Understanding The Role Of MCOs In the Unwinding of the Medicaid Continuous Enrollment Provision

More than 5 million people have lost Medicaid coverage since the end of the Medicaid continuous enrollment provision earlier this year. Of these, 79% were disenrolled for procedural reasons, not for any factors related to eligibility. To address this problem, the Centers for Medicare and Medicaid Services (CMS) is actively encouraging states to partner with Managed Care Organizations (MCOs).

As of August 2023, state Medicaid disenrollment data shows that more than 5 million people, or approximately 38% of enrolled individuals in reporting states, have lost Medicaid coverage since the end of the Medicaid continuous enrollment provision earlier this year. Data from the 47 reporting states show a wide range of disenrollment rates, likely due to varying state policies regarding renewal timelines and distribution plans.

June 2023 data detailing state renewal timelines indicated that 12 states prioritized renewals for individuals already determined to be likely ineligible for Medicaid. Texas reported the highest disenrollment rate (72%), reflecting their plan to focus on likely ineligible individuals for the first 6 months of initiating unwinding-related renewals. Eleven other states reported a disenrollment rate over 50%.

Of those who lost Medicaid coverage, Medicaid.gov renewal data shows that 79% were disenrolled for procedural reasons, not for any factors related to eligibility. Procedural terminations were cases where individuals lost coverage because they did not receive, understand, complete, or return their renewal packet on time. These individuals lost coverage despite potentially still being eligible for Medicaid. 

How States Engaged Managed Care Organizations in a Return to Normal Operations

In an effort to prevent procedural errors, states were encouraged by the Centers for Medicare and Medicaid Services (CMS) to partner with Managed Care Organizations (MCOs). While preparing their operational plans and timelines to complete eligibility, 47 states submitted temporary waivers from CMS in an attempt to mitigate operational challenges and facilitate the renewal process. 

To address potential procedural issues caused by system or operational limits, CMS may grant temporary authority that permits states to accept updated enrollee contact information from managed care plans without first sending a notice to the address on file with the state.

All states were required to take steps to update contact information and remind beneficiaries that they may update their information online, by phone, by mail, or in person. By ensuring that beneficiary contact details are up to date, the hope was that states could use MCOs to help reduce the likelihood that individuals lose coverage simply because they did not receive their renewal packet. 

Even in states where agencies may not receive temporary authority to accept updated contact information, MCOs are still encouraged to engage in outreach to encourage beneficiaries to update their contact information with state Medicaid agencies.

Managed Care Strategies to Maximize Continuity of Care for Beneficiaries Losing Medicaid Coverage

In addition to granting temporary flexibilities, CMS released Strategic Approaches to Engaging Managed Care Plans to Maximize Continuity of Coverage as States Resume Normal Eligibility and Enrollment Operations; a guide detailing opportunities for state and MCO collaboration to help ensure continuity of care and ease Marketplace transitions. 

Now that many states have already started the disenrollment process, it may be useful to review how MCOs can support beneficiaries who are losing coverage either due to procedural reasons or ineligibility. 

For both outreach strategies, CMS notes: “There are no federal regulatory barriers that prevent states and managed care plans from working together to help individuals who are terminated from Medicaid or CHIP coverage, including transitioning to other sources of coverage”.

Conducting Outreach to Individuals Terminated for Procedural Reasons

For individuals terminated for procedural reasons, states can provide managed care plans with monthly termination files. This enables MCOs to contact and assist individuals terminated for not having updated contact information or not returning their renewal form in time.

It's important to note that people with limited English proficiency, people with disabilities, recently incarcerated individuals, immigrants, and older adults face disproportionate procedural barriers. MCOs can proactively engage in outreach for at-risk populations.

Assisting in the Transfer of Medicaid Ineligible Enrollees to Marketplace Coverage

For individuals who are ineligible for Medicaid coverage, MCOs can assist in transferring individuals to Marketplace coverage. In addition, if plans offer a Qualified Health Plan (QHP), an MCO may also share information with enrollees and share member information with their associated Marketplace QHP to inform beneficiaries of additional options to obtain coverage. 

Requirements and considerations for outreach limitations are further detailed in this CMS document.

Incarcerated Individuals Are Disproportionately Impacted by Loss of Coverage

According to the Prison Policy Initiative, reinstating Medicaid coverage immediately after release from incarceration is crucial to ensuring justice-involved populations receive continuity and quality of care. 

The PHE unwinding exacerbates the already complex process of reinstating coverage for justice-involved individuals. If MCOs do not have updated contact information or reliable criminal justice information, it is unlikely that incarcerated individuals will be able to return renewal packets and maintain coverage.

This is especially concerning considering that this population is already at an increased risk of negative health outcomes. 

Serious Mental Illness, Substance Use Disorder, and Risk of Death

According to a report by the Substance Abuse and Mental Health Services Administration (SAMHSA), approximately two-thirds of individuals in jail or prison have a substance use disorder (SUD), and over half experience serious mental illness (SMI).

Access to Medicaid can increase continuity of beneficiaries’ treatment progress, given the increased rates of SUD and SMI, access to treatment could mean reduced rates of emergency room use, relapse, recidivism, and even death. 

Ensuring continuity of care upon release starts with ensuring MCOs have access to criminal justice data in order to locate individuals with health risks. This helps enable MCOs to develop care plans that meet these individuals’ medication and treatment needs.

Barriers to Continuity of Care and Coverage Renewal

MCOs already faced significant procedural barriers when attempting to coordinate care plans for justice-involved individuals including unreliable, inconsistent, and outdated criminal justice data. 

The end of continuous enrollment has further exacerbated these issues as individuals who have not needed to renew coverage since the beginning of the pandemic now need to be located and contacted. 

How Incarceration Intelligence Can Help MCOs Improve Health Outcomes

The Medicaid continuous enrollment provision unwinding is a multifaceted challenge that requires collaboration and outreach from states, MCOs, and various stakeholders. MCOs can significantly improve health outcomes for justice-involved individuals during the unwinding process, but this requires access to reliable, near-real time criminal justice information.

Equifax Incarceration Intelligence offers nationwide data coverage, near real-time alerts, and improved internal efficiencies in an effort to lower the cost of care and improve quality of care for Medicaid beneficiaries.