrollment Period due to the unprecedented nature of the unwinding. Consumers in Federally Facilitated Marketplace states who lose Medicaid or CHIP coverage between March 31, 2023, and July 31, 2024, can submit an updated application and receive a 60-day SEP window to enroll in coverage. State-Based Marketplaces have their own option to offer the Unwinding SEP.

Key Resources

March 2023

During this webinar, Stefanie Costello, Director of the Partner Relations Group in the CMS Office of Communications, posed commonly asked questions to various CMS staff related to renewals, terminations, Marketplace transitions, and outreach strategies.

Jessica Stephens, Senior Policy Advisor at the Center for Medicaid & CHIP Services, answered questions about Medicaid renewals, the redetermination process, next steps after losing Medicaid, and CMS coordination with states. Some states are scheduling renewal dates based on the original enrollment date to keep a 12-month schedule; others are basing renewal dates on characteristics such as potential likelihood of ineligibility. According to Ms. Stephens, states will allow a minimum of 30 days to respond to a renewal form and must provide an advance notice of termination 10 to 15 days before terminating coverage. She stressed that a beneficiary can still provide the information needed to maintain coverage if they receive an advance notice. When asked about next steps after losing Medicaid for procedural reasons or outdated contact information, Ms. Stephens suggested returning documentation to the state within 90 days for a new eligibility determination.

Jessica Brill Ortiz, Technical Advisor for Consumer Information and Insurance Oversight (CCIIO), then answered questions about Medicaid to Marketplace transitions and emphasized the need to take action. When a person is denied Medicaid eligibility, their state agency will send their account information to the Marketplace through the regular inbound account transfer process. The Marketplace will notify the individual once it has received the information, and the notice provides instruction for creating and submitting a new application. However, the Marketplace will not automatically evaluate coverage eligibility for people who have been disenrolled.

Marisa Beatley, Lead Health Insurance Specialist at CCIIO, answered questions pertaining to unwinding the special enrollment period (SEP). She recommended that individuals apply or update their existing application as soon as they receive a letter with their Medicaid or CHIP coverage termination date to avoid coverage gaps. Ms. Beatley noted that most consumers’ Medicaid or CHIP coverage will end on the last day of the month.

Evonne Muoneke, Deputy Director of the Division of Assister Programs at CCIIO, answered questions related to navigators and assisters. During the unwinding, consumers will receive a letter with information for a sister organization serving their community, which may directly contact them to help with enrollment. CMS invested $10 million into the assisters personnel program to help consumers navigate this process.

Kim Glaun, Health Insurance Specialist at the CMS Medicare-Medicaid Coordination Office, answered questions regarding Medicaid to Medicare transitions. If someone loses Medicaid coverage and is eligible for Medicare based on age and disability, they can use a new SEP to enroll. This SEP starts the day the state notifies them that their Medicaid coverage is ending, and it continues six months after their coverage ends. When asked how the unwinding will affect people enrolled in the Medicare Savings Program, Ms. Glaun said that everyone enrolled, including dual eligibles, must undergo an eligibility renewal.

Alyssa Walen, Public Affairs Specialist at the CMS Office of Communications, then answered commonly asked questions around outreach communications. CMS is putting a lot of effort into messaging and outreach, as shown through the various flyers, memos, and toolkits. The Agency has a multipronged approach to getting people coverage and will enter the second phase later this spring to reach people who may have lost Medicaid or CHIP coverage. Ms. Walen also discussed the critical role providers will play in helping people prepare. She encouraged them to use CMS resources and help drive some of the conversations with patients.

February 2023

The Biden administration has announced its intent to end the public health emergency on May 11, 2023, which is now separate from the ending of the continuous enrollment condition. This webinar discussed the Marketplace transition process for beneficiaries who are no longer eligible for Medicaid and the unwinding special enrollment period.

Marketplace Transition and Communications Efforts

Meghan Reilly, Office of Communications, CMS, outlined how if a beneficiary is found to be not Medicaid/CHIP eligible as the state initiates redeterminations, their application would then be transferred to Marketplace. To do so, the state would send a consumer an eligibility letter with the end date of Medicaid coverage and information about transferring to Marketplace coverage. Reilly outlined several consumer communications strategies to facilitate these efforts, including notices and letters, emails, autodial calls, text messages, and communications about the availability of assisters. More broadly, CMS is using a multi-pronged approach to communicate about the unwinding and is working closely with Medicaid stakeholders to ensure Medicaid enrollees are aware of the action that must be taken to maintain existing coverage or transition to different coverage.

