The End of Medicaid's COVID-19 Continuous Enrollment Provision

CENTER FOR POLICY ANALYSIS AND RESEARCH Health Equity

July 2023

Tashia Roberson-Wing, John R. Lewis Social Justice Fellow

The End of Medicaid’s COVID-19 Continuous Enrollment Provision

CPAR | The End of Medicaid’s COVID-19 Continuous Enrollment Provision

Introduction In 2020, Congress passed the Families First Coronavirus Response Act (FFCRA) in response to the COVID-19 public health emergency. The enactment of the law ensured that statewide Medicaid programs, through the end of the COVID-19 public health emergency, had a continuous enrollment provision.1 The continuous enrollment provision was a requirement for states in exchange for additional federal funding.2 Since the pandemic, the number of people without health insurance has decreased while the number of people receiving Medicaid has increased primarily due to the continuous enrollment provision.3 On December 23, 2022, the U.S. House of Representatives passed H.R. 2617, the Consolidated Appropriations Act of 2023. The Consolidated Appropriations Act brought an end to Medicaid’s continuous enrollment provision on March 31, 2023, while phasing out the enhanced federal matching dollars.4 Starting April 1, 2023, states were able to purge individuals who did not meet the administrative requirements for Medicaid enrollment. States were given up to twelve months to begin returning to Medicaid eligibility and enrollment regulations that were in place prior to COVID-19.5 Access to health coverage is pivotal for obtaining health care and surviving high medical bills. Historically, there have been disparities in health care coverage among people of color compared to their white counterparts. Between 2019 and 2021, the increase in Medicaid health insurance enrollment rates, due to the continuous enrollment provisions, ensured increases in insurance coverage among all racial/ethnic groups.6 Despite the increase in health coverage amongst all racial/ethnic groups in 2021, 10.9 percent of non-elderly Black people were reported uninsured compared to 7.2 percent of non-elderly white people.7 With the end of continuous enrollment, the U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation estimates that about 15 million people will be dismissed from the Medicaid program.8 Out of those predicted to lose Medicaid coverage, 4.6 million identify as Latino, and 2.2 million identify as Black.9 The end of continuous enrollment is detrimental to Black people accessing Medicaid and furthers the health care coverage disparities within the Black community.

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CPAR | The End of Medicaid’s COVID-19 Continuous Enrollment Provision

Background The Federal Medical Assistance Percentage (FMAP) is a percentage that differs from state to state based on average per-capita income. The state’s total Medicaid expenses are reimbursed by the Centers for Medicare & Medicaid (CMS).10 Medicaid programs are managed through states, but the federal government helps share the cost by matching funds.11 The CMS is a federal entity housed under HHS that is used to administer federal dollars to states. FMAP takes advantage of the existing state Medicaid financial structures to funnel federal dollars without having to establish new policies to create new funding sources.12 This leads to federal funding being distributed to states more quickly.

Increasing the percentage of federal funds allows for increased enrollment among those who are qualified and timely responses for needed health services.13 The FFCRA gave the federal government the authority to increase the Federal Medical Assistance Percentage (FMAP),which temporarily increased the federal government’s share of Medicaid costs among states.14 To help states answer to the Covid-19 public health emergency, Congress, through FFCRA, permitted a 6.2 percent FMAP increase to states with the exception that states abided by the maintenance of eligibility requirements.15 If states accepted the funds, they had to abide by maintenance of eligibility.16 The maintenance of eligibility requirements made certain that states upheld their Medicaid programs and did not cut coverages for beneficiaries.

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CPAR | The End of Medicaid’s COVID-19 Continuous Enrollment Provision

Continuous Enrollment Provision and the Unwinding of the Provision The continuous enrollment provision prohibited terminating an individual’s Medicaid coverage. Under the provision, the process for Medicaid’s regular eligibility renewal and redetermination was under postponement, creating conditions for states to participate in continuous enrollment of the Medicaid coverage program.17 Essentially, the continuous enrollment provision prevented insurance churn.18 Churn refers to a short period of time when Medicaid beneficiaries experience distribution in coverage. The number of individuals enrolled in Medicaid programs around the nation grew by 21.8 percent (71.2 million to 86.7 million) between the beginning of 2020 and the end of 2021.19 While income and employment changes stemming from Covid-19 aided in the increase in Medicaid enrollments, the retention of Medicaid beneficiaries was the primary force behind the increase in enrollment numbers.20 “Unwinding” refers to the period of time when the Medicaid provisions under the Covid-19 public health emergency come to an end and those no longer eligible for Medicaid coverage transition to other insurance plans.21 A phase-down of the increased federal dollars going to states for Medicaid programs has begun due to the ending of the COVID-19 public health emergency. The CMS identified the unwinding process as having two phases. Phase 1 consists of the preparation of the renewal for Medicaid’s new eligibility process and making individuals aware of the changes to the continuous enrollment provision.22 CMS is requiring states to develop and submit plans for how they will conduct this process and their timeline for doing so. Phase 2 consists of transitioning Medicaid participants to some sort of coverage whether it be Medicaid or other coverage plans.23

