What We’re Tracking in 2024: A Focus on Three Key Enrollment Policy Issues 

April 11, 2024 |  By Mary Hunt Moore and Sarabeth Zemel

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At Transform Health, we track many different health policy issues at both the state and federal levels for our clients and to stay abreast of current developments. A few weeks ago, we reported on policies we’re tracking in California, and in this blog, we turn our attention to some of the most pressing enrollment policies at the national level that we’re monitoring in 2024. 

Medicaid Unwinding 

It’s now been more than a year since Medicaid’s continuous coverage requirement ended with the passing of the Consolidated Appropriations Act of 2023.  This bill decoupled the requirement from the end of the COVID-19 Public Health Emergency and required states to re-start Medicaid and CHIP redeterminations. This meant that state agencies had to redetermine eligibility for everyone enrolled in Medicaid and CHIP after almost three years of continuous enrollment, leading to the first Medicaid coverage losses since the beginning of the COVID-19 pandemic. Recent data from KFF shows the significant impacts of the Unwinding on Medicaid programs and enrollees: 

  • Medicaid Disenrollments: Approximately 19.2 million individuals have lost their Medicaid coverage across all 50 states and the District of Columbia. Of those who completed the renewal process, 31% were disenrolled, while 69% (or approximately 40.6 million enrollees) had their coverage renewed. Dropout rates vary widely across states, from a high of 57% in Utah to a low of 12% in Maine. 
  • Procedural Disenrollments: Digging deeper, 70% of disenrollments were for procedural reasons. These coverage terminations were not about eligibility but were due to hiccups in the renewal process such as missing paperwork or outdated contact information.  
  • Impact on Children: Children under age 18 have been disproportionately affected, making up 37% (or over 3 million) of those who have been dropped in the 21 states that provided age-specific data.  
  • Medicaid Renewals: About 58% of those who kept their coverage did so through an ex parte renewal process, where eligibility was verified with available data sources without needing input from the enrollee. The Centers for Medicare and Medicaid Services (CMS) has worked with states in earnest since last fall to successfully increase the ex parte rates. California ex parte renewal rates increased from 34% to 66% and contributed to increasing numbers of enrollees keeping their Medi-Cal coverage. 

Some people disenrolled from Medicaid during this time have begun working again and now receive health coverage through their employers, but others are finding alternative coverage through the Marketplaces. 

Coverage through the Marketplaces 

The Health Insurance Marketplaces have seen an uptick in enrollments. A record-high 21.3 million signed up during the last Open Enrollment period, indicating some individuals transitioning out of Medicaid may be finding coverage through the Marketplaces. This trend also underscores the importance of the enhanced subsidies, which are set to expire in 2025, in supporting the continuity of coverage for individuals transitioning from Medicaid. The fate of the subsidies is critical, as their continuation could impact the ability of many marketplace enrollees to maintain affordable coverage.  

Another important development in the link between Medicaid Unwinding and Marketplace coverage: CMS just extended a temporary Special Enrollment Period through November 2024 for consumers losing enrollment in Medicaid/CHIP and seeking coverage through the Marketplaces. 

Building on Lessons from Unwinding  

The increase in ex parte renewals (also known as passive or auto-renewals) in Medicaid Unwinding has shown that simplifying renewals, especially for a population whose income does not fluctuate much over time, can have a dramatic effect on keeping individuals enrolled in coverage. In 2022, CMS released a proposed rule to make it easier for those eligible for Medicaid, CHIP, and the Basic Health Program to obtain and maintain their coverage in these programs. The agency recently finalized the rule, so that even once the Unwinding is over, Medicaid agencies will continue the drumbeat on enrollment and renewals by implementing some key measures, including:  

  • Establishing a clear process for preventing terminations when people are transitioned between Medicaid and CHIP when income changes. States will also need to check data sources prior to terminating eligibility when enrollees cannot be reached due to returned mail. 
  • Removing policies that create barriers to children’s coverage in CHIP, such as waiting periods or lifetime caps or lockouts for failure to pay premiums. 
  • Simplifying enrollment and renewal policies for “non-MAGI” populations (those who are age 65 and older or have disabilities), including using prepopulated renewal forms, accepting renewals through multiple modalities, and conducting renewals no more than once every 12 months.  

We may also see another new rule soon expanding both Marketplace and Medicaid eligibility to Deferred Action for Childhood Arrivals (DACA) recipients. In April 2023, the Biden Administration announced a proposed rule to expand the definition of “lawfully present” to include DACA recipients or “Dreamers.” This would make optional children and pregnant women eligible for Marketplace coverage with financial assistance, the Basic Health Program (in states with such programs), Medicaid and/or CHIP. If this rule is finalized, up to 129,000 Dreamers could gain health coverage. 

Celebrating Enrollment Wins 

The Administration recently celebrated the 10th anniversary of the Marketplaces. The coverage gains we’ve seen through the Marketplaces could not have been achieved without the enrollment assisters who have worked tirelessly over the last decade to help consumers enroll in the Marketplaces and Medicaid/CHIP. Previously, we’ve documented the importance of outreach and enrollment work by community navigators and this workforce will be instrumental to the next 10 years of the Marketplaces, as well as play a role in ensuring the success of these new rules once implemented. 

Transform Health is a nationally certified women and minority led health care consulting firm. Reach out to us today if you would like to work together. Contact Heather Bates, COO, and VP of Stakeholder Engagement at heather@transformhc.com We would love to hear from you!