During the COVID-19 public health emergency (PHE), Congress enacted a continuous coverage requirement in Medicaid, prohibiting disenrollment for most enrollees during the pandemic. Starting in April 2023, states began reassessing eligibility of all Medicaid enrollees, including 42 million children. Lessons learned from the “unwinding” of continuous Medicaid coverage during the PHE could help inform policies and strategies to support continuous program enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) among eligible children.

WHY THIS MATTERS

Historically, children have been among the groups with the highest rates of “churn,” defined as losing coverage at the time of renewal despite still being eligible and subsequently reenrolling. Declines in children’s Medicaid/CHIP enrollment during unwinding offset much of the enrollment gains they experienced during the PHE continuous coverage period. Most of these children lost coverage for procedural or administrative reasons, meaning Medicaid agencies could not verify their eligibility, but many still likely qualify for public coverage. Given the wide variation in child enrollment declines across states, understanding what policies and strategies may have contributed to lower enrollment declines for children during unwinding in some states is critical to protecting children’s coverage.

What we found

We interviewed 70 stakeholders in eight states that experienced low net enrollment declines for children and/or adopted innovative practices during unwinding. State officials and key stakeholders identified the following approaches as key to minimizing unnecessary coverage losses among children:

• a high-level commitment from state Medicaid officials with a focus on planning and managing the unwinding process to minimize unnecessary coverage losses
• effective eligibility and enrollment systems and processes that maximize automated renewals, including building on prior investments in systems’ improvements and compliance with federal rules
• vigorous, multimodal, and multitouch communications with enrollees that rely on several data sources and strategies to obtain updated enrollee contact information
• strategic and wide-ranging partnerships to inform state communications and outreach to enrollees and support direct assistance to enrollees from community-level grassroots organizations

We identified several priority actions for federal and state policymakers to consider to improve Medicaid redeterminations for children postunwinding:

• Federal policies and practices:
  • develop more detailed guidance on existing (and new) rules and strengthen federal oversight and enforcement strategies
  • implement new policies and tools and increase technical support to states to enhance eligibility and enrollment systems
  • permanently extend certain 1902(e)(14)(A) waivers, especially those related to renewals for families with low or no incomes or Supplemental Nutrition Assistance Program (SNAP) eligibility
• State policies and practices:
  • implement available strategies that support children’s coverage, such as Express Lane Eligibility
  • improve data systems, increase ex parte rates, align Medicaid and separate CHIP enrollment processes, streamline transitions to Marketplaces, and develop data sharing with other programs, like SNAP
  • maintain policies adopted through 1902(e)(14)(A) waivers and implement additional related strategies as allowed by the Centers for Medicare & Medicaid Services
  • conduct targeted outreach campaigns, continue to refine notices that go directly to enrollees, and use multiple communication modes to convey important information
  • support ongoing partnerships with community partners, including enrollment assisters, and build on the momentum of the unwinding to connect eligible children to coverage

HOW WE DID IT

Between September 2023 and June 2024, we interviewed 30 representatives of Medicaid agencies and 40 other stakeholders in eight states (Alabama, Connecticut, Illinois, Maryland, North Carolina, Ohio, Tennessee, and Washington) who were identified as potentially having lessons to share about protecting children’s coverage during unwinding based on information available in early 2024.