States are taking differing approaches to Medicaid redeterminations, making it difficult to make apples-to-apples comparisons of disenrollment data or determine if the process is widening health inequities, experts say.
After years of continuous enrollment during the pandemic, states have begun the complex and unprecedented process of figuring out which beneficiaries are still eligible for coverage under the public insurance program for low-income Americans.
States could begin disenrolling beneficiaries from Medicaid beginning in April. Since then, nearly two million people have been removed across 29 states and Washington, D.C., according to KFF.
Overall, more than 15 million people are expected to be removed from Medicaid during redetermiantions. More than six million could end up fully uninsured, reversing coverage gains during the pandemic that particularly benefited low-income Americans.
Yet currently, disenrollment numbers vary widely by state, and it’s too early to get a clear picture of the process, especially for Medicaid programs that just began removing beneficiaries from their rolls this summer, experts say.
“It is one of those examples where every state is approaching the unwinding differently, every state is going to have very different outcomes,” said Brad Corallo, a senior policy analyst in KFF’s program on Medicaid and the uninsured.
Apples-to-oranges approaches
States are conducting redeterminations in myriad ways, adding to the complexity of figuring out how the unwinding is affecting the Medicaid population, experts say.
South Carolina, for example, is initially focusing on people it thinks may be ineligible or didn’t respond to renewal requests during the pandemic. Virginia is using its regular redetermination dates, while Oklahoma is sorting its members into high- or low-risk groups, with the goal of supporting more vulnerable people like those with chronic conditions.
“States really have quite a bit of flexibility to determine what process they're using for prioritizing the groups that are being redetermined. So that is helpful, because states are able to do that in a way that makes sense locally. But it also does make it hard to make apples-to-apples comparisons,” said Kate McEvoy, executive director of the National Association of Medicaid Directors.
Only 29 states have a mostly automated system for processing renewals. Just 18 are completing half or more of their renewals through the ex parte process, where states confirm eligibility using available data without action from enrollees, according to KFF. States without these tools could face additional administrative burden for staff and beneficiaries.
“ ... It's going to be difficult to compare across states and ultimately really difficult to draw overall, national conclusions.”
Brad Corallo
KFF senior policy analyst
In states that haven’t expanded Medicaid to adults with incomes up to 138% of the federal poverty level or extended postpartum coverage, it could be easier for disenrolled beneficiaries to fall through the cracks due to the coverage gap — where people make too little to qualify for marketplace subsidies, but too much to be eligible for Medicaid.
“People who became pregnant or young adults who aged off of Medicaid in particular will have a harder time getting coverage in a non-expansion state,” said Sara Collins, a vice president at the Commonwealth Fund. “So it's very likely that we'll see higher rates of people becoming uninsured in those states just because there's a bigger gap.”
Disenrolled in non-expansion states could fall into coverage gap
An additional concern for advocates are high administrative disenrollments, which suggests beneficiaries could be removed from coverage over paperwork issues even if they’re still eligible. KFF found 73% of all people disenrolled in states with available data were removed for procedural reasons, or because they didn’t complete the renewal process. In South Carolina, 93% of disenrollments were conducted for procedural reasons.
Other vulnerable groups may struggle with confirming their Medicaid eligibility, including people with limited English proficiency, older adults, people with disabilities and those who aren't comfortable using technology or don’t have access to reliable internet.
Vulnerable groups are most at risk for improper disenrollment, but it’s difficult to compare disenrollment disparities across states, KFF’s Corallo said.
Some states are breaking down disenrollment data by factors like age, race and ethnicity, but others are not, or are reporting the data in different formats.
“It's totally up to the states on how they want to break down those subgroups, or if they want to break them out at all,” Corallo said. “And so we'll have very limited information on the subgroup analysis ... So it's going to be difficult to compare across states and ultimately really difficult to draw overall, national conclusions.”
Additionally, states’ decisions on who to prioritize may affect early data. South Carolina’s disenrollment rate is currently at 72%, but the state is targeting people first that are likely to be ineligible, according to KFF. In addition, the state’s disenrollment rate would drop considerably if pending renewals were included.
There will be a clearer picture of the impact of redeterminations in late summer as more states begin disenrollments, according NAMD’s McEvoy.
In September, the federal government is expected to release the first detailed data about marketplace plan uptake, which will provide more insight into whether disenrolled people are making the jump to the Affordable Care Act exchanges.
Redetermination navigation
As states begin disenrollments, groups like insurance navigators are working to help beneficiaries renew their Medicaid coverage or find new plans.
Health insurance navigation agency Covering Wisconsin has been preparing for Medicaid redeterminations for years, according to Adam VanSpankeren, a navigator program manager at the Wisconsin nonprofit.
Covering Wisconsin has been filling gaps with extra training, as many navigators haven’t recently worked on the Medicaid renewal process. It’s also doubling down on outreach to ensure beneficiaries know what they need to do and when, VanSpankeren said.
“We worked really closely with the state and other partners in Wisconsin, attending regular task force meetings and planning and just continuing to identify different vulnerable populations and ways that the citizens of Wisconsin could be impacted,” he said.
In Kansas, an association of health centers and community clinics called The Community Care Network of Kansas have put together a slew of resources to help providers and patients navigate the unwinding.
Cover Kansas added their resources and outside toolkits to a dashboard for the Medicaid Renewal Helper Network, a group dedicated to sharing information about redeterminations, according to Kate Gramlich, a Cover Kansas project manager.
Nearly 200 people have signed up for calls and a newsletter from the group, Gramlich said.
Despite the significant investments into outreach, many beneficiaries still aren’t aware of Medicaid redeterminations, according to NAMD’s McEvoy.
“This is not a static process. Programs are really learning as they go with this and identifying where they need to pivot with specialized outreach,” McEvoy said. “If they are seeing losses of coverage, for instance among children, that's informing different tactics for communication and support for getting coverage restored.”