Ongoing and future outreach and marketing campaigns are split into two phases. The first focuses on preparation and awareness, with the primary objectives being encouraging beneficiaries to update contact information and to build awareness about the unwinding. The second phase focuses on consumers retaining coverage through Medicaid or Marketplace, as redeterminations begin to occur.

Unwinding Special Enrollment Period

Jessica Brill Ortiz, Technical Advisor, Division of Marketplace Eligibility Policy & Operations, Eligibility & Enrollment Group, CMS provided additional context on Medicaid to Marketplace transitions and outlined considerations for the Special Enrollment Period for the unwinding. Ortiz emphasized that Medicaid/CHIP enrollees do not need to wait until their Medicaid/CHIP coverage ends to sign up to obtain Marketplace coverage.

Anyone can apply for Marketplace coverage during Open Enrollment, which occurs annually from November 1 – January 15. Individuals may qualify for a Special Enrollment Period (SEP) to enroll in Marketplace coverage if they attest to their loss of Medicaid/CHIP up to 60 days before or 60 days after their Medicaid/CHIP coverage ends. Healthcare.gov is offering an additional “Unwinding” SEP due to the unprecedented nature of the unwinding. Consumers in Federally Facilitated Marketplace states who lose Medicaid or CHIP coverage between March 31, 2023, and July 31, 2024, can submit an updated application and receive a 60-day SEP window to enroll in coverage. State-Based Marketplaces have their own option to offer the Unwinding SEP.

January 2023

Medicaid and CHIP enrollment is at an all-time high, with nearly 91 million individuals enrolled as of September 2022 – an increase of nearly 29 percent since February 2020. Much of the increase is due to the continuous enrollment condition.

With the enactment of the CAA, 2023, the Medicaid continuous enrollment condition will end on March 31, 2023. When this occurs, states will resume normal operations and be able to terminate Medicaid enrollment for individuals no longer eligible beginning on April 1, 2023. States will be required to initiate renewals for the state’s entire Medicaid and CHIP population within 12 months and complete renewals within 14 months. To complete this process, states must first attempt ex-parte renewal. If the state does not have sufficient information to process the renewal, it would then send a renewal form and request additional beneficiary information. If the Medicaid agency finds that an individual is ineligible for Medicaid, the state would then examine potential eligibility for other programs, such as the Marketplace, and transfer their account information for a redetermination.

CMS anticipates that the large volume of renewals, workforce and staffing shortage, and likelihood of outdated contact information will pose challenges to states planning for renewals.

December 2022

Speakers presented research showing the wide unawareness of re-enrollment or re-determination, especially among certain demographics. They emphasized specific areas to include in messaging.

Stefanie Costello began the call with an overview of the current status of the PHE. She said that since HHS previously committed to providing 60-days’ notice before terminating the PHE, and the 60-day mark passed on November 11 with no notification, the PHE will likely be extended until mid-April if the Biden Administration follows past practice. Ms. Costello recommended that states use the additional time to prepare for the unwinding.

Clarese Astrin, Director of CMS’s Division of Research, outlined CMS’s Consumer Research used to inform HealthCare.gov outreach to people who no longer have Medicaid. CMS distributed an attitude and awareness survey to 406 beneficiaries in May 2022 and organized focus groups of English and Spanish speaking beneficiaries to test messaging in August 2022. Survey findings indicated that many people are not hearing about re-enrollment or re-determination; only about one-third of respondents reported hearing about it. Research also showed that effective outreach plans should address plans’ affordability with specific dollar messaging as well as mention their high quality and the services covered. These findings also show that African American people were the most skeptical and will need targeted outreach, and Spanish-speaking people found the inclusion of the concept of “family” compelling.

Jennifer Haley, Principal Research Associate at the Urban Institute, then provided an overview of their recent consumer awareness report, Most Adults in Medicaid-Enrolled Families are Unaware of Medicaid Renewals Resuming in the Future. Researchers used Health Reform Monitoring Survey data from June 2022 to survey nearly 9,000 adults aged 18 to 64 enrolled in Medicaid or with a spouse, partner, or child enrolled. When asked about the upcoming return to regular Medicaid renewals, the Urban Institute found that 62 percent knew nothing, 15.7 percent new a little, 16.2 percent knew some, and five percent knew a lot. Researchers found that people primarily heard of the change through social media or media, followed by a state agency. This research highlights the importance of outreach and information campaigns, clear terminology in messaging, and the use of automated renewal processes.

October 2022

Speakers discussed information for consumers transitioning from Medicaid to Medicare, state strategies for engaging with local partners on unwinding, and partner outreach tactics.

