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On March 18, 2020, Congress passed the Families First Coronavirus Response Act. The speedy response to the pandemic – at its time of passage, there were fewer than 7,500 reported cases of COVID-19 in the U.S. and New York City had not yet issued a shelter-in-place order—offered enhanced federal Medicaid funding to states that maintained Medicaid beneficiaries’ enrollment throughout the COVID-19 public health emergency.

As a result, the number of people who were covered by Medicaid grew substantially: from 71 million in February 2020 to 94 million in March 2023.

The Consolidated Appropriations Act of 2023 delinked the continuous enrollment policy from the public health emergency and allowed states to start redeterminations for more than 90 million people—a massive challenge for state Medicaid departments and Medicaid managed care plans around the country.

According to KFF, at least 23 million people have been disenrolled as of June 14, 2024; an estimated 7 in 10 of such disenrollments were for procedural reasons rather than eligibility – an alarmingly high rate.

ACAP health plans took innovative approaches to communicate with enrollees, assure the continuity of care, and minimize coverage losses.

Following are a few such notable initiatives.

 

Partnering with Other Health Plans to Collect Updated Contact Information

Since redeterminations were last conducted in early 2020, enrollees may have moved and changed addresses or phone numbers, making outreach difficult. Even before the COVID-19 pandemic, reaching enrollees and confirming eligibility was a challenge.

In late 2022—before redeterminations began—Neighborhood Health Plan of Rhode Island (Neighborhood) partnered with the two other health plans in the state to create a rack card with QR codes for each plan. Distributed to hospitals, providers, and other community partners, the card allows enrollees to scan the code for their health plan to update contact information.

Working with Local Authorities

CalOptima Health, the sole Medicaid MCO in Orange County, Calif., joined the county’s Social Services Agency on an innovative “City Tour.” This was a dedicated effort to educate city councils across the county about the unwinding process and share statistics about how many of their residents rely on Medicaid; efforts also included messages from local leaders, such as state Rep. Cottie Petrie-Norris (below). CalOptima Health also created and shared a toolkit of resources for cities to reach residents.

Gold Coast Health Plan (GCHP), which serves Medi-Cal beneficiaries in Ventura County, California, blanketed its community with information about redeterminations via digital, TV, radio, and print ads, billboards and transit shelters. The plan also participated in community events such as back-to-school nights and food distributions.

GCHP built on these efforts to include canvassing communities with door hangers and planning an educational health fair for the holiday season where they will educate members about the importance of completing their renewal form, as well as address other barriers members may be experiencing.

GCHP also provided embedded support onsite at provider offices. Community Relations Specialists held regular office hours in provider offices to answer member questions, check their redetermination status, and raise awareness of the need to submit renewal information.

iCircle, a managed long-term care plan in New York, was able to retain an extremely high proportion of their members during the unwinding process through a proactive approach and close coordination with Local District Social Services (LDSS). iCircle took advantage of the ability to report address updates to New York State and partnered with providers to assist members with renewals. They dedicated a team to initial outreach to members and follow-ups at the end of their renewal month. They also performed daily outreach to the LDSS to confirm members’ submission of forms.

If a member proved hard to reach, iCircle attempted home visits to assist with renewal forms.

 

Community Grants

Leveraging trusted community organizations to share information and raise awareness about unwinding can help reach beneficiaries.

CareOregon has been providing grants to community partners to help fund outreach efforts as part of their Medicaid redetermination efforts. They have been prioritizing grants to organizations who focus on non-English speakers and who are networked partners with the plan. They aim to make at least $2 million in grants by the end of 2023 and have had positive feedback from partners.

AlohaCare developed the Community Health Advisory Partnership (CHAP) to leverage existing community relationships for a multi-channel unwinding outreach campaign. AlohaCare has since enlisted and received funding for the CHAP from three of the other four MCOs in Hawaii. They have funded community health centers and community-based organizations that are led by and serve Pacific Islanders, COFA migrants, recent immigrants and LEP communities, unhoused individuals, and young and single mothers. These include 6 of Hawai’i’s largest community health centers and several community-based organizations who serve and represent communities with limited English proficiency and others who might be disproportionately impacted by redetermination.

