Medicaid eligibility review paths diverge across states, posing challenges for cross-state comparison and fairness assessment

States are taking vastly different approaches to Medicaid redeterminations, making it difficult to compare disenrollment data across states and to determine whether the process is exacerbating health inequities, experts say.

After the continuous enrollment period during the pandemic ended, states have begun tackling the complex and unprecedented task of determining which beneficiaries in the public insurance program for low-income Americans remain eligible.

Since April, states have been able to begin removing beneficiaries from Medicaid. According to KFF data, as of June, nearly 2 million people had been removed from the program in 29 states and the District of Columbia.

Overall, more than 15 million people are expected to be disenrolled from Medicaid during the redetermination process, according to estimates from the Georgetown University Center for Children and Families. Of those, more than 6 million may end up completely uninsured, reversing the gains in coverage during the pandemic—gains that particularly benefited low-income Americans.

However, disenrollment numbers currently vary widely by state, and experts say it is too early to judge the overall process, especially in states that only began removing beneficiaries this summer.

"This is a classic example of every state handling the 'unwinding' differently, and every state will produce vastly different results," said Brad Corallo, senior policy analyst for KFF's Medicaid and uninsured programs.

Apples and Oranges: States' Approaches Differ

Experts note that states are conducting redeterminations in multiple ways, adding complexity to assessing the impact of the unwinding on the Medicaid population.

For example, South Carolina initially focused on those who might not be eligible or who had not responded to renewal requests during the pandemic. Virginia used regular renewal dates, while Oklahoma divided members into high-risk or low-risk groups, aiming to provide support to more vulnerable populations such as those with chronic conditions.

"States do have considerable flexibility in deciding who to prioritize for renewals. That's helpful because states can take reasonable approaches based on local circumstances. But it also makes cross-state comparisons difficult," said Kate McEvoy, executive director of the National Association of Medicaid Directors.

Among the 29 states, only a few have largely automated renewal processing systems. According to KFF data, only 18 states complete half or more of their renewals through the 'ex parte process'—a procedure that allows states to use existing data to confirm eligibility without requiring enrollees to take action. States lacking these tools may face additional administrative burdens for staff and beneficiaries.

"...Cross-state comparisons will be difficult, and ultimately it will be hard to draw comprehensive national conclusions."

—Brad Corallo, Senior Policy Analyst, KFF

In states that have not expanded Medicaid to adults with incomes up to 138% of the federal poverty level, or that have not extended postpartum coverage, disenrolled beneficiaries are more likely to fall into the 'coverage gap'—where incomes are too low for marketplace subsidies but too high for Medicaid eligibility.

"In non-expansion states, especially pregnant individuals or young people leaving Medicaid will have a harder time getting coverage," said Sara Collins, vice president of The Commonwealth Fund. "Therefore, those states are likely to see higher uninsured rates because there is a larger gap."

Procedural Disenrollments Raise Concerns

Advocates also worry about high rates of procedural disenrollments, which indicate that beneficiaries may be removed due to paperwork issues even if they remain eligible. KFF found that in states with data, 73% of disenrollments were due to procedural reasons, meaning the renewal process was not completed. In South Carolina, 93% of disenrollments were procedural.

Other vulnerable groups may have difficulty confirming their Medicaid eligibility, including those with limited English proficiency, the elderly, people with disabilities, and those unfamiliar with technology or without reliable internet access.

Vulnerable populations are most susceptible to improper disenrollment, but comparing disenrollment differences across states is difficult, said KFF's Corallo. Some states break down disenrollment data by factors such as age, race, and ethnicity, but others do not, or report in different formats.

"It's entirely up to the states to decide how to break down these subgroups, or whether to do so at all," Corallo said. "So, the information we get on subgroup analyses will be very limited...Cross-state comparisons will be difficult, and ultimately it will be hard to draw comprehensive national conclusions."

Additionally, states' decisions on priority groups may affect early data. According to KFF, South Carolina's disenrollment rate is currently 72%, but the state first targeted those who might not be eligible. Moreover, if pending renewals are included in the calculation, the state's disenrollment rate would drop significantly.

NAMD's McEvoy said that as more states begin disenrollments, a clearer picture of the impact of redeterminations will emerge by late summer. In September, the federal government is expected to release the first detailed data on marketplace plan enrollment, which will help understand whether disenrollees are moving to Affordable Care Act exchanges.

Navigating Renewals: Assistance Organizations Respond

As states begin disenrollments, groups such as insurance navigators are working to help beneficiaries renew Medicaid or find new plans.

Adam VanSpankeren, program director for navigators at Covering Wisconsin, a nonprofit in Wisconsin, said the organization has been preparing for Medicaid redeterminations for years. Covering Wisconsin is filling gaps through additional training because many navigators have not recently been involved in the Medicaid renewal process. The organization is also strengthening outreach to ensure beneficiaries understand what they need to do and when.

"We work closely with Wisconsin and other partners, regularly participating in workgroup meetings to continuously identify different vulnerable groups and how Wisconsin citizens may be affected," he said.

In Kansas, The Community Care Network of Kansas, an association of health centers and community clinics, has compiled a series of resources to help providers and patients navigate the unwinding process. Cover Kansas added its resources and external toolkits to the dashboard of the Medicaid Renewal Help Network, which is dedicated to sharing renewal information, according to Kate Gramlich, project manager at Cover Kansas. The organization has nearly 200 people registered for conference calls and newsletter subscriptions.

Despite significant resources invested in outreach, many beneficiaries still do not understand Medicaid redeterminations, said NAMD's McEvoy.

"This is not a static process. Plans are learning as they go and determining where they need to adjust outreach strategies," McEvoy said. "If they find that groups like children are losing coverage, they will adjust communication strategies and support reinstatement of coverage."