Kim Glaun, Health Insurance Specialist at the CMS Medicare-Medicaid Coordination Office, reviewed information for beneficiaries who may be transitioning from Medicaid to Medicare, including issues impacting dually eligible individuals, the Medicare Special Enrollment Period (SEP), and requirements for renewals. Ms. Glaun noted that individuals who maintained Medicaid coverage due to the continuous enrollment requirement during the PHE may not have enrolled in Medicare during their initial enrollment period (the seven-month period starting three months before their Medicare eligibility). To address the potential loss of coverage for Medicaid beneficiaries, CMS is proposing a Medicare SEP for individuals who lose Medicaid coverage after normal operations resume or who did not sign up for Medicare on time. Additionally, Ms. Glaun highlighted actions states are required to take for Medicaid renewals, including attempting to renew beneficiaries on an ex parte basis and sending the beneficiary a contact form if the Agency is unable to renew without updated information.

Speakers from the Arizona Health Care Cost Containment System (AHCCCS), Arizona’s State Medicaid Agency, discussed Arizona unwinding stakeholder engagement strategies. AHCCCS is the largest insurer in Arizona and is taking a hybrid approach to process member renewals. Strategies AHCCCS uses include processing ineligible beneficiaries before non-responsive beneficiaries and aligning household renewal dates. Additionally, AHCCCS is relying on community partners, such as managed care organizations (MCOs), health plan associations, hospitals, committees and councils, and tribes to expand renewal outreach. AHCCCS is also sharing data with MCOs so they can directly connect with members to obtain updated beneficiary information and initiate renewals.

AHCCCS has developed tools in additional languages, PHE toolkits and FAQs, and one-page fliers to disseminate information through its partners. Direct member outreach efforts include text message campaigns, robocall campaigns, letter campaigns, and a call center. When 60-days’ notice of the end of the PHE is initiated, AHCCCS plans to further expand its communication efforts through a public awareness campaign on the availability of health insurance.

Marcus Johnson, Director of State Health Policy and Advocacy of Vitalyst Health Foundation, a public charity that serves Arizona and provides advocacy support, discussed equitable approaches to outreach. Mr. Johnson emphasized the need to reach geographic areas with the most beneficiaries at risk for coverage losses. Like AHCCCS, Vitalyst Health Foundation is collaborating with traditional and non-traditional stakeholders to expand outreach, including MCOs, marketplace issuers, county health departments, trade associations, Arizona Academy of Pediatrics, libraries, small businesses, food banks, daycare centers, and more. Communication strategies include direct-to-consumer messaging and media opportunities, such as op-eds in local papers, digital ads, and press conferences.

September 2022

Speakers discussed the potential impact the unwinding may have on the Latino community, strategies on how partners are working to educate beneficiaries about the unwinding, and CMS resources available in additional languages.

Dr. LaShawn McIver, Director of the Office of Minority Health at CMS, discussed health equity implications for the PHE unwinding, noting the CMS Framework for Health Equity as a guiding principle for unwinding preparations, given the expected disproportionate loss of coverage for people of color and children. Additionally, she discussed CMS and HHS guidance implemented to protect health-related benefits for non-citizens and immigrants.

Stan Dorn, Director of the Health Policy Project at UnidosUS, reviewed steps UnidosUS, a Latino civil rights and advocacy organization, is taking to protect Latino families when the PHE ends, as 4.6 million Latino Medicaid beneficiaries are expected to lose coverage. Many of the projected losses are people who will still be eligible for Medicaid but will lose coverage due to administrative reasons. UnidosUS’s key messages for families include reminding them to call Medicaid to update their information, filling out forms as soon as they are received, and noting that Medicaid will not hurt a family’s ability to legalize or stay in the US. Additional UnidosUS priorities include finding experts to support technical assistance, connecting with state advocacy coalitions, and developing an early warning system for when the PHE ends.

Erica Andrade, Chief Program Officer, and Justin Gust, Director of Community Health, highlighted how El Centro, a non-profit committed to the growing Hispanic populations of Wyandotte and Johnson Counties in Kansas, is preparing for the unwinding. Efforts include developing public service announcement messaging with the support of managed care organization UnitedHealthcare and partnering with local Latino media partners.

Stefanie Costello reviewed resources available in other languages, including the Unwinding Communications Toolkit and Graphics, the Spanish version of healthcare.gov, and Spanish materials on Marketplace.cms.gov and InsureKidsNow.gov. CMS also offers several Coverage to Care and Office of Minority Health resources in other languages.

