Government Abstract
At first of the pandemic, Congress enacted the Households First Coronavirus Response Act (FFCRA), which included a requirement that Medicaid packages preserve folks repeatedly enrolled by the tip of the COVID-19 public well being emergency (PHE) in change for enhanced federal funding. Primarily because of the steady enrollment provision, Medicaid enrollment has grown considerably in comparison with earlier than the pandemic. When the continual enrollment provision ends, tens of millions of individuals may lose protection if they’re not eligible or face administrative obstacles throughout redeterminations regardless of remaining eligible. The Consolidated Appropriations Act, 2023 de-links the Medicaid steady enrollment provision from the PHE permitting states to renew disenrollments beginning April 1, 2023. States can work with Medicaid managed care organizations (MCOs), which ship care to greater than two-thirds of all Medicaid beneficiaries nationally, to conduct outreach to enrollees to organize them for the tip of the continual enrollment interval. CMS has issued particular steering permitting states to allow MCOs to replace enrollee contact data and conduct outreach concerning the eligibility renewal course of to facilitate continued enrollment in addition to Market transitions, the place acceptable.
To higher perceive the function Medicaid MCOs could play in unwinding the continual enrollment provision, KFF, in collaboration with the Affiliation for Group Affiliated Plans (ACAP), fielded a brief survey of Medicaid MCOs (additionally known as managed care plans all through) in October-November 2022. ACAP member plans are not-for-profit security web well being plans that serve greater than 20 million Medicaid enrollees, or about one in 5 Medicaid enrollees. The survey was fielded amongst all ACAP well being plans that take part within the Medicaid market. A complete of 29 plans (of 65), accounting for over 13.2 million Medicaid beneficiaries enrolled in Medicaid MCOs as of September 2022, throughout 15 states (of 26) responded to the survey. To achieve further insights, a roundtable dialogue was held in mid-November 2022 with representatives from 10 plans. Whereas ACAP member plans could differ in essential methods from for-profit plans (which enroll greater than 50% of all Medicaid beneficiaries nationally), all plans are going to need to preserve enrollment and income to the extent potential, and outcomes present essential insights into implications and challenges of unwinding. For extra particulars, see the Strategies part on the finish of this temporary. Key findings embody the next:
Updating beneficiary contact data. Solely about one-third of responding plans reported having verified/present contact data for between 76% to 100% of their Medicaid members. Most responding plans reported they’re taking motion to achieve out to members straight to help with updating contact data and lots of are working with third events (e.g., suppliers, community-based organizations (CBOs), subcontractors/distributors and so forth.). Practically all responding plans stated that reaching Medicaid beneficiaries is a problem. Plans additionally described challenges concerned with transferring up to date contact data information to the state.
Renewal Outreach. Practically all responding plans reported the state the place they function is planning to supply month-to-month recordsdata containing data on members for whom the state is initiating the renewal course of, and greater than half reported that they count on to obtain month-to-month recordsdata with data on members that haven’t submitted renewal data and are vulnerable to dropping protection. Just one in 5 responding plans reported hiring (or planning to rent) further employees to assist with renewal efforts. About half of responding plans indicated their renewal outreach technique consists of focused outreach for particular populations (e.g., pregnant, or postpartum people, people with power circumstances, people with psychological sickness or substance use dysfunction (SUD)).
Protection Transitions. Greater than half of responding plans reported that their state Medicaid company is planning to supply periodic termination recordsdata so plans can conduct outreach to people terminated for procedural causes. Nonetheless, a number of plans indicated termination recordsdata obtained from the state don’t embody the rationale a beneficiary could also be dropping protection. Plans careworn that with out this data their potential to conduct focused outreach is constrained. Practically all responding plans that additionally supply a Certified Well being Plan (QHP) within the Inexpensive Care Act (ACA) market reported that the state will allow the plan to share details about their QHP with enrollees discovered ineligible for Medicaid. The expectation is that many individuals not eligible for Medicaid as a result of their incomes have risen will probably be eligible for premium help beneath the ACA.
Unwinding implications. Three-quarters of responding plans reported anticipating between 10% to 25% of their enrollees to lose Medicaid protection over the unwinding interval. Responding plans most ceaselessly reported decline in Medicaid enrollment, loss in income, churn, and disruptions in member care as vital challenges they count on associated to unwinding. Most responding plans count on the chance profile (or acuity) of members to extend, as plans anticipate “stayers” will probably be sicker than “leavers” and count on medical loss ratios (MLRs) – the share of premiums going to pay for care – to extend.
