Jun, 01, 2022

Ensuring Continuity of Coverage and Care for High Need Enrollees When the Medicaid Continuous Coverage Ends: Medicaid Strategies

Patricia Boozang and Kinda Serafi, Manatt Health


The current Medicaid continuous coverage requirement enacted by the Families First Coronavirus Response Act (FFCRA) prohibits states from disenrolling individuals from Medicaid for the duration of the public health emergency (PHE) as a condition of accessing the enhanced federal Medicaid funding. The PHE is currently in effect through July 14, 2022, and is expected to be extended further–possibly to the end of 2022. When the PHE ends, state Medicaid agencies will undertake the massive task of redetermining eligibility for nearly every Medicaid enrolled person in the country, as many as 80 million enrollees. This undertaking has significant health equity implications, as communities of color are expected to be disproportionately impacted by the unwinding effort.

On March 3, 2022, the Centers for Medicare & Medicaid Services (CMS) released a State Health Official (SHO) letter, “Promoting Continuity of Coverage and Distributing Eligibility and Enrollment Workload in Medicaid, the Children’s Health Insurance Program (CHIP), and Basic Health Program (BHP) Upon Conclusion of the COVID-19 Public Health Emergency.” The guidance lays out expectations for states as they resume processing renewals for Medicaid eligibility, and provides options and flexibilities for states to consider as they develop their operational plans to resume Medicaid redeterminations. Per CMS guidance, states are expected to adopt a “risk-based approach” when prioritizing pending eligibility and enrollment actions, which could be a:

  • Time or age-based approach, which prioritizes cases based on the length of time the case has been pending;
  • Population-based approach, that prioritizes renewal actions based on characteristics of cohorts or populations that are likely to remain eligible, have become eligible for more expansive Medicaid benefits, or become ineligible for Medicaid and eligible for different coverage;
  • Hybrid approach, which combines the population and time-based approaches; or
  • State-developed approach, which must meet the goals of maintaining coverage of eligible individuals, minimizes the extent to which potentially ineligible individuals remain enrolled, achieves a sustainable renewal schedule, and meets the 12-month unwinding timeline expectations.


Most states are pursuing a hybrid approach by planning for a time/age-based approach overall, but layering on a population-based approach by flagging specific populations for renewal earlier or later in the process, for example:

  • Renewing early those individuals for whom the state has more current data or enrollee provided information that indicates they are no longer eligible for Medicaid; or
  • Timing renewal for people turning age 65 so that they can transition more seamlessly to Medicare coverage.


State Medicaid agencies have (appropriately) been devoting their resources to planning their risk-based approaches, improving their overall renewal processes (including ex-parte processes), strengthening communication, reducing returned mail, and leveraging their community-based organizations and Medicaid managed care plans for outreach and communication. In addition to implementing these broad continuity of coverage strategies for all current Medicaid enrollees, states can consider additional targeted strategies to ensure continuity of coverage and care for sicker individuals with higher healthcare access needs who will be at risk of harm if they lose access to healthcare services, even temporarily.

This expert perspective, the first in a two-part series, outlines strategies state Medicaid agencies can take to identify people with high health needs and provide them with additional support to retain or transition their health coverage in order to maintain access to essential healthcare services. A second expert perspective will identify complementary strategies State-Based Marketplaces (SBMs) and departments of insurance can implement to help these individuals transition without gaps in coverage or care.

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

As noted above, most states are taking a “hybrid” approach to staging their redeterminations, and some states are considering population-based strategies specifically targeted to ensuring coverage and care continuity for populations with high health needs. These strategies are discussed in more detail below.

