Ensuring Continuity of Coverage for Enrollees in Need When Continuing Medicaid Coverage Ends | Manatt, Phelps & Phillips, LLP


On March 3, 2022, the Centers for Medicare & Medicaid Services (CMS) released a Letter from State Health Officer (SHO)Promote continuity of coverage and distribute eligibility and enrollment workload across Medicaid, Children’s Health Insurance Program (CHIP), and Basic Health Program (BHP) at the end of the emergency public health COVID-19.” The guidance sets out expectations, options, and flexibilities for states when developing their operational plans for resuming new Medicaid determinations. According to the CMS guidelines, States are expected to adopt a “risk-based approach” when prioritizing pending eligibility and listing actions, which could be:

  • Temporal or age-based approachwho prioritizes cases based on how long the case is pending
  • Population-based approachthat prioritizes renewal actions based on the characteristics of cohorts or populations that may remain eligible, become eligible for expanded Medicaid benefits, or become ineligible for Medicaid and eligible for different coverage
  • Hybrid approachwhich combines population and temporal approaches
  • Approach developed by the Statewhich must achieve the goals of maintaining coverage of eligible individuals, minimizing the extent to which potentially ineligible individuals remain enrolled, achieving a sustainable renewal schedule, and meeting 12-month rollout schedule expectations.

Most states pursue a hybrid approach by broadly planning a time/age-based approach, but applying a population-based approach by flagging specific populations for earlier or later renewal.

State Medicaid agencies have (rightly) devoted resources to planning their risk-based approaches, improving their overall refill processes, strengthening communication, reducing returned mail and leveraging their community organizations and Medicaid managed care plans for outreach and communication. In addition to these broad coverage continuity strategies for all current Medicaid enrollees, states may consider additional targeted strategies to provide continuity of coverage and care for sicker individuals with health care access needs. higher health.

Medicaid Strategies to Support Continuity of Coverage and Care for Enrollees in Need

Identify enrolled populations that may be at risk if they lose or have gaps in coverage. According to CMS guidelines, states may not prioritize populations for re-determination “based solely on the Medicaid eligibility group in which they are enrolled” and may not conduct a population-based re-determination approach that is discriminatory . CMS has confirmedhowever, that states may develop specific relaxation approaches for people undergoing treatment for chronic or life-threatening illnesses

Prioritize renewal for high-risk enrollees based on a schedule that mitigates the risk of loss of coverage and access gaps. Once states have identified high-risk enrollees, they can prioritize the timing of their re-determination with a view to minimizing the risk of loss of coverage and access gaps, for example by aligning the timing of renewals for those pregnancy/postpartum eligibility groups with the implementation of postpartum coverage expansion through the American Rescue Plan Act new status option.

Adopt special redetermination processes, including targeted communications, for high-risk registrants. States may implement special redetermination processes, including notification, to help high-risk enrollees retain coverage or transition seamlessly to new coverage, such as longer response times, follow-up of second requests for information and/or telephone contacts, and an improved offer helps with awareness and renewal.

In states with state-based markets (SBMs), flag high-risk individuals transferred to the market as requiring specialist assistance to ensure continuity of coverage and care. Medicaid agencies and Marketplaces in SBM states could collaborate to design a system indicator to identify people with unique health needs who require specialized Marketplace and Navigator/assistant support to ensure continuity of coverage, services , network providers or pharmaceuticals.


The end of Medicaid’s continued coverage guarantee is an imminent and seismic health coverage event. All people currently enrolled in Medicaid face the risk of losing coverage, including for procedural reasons, and a related gap in access to affordable health coverage. This risk is most acute and most likely to cause harm to people with serious health conditions who depend on continued coverage to allow them to access care to treat chronic, debilitating and sometimes life-threatening conditions. Importantly, collaboration between Medicaid agencies, marketplaces, and state insurance regulators will be essential to preserve access to coverage and care for these individuals.


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