With a date sure for the tip of the continual enrollment provision, states are finalizing unwinding operational plans and prioritization approaches in addition to readying techniques. Plans highlighted methods that would assist handle unwinding challenges together with strengthening communication throughout state and county businesses, suppliers, community-based organizations (CBOs), and medical insurance Marketplaces; offering detailed, well timed information transfers to allow plans to conduct focused outreach; growing computerized (“ex parte”) renewals; maximizing lead time for plans to conduct outreach to members earlier than terminating protection; state consideration of adopting steady eligibility insurance policies, and enhancing alignment of eligibility necessities and processes throughout packages/eligibility pathways.
Findings
Updating Beneficiary Contact Data
To assist guarantee eligible enrollees retain protection, states could direct MCOs to hunt up to date contact data from enrollees. If plans contract with a 3rd get together to gather this data, they need to affirm the accuracy of updates with enrollees straight. MCOs could share this data with the state or help people in offering their up to date contact data to the state. States could settle for up to date enrollee contact data from MCOs together with mailing addresses, phone numbers, and electronic mail addresses offered the state complies with sure beneficiary discover necessities (to substantiate the accuracy of up to date contact data) or the state receives a waiver of such necessities from CMS.
Solely about one-third of responding plans reported having verified/present contact data for between 76% to 100% of their Medicaid members (Determine 1). As background, plans had been requested to determine the share of Medicaid members for which they presently have verified contact data. This data is important to making sure members obtain renewal notices and different communication from the state and the plan. Plans had been additionally requested how usually member mailing handle, telephone quantity, and electronic mail data obtained from the state is correct. Lower than half of responding plans (38%) reported member data obtained from the state Medicaid company is correct “more often than not” (Determine 1). Through the roundtable, a number of plans mentioned the necessity to preserve “shadow recordsdata” to retain up-to-date member contact data, as periodic information feeds from the state could override their member information. Plan employees additionally reported variable success in transferring up to date information to the state (mentioned in additional element under).
Most plans reported they’re taking motion to achieve out to members straight to help with updating contact data. Plans reported conducting direct member outreach through textual content, electronic mail, telephone, robocall, interactive voice response (IVR), and letter/postcard. A number of plans famous they confirm contact data on each inbound and outbound name. Along with conducting direct member outreach, plans additionally reported mass messaging through social media, web site, member e-newsletter, television/radio segments, and different advertising/commercials. Plans could help Medicaid members with updating their contact data with the state (or county) Medicaid company or could receive up to date contact data to share with the state straight. Typically, plans reported dwell calls and textual content messaging have been the best strategies to acquire and replace contact data.
Practically all responding plans reported reaching Medicaid beneficiaries poses a problem to updating member contact data (Determine 2). Specifically, restrictions on textual content messaging imposed by the Phone Client Safety Act (TCPA) or state guidelines had been cited as a problem by about half of responding plans. TCPA prohibits sending automated textual content messages with out acquiring the recipient’s prior consent. Whereas prior Federal Communications Fee (FCC) rulings confirmed federal and state governments are usually not topic to TCPA restrictions, CMS had been working to make clear with the FCC whether or not contractors of state businesses (together with MCOs) are topic to the TCPA. On January 23, 2023, the FCC offered steering to federal and state businesses, in addition to their companions (together with managed care entities), enabling them to make autodialed (and prerecorded) textual content and voice calls to lift consciousness about Medicaid eligibility and enrollment necessities with out violating the TCPA. Different challenges recognized by plans embody issue acquiring documentation from beneficiaries to help with updating data; lack of communication between state Medicaid company and Medicaid beneficiaries in the course of the PHE resulting in extra outdated member data; and issue acquiring member approval/affirmation for updates obtained from third events.
The vast majority of plans reported working with third events to assist receive up to date member contact data and to assist outreach and communication efforts. Plans stated they’re partnering with totally different entities together with suppliers, community-based organizations (CBOs), different state and native businesses (e.g., social companies, public well being, colleges), and subcontractors and distributors (e.g., transportation distributors, pharmacy profit managers (PBMs), contractors engaged particularly to do outreach/assist members in the course of the unwinding course of) to make sure member contact data is up-to-date. A number of plans described efforts to implement “feeds” for up to date addresses or to flag cases of mismatched information with pharmacy or transportation distributors. One plan reported all competitor well being plans out there got here collectively and developed a rack card which incorporates contact data/branding for every well being plan, temporary messaging round making certain Medicaid member addresses are up-to-date, and a QR code enabling members to simply replace their handle. Their objective is to ship these playing cards to hospitals, suppliers, behavioral well being businesses, social service neighborhood businesses, colleges, and pharmacies throughout the state. Plans additionally reported a wide range of efforts to teach and have interaction suppliers and CBOs concerning the upcoming finish of the continual enrollment interval (e.g., creating supplier toolkits and coaching) and to assist supplier and CBO outreach and communication efforts (e.g., internet hosting renewal/recertification occasions with suppliers and CBOs and different co-branded methods).
