The federal government suspended all Medicaid renewals (also known as Medicaid redetermination or recertification) during the COVID-19 Public Health Emergency to allow for continuous enrollment. However, states were permitted to resume Medicaid renewals on April 1, 2023. How states process and prioritize this reintroduction of renewals will impact continuity of coverage especially for nursing home and assisted living residents. According to KFF, about 18% of Medicaid beneficiaries are likely to be disenrolled over the next year. This article explores the timing, processes, prioritization, and consequences of the unwinding process.
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Timing, Priority and Process Updates for Medicaid Renewals
Along with getting the green light to restart Medicaid renewals on April 1, 2023, guidance from the Centers for Medicare and Medicaid Services (CMS) gave states up to 12 months to initiate all renewals and 14 months to complete them. This reintroduction of Medicaid renewals is also referred to as the ?unwinding? period or process because it is ?unwinding? the continuous Medicaid enrollment that occurred during the COVID-19 Public Health Emergency.
Prior to the COVID-19 pandemic, Medicaid renewals generally took place once per year on the anniversary of the beneficiary?s initial Medicaid approval, although in some cases they could happen more than once per year. However, during the unwinding period, this April 2023 report from KFF asserts that 35 of 49 replying states replying planned to use a hybrid approach to prioritizing Renewals that will consider multiple factors, including vulnerability, potential ineligibility, and time since last Renewal. This approach allows states to delay action with at-risk groups, such as seniors in nursing homes. Twelve states are basing the new Renewals strictly on timing.
How long it will actually take state Medicaid offices to process and complete this wave of renewals is still in doubt. Yes, guidance from the CMS gave states up to 14 months to complete these renewals, but many states are facing serious staffing shortages. More than half of the reporting states (16 of 26 in this case) told KFF they had staff vacancy rates greater than 10% for frontline eligibility workers. And just less than half of the reporting states (13 of 28) had a greater than 10% vacancy rate for call center staff.
However, the staffing shortages are countered in some measure by an increase in automatic renewals, also known as ex parte renewals. With ex parte renewals, the state verifies a beneficiary?s financial information electronically and can renew their Medicaid coverage without any effort from the beneficiary. Thirty (30) states told KFF they have increased their share of ex parte renewals during the past year, and 18 states are processing more than half of their renewals automatically, which is up from 11 in 2022. However, only six states reported processing more than half of their renewals for people age 65 and over via ex parte renewals.
While ex parte renewals may not be increasing for seniors at the same rate as non-seniors, other steps have been taken to streamline and simplify the Medicaid renewal process for seniors over the past year. For example, 45 states told KFF they have eliminated in-person interviews for Medicaid renewals for seniors, 42 states now limit renewals to once a year, and 33 states send out pre-populated Medicaid Renewal Forms.
Disenrollment Consequences during the Unwinding Process
According to KFF, about 18% of Medicaid beneficiaries are likely to be disenrolled during this unwinding period, which would be about 17 million people. However, this percentage will vary widely by state, with anywhere from 7% to 33% of Medicaid beneficiaries losing their coverage in a particular state. The variance will be tied to the policies and capabilities of each state.
This KFF report from May 2023 analyzed the policies and capabilities from 48 states (Ohio and Texas did not respond) and came up with nine key metrics that measure how much states will support continued Medicaid coverage (in other words limit disenrollment) through the current Renewal process for beneficiaries who are still eligible. The nine key metrics are broken down into three categories as follows:
1. State will allow 12-14 months to complete all Renewals
2. State follows up on returned email
3. State follows up with enrollees who have not responded to a renewal request before ending coverage
System Capacity Measures
4. Process of Renewals is mostly automated
5. 50% or more of Renewals are completed on an ex parte basis (meaning on input from the beneficiary is needed)
6. State has taken steps to improve ex parte Renewal Rates
7. State has adopted the Medicaid expansion
8. State has adopted 12-month postpartum coverage
9. State has adopted a 12-month continuous eligibility for all children in Medicaid and CHIP (Children?s Health Insurance Program)
The states that meet eight or nine of those nine key metrics are Washington, Colorado, New Mexico, Illinois, Indiana, Virginia, North Carolina and Massachusetts. On the other end of the spectrum, states that only meet three or four of the key metrics are Wyoming, South Dakota, Nebraska, Oklahoma, Missouri, Arkansas and South Carolina.
