How Many Medicaid Enrollees Moved In 2020 And What Are The Implications For Unwinding the Public Health Emergency?

The Families First Coronavirus Response Act (FFCRA), enacted at the beginning of the coronavirus pandemic, requires states to provide continuous enrollment to Medicaid enrollees until the end of the month in which the public health emergency (PHE) ends in order to receive enhanced federal funding. During this time, states generally cannot disenroll people from Medicaid, which has prevented coverage loss and churn (moving off and then back on to coverage) among enrollees during pandemic. The PHE is currently in effect through mid-April 2022 and the Biden administration has said it will give states 60 days’ notice before the PHE ends. Since that notice was not issued in February 2022, it is expected the PHE will be extended again, although there is uncertainty over how long the extension will last.

Once states resume redeterminations and disenrollments at the end of the PHE, Medicaid enrollees who moved within a state during the pandemic but are still eligible for coverage are at increased risk of being disenrolled if their contact information is out of date. Many state Medicaid programs are heavily reliant on the mail for communicating with enrollees about renewals and redeterminations, including requests for information and documentation. States can disenroll individuals who fail to respond to these requests. We analyzed federal survey data for 2020 and found:

  • Roughly 1 in 10 Medicaid enrollees (9%) moved in-state in 2020. A much smaller share, just 1%, moved to a different state in the U.S. Individuals that move within the same state may continue to be eligible for Medicaid, while a move out of state would make them no longer eligible for Medicaid coverage in their previous state. Shares of Medicaid enrollees moving within a state has trended downward in recent years, but trends could have changed in 2021, as more people became vaccinated against COVID-19 and the national eviction moratorium was lifted in August 2021.
  • Among those covered by Medicaid, young adults and single-parent families with children were more likely to move within a state than other groups. Among Medicaid enrollees that moved within the same state in 2020, half (50%) moved for housing-related reasons and 28% moved for family-related reasons.

States can take a number of actions to update enrollees’ addresses and other contact information to minimize coverage gaps and losses for eligible individuals after the end of the PHE, particularly for individuals who may have moved within a state. These actions include conducting direct outreach to enrollees, partnering with managed care organizations and other stakeholders in outreach efforts, developing clear policies for returned mail, and checking available data sources for more up-to-date contact information. A recent survey of states found that most states (46) were taking proactive steps such as these to update contact information, although fewer (35) are following up on returned mail. Careful monitoring and oversight of state progress during the unwinding period could provide information to prevent erroneous terminations of coverage.

Introduction

To understand who may be at increased risk of losing Medicaid coverage because of out-of-date contact information, this brief analyzes data from the Current Population Survey’s (CPS) Annual Social and Economic Supplement (ASEC) from March 2021 to examine the share of Medicaid enrollees who moved within a state (and therefore are more likely to remain eligible for Medicaid in the same state) in 2020 and the demographic characteristics of those individuals. It also examines trends in residential mobility over time and discusses strategies states can adopt to minimize coverage losses among these individuals.

The data used in our analysis reflect mobility patterns during 2020 and were collected before important events, such as when the COVID-19 vaccine became widely available to all adults and the end of the national eviction moratorium, that may have affected the number of people who moved more recently. Additionally, our analysis focuses on non-elderly Medicaid enrollees (because enrollees ages 65 and older likely have Medicare as their primary source of coverage) and so we refer to non-elderly Medicaid enrollees simply as “enrollees” for the remainder of this brief. See the Methods box at the end of this brief for more details about the analysis and limitations.

What do we know about Medicaid enrollees who moved in-state in 2020?

Roughly 1 in 10 Medicaid enrollees (9%) moved in-state in 2020. A much smaller share, just 1%, moved to a different state in the U.S., which would make them no longer eligible for Medicaid coverage in their previous state. The share of enrollees moving within the same state was slightly higher compared to people who are not enrolled in Medicaid (8%), although the share was not significantly different for non-enrollees who moved to a different state in 2020 (2%). These estimates are based on CPS ASEC data, which asks survey respondents whether they lived in the same house one year ago. One limitation of this approach is that the CPS ASEC data do not identify people who have moved multiple times over the course of the year, reflecting more severe housing instability that is more common among low-income populations. Additionally, these data do not identify temporary (or seasonal) moves during the year, such as moving in with family or friends, which became more common in 2020 and early 2021 in response to the pandemic.

