Public Health Emergency Unwind - Community Catalyst

Introduction

At the onset of the COVID-19 pandemic, Congress established protections for Medicaid and Children’s Health Insurance Program (CHIP) enrollees to stay on their health coverage — which is sometimes called continuous eligibility — during the Public Health Emergency (PHE).

But in December 2022, Congress de-linked the Medicaid and CHIP continuous eligibility requirements from the declaration of the PHE, setting a start date for when states can begin to re-determine eligibility and remove people from coverage (also known as “disenrollment”).

It is predicted that 5 to 18 million people will lose coverage or be forced to transition to other forms of health care coverage because of changes in income or life circumstances.

Introduction
Introduction
What is the Public Health Emergency (PHE)?
What is the Public Health Emergency (PHE)?
How does the PHE effect health care coverage?
How does the PHE effect health care coverage?
People impacted
People impacted
Take action
Take action
Key resources
Key resources
Questions
Questions
Spread the word
Spread the word

“People want affordable care and they want it now.”

Executive Director Emily Stewart

What is the Public Health Emergency (PHE)?

A Public Health Emergency (PHE) is a declaration by the Secretary of the U.S. Department of Health and Human Services (HHS) that allows the Secretary to take certain actions during the PHE. During the COVID-19 PHE, the Centers for Medicare & Medicaid Services (CMS) “used a combination of emergency authority waivers, regulations and sub-regulatory guidance to ensure and expand access to care and to give health care providers the flexibilities needed to help keep people safe.”

The federal PHE will expire at the end of the day on May 11, 2023.

How does the PHE affect health care coverage?

The Centers for Medicare & Medicaid Services (CMS) has announced a Special Enrollment Period (SEP) to mitigate some of the anticipated coverage losses. However, up to 7 million people — who are still eligible for Medicaid or CHIP — are at risk of being disenrolled or removed from their health coverage programs due to procedural issues like incorrect contact information.

Beyond Medicaid, many other PHE-related policies will begin to phase out once the PHE officially ends on May 11, 2023. The Biden administration and individual states are actively considering strategies to ensure continued access to free COVID-19 vaccines, testing and treatment — especially for the uninsured.

Congressional action during the PHE also extended Medicare telehealth flexibilities, which allowed individual states to implement it for Medicaid and CHIP. So far, most states have committed to making those flexibilities permanent.

Who does the PHE impact and how?

Many communities will be impacted by the Medicaid and PHE unwinding, including:

Community	Context	Resources
Children, people of color, ACA expansion adults	Children, people of color, ACA expansion adults saw the largest gains of coverage during the continuous eligibility and are estimated to lose coverage at higher rates.	States Must Act to Preserve Medicaid Coverage as End of Continuous Coverage Requirement Nears Fact Sheet: Medicaid Unwinding: How To Protect Children from Losing Coverage Not a Moment to Lose: Critical Changes States Should Implement to Prevent Medicaid Coverage Losses
American Indian/Alaska Natives	Upward of 250,000 American Indian/Alaska Native people may lose coverage during the unwinding due in part to limited access to postal mail and/or broadband access.	National Indian Health Board – Medicaid Unwinding webpage NIHB Medicaid Unwinding Webinar: Updates and Best Practices for Tribal Enrollment Assisters
Immigrants and their families	Immigrants will need messages to reassure them that applying for health care coverage will not impact their or a loved one’s immigration status. People with limited English proficiency may face challenges to find resources and support in their primary language.	CMS Letter: Ensuring Language Access for Limited English Proficient (LEP) Individuals and Effective Communication for Individuals with Disabilities During the States’ Unwinding of the Medicaid. Use this checklist (Google doc) to encourage your state to create immigrant-friendly unwinding plans. This memo (Google doc) summarizes CMS unwinding guidance related to immigrants. States Can Help Eligible Immigrants Keep Medicaid Coverage at PHE’s End Protecting People with Disabilities and People with Limited English Proficiency during the Unwinding of the Continuous Coverage Provision
People with disabilities	The PHE permitted regulatory flexibilities for disability service providers, like expanded service settings, and the ability to provide temporary direct support wage increases and pay family caregivers which may go away. People who are deaf, hard of hearing, blind, or visually impaired may face challenges to find resources on the redetermination process in American Sign Language (ASL), braille, or from a trained translator.	This ANCOR survey found that 66% of providers are concerned that the loss of COVID-19 relief funding and regulatory changes after the Public Health Emergency ends will lead to higher vacancy and turnover rates in their workforce. States Should Streamline Medicaid Enrollment and Renewal for Older Adults and People With Disabilities Ahead of Unwinding Disabilities Ahead of Unwinding
Dually-eligible population	Compared to people only enrolled in Medicare, Medicare-Medicaid enrollees need more support for daily living, have higher rates of poverty, and have communications needs that require specific outreach, enrollment assistance, and care coordination. Without specialized support to navigate the redetermination process, people dually enrolled in Medicare and Medicaid are at risk of losing Medicaid services that are not covered by Medicare, such as transportation and other home and community-based services. Loss of Medicaid will also eliminate the financial supports that make Medicare insurance affordable, such as reduced premiums and protections from deductibles and co insurance, which puts independent living at risk.	Unwinding Medicaid Continuous Coverage Protections: Implications and Advocacy for Individuals Dually Eligible for Medicare and Medicaid
People who rely on Medicaid for oral health coverage, substance use disorder treatment, and mental / behavioral health	Dental care is not considered an essential health benefit. Even if someone successfully transitions to private insurance, they may lose dental benefits they previously had covered under Medicaid. People who end up uninsured will lack access to dental as well as medical care. For people with substance use disorders, suddenly losing health insurance could result in losing essential medications and services. Lapses in treatment can result in dangerous return to drug use, putting the person at risk for fatal overdose. Telehealth flexibilities may change from state-to-state and could impact people who rely on telehealth access for mental and behavioral health services, especially in rural communities.	Supporting Continuity of Coverage from Medicaid into the Marketplace: Unwinding Considerations for States How many adults will lose their Medicaid dental benefits?
LGBTQ+ Communities	Navigating coverage for gender affirming health care may be particularly challenging for transgender and nonbinary people seeking services and transitioning from Medicaid to other health insurance plans. Out2Enroll found that only half of health insurance plans on the federal marketplace for 2023 name the types of services they cover within gender affirming health care.	Advocates can share health insurance guides from Out2Enroll that summarize coverage for gender-affirming health care in their state. They can also encourage people to reach out to LGBTQ+ competent enrollment assisters and encourage their state to implement LGBTQ+ competency trainings to broaden the network of available supports.
Adults with low incomes in non-expansion states*	Adults with low-incomes who are in the coverage gap are at risk because their incomes are above the Medicaid thresholds in non-expansion states but too low to qualify for subsidies in the ACA marketplace. In the 10 non-expansion states undergoing redeterminations, hundreds of thousands of people — 60 percent of whom are people of color — could lose their Medicaid coverage without any other affordable coverage option.	This report emphasizes why states should expand Medicaid as the PHE unwinds. It includes state-level data for non-expansion states on: (1) the number of people estimated to become uninsured during the unwinding; (2) how many could gain coverage with expansion; and (3) new estimates for federal funding available through the two-year American Rescue Plan incentive for states that newly expand Medicaid.
People who have moved since the they last renewed their Medicaid coverage	Medicaid agencies may not have up-to-date address and contact information for people who have moved since they last renewed their Medicaid coverage. If communication is not achieved in a timely manner, lapses in coverage can occur for people despite still being eligible.	State-by-state flyers to help Medicaid enrollees update their contact information and apply for marketplace coverage. As State Medicaid Programs Prepare to Resume Disenrollments, Many States Are Using a Range of Strategies to Make it Easier for People Who Remain Eligible to Retain Coverage, But in Others it Will be More Difficult

