As life begins to resemble pre-pandemic normalcy, states are preparing for the end of federal pandemic-era supports, including certain health coverage options.
In particular, the Families First Coronavirus Response Act of 2020 provided an enhanced federal match rate of 6.2% to states in anticipation of increased Medicaid enrollment at the onset of the pandemic. To receive the enhanced rate, states maintained continuous Medicaid coverage for all who enrolled during the COVID-19 public health emergency, even if enrollees experienced a change in circumstance that would normally make them ineligible for the program.
The continuous coverage requirement was originally scheduled to last until the end of the public health emergency. That changed in December, when the Consolidated Appropriations Act of 2023 became law. The act decoupled the requirement from the end of the public health emergency. States must wait until April 1 before disenrolling individuals from Medicaid but could choose to start the so-called unwinding process as of Feb. 1. Once a state has started the unwinding process, it has a year to initiate redeterminations for all beneficiaries and 14 months to complete redeterminations.
An estimated 5.3 million to 14.2 million people may lose Medicaid coverage during the unwinding period if they are not connected to other sources of coverage, with numbers varying by state. One-third of adults who are set to lose Medicaid coverage could be eligible for subsidized insurance coverage through the Affordable Care Act marketplaces. States are looking to ensure continuous coverage by coordinating with state Medicaid agencies to find past enrollees no longer eligible for the program and help them with marketplace enrollment.
Eligibility and Enrollment
Streamlining eligibility and enrollment processes may assist with a more seamless transition between coverage types. The ACA included certain requirements intended to simplify eligibility determinations across Medicaid, CHIP and exchange coverage. These include: a common income standard; a single, streamlined application process; and standardized procedures for transferring eligibility data between programs. Along these lines, Idaho uses a single eligibility system, Idalink, for its state-based marketplace, Medicaid and CHIP programs. Florida electronically refers individuals who are not eligible for Medicaid to the federally facilitated marketplace.
For easy enrollment, California allows the state-based marketplace to automatically enroll consumers into the lowest-cost ACA silver plans when they lose Medicaid eligibility. Rhode Island is similarly developing automatic enrollment into marketplace coverage supported by a funding allocation in the 2023 state budget. The allocation also leverages ARPA funds to cover the first month’s premium for qualified health plans purchased on the exchange.
Communication and Outreach
Marketplace open enrollment typically occurs annually from early November to mid-December, though every marketplace offers a special enrollment period that allows consumers losing Medicaid (or other coverage) to enroll in the marketplace 60 days before or after coverage terminates. Additionally, the Centers for Medicare & Medicaid Services recently released information on a new temporary “exceptional circumstances” period for federal and state marketplaces from March 31, 2023 to July 31, 2024, for those losing coverage due to the unwinding of the continuous coverage requirement. To maintain coverage, individuals would then need to apply within these periods. Contacting these enrollees and outlining this process within time-limited special enrollment periods can be essential to avoiding coverage gaps.
Twenty-two states have created webpages to alert enrollees to upcoming changes and coverage options. The pages often provide contact information for state navigators or others to help enrollees transition to marketplace health plans, as well as answers to frequently asked questions about the process.
Arizona • Colorado • Georgia • Indiana • Iowa • Michigan • New Hampshire • New Jersey • New York • North Carolina • North Dakota • Oklahoma • Oregon • Pennsylvania • Rhode Island • South Carolina • Texas • Utah • Vermont • Virginia • Washington • Wisconsin
Like many states, Oklahoma is alerting affected enrollees by sending up to three notices to them across multiple communication channels.
Navigators and assistors can play an important role in helping individuals understand coverage options and enroll in plans. To bolster access to marketplace plans, CMS is investing nearly $100 million in navigator programs to help people find and enroll in marketplace plans, with a focus on outreach to underserved communities.
Massachusetts requested an increase to its navigator budget to allow more workers at call centers to reach out to those dropped from Medicaid and assist their transition to the marketplace. The Pennsylvania Department of Human Services created a “helper” position to work with neighbors and community members to help them renew and maintain health coverage.
To improve the affordability of marketplace plans, Congress passed the American Rescue Plan Act of 2021, which included temporary premium subsidies to reduce costs to consumers. In 2022, Congress extended the subsidies for three years through the passage of the Inflation Reduction Act.
In addition, several states have also provided subsidies to individuals purchasing marketplace plans. Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, Vermont and Washington offer premium subsidies, funded through an array of sources such as general revenue, employer contributions and tobacco taxes
States have the opportunity to coordinate across Medicaid and the marketplace to assist constituents in avoiding gaps in health coverage during the transition out of the pandemic.
Samantha Scotti is a project manager in NCSL’s Health Program.
This resource is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $813,543 with 100% funded by HRSA/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS or the U.S. government.