Maintaining Medicaid and CHIP Coverage Amid Postal Delays and Housing Displacements
Patricia Boozang, Kinda Serafi, and Kaylee O’Connor, Manatt Health
In light of recent postal delays and housing displacements caused by the COVID-19 pandemic and related economic crisis, and a wave of natural disasters across the country, state Medicaid and Children’s Health Insurance Program (CHIP) agencies face new challenges communicating with their enrollees about their health coverage. Acting now to mitigate these challenges is essential as states are preparing for the end of the public health emergency (PHE) and “catching up” on coverage renewals for a large portion of their enrollees.
Currently, states are prohibited from disenrolling Medicaid enrollees as a condition of receiving enhanced federal funding under the Families First Coronavirus Response Act. Many states have also paused renewals and disenrollments for their CHIP enrollees. Both of these actions aim to ensure continuity of coverage for low-income people during the pandemic, and states’ authority to continue them is tied to the COVID-19 PHE, currently slated to end on October 22, 2020. When the COVID-19 PHE ends, states will resume normal eligibility and enrollment processes, including redetermining eligibility and acting on changes in circumstances that may make individuals ineligible for Medicaid and CHIP. In all states, these eligibility renewal processes rely heavily on communication with enrollees by mail if Medicaid agencies are unable to redetermine eligibility based on available data sources. States routinely mail consumer notices, often with pre-populated renewal forms, and enrollees frequently return forms and other required paper work by mail to the state Medicaid agency.
Postal delays and housing displacements resulting in change of address or unstable housing could lead to coverage loss for eligible individuals. However, there are strategies that state Medicaid and CHIP agencies may consider to help mitigate coverage losses.
Potential Impact of Postal Delays and Housing Displacement on Medicaid and CHIP Coverage
Postal Delays and Consumer Communication Timelines. When state Medicaid and CHIP agencies are unable to determine an enrollee’s continued eligibility for coverage based on available data sources, federal regulations require the agency to send a renewal form to the enrollee via mail, and provide at least 30 days from the date of the renewal form for that enrollee to respond and submit any required information. Separate and apart from renewal procedures, states may request eligibility information from enrollees when the state is presented with new updates in its eligibility system, and generally provide 10 to 15 business days for enrollees to submit requested information or documentation. As states restart renewal and eligibility processes in the fall, reliance on the U.S. mail will increase. Because of the ongoing COVID-19 pandemic, local Medicaid offices (where enrollees could previously submit their paperwork) are closed, and consumers, fearful of COVID-19 infection, are less likely to submit their Medicaid paperwork in person even in areas where offices are open. U.S. businesses and residents have dramatically increased reliance on the U.S. Postal Service since the beginning of the pandemic. The strain on the system has been apparent throughout the summer months, with reports of postal delays caused by increased volume and U.S. Postal Service operational changes, and delays are likely to continue through the calendar year at a minimum.
Housing Displacements and Returned Mail. State Medicaid and CHIP agencies are beginning to receive an influx of returned mail from Medicaid enrollees, as the economic recession has amplified housing instability and homelessness, and natural disasters such as West Coast wildfires and Atlantic hurricanes have caused displacement. During the first week of September, the Centers for Disease Control and Prevention (CDC) issued a nationwide moratorium on residential evictions until 2021. While the measure provides some reprieve, tenants will still be obligated to pay back owed rent and landlords may still impose late fees once the moratorium ends. (Xanax)  Estimates from the U.S. Census Bureau analyzed by the Aspen Institute suggest that without rental support, 30 to 40 million Americans could face evictions in the coming months (likely to culminate when the moratorium ends in January).
Many state Medicaid and CHIP agencies do not, as a standard practice, follow-up on returned mail but rather terminate eligibility for individuals whose addresses no longer appear valid. This, combined with populations becoming more transient or losing housing security, may result in significant loss of coverage of eligible individuals who may continue to reside in the state but in new or unstable housing.
Strategies to Mitigate Medicaid and CHIP Coverage Loss
States may consider implementing the following strategies to help mitigate coverage loss for individuals who continue to be eligible for Medicaid or CHIP, but risk disenrollment in light of these challenges:
Communicate with Enrollees Now. In advance of the expected housing crisis and end of the PHE, states can seek to communicate with enrollees now to encourage them to inform the Medicaid agency of a change in address, provide a mobile phone number as part of their case record, and set up an online account, if appropriate and they haven’t already done so. Additionally, the agency can remind consumers that they may need to review their coverage soon and to be on the look out for mail from the agency, and provide a number to call if they have questions about their Medicaid renewal date.
