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Millions of Medicaid beneficiaries will lose coverage once Medicaid reassessments begin, many of whom are still eligible.

Softheon spoke to multiple states about their plans for the Medicaid Unwinding period (Unwinding). Softheon’s policy experts identified five ways states could save resources while making sure more eligible people stay enrolled.

Regulatory Changes Make It Difficult for States to Prepare – CMS Guidelines and the Unwinding Timeline

States struggle to adapt to the ongoing changes and uncertainty surrounding the end of the Public Health Emergency (PHE).

The Centers for Medicare and Medicaid Services (CMS) continues to release guidelines for reassessing Medicaid populations. Frequent changes make it difficult for states to construct a solid plan for the Unwinding. Some states also await decisions on proposed waivers.

The most recent and relevant guidelines released by CMS include the:

  • recommendation that states not begin reassessments for more than 1/9 of their caseload in a month.
  • need for an operational plan to move through reassessments while mitigating coverage loss.
  • specification that all reassessments need to be started within 12 months following the end of the PHE but completed within 14 months.
  • need for every member to have a full redetermination. Renewals occurring before the PHE ends will need to be revisited.
  • streamlined transfer to marketplace coverage or other state programs.

States have historically expressed frustration at the late inclusion of certain specifics surrounding the Unwinding. For example, many states began processing ex partes before CMS mandated that all members be reassessed after the PHE expires.

Reduce Coverage Loss by Taking the Full 14 Months to Reassess


The end of the PHE is not official, but we predict the Unwinding could begin as soon as February 1, 2023. We base the February date on our prediction that the PHE will not be allowed to expire in October, right before an election. Instead, we think the PHE may expire in January 2023. Surges in COVID-19 cases in the Northeast make the case for extending the PHE for additional months. 


If the Unwinding Period begins in February 2023, the 6.2% FAMP increase would extend until March 2023.

States have the freedom to navigate the 14-month reassessment period in ways that ease operational strain.

Getting a late start or falling behind the 1/9 per-month marker is not a death sentence for states. Processing all redeterminations in a comprehensive manner is key to mitigating coverage loss.

States have the option to spend most of the 14 months processing redeterminations to prevent overwhelming Medicaid staff. Despite states increasing staff numbers and scaling training efforts, most cannot respond to such a large wave of reassessments in under nine months.

Stretched resources could result in individuals losing their coverage despite still being eligible. Additionally, spreading out reassessments will prevent a reoccurring annual surge in renewals.

According to a Kaiser Family Foundation survey, 41 states plan to take the full 9-12 months to complete redeterminations. The remaining states plan to expedite the process. Four states (Indiana, Missouri, Nevada, and New Mexico) estimate completion within 6-9 months. Three states (Arkansas, Idaho, and New Hampshire) expect to take 3-6 months.

1. Stagger and Stage Redeterminations – Using Member Data for a Custom Unwinding Plan

Only about half of states report having a plan for prioritizing eligibility reassessments.

A time-based approach starts with the oldest cases and works towards the more recent. Most states already organized their redeterminations using the time-based approach. But this does not make use of member behavior data.

States opting for a population-based renewal approach utilize member data to stagger and stage redeterminations. Starting the redetermination process with “low-risk” populations allows eligibility workers to expedite reassessments. Those who are blatantly ineligible due to factors such as moving out of state can be removed before the 6.2% FMAP increase ends.

Reversely, populations at a greater risk can move further down the timeline for added attention.

One example of a population-based approach is delaying members undergoing expensive, life-saving treatments. Colorado plans to expedite the COVID Optional Testing & Treatment Group as their eligibility will expire with the PHE.

Pulling from different data sources, including Medicaid managed care plans, will provide a holistic view of the member. Determining at-risk groups will inform redetermination business rules.

CMS encourages states to produce their own plan for prioritizing reassessments. A hybrid between the time-based and population approaches will be most common.

2. Streamline Over 65% of Redeterminations with Ex Parte Renewals

Ex parte renewals address redeterminations using pre-existing data sources. States can use ex partes to reduce reassessment backlogs by expediting low-risk individuals.

Jessica Kahn, a Partner at McKinsey’s Washington D.C. office, spoke to ex partes at the 2022 Annual State HIT Connect Summit. She advocates for states to increase ex parte rates. Those conducting less than 65% of redeterminations through ex partes will struggle.

