Saturday, September 10, 2022

Preparing for the great Medicaid unwinding: the case of New Jersey

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NJ FamilyCare end-of-PHE alert

The pending end of the Public Health Emergency declared by the federal government in March 2020 will trigger something of an earthquake among Medicaid enrollees.  

As of May of this year, enrollment in Medicaid and CHIP had increased by 18.3 million -- 26% -- since February 2020, the last month unaffected by the pandemic. Some 90 million Americans, well more than a quarter of the population, are now enrolled in Medicaid or CHIP.  That increase is mostly due to a moratorium on disenrollments enacted in March 2020 as part of the Families First Coronavirus Response act, which conditioned a 6.2% increase in the federal government's share of each state's Medicaid costs on implementing the moratorium (all states complied).  The Kaiser Family Foundation (KFF) estimates that 84% of the enrollment increase during the pandemic is attributable to the moratorium.

The moratorium will end when the PHE ends. That end was expected to come on April 15 of this year, but like the pandemic itself, the PHE lingers on, repeatedly extended in three-month increments, the latest of which ends in mid-October. As the government has promised states 60 days’ notice before ending the PHE, the earliest it can now end is mid-January. But end it will,  at which point states will resume “redetermining” the eligibility of current enrollees, and disenrolling those whom they find to no longer qualify. The Urban Institute estimated last September that 15 million people may be disenrolled nationwide. KFF estimates the losses in a range, from 5.3 million to 14.2 million.

Given the huge backlog of cases to determine, the federal government has asked states to act with all due deliberation, allowing up to 12 months to initiate renewals for every enrollee and up to 14 months to complete the process. CMS has offered resources and a roadmap to states to manage an orderly unwinding, urging state Medicaid agencies to, among other things, implement automated processes such as ex parte renewal (automated renewal enabled by state data sources), stagger and prioritize monthly redeterminations to minimize churn, engage with community partners and MCOs to reach enrollees, and develop effective communication and outreach tools and processes. 

States vary widely in the degree to which they have been proactively preparing for the unwinding and/or making their efforts public. One state that has been preparing actively is New Jersey. The state's Medical Assistance Advisory Council (MAAC) posts quarterly meeting minutes and presentation slides, and the materials from April and July of this year include detailed information about planning for the end of the PHE.

Efforts thus far have focused mainly on verifying and updating contact information for enrollees  (always a challenge with low income populations); developing effective communication tools; reaching out to enrollees to prime them for the coming redeterminations; and tapping healthcare providers, nonprofits and other state agencies to help with that outreach, aided by shareable communication tools (such as the one pictured above). 

In the April 28 MAAC meeting, the state's Medicaid and CHIP director, Jennifer Langer Jacobs, asserted that throughout the pandemic the state has also made good progress updating and standardizing  eligibility systems and communications among 21 county offices.

The unwinding, Jacobs said in an interview, "is the largest eligibility undertaking in the history of Medicaid. But CMS has made a lot of resources available. We've been involved with the National Association of Medicaid Directors. We're meeting regularly with community advocacy organizations." As the end of the PHE has been postponed, "We've had extra time, which gave us the opportunity to further refine this process." 

In somewhat more detail, here are key elements of the unwinding effort described in MAAC materials.


Hotline: The state has created and publicized a single phone number (800-701-0710) that enrollees can call to update their contact information. Previously, they had to call their county offices

Tapping MCOs:  Via a waiver from CMS, for the first time, the five managed care organizations through which most NJ FamilyCare enrollees are insured can now directly share updated contact information for their enrollees with NJ FamilyCare. Previously, the state could not accept such updates -- the enrollee had to contact her county office separately. The presentation for the July MAAC meeting asserts that between January and May, 58,000 address updates were collected via the MCOs.

Flagging non-responders: throughout the pandemic, the state has been sending out redetermination packets -- they simply haven't been disenrolling anyone. Those who have not responded become top priority for locating. The state will contact the non-respondent's MCO, which also also try to reach the enrollee. If the MCO gets new contact information, it will be shared with the state. As for those who do respond and are found eligible, they will be renewed for twelve months.


Core messages: In the runup to the PHE, NJ FamilyCare is keeping its messages simple: 1) update your contact information (when necessary) via the hotline, and 2) be on the lookout for redetermination packets. 

Amplifiers: The state is relying in large part on community partners to reinforce these messages, via these materials:

Renewal and transitions

Informal resolution: Enrollees who engage in the renewal process and are determined ineligible are entitled to a formal hearing if they think the determination is erroneous. In the April 28 MAAC meeting, however, Jacobs emphasized that the agency is committed to resolving eligibility questions informally if at all possible. "We would like to take care of it quick and clean if there's a way to do that," Jacobs said, emphasizing both rapid response and empathy -- "showing people we care, that we are leading our program with our hearts."  A hotline similar to the one instituted for address updates would be a logical way to encourage such informal resolution.

Multiple touch points: When enrollees are slated for disenrollment (presumably because of nonresponse),  MCOs will attempt to reach them and help them avoid disenrollment. After the fact,  CMS is allowing post-disenrollment outreach, which has been forbidden until now.

Handoff: For those determined ineligible for Medicaid, NJ FamilyCare will attempt a warm handoff to the state ACA marketplace, GetCoveredNJ, which will contact the person about enrollment in the subsidized private plans available in the marketplace. Thanks to the enhanced premium subsidies established by the American Rescue Plan Act in 2021 and renewed through 2025 by the Inflation Reduction Act in August 2022, along with state supplemental subsidies provided in GetCoveredNJ, silver plans enhanced with strong Cost Sharing Reduction are available for free, or very close to free, for enrollees with incomes up to 200% of the Federal Poverty Level -- if they lack access to other affordable coverage, e.g., from an employer. 

By one measure, New Jersey is out front at least in communicating its preparation for the unwinding. Georgetown University's Center for Children and Families (a research team constantly advocating for improved Medicare and CHIP access and service) have posted a 50-state unwinding tracker that monitors how many of six key documents each state has posted. New Jersey is one of ten states that have produced at least five: a public plan, a landing page, an alert (a bit buried in rolling banners) to update contact info, an FAQ, and a communication/marketing materials toolkit.

Will and capacity are two different things.  As Jacobs noted, NJ FamilyCare has had more time than expected to prepare for the end of the PHE, and the commitment to minimizing churn and an increase in the uninsured population when redeterminations restart seems wholehearted. How the actual unwinding plays out in 2023 remains to be seen.

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