The “Unwinding” of the Medicaid Continuous Enrollment Condition: 3 Things to Know

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Beginning April 1, 2023, states may resume Medicaid redeterminations and terminations of coverage for those no longer eligible. As recognized by the Center on Budget and Policy Priorities, it is estimated that as many as 18 million individuals could lose Medicaid coverage because they no longer meet Medicaid eligibility requirements or fail to complete the redetermination process.¹

Although many individuals may qualify for other types of insurance coverage, patients with serious mental illness (SMI) and substance use disorders (SUDs) are expected to be particularly affected by this.

Thankfully, states have been anticipating the “unwinding” of the Medicaid continuous enrollment condition. The National Association of Medicaid Directors (NAMD) polled members, and 58% of Medicaid agencies plan to start their unwinding period in April 2023, 23% plan to begin in March 2023, and 16% plan to begin in February 2023.²

Here are 3 things to know:

• State Medicaid agencies are required to use the most reliable sources of Medicaid beneficiary contact information, make good-faith efforts to contact the beneficiary prior to disenrollment, comply with US Department of Health and Human Services (HHS) requirements and procedures related to redeterminations and dis-enrollments, and meet Centers for Medicare & Medicaid Services (CMS) reporting requirements.
  • What does this mean? Medicaid beneficiaries can act now to confirm whether they qualify for Medicaid at healthcare.gov.
  • For individuals who no longer qualify for Medicaid coverage, the Biden Administration published guidance on 2 ways to help them enroll in marketplace coverage.³
• For federally facilitated exchanges, CMS released additional guidance⁴ on January 27, 2023, for qualified individuals and their families who lose Medicaid or Children’s Health Insurance Program (CHIP) coverage to enroll in marketplace health insurance coverage outside of the annual open enrollment period. The guidance states:
  • Marketplace-eligible consumers who submit a new application or update an existing application between March 31, 2023, and July 31, 2024, and attest to a last date of Medicaid or CHIP coverage within the same time period, are eligible for an unwinding special enrollment period (SEP).
  • Consumers who are eligible for the unwinding SEP will have 60 days after they submit their application to select a marketplace plan with coverage that starts the first day of the month after they select a plan.

• What does this mean? This is a long SEP for consumers. Federally facilitated marketplaces operate in 30 states.⁵

• For state-based marketplaces, CMS recently released the Marketplace Notice of Benefit and Payment Parameters proposed rule.⁶ In that rule, CMS proposes that beginning January 1, 2024, marketplaces will have the option to implement a new special rule for consumers losing Medicaid or CHIP coverage that is also considered minimum essential coverage (MEC).
  • What does this mean?
    • This special rule would mean that consumers would have 60 days before, or 90 days after, their loss of Medicaid or CHIP coverage to select a plan for marketplace coverage via an SEP.
    • State-based exchanges will have that option, and states with state-based exchanges have discretion to make SEPs even longer than that.
    • State-based marketplaces can implement the federal unwinding SEP timeframe (previously outlined) per federal regulation at 45 CFR 155.420(d)(9).
    • Although the minimum timeframe a state-based exchange can allow consumers to select a plan is 60 days before losing coverage, states have discretion to make SEP longer than that.

To find out what type of marketplace exists in your state, go to healthinsurance.org.

Given that patients with SMI and SUDs are expected to be particularly affected by the “unwinding” of the Medicaid continuous enrollment condition, each state Medicaid agency should take an incremental approach to redetermining status that ensures every measure is taken to support these beneficiaries to retain coverage through Medicaid, the marketplace, or employer-sponsored insurance.

States would be put on a corrective action plan if they fail to meet the guardrail requirements, and the increased Federal Medical Assistance Percentages (FMAP) percentage could be further reduced as an enforcement mechanism.

Mr Santarsiero is the vice president of government affairs at Connections Health Solutions. A strategic leader of the growth and development team, he develops and executes federal and state policy outcomes that drive market access, innovative value-based care models, thought leadership, and new business opportunities. At Connections, Mr Santarsiero advocates for the value of its medically integrated care model that serves the highest acuity crisis patients presenting with suicidal behaviors, acute agitation, and substance intoxication. He has 24 years of experience in growth, market access, and profitability-driven government relations, contract procurement, and consulting.

References

1. Erzouki F. States must act to preserve Medicaid coverage as end of continuous coverage requirement nears. Center on Budget and Policy Priorities. February 6, 2023. Accessed February 7, 2023. https://www.cbpp.org/research/health/states-must-act-to-preserve-medicaid-coverage-as-end-of-continuous-coverage

2. Connecting people who care about Medicaid. National Association of Medicaid Directors. Email. January 31, 2023.

3. Statement by President Joe Biden marking the 57th anniversary of Medicare and Medicaid. The White House. News release. July 30, 2022. Accessed February 7, 2023. https://www.whitehouse.gov/briefing-room/statements-releases/2022/07/30/statement-by-president-joe-biden-marking-the-57th-anniversary-of-medicare-and-medicaid/

4. Temporary special enrollment period (SEP) for consumers losing Medicaid or the Children’s Health Insurance Program (CHIP) coverage due to unwinding of the Medicaid continuous enrollment condition—frequently asked questions (FAQ). Centers for Medicare & Medicaid Services. January 27, 2023. Accessed February 7, 2023. https://www.cms.gov/technical-assistance-resources/temp-sep-unwinding-faq.pdf

5. State health insurance marketplace types, 2023. Kaiser Family Foundation. 2023. Accessed February 7, 2023. https://www.kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

6. Patient protection and Affordable Care Act, HHS notice of benefit and payment parameters for 2024. Federal Register. December 21, 2022. Accessed February 7, 2023. https://www.federalregister.gov/documents/2022/12/21/2022-27206/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2024