*Non-expansion states — which are states with elected officials who refuse to expand Medicaid — include Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wyoming, Wisconsin. North Carolina passed Medicaid Expansion in 2023.

How can I help?

Local, state, and national advocacy organizations are working tirelessly to make sure that Medicaid and CHIP enrollees do not experience lapses in coverage. Here’s some ways you can advocate in your community:

Push your state’s Medicaid agency to publicly publish its unwinding operational plans, plans for communicating with Medicaid and CHIP enrollees, and a corrective action plan (if your state anticipates not being able to meet federal requirements for redetermination). Similarly, CMS should be pushed to publish its plans for all states.

Assess these plans to ensure the needs of dually eligible people, immigrants, transgender and nonbinary people are taken into account.

Clearly communicate how health care coverage benefits differ between Medicaid/CHIP, ACA Marketplace, and employer-sponsored plans. As people transition, they need to know what to expect. This might be health services that are no longer available or new or different out-of-pocket costs. For example, your state may require Medicaid to cover adult dental care, but ACA Marketplace plans may not include dental coverage.

Key Resources

Dates to Know

March 31, 2023 – Medicaid and CHIP continuous coverage ends.

April 1, 2023 – Renewals resume for all Medicaid enrollees. States can begin disenrolling people from Medicaid and CHIP they determine no longer eligible.

May 11, 2023 – Public Health Emergency (PHE) ends.

March 31, 2023 – July 31, 2024 – Special Enrollment Period (SEP) for people who lose coverage during this time frame.

Websites to Bookmark

50-State Unwinding Tracker: a map-based tracker from Georgetown University’s Health Policy Institute offers a broad overview of how individual states are preparing for the unwinding.
Unwinding and Returning to Regular Operations after COVID-19: is an official government resource maintained by the Center for Medicaid and CHIP Services (CMCS), hosted on Medicaid.gov.
State Health and Value Strategies, Center for Children and Families, Center on Budget and Policy Priorities, and Kaiser Family Foundation all have dedicated materials on the unwinding.
Organizing for Outreach: Materials available in up to 20 languages to support your outreach and enrollment efforts, enrollee outreach videos and flyers.
Medicaid Continuous Enrollment Condition Unwinding Marketplace Frequently Asked Questions (FAQ): New FAQ from CMS on Medicaid unwinding and how to transition to Marketplace coverage.

Need more help?

Do you need help navigating the PHE unwind in your community? Let us know how best we can assist by commcat@communitycatalyst.org.

Spread the word

This is vital information that will impact millions of people throughout the United States. Connect with us on social media and help us spread the word and share accurate, timely information so that everyone can have the tools they need and deserve to be as healthy as possible.