To Emergency and Beyond….

To Emergency and Beyond. From Pandemic to Endemic. Sounds like science fiction, but it is our reality and our future as we attempt to navigate through and beyond the COVID-19 virus our world has been plagued with for more than two years.

 

Record high Medicaid and CHIP enrollment

During these two-plus years, enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) has increased by over 14 million, a result of states’ response to the Families First Coronavirus Response Act (FFCRA).  This legislation increased a state’s Federal Medical Assistance Percentage (FMAP) by 6.2 percentage points so long as the state maintains “continuous eligibility” for their Medicaid beneficiaries. Continuous eligibility extends through the calendar month in which the Health and Human Services (HHS) declared Public Health Emergency (PHE) ends and the 6.2 percentage point FMAP increase through the calendar quarter in which the HHS’ PHE ends. The latter is a duration of approximately two and one-half months.

 

The PHE end date has been a source of angst for Medicaid beneficiaries, healthcare providers, health plans, and states. As of September 2021, nearly 85 million people were enrolled in Medicaid and CHIP. According to the Centers for Medicare and Medicaid Services (CMS), every beneficiary will be due for a renewal at the end of the PHE, currently set to expire April 16.

 

“Unwinding”

HHS must renew the PHE every 90 days. President Biden has committed to giving states 60-days’ notice before the end date of the final renewal. Notice has not been issued which leads us to believe the PHE will be renewed again, through at least mid-July. Some predict the PHE will be renewed until after the mid-term elections. Regardless, the time to prepare for “unwinding” Medicaid and CHIP continuous eligibility is now! A comprehensive Unwinding website has been established to guide states.

 

On March 8, 2022, CMS issued a 46-page State Health Official (SHO) letter #22-001 to assist states in their planning efforts. This SHO has two overriding themes: 1) promotion of coverage continuity and 2) guarding against inappropriate terminations.

 

SHO #22-001 give states 12 months to “initiate” their unwinding with an additional two months to “complete” it, for a total of 14 months. States may initiate their unwinding up to two months before the end of the PHE but no later than the month following the end of the PHE. They may not terminate coverage for any beneficiary until the first of the month following the end of the PHE without risking their 6.2 percentage point FMAP increase. The 14-month timeclock starts ticking the month a state starts its unwinding. CMS will gather baseline enrollment data for each state and then monitor ongoing. Of concern to CMS will be any state who processes more than one-ninth of their “total caseload” in any given month and could result in corrective action.

 

Operational plan

States will need to develop a comprehensive “unwinding operational plan” to restore routine operations, detailing how they will complete outstanding work and maximize uninterrupted coverage for eligible individuals. A state’s operational plan does not have to be reported to nor approved by CMS, except upon request. There is not a transparency requirement so accessing a state’s plan may prove to be difficult. State plans will be like snowflakes, no two will be alike. Depending on what actions and strategies a state chooses to deploy, there will be other documents that states may need to complete and possibly get approval on. These include State Plan Amendments, various waivers, verification plans, and more.

 

MAGI vs. Non-MAGI

Federal rules for Medicaid renewals vary depending on whether a program of eligibility is or isn’t based on Modified Adjusted Gross Income (MAGI). States are required to use an ex parte process for MAGI-based renewals. This means they attempt to conduct the renewal using reliable information and electronic data sources, without requesting information from the beneficiary. If the agency can renew eligibility based on the available reliable information, the agency sends a notice to the beneficiary. The renewal is complete. No action is required by the beneficiary. If a state cannot renew on an ex parte basis, they will send the beneficiary a pre-populated form, wait for a response, and then act according to what they receive back. The reconsideration period allows the state to accept and process the renewal form as they would an application, without requiring a new application. In most states, eligibility can be retroactive, so it is possible for a lapse in coverage to be avoided. Less work for the beneficiary, less work for the state.

 

Below is a table illustrating some of the renewal differences between MAGI and Non-MAGI.

MAGI	Non-MAGI
Children, newborns, pregnant women, parents and caretaker relatives, Group VIII “expansion adults” aged 19-64 with no other coverage	Aged (65+), blind, disabled, Medicare secondary payers (QMB, SLMB, QI-1), long-term care, many medically needy or spenddown programs
Income limit	Income and asset limits
Ex parte process required	Ex parte process not required
Pre-populated form with instructions	Form with instructions
30 days to return	Return within “a reasonable period of time”
90-day reconsideration period required	Reconsideration period optional