Tricia Brooks, Research Professor at Georgetown University, then shared information on the University’s 50-State Unwinding Tracker, which provides information on whether states have publicly available resources on the PHE, including: 1) the state’s unwinding plan or a summary; 2) specific information about the unwinding; 3) an alert to update contact information; 4) communications materials for partners; 5) an unwinding FAQ; and 6) state plans to launch an unwinding data dashboard or publicly post key unwinding data.

The call closed with a brief question and answer session. Jessica Stephens noted that the renewal process must be completed every 12 months for most individuals, and beneficiaries will also have to go through a renewal during the unwinding period. However, beneficiaries will not need to reapply for Medicaid unless they lose eligibility and are subsequently disenrolled.

August 2022

During the August webinar, CMS staff reviewed the Health Insurance Marketplace and plans to navigate the unwinding.

Beth Lynk noted CMS’s report that includes resources and data on the impact of the eventual unwinding on the Medicaid and CHIP population, the impact of losing coverage, and the Inflation Reduction Act.

Megan Reilly, Senior Advisor for the Office of Communications at CMS, provided a high-level overview of the Health Insurance Marketplace. She reviewed guidance on determining Marketplace eligibility, State-based Marketplace (SBM) compared to Federally-facilitated Marketplace (FFM), how consumers use the Marketplace, premium tax credits, cost-sharing reductions, application and enrollment information, Marketplace plan requirements, essential health benefit categories, health plan categories, and premium payments.

Dr. Ellen Montz, Deputy Administrator and Director of the Center for Consumer Information and Insurance Oversight, outlined the FFM’s key processes and plans for the PHE unwinding to ensure coverage transitions are successful and efficient. Dr. Montz emphasized several times that consumers can sign up for Marketplace coverage as soon as they know their Medicaid coverage is ending and to not wait until they have lost coverage. She noted FFM’s work to reduce the amount of required documentation after application submission, streamline communication for account transfers and eligibility results, and make the consumer experience more efficient. In alignment with CMS’s stakeholder engagement strategy, the Agency has partnered with states, consumer advocates, health plans, navigators, agents and brokers, departments of insurance, and more to expand its reach. CMS is also establishing a consumer engagement strategy meant for individuals who are directed to the Marketplace but have not yet enrolled in coverage. CMS is working will all 18 SBMs, and each has coordinated with their state Medicaid/CHIP agencies, assessed current system and business processes for potential updates, and is engaging with stakeholders.

July 2022

July’s webinar focused on maintaining and initiating coverage for children, teens, and families who are eligible for Medicaid and/or CHIP. Panelists reviewed ways their organizations used the Connecting Kids to Coverage Campaign materials and the new Affordability Connectivity Program.

Jessica Beauchemin, Health Insurance Specialist at CMS, began the call with an overview of the Connecting Kids to Coverage National Campaign, which was established in 2009 to reach uninsured children and families. On July 19, HHS, through CMS, announced $49 million in awards to 36 organizations dedicated to connecting people with healthcare coverage. These awards are CMS’s largest investment in outreach and enrollment through the Connecting Kids to Coverage program. This year, the campaign is focused on helping families maintain healthcare coverage when the PHE concludes. Nearly seven million children could transition from Medicaid coverage or lose coverage, disproportionately impacting Black and Latinx children.

With the school year beginning, CMS focused on its Back-to-School Initiative, an annual campaign aimed to remind Medicaid or CHIP beneficiaries to ensure that their state Medicaid office has their correct address. The initiative has three main messages: (1) prepare for the end of the PHE now, (2) healthcare coverage helps children thrive at school and in life, and (3) remind parents that their children are eligible for Medicaid and CHIP. CMS developed several customizable materials for this initiative, including digital resources, infographics, social media posts, and text messages. These resources are available in over 20 languages on the insurekidsnow.gov webpage.

Emily Roller, Natalie Pennywell, and Rachel Lawrence, Virginia Department of Medical Assistance Services,provided examples of ways their organizations use the Connecting Kids to Coverage Campaign materials as the school year begins. The speakers reiterated the importance of using both digital and print materials to provide information on Medicaid and CHIP enrollment. The Virginia Health Care Foundation, for example, uses print materials at back-to-school nights and for renewal reminders, and digital materials on Facebook. Similarly, the Virginia Department of Medical Assistance Services uses a blend of tools as part of its own back-to-school campaign.

Hannah Garden-Monheit, Executive Office of the President at the White House, highlighted the White House’s Affordability Connectivity Program, which is a federal program that helps low-income families afford internet access. About 13 million households signed up by July 2022, and approximately 40 percent of U.S. households were eligible. Ms. Garden-Monheit highlighted the getinternet.gov webpage to connect people with this affordable access.