Identify enrolled populations who are likely to be at risk of harm if they lose or have gaps in coverage. Per CMS guidance, states may not prioritize populations for redetermination “based solely on the Medicaid eligibility group in which they are enrolled” and may not conduct a population-based redetermination approach that is discriminatory. CMS has confirmed, however, that states may develop specific unwinding approaches for individuals who are in a course of treatment for chronic or life-threatening diseases and who would face particular health risks if such treatment were to be interrupted. States can consider a variety of approaches to identifying such “high-risk” enrollees, including:

  • Identifying particular eligibility groups that may be at higher risk for harm if they lose or have gaps in healthcare coverage. These groups may include: pregnant or postpartum enrollees; enrollees in the aged, blind, or disabled eligibility group who would be at a greater risk of harm due to coverage loss; enrollees that are receiving home and community-based services (HCBS) through a waiver or the state plan; enrollees that are identified as seriously mentally ill or with a substance use disorder, including by virtue of health home or waiver program enrollment; and children with special health needs.
  • Conducting claims and encounter data analysis to identify enrollees who appear to be in an active course of treatment, or otherwise have high health needs [based on Home and Community Based Services (HCBS), behavioral health, and clinical service use].
  • Encouraging plans or providers to identify high-need Medicaid members or patients that are at particular risk of coverage loss and related harm.


These strategies are not mutually exclusive and states may adopt one or more of these approaches.

Prioritize renewal for high-risk enrollees based on timing that mitigates risk of coverage loss and access gaps. Once states have identified high-risk enrollees, they can prioritize timing for their redetermination with an eye to minimizing risk of coverage loss and access gaps. For instance, states may consider the following approaches:

  • Children and Adults with Special Health Needs: For children and adults likely to remain eligible for coverage and facing high-risk of harm due to coverage loss (e.g., people enrolled in a HCBS program), states can trigger a redetermination process that comes later in the year and provide more time and special outreach assistance to ensure these individuals maintain coverage.
  • Individuals in a Pregnant/Postpartum Eligibility Group: States that are adopting the American Rescue Plan Act’s new state option to extend Medicaid coverage to 12-months postpartum can consider timing renewals of people in the pregnancy group to dovetail with the implementation of expanded postpartum coverage.
  • People Who Appear Eligible for Qualified Health Plan (QHP) or Employer Sponsored Insurance (ESI) Coverage: Redeterminations for high-risk individuals who appear likely to become ineligible for Medicaid and eligible to transition to a QHP or ESI could be timed to avoid high deductibles (given deductibles are not prorated for consumers transitioning to the Marketplace late in the year) and the requirement to quickly renew their QHP coverage.
  • People Likely to be Eligible for “Bridge” Coverage: States working on initiatives to bridge coverage for people exiting Medicaid (e.g., BHP-like programs, premium support, new continuous coverage) could delay redetermining eligibility for those enrollees until new programs are ready.


Adopt special redetermination processes, including targeted communications, for high-risk enrollees. States can implement special redetermination processes, including noticing, aimed at helping high-risk enrollees retain coverage or transition seamlessly to new coverage, including:

  • Providing longer timeframes for enrollees to respond to requests for information to complete renewal processes;
  • Following up with a second request for information and/or telephone outreach for enrollees who don’t respond to requests for information; and
  • Offering enhanced outreach and renewal assistance through state or county eligibility offices, requiring managed care plans to offer assistance, funding Navigators/assisters, or some combination of assistance resources.


In SBM states, flag high-risk individuals being transferred to the Marketplace as requiring specialized assistance to ensure continuity of coverage and care. Medicaid agencies and Marketplaces in SBM states could collaborate to devise a system flag to identify individuals who have unique health needs that require specialized Marketplace and Navigator/assister support to ensure continuity of coverage, services, network providers, or pharmaceuticals. This process could include Medicaid sharing claims and encounter data to enable the Marketplace to map to products with networks that include the essential providers.


The end of the Medicaid continuous coverage guarantee is a looming and seismic health coverage event. All currently enrolled Medicaid individuals face a risk of coverage loss, 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 for people with serious health conditions that rely on continuous coverage to enable them to access care to treat chronic, debilitating, and sometimes life-threatening conditions. Importantly, collaboration across Medicaid agencies, Marketplaces, and state insurance regulators will be essential to preserving access to coverage and care for these individuals. While these strategies may be challenging to implement, states may have as long as through the end of 2022 before the PHE officially ends to begin making policy, operational, and systems changes to preserve coverage and care continuity for those with high health risks who have relied on Medicaid coverage and care for the past three years.