Unwinding the Continuous Enrollment Requirement

Unwinding the Continuous Enrollment Requirement  

Although the Public Health Emergency (PHE) end has not been formally announced, the administration has taken steps to start the process of unwinding the Continuous Coverage Requirement (CCR). The Consolidated Appropriations Act of 2023 2023 (P.L. 117-328) (the Omnibus Act) was signed into law on December 29, 2022, and includes a pathway to unwinding the CCR that has been in effect since January 2020. As a reminder, since January 2020, when the US Department of Health and Human Services (HHS) declared a nationwide PHE, the Families First Coronavirus Response Act (FFCRA) authorized the Continuous Coverage Requirement (CCR) that required states to maintain enrollment of nearly all Medicaid enrollees. As a result, Medicaid enrollment has reached a record high, with an estimated 90.0 million individuals as of September 2022 enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). The PHE has been renewed every 90 days to maintain the CCR and certain health care flexibilities.  

At the end of December 2022, twenty-five state governors had signed a letter that urged the administration to provide notice of the end of the PHE, which is currently set to expire on January 11, 2023. Since states had not received an official 60-day notice, it was assumed the PHE will be extended until April. In their letter, the signatory states advocated for certainty from the administration, and an end date to begin the unwind process by setting the expiration for April 2023. One such unwinding step will be the redetermination of the eligibility of over 89 million Medicaid recipients. 

Under the FFCRA, states have been receiving a 6.2 percent increase in Federal Medicaid Assistance Percentage (FMAP) throughout the PHE. The Omnibus Act outlines a phase down of the increased FMAP that would correspond to the one-year un-winding of the CCR, allowing states support during the wind down efforts in terms of supporting continued higher enrollment than pre-PHE.  

Figure 1: Phase Down of the FF FMAP Increase  

As we wrote about in the fall 2022 HPN white paper – The End of the COVID 19 Public Health Emergency and the Effect on Health Insurance Coverage– the potential loss of coverage due to the large-scale redetermination efforts could be massive. The breath of the work related to unwind will also include newly released detailed reporting requirements as outlined in the Omnibus Act. This data will be critical to help ensure the tracking of enrollees as they potentially move from Medicaid to other qualified coverage, but also add to the workload on Medicaid departments. 

Departments will have to submit monthly reports starting April 2023, and throughout the unwinding period on the following data points:  

  •  Number of eligibility renewals initiated 
  •  Number of enrollees renewed on total and ex-parte basis 
  • Number of individuals whose coverage for medical assistance, child health assistance, or pregnancy related assistance was terminated, and the number of individuals terminated for procedural reasons 
  • Number of children enrolled in separate CHIP programs 
  • Total call center volume, average wait times, and average abandonment rate for each call center  
  • Such other information related to eligibility determinations and renewals as identified by the Secretary of Health and Human Services (the “Secretary”) 
  • For State-Based Marketplaces that are not integrated with the Medicaid eligibility system, reporting will include the number of individuals received via electronic transfer, eligibility determination for QHP/BHP metrics, and plan selection 
  • For integrated marketplace/Medicaid eligibility states, the information required will include the number of individuals determined eligible for a QHP/BHP and the number of individuals who selected and enrolled in plans 

To date, the message from HHS has been one of collaboration to minimize the impact on individuals and Departments but the Omnibus Act does include monetary implications in the form of a .25-point reduction in the state FMAP for each quarter that reporting is not in compliance. If the reporting continues to be noncompliant, the Secretary may issue a corrective action plan, suspend eligibility terminations, and fine the state, in addition to the FMAP reductions.  

Over the coming months, Departments will begin the process of determination of eligibility, in many instances a full eligibility review or the optional ex-parte review methodology, but nevertheless a better picture of the enrollee populations in each state. As the reporting is compiled and published, the full impact of the CCR will emerge in the data reported to HHS.  

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