Among those covered by Medicaid, young adults and single-parent families with children were more likely to move within a state than other groups (Figure 1). In 2020, approximately 11% of young adults (ages 19-34) with Medicaid coverage moved in-state compared to 8% of children and 7% of adults ages 35-64 with Medicaid. Among the different family types analyzed, enrollees who live in single-parent families were the most likely to move in 2020 (12%), while enrollees living in multi-generational families were among the least likely to move (6%). When we compared residential mobility by race/ethnicity, a smaller share of Hispanic people enrolled in Medicaid moved within state in 2020 (7%) compared to White people (9%), while the shares of Black people (9%) and people of other races (9%) who moved were not different compared to White people.

Among enrollees that moved within the same state in 2020, half (50%) moved for housing-related reasons and 28% moved for family-related reasons (Figure 2). Housing-related reasons include wanting a better home and/or neighborhood, wanting cheaper housing, foreclosure or eviction, and other unspecified housing-related reasons. Family-related reasons include establishing one’s own household, changes in marital status, and other unspecified family reasons. Generally, Medicaid enrollees were more likely to move in-state for family-related reasons compared to people who were not enrolled in Medicaid (28% vs. 24%) and were less likely to move in-state for job-related reasons compared to people who were not enrolled (9% vs. 12%). Medicaid enrollees and non-enrollees both moved within the same state for housing-related or other reasons at about the same rate. When compared to the reason people moved in 2018 (the most recent measurement year before the pandemic), Medicaid enrollees’ reasons for moving have stayed relatively steady despite economic disruptions in 2020 related to the pandemic.

The share of Medicaid enrollees moving within the same state has declined slightly in recent years, from 15% in 2014 to 9% in 2020, although that trend could change in 2021 and 2022 (Figure 3). Declining shares of Medicaid enrollees moving within the same state since 2014 mirrors national trends of fewer people moving over time. However, the share of Medicaid enrollees moving has decreased faster compared to non-enrollees in recent years. While the pandemic has raised concerns about economic disruptions and housing instability among low-income populations, the data for 2020 indicate that residential mobility among both Medicaid enrollees and non-enrollees largely followed pre-pandemic trends. However, these trends could have changed in 2021, as more people became vaccinated against COVID-19 and the national eviction moratorium was lifted in August 2021.

How can states minimize coverage losses among eligible enrollees who move?

With the continuous enrollment requirement in place during the PHE and the prohibition on disenrolling individuals from Medicaid, states may not be communicating regularly with enrollees and, as a result, may have outdated contact information for those who have moved within the state during the past two years. When the PHE ends and states resume routine redeterminations and disenrollments, some enrollees may be at risk of losing coverage simply because they do not receive notices or renewal information. As states prepare to resume normal operations, they can take a number of actions to update enrollee addresses and other contact information to minimize coverage gaps and losses for eligible individuals. The Centers for Medicare and Medicaid Services (CMS) has developed a broad set of policy and operational strategies states can adopt to maintain continuous coverage for eligible individuals, including specific strategies for updating contact information and reducing returned mail:

Conduct communication campaigns through mail, text, and email to encourage enrollees to provide updated contact information. States can send periodic notices during the PHE to remind enrollees to update their contact information. To the extent states have alternative contact information, they can also reach out through automated phone calls, text messages and emails. And, to ensure that enrollees are reminded when they proactively reach out to the Medicaid or other social services agencies, states can update call center scripts to request updated contact information at the beginning of the call and can add alerts to Medicaid, CHIP, and social services websites.

Partner with managed care organizations (MCOs), community-based organizations, application assisters, and providers in outreach efforts. To expand the reach of outreach efforts, states can work with MCOs, community partners, and providers to reinforce messages and remind enrollees to provide updated information. Enrollees are used to receiving communication from MCOs and may be more likely to respond to reminders from them. Navigators and certified application assisters can also be effective partners because they regularly update contact information during interactions with clients. States can opt to accept updated information from these entities, or in the case of MCOs require that they share this information but should develop policies for verifying updated information with enrollees.

Develop clear policies for following up on returned mail that can include checking available data sources and contacting enrollees via phone, text, or email. When mail is returned and no forwarding address is provided, states are encouraged to check available data sources, including the United States Postal Service (USPS) National Change of Address Database, the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) or other programs, and/or contact information from MCOs. They can also contact enrollees via phone, text, or email to obtain updated mailing addresses.

