CMS Releases First Batch of State-Reported Unwinding Data
Patricia Boozang, Kaylee O’Connor, and Michelle Savuto, Manatt Health
Overview of CMS Data Release
On July 28, 2023, the Centers for Medicare & Medicaid Services (CMS) released publicly through its “Unwinding and Returning to Regular Operations after COVID-19” landing page state-reported data providing a window into how the unwinding of the federal Medicaid continuous coverage requirement is progressing. This initial data release is captured under the “Data Reporting” menu option. This landing page offers aggregated historical information—such as pre-pandemic rates of health coverage and churn—to help contextualize state unwinding data, and key takeaways summarizing Medicaid and Children’s Health Insurance Program (CHIP) renewal outcomes for April 2023. The navigation bar on the left features three sub-tabs that provide more detailed data and information:
- “Monthly Data Reports” includes March and April 2023 data, nationally and by state, pertaining to Medicaid and CHIP eligibility renewals, transitions to HealthCare.gov and State-Based Marketplace (SBM) coverage, and call center operations, as well as Medicaid and CHIP enrollment and Modified Adjusted Gross Income (MAGI) application processing. These data are available for download through an Excel file and as a PDF summary encompassing data definitions and contextual detail.
- “Understanding the Data” provides two resources to better understand and interpret the unwinding metrics:
- “Data Sources and Metrics Definitions Overview” summarizes the Medicaid, CHIP, and Marketplace data sources used by CMS to develop the unwinding reports, including data from the monthly Unwinding Data Report and Performance Indicators (as noted above), Transformed Medicaid Statistical Information System (T-MSIS), HealthCare.gov, SBMs, and Basic Health Programs. CMS provides measure definitions, notes and important details on how and why various measures differ—urging caution in comparing metrics. Reviewing this document is essential for anyone planning to analyze the unwinding data.
- “Historic Trends in Coverage Continuity, Loss, and Churn” provides a 2018 snapshot of the rates of continuous coverage, coverage loss, and churn for Medicaid and CHIP enrollees.
- “Data Reporting Tools” compiles unwinding data reporting templates, forms, and specifications to support states with their reporting obligations during the unwinding period. CMS does not appear to have modified any of these existing resources in light of the July data release.
CMS plans to continue releasing unwinding data on a monthly basis in two releases until all data are reported for the months through June 2024. The first release for a given month will capture renewal outcomes, call center operations, and initial transitions to Marketplace coverage (as is reflected for July). The second release will come two months later and will focus on Medicaid/CHIP transitions to Marketplace coverage in HealthCare.gov states (see the illustrative timeline for data release below). (CMS does not expect to have comprehensive data on individuals transitioning from Medicaid/CHIP to Marketplace coverage until fall 2023—likely due to the lag in T-MSIS data.)
Making Sense of the Data
The new unwinding data from CMS indicates that, among the 18 states that reported at least one full cohort of unwinding-related renewals due in April 30, 2023, close to half (46%) of people that were due for renewal had their coverage successfully renewed. About one third (32%) of the 2.2 million people that were due for renewal lost coverage; and the remainder of cases were still pending. Most terminations (almost 80%) happened for procedural reasons; and 54,000 consumers with previous Medicaid or CHIP enrollment or with a Medicaid/CHIP denial/termination made a qualified health plan selection, with the caveat that full data on Marketplace transitions is still forthcoming and HealthCare.gov and SBM data are generally not comparable. These preliminary transition numbers may exceed expectations of some observers, given Medicaid and CHIP Payment and Access Commission findings that only about 3% of people terminated from Medicaid and CHIP enroll in Marketplace coverage within a year after disenrolling.
While CMS is making granular, state-level data available through this and subsequent releases, the reporting falls short in providing a complete picture of unwinding status given the protracted timeline and lag in data releases. Some stakeholders are instead leveraging state-released data and other external tools that utilize the same underlying source of data (i.e., the monthly CMS Unwinding Data Report), which is accessible to the extent states voluntarily publish their reports or reports are obtained by Freedom of Information Act requests. For example, Georgetown University Center for Children and Families’ interactive chart tracks key metrics across states (e.g., ex parte renewals, procedural denials) and provides three different views of the data to evaluate outcomes against: (1) all renewals due, (2) completed renewals only, and (3) disenrollments.
