Eligibility

While making their financial projections for 2023, health insurers have had to acknowledge that the timing of a major headwind — the resumption of Medicaid eligibility redeterminations — continued to be a question mark. Now, if a newly released draft of Congress’ year-end spending bill is passed as written, that uncertainty will be removed and replaced with a firm date: April 1.

Industry observers tell AIS Health, a division of MMIT, that it’s helpful for both state governments and managed care organizations to have a definite answer about when millions of people will start losing their Medicaid eligibility — although the event itself remains a net negative for MCOs.

At some point in the next year, it’s likely that Medicaid eligibility redeterminations will resume — a process that will be kicked off when the Biden administration declares an end to the COVID-19 public health emergency (PHE). Medicaid has hit record-high enrollment this year, meaning states and managed care organizations will have to contact more people than they ever have before in a short period of time; meanwhile, MCOs will also have to deal with looming cuts to reimbursement and rising provider rates.

Margins for MCOs seem likely to shrink. Provider rate increases are coming soon, though it’s likely that they will vary in timing and scope depending on market and contract cycles. However, the pricing effects of workforce shortages and inflation will impact every plan and provider, sources previously told AIS Health.

For decades, a successful vaccine for respiratory syncytial virus (RSV) — which sends thousands of infants and older adults to the hospital each year — has remained elusive. Yet several heavyweight pharmaceutical companies are now poised to fill the void, as they’re nearing the finish line in the development of RSV vaccines that could ultimately comprise a multibillion-dollar market. Coverage of the new vaccines, according to an industry expert, will hinge on the all-important Advisory Committee on Immunization Practices (ACIP), which requires payers to fully reimburse any inoculation that it recommends.

During the past two years, the number of people enrolled in Medicaid and marketplace plans has significantly increased thanks to legislation meant to help people as the COVID-19 pandemic continues. But millions of those people may lose their health insurance coverage in the coming months if those policies end, which could lead to difficult circumstances for them and the health care industry as a whole, according to health policy experts who spoke during a July 15 webinar sponsored by Alliance for Health Policy, a Washington, D.C., nonprofit.

As of March 2022, nearly 87.9 million people were enrolled in Medicaid or the Children’s Health Insurance Program, up from just over 71.2 million in February 2020, according to the Kaiser Family Foundation (KFF). Sara Collins, Ph.D., vice president for health care coverage and access at the Commonwealth Fund, noted that much of the increase could be attributed to the Families First Coronavirus Response Act (FFCRA).

When the Biden administration ends the COVID-19 public health emergency (PHE), states will disenroll millions of Medicaid beneficiaries — and insurers will have to take Medicaid MCO members off their books. Experts tell AIS Health, a division of MMIT, that carriers can take steps to retain some of those members by helping them enroll in Affordable Care Act (ACA) marketplace coverage — but say the number of people who make the switch will be far lower than the number of people who joined the Medicaid rolls during the pandemic (see infographic).

Medicaid and individual exchange enrollment have both boomed with the higher federal funding that was included in the American Rescue Plan Act (ARPA) — and both segments’ total enrollment and enrollee profiles will change significantly when that extra funding ends.

With the COVID-19 public health emergency presumably continuing into October, state Medicaid agencies and their partners theoretically have more time to communicate with enrollees and prepare for the inevitable resumption of eligibility redeterminations once the PHE ends. But ongoing uncertainty over the PHE’s end date presents a host of challenges for states as they handle unprecedented numbers of Medicaid enrollees and attempt to conduct other program work unrelated to redeterminations, according to officials from California, Iowa and North Carolina who spoke during a May 24 webinar hosted by the National Association of Medicaid Directors (NAMD).

Throughout the PHE, which was declared in January 2020 and first renewed that April, states have received a temporary 6.2 percentage-point increase in their Federal Medical Assistance Percentage (FMAP) in exchange for maintaining continuous enrollment of nearly all Medicaid recipients. Once the PHE ends, states have 12 months to initiate eligibility reverifications for everyone enrolled in Medicaid and CHIP and 14 months overall to complete redetermination efforts.

When the Biden administration ends the COVID-19 public health emergency (PHE), states will disenroll millions of Medicaid beneficiaries — and insurers will have to take Medicaid MCO members off their books. Experts tell AIS Health, a division of MMIT, that carriers can take steps to retain some of those members by helping them enroll in Affordable Care Act (ACA) marketplace coverage — but say the number of people who make the switch will be far lower than the number of people who joined the Medicaid rolls during the pandemic (see infographic).

Medicaid and individual exchange enrollment have both boomed with the higher federal funding that was included in the American Rescue Plan Act (ARPA) — and both segments’ total enrollment and enrollee profiles will change significantly when that extra funding ends.

With radio silence from HHS on May 16 — when states at the very latest had expected to hear whether the COVID-19 public health emergency would end in July — HHS at press time appeared to be gearing up for another extension of the PHE. This will give states, insurers and other stakeholders more time to prepare for the inevitable resumption of Medicaid eligibility redeterminations, which could cause millions of adults and children to lose health insurance coverage.

The PHE has been extended multiple times since the start of the pandemic and remains a moving target. As a condition of receiving enhanced federal funds during the PHE, states have been required to ensure continuous Medicaid and CHIP coverage for most enrollees by pausing eligibility redeterminations. And the Biden administration has promised to provide states 60 days’ notice before any possible termination or expiration. But without such notification, sources estimate the next end date could be Oct. 13. Bloomberg on May 16 reported that the PHE would be extended past mid-July, “according to a person familiar with the matter.”

A pilot with Drips’ trademarked “conversational texting” platform has helped WellCare significantly lower the percentage of Prescription Drug Plan policies that were being terminated due to nonpayment, according to a case study presented at the 13th Annual Medicare Market Innovations Forum, held May 11 and 12 in Phoenix.

Since WellCare was acquired by Centene Corp. in January 2020, the PDP team has been focused on “optimizing operational execution” and ensuring a positive member experience, said WellCare Senior Director of Prescription Drug Plans Talia Duany, who presented the case study with Drips. “When you’ve got 4.1 million members in an industry that’s shrinking — this year we saw the biggest [decline] in available PDP options, everyone’s moving into [Medicare Advantage] — having a robust member retention strategy” is critical.

As a condition of receiving enhanced federal funds during the COVID-19 public health emergency (PHE), states were required to take certain steps to ensure continuous Medicaid and CHIP coverage for most enrollees, leading to a nearly 18% jump in Medicaid enrollment. But with the latest PHE extension set to expire on Jan. 16, states will no longer receive such funds and will therefore no longer be required to maintain continuous coverage, although CMS has given them 12 months after the month in which the PHE ends to complete eligibility redeterminations. As a result, supporting states’ reverification efforts and ensuring that eligible members stay on the rolls or have a viable landing spot will be critical to Medicaid managed care organizations this year, industry experts tell AIS Health, a division of MMIT.