Practically three in 4 responding plans reported offering up to date member contact data information to the state or county Medicaid company on a weekly, bi-weekly, or month-to-month foundation, though plans additionally recognized challenges that undermine efforts to share this data. In numerous states, counties administer the Medicaid program; notably, plans working in California reported information is exchanged with county businesses as a substitute of straight with the state Medicaid company. Plans described a wide range of challenges concerned with transferring up to date information together with constructing techniques/processes to permit for information change; lack of affirmation from the state company that up to date contact data was obtained and motion was taken; lag in time for state techniques to replace member data; and subsequent state information runs that don’t mirror up to date information equipped by plan. Plans from a number of states reported the state is presently unable to obtain up to date contact data from the plan.
Renewal Outreach
Practically three-quarters of responding plans reported conducting outreach about Medicaid renewals previous to the COVID-19 pandemic. As background, plans had been requested whether or not they communicated with enrollees about renewals previous to the pandemic. Pre-pandemic outreach reported by plans ranged from sending member reminders (mailings, telephone calls and so forth.) to extra energetic renewal software help in addition to engagement with neighborhood companions.
Practically all responding plans stated their state is planning to supply month-to-month recordsdata containing data on members for whom the state is initiating the renewal course of. Moreover, greater than half of responding plans reported they count on the state Medicaid company to supply month-to-month recordsdata with data on members which have but to submit renewal kinds or further documentation and are vulnerable to dropping protection. CMS steering emphasizes federal Medicaid managed care advertising guidelines (42 CFR 438.104) don’t prohibit plans from offering data and conducting common outreach concerning the eligibility renewal course of on behalf of states. To allow plans to conduct focused outreach and supply help with the renewal course of, CMS has inspired states to share data with plans together with beneficiaries due for renewal and people vulnerable to dropping protection who’ve but to submit renewal kinds or different documentation.
Just one in 5 responding plans reported hiring (or planning to rent) further employees to assist with renewal efforts. Even with out new employees, plans reported planning a number of outreach efforts. Practically three-quarters of responding plans stated they’ll disseminate outreach supplies developed by the state Medicaid company about the necessity to renew protection and also will develop different outreach supplies to speak with Medicaid members. All responding plans reported outreach supplies will probably be obtainable in a number of languages, mostly Spanish. About three-quarters of responding plans reported utilizing social media to conduct outreach. Some plans indicated they are going to be creating textual content messaging campaigns round renewals and others famous they’ll name members whose renewals are due. Plans additionally stated they had been creating supplier toolkits particularly targeted on renewals that, in some circumstances, embody movies suppliers can present of their ready rooms.
About half of responding plans reported their renewal outreach technique consists of focused outreach for particular populations (Determine 3), most ceaselessly for people with power circumstances, pregnant people, postpartum people, and people with psychological sickness or substance use dysfunction. Plans indicated these focused outreach methods would come with further communication; custom-made messaging; name heart and supplier portal alerts for choose members; leveraging care managers, transition groups, and life coaches; and partnering with CBOs to supply in-home software help for members with disabilities and homebound members.
Protection Transitions
Greater than half of responding plans reported that the state Medicaid company is planning to supply periodic termination recordsdata; nevertheless, outreach could also be troublesome if recordsdata don’t embody the rationale for termination. Most plans reported anticipating to obtain termination recordsdata month-to-month. Medicaid managed care advertising guidelines at 42 CFR 438.104 don’t prohibit common outreach from Medicaid managed care plans for eligibility functions; a plan’s potential to conduct this exercise relies on the plan’s contract with the state company. CMS additionally clarified in current steering that federal advertising guidelines don’t differentiate between protection termination causes and states could use plans to conduct common eligibility outreach (on behalf of the state) for any potential protection termination purpose. Nonetheless, a number of plans indicated termination recordsdata usually don’t embody the rationale a beneficiary could also be dropping protection. Plans careworn that with out this data, their potential to conduct focused outreach is constrained.
Practically all responding plans that additionally supply a QHP reported that the state will allow the plan to share details about their QHP with enrollees discovered ineligible for Medicaid. CMS steering outlines states could encourage MCOs that additionally supply a QHP within the ACA Market to share data with their very own enrollees who’ve been decided ineligible for Medicaid to help within the switch of people to Market protection (which has greater revenue eligibility thresholds than Medicaid). To keep away from gaps in protection, managed care plans could attain out to people earlier than they lose protection to permit them to use for Market protection prematurely. Despite the fact that CMS signifies this exercise is allowable beneath federal guidelines, plans should adjust to state-specific legal guidelines and/or contract necessities that will prohibit this exercise. Through the roundtable, a number of plans highlighted the importance of with the ability to direct ineligible members to affiliated Market plans which was not commonplace protocol beforehand. Plans will outreach in a wide range of methods (e.g., disseminating written supplies) and affiliated QHP plans are additionally planning on doing direct outreach as properly.
