Back in April, I covered the end of the federal government’s declared COVID-19 public health emergency (PHE), which ended in May, and along with it, the start of one of the largest related program rollbacks: that of the Medicaid continuous coverage requirement.
This pandemic-era requirement directed states to keep Medicaid beneficiaries enrolled regardless of changes to their eligibility, in exchange for a boost in federal funding. When the requirement expired, states were able to resume income eligibility checks or redeterminations, for the first time since 2020.
Since that time, states have been terminating Medicaid coverage for millions of people who remained covered under the Medicaid program during the pandemic. So, I thought I would check in on how this has been unfolding over the last five or so months.
The Centers for Medicare & Medicaid Services (CMS) initially estimated that over 15 million of 92 million Medicaid enrollees would lose coverage throughout the redetermination process. That’s 16 percent of total Medicaid beneficiaries. Additionally, of those 15 million, 7 million were expected to remain eligible for the program, but still lose their coverage because of administrative or bureaucratic hurdles, such as missed or poorly written notices or incorrect paperwork.
As of late September, a total of 7.5 million people nationwide had been disenrolled from their Medicaid coverage as a result of state redeterminations.
Another of CMS’s estimates was that one-third of the 15 million enrollees expected to lose Medicaid coverage as eligibility checks resumed would qualify for Patient Protection and Affordable Care Act (PPACA) coverage. Unfortunately, the Washington Post reported last week that as Medicaid rolls are being cut, few are finding refuge in PPACA plans.
Until now, federal officials have refused to release data showing how many people leaving Medicaid have an PPACA plan, but once they do, the initial figures are expected to lag.
The government requires Medicaid agencies to electronically transfer to marketplaces the cases of consumers who appear eligible for PPACA coverage. But some cases are transferred with outdated addresses or phone numbers, making it difficult for the exchanges to reach people who might benefit.
Furthermore, according to the U.S. Department of Health and Human Services (HHS), the government has been actively collaborating with states to make sure Medicaid beneficiaries don’t lose coverage because of administrative issues. Alas, states continue to face challenges with Medicaid redeterminations all the same.
CMS believes that Medicaid eligibility systems in a number of states are programmed incorrectly and are conducting automatic renewals at the family level and not the individual level, even though individuals in a family may have different eligibility requirements to qualify for Medicaid. Correspondingly, HHS announced in a September press release that 30 states had reported such problems.
HHS has since noted that the agency will continue to work with states for as long as it’s needed to help prevent anyone eligible for Medicaid coverage from being disenrolled.
Although identifying this lingering issue, which has been leading to many coverage losses, is seen as a step in the right direction, coverage losses continue to occur more quickly than anticipated.
On the bright side, HHS just announced that the agency has helped 500,000 children and adults get their Medicaid coverage restored, while PPACA exchange directors have pointed out that marketplace health plans could become more popular over time.
However, millions of Medicaid beneficiaries are still without health insurance, and thousands more have the potential to still lose coverage via ongoing redeterminations, so it doesn’t seem like nearly enough is being done on a larger scale. There are clearly important lessons to be learned from the fallout thus far of the Medicaid continuous coverage requirement and its impact on continuity of care. Perhaps there will be a rosier outlook if we check back in another five months.
It finally happened! The Centers for Medicare & Medicaid Services (CMS) finally released the 2026 Outpatient Prospective Payment Final Rule on Friday at 4:15 pm,
Lots of things happening last week for me to talk about. First, still no sign of the 2026 Outpatient Prospective Payment System (OPPS) Final Rule.
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