States Obtain Special Waivers to Help Unwinding Efforts
As states unwind the continuous enrollment provision and complete redeterminations for all Medicaid enrollees, they face numerous challenges including staffing shortages and outdated systems. Early into the unwinding of the continuous enrollment provision, over 7.4 million individuals have been disenrolled with 73% due to procedural reasons. To give states additional tools to comply with federal renewal requirements and meet conditions under the Consolidated Appropriation Act (CAA) to receive enhanced matching funds, the Centers for Medicare and Medicaid Services (CMS) identified a range of strategies, including the availability of temporary waivers. Some states adopted these temporary waivers to address areas of non-compliance with renewal requirements identified by CMS. As of September 20, 2023, CMS had approved a total of 319 waivers for 49 states and the District of Columbia.
How are states using unwinding waivers?
CMS groups available “1902(e)(14)(A)” waivers into three buckets: options to increase ex parte renewals, supporting enrollees in completing and submitting renewal forms, and facilitating reenrollment for individuals disenrolled for procedural terminations. States can also request authority to adopt additional strategies to protect enrollees during the unwinding; these waivers are counted in the “Other” category in Figure 1 but discussed in the bucket where the strategy fits in best.
- Nearly all states (47) have approved waivers to help increase ex parte rates. Ex parte renewals work by eliminating the need for beneficiaries to submit renewal forms; instead, state Medicaid staff use administrative data on income and other circumstances to determine eligibility. Of these states, 38 adopted waivers to allow for ex parte renewals for individuals with no income and /or income at or below 100% of the federal poverty level (FPL). Under this option, CMS allows an ex parte renewal if the most recent income determination was no earlier than March 2019 and the state has checked financial data sources and no information is received; without the waiver states would need to conduct new data matches or otherwise document that an individual has no or low-income. Nearly half of states (23) have waivers to use Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) eligibility to confirm ongoing Medicaid eligibility. Twenty-two states have waivers to allow the state to assume no change in assets if there is no information returned through the asset verification systems (AVS) or if the AVS call is not returned in a reasonable timeframe. Five states requested and were granted authority to allow them to waive the asset test at renewal for non-MAGI enrollees (these are included in the other category).
- Forty-four states have waivers to help enrollees complete and submit renewal forms. Forty-three states have waivers to facilitate updating contact information to ensure that renewal forms are sent to the correct addresses. States can obtain updated contact information from the National Change of Address (NCOA) and/or USPS returned mail databases (37 states), Managed Care Organizations (MCOs) (32 states), enrollment brokers who aid beneficiaries in enrollment (6 states), or Programs of All-Inclusive Care for the Elderly (PACE) (6 states). In addition, there are a number of waivers in the “Other” category: at least 14 states have waivers allowing MCOs to help complete sections of a renewal form, beyond sections relating to managed care plan selection, and seven states have waivers that permit applicants and beneficiaries to designate an authorized representative over the phone without requiring a signed designation. This phone designation enables assisters and others who are helping enrollees complete renewals by phone to provide timely support without waiting for signed documents.
- A total of 31 states have waivers to help individuals re-enroll if they were disenrolled for procedural reasons. For example, 23 states have waivers to extend the amount of time to take final actions on fair hearing requests beyond the standard 90 days. Nine states have waivers to extend automatic reenrollment into an MCO plan from the standard 60 days up to 120 days. Other waivers designate state agencies, community organizations, pharmacies, and providers as qualified entities to determine presumptive eligibility for MAGI enrollees who were disenrolled for procedural reasons. Waivers have also been approved to reinstate coverage from the date of termination for individuals who were disenrolled for procedural reasons but later found to be eligible. This ensures that any health care services obtained after individuals were disenrolled are covered.
States vary widely in their use of 1902(e)14(A) waivers, ranging from 13 in Tennessee to 0 in Florida. There may be several reasons for this variation in uptake related to differences in how state eligibility systems function, the need to address compliance issues, interest in maintaining coverage, and more.
What are the key issues to watch?
During the unwinding period, CMS has been notifying states to identify areas of non-compliance with federal renewal requirements and has provided states with options for mitigating any compliance issues, including by adopting temporary 1902(e)(14)(A) waivers. In letters sent to states on August 9, 2023, CMS expressed general concern over procedural disenrollment rates, calling out 28 states where it deemed those rates were too high, and urged all states to take action to reduce the rates. In response, some states have requested additional waivers to enable them to streamline ex parte renewal processes or to facilitate reenrollment of those who were procedurally disenrolled. While CMS continues to support use of ex parte or automatic renewals as a key strategy for helping eligible people maintain coverage during renewals, CMS identified problems with how some states were processing ex parte renewals that led to an estimated 500,000 individuals (mostly children) being incorrectly procedurally disenrolled. States are required to reinstate coverage for these individuals.
Efforts to improve renewal processes and reduce procedural disenrollments will likely last beyond the unwinding period and CMS and states may look to extend some unwinding flexibilities and/or make some permanent for regular operations. Learning from states which waivers have been most effective at achieving the goals of increasing ex parte renewal rates, updating contact information, or reducing administrative burden can inform CMS decisions over whether to maintain some waiver options.