Among the CHAP’s outreach efforts was a series of videos tailored to people for whom English is a second language; the above image is from a PSA recorded in Kosraean, a language spoken on Kosrae, part of the Federated States of Micronesia.

 

Continuity of Care

Experiencing gaps in coverage and care is detrimental for enrollees with significant health care needs; even transitioning plans and navigating a new provider network can be hard.

Neighborhood offers a Qualified Health Plan (QHP) on the Marketplace, positioning them to make smooth transitions of coverage and care. If a Medicaid member transitions to their QHP and finds a prescription of theirs isn’t on the QHP drug formulary, Neighborhood has been covering it for a period of time through non-formulary approval, if the member is stable on the drug. This gives them time to work with the provider or transition the member to a covered drug.

Neighborhood, concerned about continuity of care for their high-needs members, created focus groups within the plan and used pharmacy claims data to identify members who have a high volume of prescriptions or who utilize high-cost drugs – with the goal of targeting those members with direct outreach. Care managers have been making up to 500 calls per month to the identified high-needs enrollees, and home care managers have gone door to door for those who can’t be reached by phone.

Nascentia Health, an MLTSS plan in New York, was informed by the state that 20 percent of high-needs members did not complete their renewals in June. Nascentia was able to work with the State by June 30 to prevent disenrollments. Because of Nascentia’s collaboration with the State, eligible members remained enrolled and did not experience gaps in essential care.

 

 

StayCovered.org: Supporting Plan Efforts with a Targeted Digital Campaign

To help smooth unwinding and connect people at risk of being disenrolled from Medicaid with their state agencies, ACAP launched a digital campaign aimed at driving traffic to StayCovered.org, a Web site targeting parents and guardians who make health care decisions for minors likely eligible for Medicaid.

The campaign’s objective was to increase awareness of Medicaid unwinding and connect people to available resources. The campaign was targeted to states where children are at the highest risk of losing coverage. It employed a multi-faceted approach:

• Digital Advertising: Google, Facebook, Instagram, and TikTok advertisements target parents and household healthcare decision-makers.
• Out-of-Home Advertising in English and Spanish on billboards and posters at bus stops, convenience stores, and other public locations featured a QR code to quickly direct people to StayCovered.org.
• A customizable toolkit for ACAP-member plans provided additional messaging support in the form of flyers, social media content, sample articles and more.

The campaign significantly outperformed industry engagement rates: more than 18 million impressions across the digital and environmental platforms led to 133,000 people and families visiting CMS resources to better prepare for redetermination.

 

Conclusion

The unwinding of the COVID pandemic came with a clear challenge – to determine accurately and expeditiously the eligibility status of more than 94 million people who had relied on Medicaid for coverage.

The suspension of redeterminations was an important and necessary feature of the pandemic response – but in the three years between redeterminations, millions of Medicaid enrollees would inevitably change their address. Hundreds, if not thousands, of workers in state Medicaid departments would change jobs, and their experience processing redeterminations would walk out the door with them.

Restarting redeterminations was a process bound to be fraught with risk for inadvertent disenrollment of the eligible. It was incumbent on all stakeholders to make every possible effort to minimize the number of people who would be churned off of Medicaid while remaining eligible.

It involved significant cooperation with providers, state agencies, and other health plans – including, often, plans with which ACAP-member Safety Net Health Plans compete. The end goal, helping people with Medicaid stay covered, was too critical to do otherwise.

As mentioned previously, of the 23 million who have been disenrolled from Medicaid, nearly 7 in 10 were disenrolled for procedural reasons. Put another way, 15.8 million people were disenrolled from Medicaid without a meaningful examination of their eligibility. For many, this is the system working as intended: it doesn’t make sense for someone who re-entered the workforce and regained access to employer-sponsored insurance to go through redetermination. But there are untold numbers who lost coverage despite remaining eligible.

The good news for them is that Medicaid remains open for them when they need it. StayCovered.org now redirects people to re-enroll with their state Medicaid agency; as redetermination winds down, the work of reconnection to coverage continues.