Regardless of data source, foundational to interpreting states’ unwinding data and improving coverage retention for eligible people is understanding the various factors and state-specific circumstances that influence the unwinding process and related data. CMS recommends exercising caution in comparing data across states and different data sources, since state variation and data limitations/nuances have the potential to result in misleading conclusions.
To briefly illustrate why context matters and the imperative for states and other stakeholders to tread carefully when making interpretations about unwinding data:
- States initiated renewals and began processing terminations of Medicaid and CHIP coverage for individuals determined ineligible on different timelines. Idaho, New Hampshire, Oklahoma, and South Dakota, for example, resumed terminations in April, while many other states waited until July.
- Some states are prioritizing in the earlier months of unwinding renewals for individuals they believe are most likely ineligible for Medicaid/CHIP coverage. South Dakota and Utah are two states that have adopted this approach, likely contributing to higher rates of terminations in the earlier months of unwinding.
- States differ in their unwinding approaches—including the mitigation strategies adopted to address noncompliance with the federal renewal requirements, flexibilities taken up voluntarily to support unwinding, as well as the level of effort and engagement with community partners to ensure eligible individuals remain enrolled. Arizona is a state that has taken up high-impact section 1902(e)(14) waivers likely to increase ex parte renewal rates. Arizona also has a waiver authorizing managed care plans to assist enrollees with completing the renewal process.
- Certain mitigation strategies may skew unwinding data (e.g., underreporting of ex parte renewals when manual workarounds are in place, pended procedural terminations driving up the number of pending cases). Idaho is a state that pended some of its procedural denials, resulting in a procedural termination rate of 0% for March and April.
Much like the renewal data, CMS lays out contextual considerations in regard to enrollment, application, and call center data—asserting the need for call center data, in particular, to be evaluated in the broader context of state-specific environments (e.g., whether a call center is integrated with other human services programs, how callback functionality impacts wait times, etc.). Notably, a number of states are experiencing challenges processing MAGI determinations at application within 45 days, and, in a handful of states, call center wait times appear to have increased dramatically from March to April 2023 (by 600% in one instance). Average wait times and abandonment rates ranged from 0 to 51 minutes, and 0% to 54%, respectively. As states explore ways to improve call center functionality to support unwinding and beyond, they can look to a forthcoming State Health and Value Strategies (SHVS) tactical toolkit authored by Manatt Health.
CMS is taking a holistic approach to ensuring that individuals retain coverage for which they are eligible—whether through Medicaid/CHIP, subsidized Marketplace coverage, or employer-sponsored insurance—and continues to work with states and other stakeholders to achieve this aim. CMS plans to continue its monitoring and oversight activities related to the resumption of regular eligibility and enrollment operations, which so far have entailed working directly with states to make sense of their data and address areas of noncompliance with the federal renewal requirements (or nonadherence to negotiated mitigation plans). Many states, as a result, have paused terminations, reinstated coverage for disenrolled consumers, taken up strategies to support the renewal process, and otherwise taken action to course correct, sometimes at CMS request or mandate, and often with CMS technical assistance.
 In March, four states (Idaho, New Hampshire, Oklahoma, and South Dakota) completed at least one full cohort of renewals; in April, 14 additional states (Arizona, Arkansas, Connecticut, Florida, Indiana, Iowa, Kansas, Nebraska, New Mexico, Ohio, Pennsylvania, Utah, West Virginia, and Wyoming) completed their first full cohort of renewals.
 Procedural reasons refers to terminations that occur because an enrollee does not return the renewal form.
 Per CMS, “HealthCare.gov Marketplace data count the cumulative number of unique consumers for each metric across reporting periods, whereas the data reported for SBM states count unique Marketplace activities during the reporting period month in which the relevant activity occurs. SBMs report on the previous full month. The HealthCare.gov Marketplace data are also reported monthly but the date through which the data are reported may not line up with the last date of each month due to data limitations.”
 Arizona has taken up the “Beneficiaries with No Income Renewal” strategy as well as the “Beneficiaries with Low Income Renewal” strategy.