Extend Mail Timeframes. In light of current and likely worsening postal delays, states may consider extending current mail return timeframes for at least the next year. For example, states could extend the timeframe for returning renewal forms from 30 days to at least 60 days. At the same time, states could extend the timeframes for when individuals are required to respond to state requests for documentation or additional information. For instance, if a state currently requires an individual to submit documentation verification within 10 business days of the date of the state notice, it could consider extending the timeframe to 20 to30 business days.
Review Data Sources for Identifying Residency Changes. Upon receiving returned mail or when there is a delayed response from an enrollee, states can take additional steps to identify updated residency through available data sources prior to terminating coverage. For example, when addressing returned mail, states could crosscheck address updates with other state agencies [e.g., Supplemental Nutrition Assistance Program (SNAP) agencies for states without an integrated eligibility system and agencies that oversee shelter placement] and federal agencies (e.g., the U.S. Postal Service’s National Change of Address system). States should also make sure that existing eligibility and enrollment systems are updating addresses based on residency information changes from the consumer, either directly, or when the consumer reports that information to a state contractor – including an enrollment broker, call center, managed care plan, or provider.
Conduct Outreach via Other Modalities. States may consider pursuing additional outreach to enrollees to follow-up on returned mail, using other means of contact including email, text or phone to follow-up on returned mail, non-response to renewal forms, or requests for information. For example, if an individual set up an electronic account, states could seek to communicate through that account.
Leverage Managed Care Plans and Enrollment Assisters. States with Medicaid managed care contractors can leverage their plans to conduct outreach to update members’ mailing addresses, telephone numbers, and email addresses, as well as to reiterate the need to complete the renewal process in a timely manner. Maryland, for example, asks its health plans and providers to remind their members to report changes of address within 10 business days. Beyond managed care plans, states can look to enrollment brokers, community-based organizations, and navigators to provide direct assistance with obtaining updated contact information and ensuring individuals respond to requests for information and renewal forms.
Absent another renewal of the PHE, Medicaid and CHIP enrollees will face unprecedented challenges maintaining their Medicaid coverage. This expert perspective describes some potential mitigation approaches that states can consider and implement now or be ready to implement when they restart renewals. States may also wish to look to other existing or new eligibility and enrollment strategies to meaningfully engage consumers and ensure they maintain coverage amid the compounding effects of COVID-19 and the economic recession. For more information on potential state strategies to support Medicaid and CHIP eligibility and enrollment, go to this link for State Health and Value Strategies webinar materials.
 “Example of CHIP Disaster Relief State Plan Amendment,” Centers for Medicare and Medicaid Services, available at https://www.medicaid.gov/medicaid-chip-program-information/by-topics/childrens-health-insurance-program-chip/downloads/chip_disaster_relief_spa_sample_01102012.pdf.
 “Renewal of a Determination that a Public Health Emergency Exists,” U.S. Department of Health and Human Services, July 23, 2020, available at https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-23June2020.aspx.
 42 C.F.R 435.916; and 42 CFR § 457.343. For individuals who fail to meet the state’s determined timeframe, they have at least 90 days after the date of termination to resubmit the renewal form and have their eligibility reconsidered by the state without completing an application.
 T. Frankel, “Postal Problems Could Continue Despite Suspension of Policies Blamed for Mail Delays,” Washington Post, August 19, 2020, available at https://www.washingtonpost.com/business/2020/08/19/postal-problems-could-continue-despite-suspension-policies-blamed-mail-delays/.
 “Temporary Halt in Residential Evictions To Prevent the Further Spread of COVID-19,” CDC, September 4, 2020, available at https://www.federalregister.gov/documents/2020/09/04/2020-19654/temporary-halt-in-residential-evictions-to-prevent-the-further-spread-of-covid-19.
 E. Benfer, D. Bloom Robinson, S. Butler, L. Edmonds, S. Gilman, K. Lucas McKay, Z. Neumann, L. Owens, N. Steinkamp, and D. Yentel, “The COVID-19 Eviction Crisis: an Estimated 30-40 Million People in America Are at Risk,” Aspen Institute, August 7, 2020, available at https://www.aspeninstitute.org/blog-posts/the-covid-19-eviction-crisis-an-estimated-30-40-million-people-in-america-are-at-risk/.
 T. Brooks, L. Roygardner, S. Artiga, O. Pham, and R. Dolan, “Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2020: Findings from a 50-State Survey,” Kaiser Family Foundation, March 26, 2020, available at https://www.kff.org/coronavirus-covid-19/report/medicaid-and-chip-eligibility-enrollment-and-cost-sharing-policies-as-of-january-2020-findings-from-a-50-state-survey/.
 “Medicaid Mail Returns,” Maryland Department of Health, November 2017, available at https://mmcp.health.maryland.gov/Documents/MMAC/2017/November/MMAC%20Medicaid%20Mail%20Returns%20Nov%2017.pdf.