June 2022

In June, CMS reviewed its priorities in preparing for the continuous enrollment unwinding, and panelists shared various states’ engagement efforts.

Dan Tsai, Deputy Administrator and Director of the Center for Medicaid and CHIP Services, first discussed four areas of interest: proactively communicating to make sure agencies and beneficiaries are prepared, providing communications resources for states, considering the Medicaid marketplace, and local engagement. CMS has developed online resources to support these efforts, including the Unwinding Communications Toolkit, which provides states with communication tools for outreach to beneficiaries with CHIP or Medicaid, and a beneficiary-focused webpage where organizations and states can refer beneficiaries for renewals.

Jennifer Wagner, Director of Public and Government Affairs, and Farah Erzouki, Senior Policy Analyst at the Center on Budget on Policy Priorities (CBP), provided state-focused information. They emphasized strategies to maintain coverage for beneficiaries who are eligible for Medicaid but may be disenrolled for procedural reasons. Examples of state actions include Arkansas’s new call center to facilitate outreach and updating beneficiary contact information, New Mexico’s investment of $35 million to help beneficiaries transition to the marketplace, and Tennessee’s digital ad campaign that doubled renewals in three months.

Jacey Cooper, California’s State Medicaid Director, reviewed the state’s proactive work, underscoring that large coverage losses are not inevitable if states do their share. Notably, California launched the Department of Health Care Services (DHCS) Coverage Ambassadors campaign, which now has more than 1,000 ambassadors to deliver important messages to beneficiaries in the community (available in English andSpanish). California has also published its Medi-Cal COVID-19 Public Health Emergency Operational Unwinding Plan. The state split its PHE unwinding communications strategy into two phases. The first phase will include a multi-channel communications campaign to encourage beneficiaries to update their contact information. The second phase, which will be launched 60 days prior to the end of the PHE, will encourage beneficiaries to watch for their renewal packets in the mail.

Throughout the webinar, CMS reiterated its commitment to communication and engagement with state Medicaid agencies and other organizations serving Medicaid beneficiaries. CMS staff offered to connect organizations that serve Medicaid beneficiaries with their Medicaid state agencies and noted that organizations may request a CMS representative for speaking engagements at upcoming events. Additionally, the Department of Health and Human Services (HHS) and CMS are focusing on local engagement. Jesse Cross-Call, Deputy Director of External Affairs at HHS, shared the Agency’s regional administrators’ and HHS directors’ emails for each of 10 federal regions. These regional staff are looking for feedback throughout the process, including information beneficiaries need and do not have and potential additions to the toolkit. Jessica Stephens noted that while large enrollment numbers, agency staffing challenges, and communications barriers will challenge states, CMS will continue to develop resources and toolkits to support them.

May 2022

To kick off this series, CMS staff reviewed its work to prepare for the continuous enrollment unwinding.

Beth Lynk, Director of the Office of Communications at CMS, led the call and said that the unwinding will create a heavy burden on states as they address the large volume of pending renewals, likelihood of outdated mailing addresses and contact information, and workforce shortages. Jessica Stephens, CMS, noted that the Agency encourages states to develop unwinding plans; obtain updated contact information from beneficiaries; launch an outreach and communication plan; and engage with community partners, health plans, and the provider community.

Erin Pressley, Director of Creative Services at CMS, reviewed the Agency’s emphasis on communication strategies to ensure beneficiaries do not lose healthcare coverage. The goal is to guarantee that beneficiaries are aware of the steps they need to take to maintain enrollment or obtain an alternative form of coverage. CMS established a national outreach campaign that engages with partners and stakeholders to achieve this goal. Engaging with additional stakeholders may be useful for outreach, such as healthcare providers, local health departments, social services, managed care plan issuers, and community sources. Ms. Pressley noted the importance of keeping beneficiaries’ contact information up to date and reminding them to check for mail and complete renewal forms (if applicable). CMS hopes to maintain the record levels of enrollment in their healthcare programs through proactive communication with states and beneficiary outreach.

 

This Applied Policy® Summary was prepared by Emma Hammer and Marlowe Galbraith with support from the Applied Policy team of health policy experts. If you have any questions or need more information, please contact them at ehammer@appliedpolicy.com or mgalbraith@appliedpolicy.com or at 202-558-5272.

[1] https://www.whitehouse.gov/wp-content/uploads/2023/01/SAP-H.R.-382-H.J.-Res.-7.pdf