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CPAR | The End of Medicaid’s COVID-19 Continuous Enrollment Provision

Impact of Ending the Continuous Enrollment Provision on the Black Community Access to healthcare insurance is important for the overall mental, physical, and social health of a human being. Access to healthcare coverage provides opportunities to obtain affordable healthcare services, participate in preventative care, seek primary care doctors, and gain access to emergency services. Lack of coverage can impact a person’s access to a primary care doctor, mental health services, and preventative care. The ending of the continuous enrollment provision hinders access to life-affirming health care. Ending the continuous enrollment provision also leads to insurance churn. People who lose Medicaid and then reenroll are more likely to experience changes in doctors and disruptions in medication.

Because Black and Hispanic people are more likely to enroll in the Medicaid program, the sunsetting of the continuous enrollment provision will cause catastrophic gaps in coverage for Black and Brown communities and families. With potentially an estimated 15 million people losing Medicaid coverage, 4.6 million identify as Latino, and 2.2 million identify as Black.24 In 2021, the U.S. Department of Health and Human Services Office of Minority Health revealed that 42.7 percent of people who identified as non-Hispanic Black/ African American depended on Medicaid or other public health insurance.25 For the year 2021, the United States Census reported that 9.6 percent of Black/African American were living without health insurance compared to their white counterparts at 5.7 percent.26 FIGURE 1 Percentage of People without Health Insurance Coverage by Race and Hispanic Origin: 2021 8.6

Total American Indian and Alaska Native alone, Not Hispanic or Latino

18.8 5.8

Asian alone, Not Hispanic or Latino Black or African American alone, Not Hispanic or Latino

9.6

Multiracial, Not Hispanic or Latino

7.5 10.1

Not Hispanic or Latino

10.6

Some Other Race alone, Not Hispanic or Latino 5.7

White alone, Not Hispanic or Latino

17.7

Hispanic or Latino

Source: U.S. Census Bureau, 2021 American Community Survey, 1-year estimates.

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CPAR | The End of Medicaid’s COVID-19 Continuous Enrollment Provision

Understanding that access to health insurance coverage is a social determinant of health, health insurance directly influences an individual’s health status and health outcomes.

Research illustrates that African Americans face significant disparities regarding health status and health outcomes compared to white Americans.27 Non-Hispanic Black people represent over 12 percent of the United States population but when compared to the U.S. population experience chronic disease, morbidity, and mortality at a higher rate.28 A report from the U.S. Census Bureau disclosed that COVID-19, heart disease, stroke, cancer, asthma, influenza and pneumonia, diabetes, and HIV/AIDS contributed to the deaths of Black people at a higher rate than white people.29 There is a need for access to healthcare coverage in the Black community. The end of the continuous enrollment provision causes greater health disparities in the Black community while widening the quality of health and health coverage access gaps.

Policy Recommendations To help alleviate the coverage loss expected due to the end of continuous enrollment provision, there are legislation recommendations that federal and state policymakers can consider.

Expand the 12 months of continuous eligibility provisions: Twelve months of continuous eligibility is a tool that states use to guarantee that children have continuous health insurance through Medicaid and the Children’s Health Insurance program no matter the change in income/circumstance throughout the 12 months.30 26 Expanding the continuous eligibility provision within Medicaid could ease coverage loss and churn for those expected to lose coverage due to the end of the public health emergency.31 Continuous eligibility can offer individuals, who are expected to lose coverage under the conclusion of the continuous enrollment provision, more time to secure new coverage preventing gaps in coverage.

Expand Medicaid in all states: Medicaid expansion refers to the expanding Medicaid eligibility to almost all adults with incomes up to 138% of the Federal Poverty Level.32 States that decide to expand are provided additional federal funding towards their federal matching percentage. As of late, 40 states and Washington, D.C. have expanded, while 10 states haven’t opted into participating in the expansion.33 Within the states that aren’t expanding Medicaid, more than 300,000 people are expected to lose Medicaid coverage due to the end of the COVID-19 public health emergency. Expanding Medicaid could mitigate coverage loss.34

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CPAR | The End of Medicaid’s COVID-19 Continuous Enrollment Provision

Conclusion Ultimately, states have the authority to end insurance coverage for individuals who do not meet the Medicaid requirements due to the end of the continuous enrollment provision.