Of the 42 states that reported to KFF that they were conducting ex parte renewals, most could not process 50% of members with current data sources.

States can increase ex parte rates by sending renewal forms or documentation requests. 30 states reported already reaching out to these members for missing documentation.

Additionally, states can partner with vendors to increase their access to data sources. Partnerships could feature lasting integrations with downstream data sources. But this may be difficult to execute by 2023.

A faster and more cost-effective solution would be to increase states’ access to data source information via batch files. States can opt for short term partnerships to accommodate the increased Unwinding workload.

3. Scale Communication Efforts – Updating Templates and Partnering with Member Touchpoints

Redeterminations themselves can result in coverage loss, even among eligible enrollees. Due to COVID-19, the last two years saw an increase in relocations and income changes. Finding individuals proves to be one of the biggest issues for states.

Many states are ramping up outreach and communications to Medicaid enrollees to ensure populations are ready to fill out and return renewal documentation when the unwinding period begins.

Confirming Member Information and Renewal Forms


Out-of-date addresses make communication efforts difficult. States should begin working with vendors to get updated addresses. Now is the time to get creative in how states use their relationships and available data.

Managed Care Organizations (MCOs), brokers, and community partners are great resources for getting in touch with members.

After finding current addresses, the second half of the challenge is getting members to respond to renewal forms. States need to update messaging and scale outreach to get high response rates. Clear messaging conveying changes to eligibility and next steps should be brief and simple to understand. Personalization fields in notice generation allows for a tailored approach while scaling outreach.

States should take time now to update notice templates and ensure that fulfillment partners can meet increased demand.

Tailoring Messaging for Those Determined Ineligible


MACPAC estimates that only 4% of individuals exiting Medicaid enter Marketplace plans. Messaging about unenrollment should push members towards the ACA Marketplace and CHIP.

Using positive language to describe the Marketplace/CHIP can help reduce potential concerns. The messaging can be centered around Advance Premium Tax Credits (APTCs) and lower premiums. Individuals can be directed towards their Exchange website as a next step.

With the potential expiration of the American Rescue Plan (ARPA) enhanced subsidies on the horizon and an increase in the number of available qualified health plans (QHPs), enrolling in Marketplace coverage is difficult. Communicating with MCOs, brokers, and community partners will help at-risk individuals transition. Extra hand holding can reduce uninsured rates.

4. Improve the User Journey and Remove Renewal Pain Points Through Automated Client Interactions

The little details that make renewing or enrolling in coverage frustrating aren’t always on top of the list. But a lackluster user experience can result in members abandoning the renewal process halfway through.

Automating customer service with interactive voice response (IVR) can reduce call center backlogs. Members calling to do simple tasks like reset a password can navigate through interactive prompts.

Medicaid agencies should allow for multiple ways to submit eligibility documents. An online portal that accepts a variety of file formats – including cell phone pictures.

For those enrolling, an e-commerce approach to plan shopping helps guide worried members to a tailored plan. Decision shopping tools create a customized shopping journey.

5. Lean on Technology Vendors to Expediate Redeterminations and Move Towards Integration

Partnering with vendors with a shared vision can help members keep coverage while reducing strain on state resources.

Expediting Renewals with State-Specific Business Rules


Vendors can help states automate eligibility determinations through customizable business rules. For example, members eligible for SNAP are often also eligible for Medicaid. Expediting those who receive SNAP can reduce reassessment workloads.

Colorado looks to forego the need for signature from their homeless population through a waiver. If this process gets approved, their system can determine homeless members, remove them from the queue, and bypass redetermination checkpoints. All exceptions can be automated through customized business rules.

Integrating with Other Public Assistance Programs for Streamlined Eligibility Determinations


The upcoming end of the PHE escalates an issue that states have been dealing with for decades: members lapsing in coverage as they move between programs. Determining eligibility for all assistance programs through an integrated approach helps prevent churn.

Some states can transfer accounts as members move from Medicaid to the Marketplace, while others have fully integrated Medicaid and Marketplace systems.

But barriers such as monthly vs. yearly income checks and member identification can limit integration. Even states with experience transferring member information might struggle scaling without a vendor.

Book 15 minutes with Josh Schultz to discuss how Softheon makes smarter eligibility determinations, faster.