However, two of the three metrics in the Policies and System Capacity Measures category (postpartum coverage and children?s eligibility) are not relevant for seniors and this article. With that in mind, here?s a breakdown of how states fared in the two relevant categories, Renewal Policies and System Capacity Measures:
? States that meet 6 of the 6 Renewal Policy and System Capacity Measures key metrics: Colorado, Indiana, Massachusetts, Virginia
? States that meet 5 of 6: Alabama, Connecticut, Idaho, Illinois, Kentucky, Maryland, Michigan, Nevada, New Hampshire, New Mexico, North Carolina, Tennessee, Washington, Wisconsin
? States that meet 4 of 6: Arizona, California, Delaware, Florida, Georgia, Iowa, Louisiana, Mississippi, Montana, New Jersey, New York, North Dakota, Oregon, Pennsylvania, Rhode Island, South Carolina, Utah, Vermont,
? States the meet 3 of 6: Alaska, DC, Hawaii, Kansas, Maine, Minnesota, Missouri, West Virginia,
? States that meet 2 of 6: Arkansas, Nebraska, Oklahoma, South Dakota, Wyoming
Are Medicaid Beneficiaries Ready for the Reintroduction of Renewals?
Another KFF report from May 2023 found that 68 percent of Medicaid beneficiaries who are age 65 or older have never been through the renewal process, which means they will be entering unfamiliar territory and be more likely to need help when their renewal begins. The same survey says 33% of all Medicaid beneficiaries have not updated their contact information with their state Medicaid offices, which means they could miss critical communication concerning their renewal. And roughly the same amount of all Medicaid beneficiaries, about 33%, say they have had some financial change during the last three years that could make them ineligible.
The overwhelming majority (85%) of all Medicaid beneficiaries polled in the survey said they would find it useful if they had someone to help them with the Medicaid renewal process and to look for other coverage, if needed. And 27% of all Medicaid beneficiaries said they would not know where to look for coverage if they lost their Medicaid, while 15% said they would simply wind up uninsured.
Refresher: Medicaid Renewal Basics
As discussed above, some beneficiaries don?t need to take any action (which means they won?t need any assistance) when it comes to Medicaid renewal because the state can assess their financial status electronically. This is known as ex parte or automatic renewal.
If the state can not evaluate a Medicaid beneficiary?s financial status electronically, it will send the beneficiary a letter and/or an email with a Medicaid Renewal Form that must be completed and returned within 30 days to ensure continued coverage.
To complete the Medicaid Renewal Form and confirm their financial eligibility, beneficiaries will need to provide documents detailing the status of their income, assets and home ownership. These documents might include tax forms, bank statements, pensions statements, SSI award letters, alimony checks and mortgage statements. This will help prove the beneficiary meets the income and asset limits for Medicaid eligibility in their state of residence.
When it comes to home ownership, a beneficiary?s home can be exempt from the asset limit under multiple circumstances and depending on the value of the home as measured by home equity interest (the portion of the home?s equity value that the applicant owns minus any outstanding mortgage / debt). If the Medicaid beneficiary lives in their home and the home equity interest is less than $688,000 or $1,033,000 (as of 2023 and depending on state) then the home will be exempt. If the beneficiary?s spouse, minor child, or blind or disabled child of any age lives there, the home is exempt regardless of the beneficiary?s home equity interest, and regardless of where the beneficiary lives. If none of the above people live in the home, the home can still be exempt as long as the beneficiary files an ?intent to return? form and the home equity interest is at or below $688,000 or $1,033,000.
Medicaid beneficiaries must also meet functional criteria in addition to financial criteria to be eligible for Medicaid. This functional criteria may also be reevaluated during the Medicaid Renewal process, but in general states are more focused on re-evaluating the financial criteria.
What Happens if Medicaid is not Renewed?
As mentioned above, Medicaid beneficiaries have 30 days to complete and submit their Medicaid Renewal Forms. If they don?t do this, or if they are found to no longer be eligible during the renewal process, their benefits and coverage will also stop.
From the day of the stoppage, beneficiaries have a 90-day window to submit or resubmit their Medicaid Renewal Form and re-enroll without needing to reapply. If they do not submit the form or are still found ineligible during that 90-day window, they will lose their coverage and benefits and will need to reapply.
Medicaid beneficiaries who come into extra income or assets that pushes them over eligibility limits could potentially face situations like being evicted from a nursing home or losing their in-home long term care benefits and needing to reapply and wait on a list to get them again. However, most of these Medicaid beneficiaries can implement strategies and come to an arrangement with the state that will allow them to stay in their nursing home or keep their in-home long term care benefits, but they will likely need some help to do that.