To prepare for the end of the PHE and continuous enrollment requirement, most states (46) are taking proactive steps to update enrollee addresses, although fewer (35) are following up on returned mail as of January 2022. Actions to update addresses include conducting outreach to enrollees, checking other programs for updated addresses, and working with managed care plans and providers to update address information. States that follow up on returned mail are most likely to call or email enrollees using information on file when they received returned mail from a notice sent to an enrollee.

Looking Ahead

As states resume redeterminations and disenrollments at the end of the PHE, evidence suggests that it is unlikely that large proportions of enrollees would be no longer eligible for Medicaid because they moved out of state. When asked to predict the primary reasons people will lose coverage after the continuous enrollment requirement is lifted, few states (3) identified moving as a key driver of disenrollments, and all cited other reasons, including increased income or other changes in circumstances, in addition to moving. While the number of Medicaid enrollees moving within the same state did not increase during the first year of the pandemic, the 9% of Medicaid who moved in-state in 2020 still amounts to a significant number of enrollees whose contact information is more likely to be out of date and who are at increased risk of losing coverage as states unwind the continuous enrollment requirement. It is also possible that, as the pandemic continued into 2021 and 2022, the cumulative number of Medicaid enrollees who moved has increased as well. States with relatively large numbers of disenrollments due to returned mail may indicate erroneous terminations, as returned mail alone does not necessarily indicate a change in economic circumstances that affects eligibility, especially when relatively few enrollees move out of state (approximately 1% of enrollees in 2020). Careful monitoring and oversight of state progress during the unwinding period could provide information to prevent erroneous terminations of coverage.

Methods
We analyzed data from Current Population Survey’s (CPS) Annual Social and Economic Supplement (ASEC) from March 2021, 2019, 2017, and 2015. These data provide information on who moved during the previous year (2020, 2018, 2016, and 2014, respectively). Our analysis focuses on people who had Medicaid coverage at some point during the year and who moved within the same state (moving out of state would mean that the enrollee no longer qualifies for Medicaid coverage in the previous state). We exclude enrollees ages 65 and older since nearly all would qualify for Medicare and are less likely to lose their primary source of coverage. Children under age 1 are also excluded because the CPS ASEC questions on moving as of March of the previous year are not applicable to respondents under age 1. Our analysis also focuses on individuals who moved within the US. While our analysis includes a small number of people who have moved from outside the U.S. (i.e., from a US territory or a foreign country), we do not include these individuals in our counts of people who moved in-state or to a different state. For the March 2021 CPS data (and not for previous years), we analyzed differences in selected demographic groups, including age group, family type, and race/ethnicity. We also analyzed the share of people moving within state by sex, urban/rural (using metropolitan statistical areas as a proxy), and foreign born, but we did not find significant differences between these groups and so are not shown in Figure 2. All differences reported in this brief are measures at the p < 0.05 level.

The analysis focuses on individuals and uses person weights, which is important for interpreting our findings on demographic groups. For example, although children will typically move with adults, the difference between child enrollees and older enrollees reflects situations where adults do not live with children or, in some cases, children (especially those aged 18) who do not live with adults. In other households, the children may be enrolled in Medicaid but their parents are not, or there could be more children enrolled in Medicaid than adults (or vice versa). In analyzing family type, we consider the type of family for each individual. For example, while we excluded enrollees ages 65 and older from our analysis, child enrollees who live with their parents and grandparents are considered to live in multi-generational households.

We conducted a robustness check of our findings by comparing the share of people moving in-state as identified in the CPS ASEC versus the American Community Survey (ACS). We compared findings for Medicaid enrollees and non-enrollees ages 1-64, using data collected in the March 2019 CPS ASEC sample and the 2019 ACS sample. Generally, the percent of people moving in-state over the past year were slightly lower in the March 2019 CPS ASEC sample (11% of enrollees and 8% of non-enrollees) compared to the 2019 ACS sample (13% of non-enrollees and 11% of non-enrollees). We would expect some differences due to different and data collection methods and timing between CPS and ACS, and so the difference of 2 or 3 percentage points seemed reasonably small.

Our findings have important limitations. First, the CPS ASEC sample does not tell us when a person moved. So, we do not know whether the person was enrolled in Medicaid before, during, or after the move. Additionally, we do not know how many times a person moved and, depending upon timing, temporary moves may not be captured. Second, the latest CPS data used here only provide data for 2020, but the economic impacts of the pandemic have lasted much longer, including when the federal government lifted the national eviction moratorium in August 2021.

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