Black and Brown communities depend on Medicaid for health coverage. Black, Hispanic, Native Americans/Alaskan Natives and low-income people will disproportionately be impacted by the ending of the provision, causing greater health disparities in the Black and Brown communities. The unwinding of COVID-19’s public health emergency Medicaid provision will result in healthcare coverage shrinkages among those deemed eligible and ineligible for Medicaid because of administrative churn. Policymakers must implement equitable policies that create opportunities for affordable healthcare coverage for Black and Brown communities and prevent disturbances in healthcare insurance.

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CPAR | The End of Medicaid’s COVID-19 Continuous Enrollment Provision

References 1 Tolbert, J. & Ammula, M. (2023, April 5). 10 things to know about the unwinding of the medicaid continuous enrollment provision. Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-ofthe-medicaid-continuous-enrollment-provision/ 2 Id. 3 Id. 4 Rudowitz, R., Burns, A., Hinton, E., Guth, M., & Tolbert, J. (2023, January 24). Medicaid: What to Watch in 2023. Kaiser Family

Foundation. https://www.kff.org/medicaid/issue-brief/medicaid-what-to-watch-in-2023/ 5 Centers for Medicare & Medicaid Services. (n.d.). Unwinding and Returning to Regular Operations after COVID-19.

Medicaid.Gov. https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-andreturning-regular-operations-after-covid-19/index.html 6 Artiga, S., Hill, L., & Damico, A. (2022, December 20). Health Coverage by Race and Ethnicity, 2010-2021. Kaiser Family

Foundation. https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/ 7 Id. 8 Office of the Assistant Secretary for Planning and Evaluation. (2022, August 19). Unwinding the Medicaid Continuous Enrollment Provision: Projected Enrollment Effects and Policy Approaches. U.S. Department of Health and Human Services,

Issue Brief HP-2022-20.

9 Id. 10 Centers for Medicare & Medicaid Services. (n.d.). 100% FMAP for LTSS — Educate Your State. CMS.Gov. https://www.cms. gov/outreach-and-education/american-indian-alaska-native/aian/ltss-ta-center/info/100-percent-fmap-educate-your-state 11 Id. 12 Musumeci, M. (2020, May 4). Key Questions About the New Increase in Federal Medicaid Matching Funds for COVID-19.

Kaiser Family Foundation. https://www.kff.org/coronavirus-covid-19/issue-brief/key-questions-about-the-new-increase-infederal-medicaid-matching-funds-for-covid-19/ 13 Id. 14 Danner, R. (2023). Millions set to lose Medicaid coverage as the continuous enrollment provision ends. Georgetown

Journal on Poverty & Policy. https://www.law.georgetown.edu/poverty-journal/blog/millions-set-to-lose-medicaid-coverageas-the-continuous-enrollment-provision-ends/ 15 Dolan, R., Musumeci, M., Tolbert, J., & Rudowitz, R. (2020, December 17). Medicaid Maintenance of Eligibility (MOE) Requirements: Issues to Watch. Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/medicaid-maintenanceof-eligibility-moe-requirements-issues-to-watch/ 16 Id. 17 Supra note 8.

18 Supra note 1.

19 Supra note 8.

20 Id.

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CPAR | The End of Medicaid’s COVID-19 Continuous Enrollment Provision

21 Id. 22 Centers for Medicare & Medicaid Services. (n.d.). What is Unwinding? CMS.Gov. Retrieved April 20, 2023, from https://www.cms.gov/aian-unwinding 23 Id. 24 Supra note 8.

25 U.S. Department of Health and Human Services Office of Minority Health Resource Center. (n.d.). Profile: Black/African Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=61 26 Branch, B., & Conway, D. (2022). Health Insurance Coverage by Race and Hispanic Origin: 2021. U.S. Census Bureau.

27 Office of the Assistant Secretary for Planning and Evaluation. (2022). Health Insurance Coverage and Access to Care Among Black Americans: Recent Trends and Key Challenges. U.S. Department of Health and Human Services, Issue Brief

No. HP-2022-07.

28 Id. 29 Supra note 25.

30 Centers for Medicare & Medicaid Services. (2021). Continuous Eligibility for Medicaid and CHIP Coverage. Medicaid.Gov. https://www.medicaid.gov/medicaid/enrollment-strategies/continuous-eligibility-medicaid-and-chip-coverage/index.html 31 Supra note 8.

32 Kaiser Family Foundation. (2023, March 27). Status of State Medicaid Expansion Decisions: Interactive Map. KFF. https:// www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/ 33 Id. 34 Supra note 8.

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CENTER FOR POLICY ANALYSIS AND RESEARCH Health Equity

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