Implications and Challenges
Three-quarters of responding plans reported they count on between 10% to 25% of their enrollees to lose Medicaid protection over the unwinding interval (Determine 4). Whereas the variety of Medicaid enrollees who could also be disenrolled in the course of the unwinding interval is very unsure, it’s estimated that tens of millions will lose protection. The share of people disenrolled throughout states will differ attributable to variations in how states prioritize and course of renewals. One-quarter of responding plans reported they count on that amongst enrollees who lose protection, 26% or extra will lose protection for procedural causes (i.e., associated to lacking or incomplete data) versus being decided ineligible (Determine 4). Solely a small share of responding plans take part as a QHP within the medical insurance Market (9 plans), however these plans reported they count on to solely enroll a small share of people into their QHP providing following Medicaid disenrollment throughout unwinding (information not proven).
Responding plans most ceaselessly reported decline in Medicaid enrollment and associated income loss, enrollee churn, and disruptions in member care as vital challenges they’re anticipating associated to unwinding (Determine 5). Previous to the pandemic, managed care plans lengthy cited lack of steady eligibility, or churn, as a key problem in making certain entry to care and care continuity for members. Through the roundtable, plans expressed concern about members with power circumstances and the numerous influence of interrupted protection on entry to wanted companies (e.g., lack of entry to HIV, behavioral well being, hypertension, or diabetes care). On the survey, plans had been additionally requested to debate the anticipated results of the tip of the continual enrollment provision on service utilization, enrollee composition, and plan medical loss ratio (MLR). Most responding plans count on the chance profile (or acuity) of members to extend, as plans anticipate “stayers” will probably be sicker than “leavers.” Plans additionally count on MLRs to extend (the MLR displays the proportion of complete capitation funds obtained by an MCO spent on scientific companies and high quality enchancment, with the rest going to administrative prices and earnings).
Trying Forward
Through the unwinding, tens of millions of individuals may lose protection if they’re not eligible or face administrative obstacles to renewing protection regardless of remaining eligible. The numerous quantity of labor that states face will place a heavy burden on eligibility and enrollment employees and will contribute to disenrollments attributable to procedural causes. Medicaid managed care plans could also be properly positioned to help states in conducting outreach and offering assist to enrollees who might want to navigate the renewal course of. With a date sure for the tip of the continual enrollment provision, states are finalizing unwinding operational plans and prioritization approaches in addition to readying techniques. Plans highlighted methods that would assist handle unwinding challenges together with strengthening communication throughout state and county businesses, suppliers, CBOs, and medical insurance Marketplaces; offering detailed, well timed information transfers to allow plans to conduct focused outreach; growing computerized (“ex parte”) renewals; maximizing lead time for plans to conduct outreach to members earlier than terminating protection; and state consideration of adopting steady eligibility insurance policies, and enhancing alignment of eligibility necessities and processes throughout packages packages/eligibility pathways.
Strategies
To higher perceive the function of Medicaid MCOs in unwinding, KFF fielded a brief Medicaid managed care plan survey in October 2022 in collaboration with the Affiliation for Group Affiliated Plans (ACAP). ACAP member plans are not-for-profit security web well being plans which serve greater than 20 million Medicaid enrollees, or about one in 5 Medicaid enrollees. Whereas ACAP member plans could differ in essential methods from for-profit plans (which enroll greater than 50% of all Medicaid beneficiaries nationally), outcomes present essential insights into implications and challenges of unwinding. The survey was fielded amongst all ACAP well being plans that take part within the Medicaid market as of October 2022 (65 plans throughout 26 states). A complete of 29 plans accounting for over 13.2 million Medicaid beneficiaries enrolled in complete MCOs as of September 2022 throughout 15 states (AZ, CA, IL, IN, MA, MD, MN, NY, OH, OR, PA, RI, TX, WA, and WI) responded to the survey. Responding plan enrollment ranged from roughly 3,600 to 2.5 million with median enrollment of roughly 310,000. 9 plans that participated within the survey reported their well being plan additionally participates as a professional well being plan (QHP) within the medical insurance Market. Workers from 10 plans throughout 9 states (AZ, CA, IL, MN, NY, OH, PA, TX, and WA) participated in a roundtable dialogue held on November 16, 2022.
