Jan, 11, 2024

State-Based Marketplace Transition Data During the Unwinding

Elizabeth Lukanen and Emily Zylla, SHADAC

States continue to refresh their reporting throughout the unwinding, but as of January 2024, no new measures have been added and no new states are reporting data.

As the unwinding of the Medicaid continuous coverage requirement progresses, SHVS is closely monitoring state reporting on the impacts of redeterminations and disenrollments. There is intense interest in data that monitors transitions between Medicaid and Marketplace coverage and, more importantly, the outcomes of those transitions. State-Based Marketplaces (SBMs) play a significant role, coordinating with Medicaid agencies using a number of different strategies to ensure a smooth transition for people who no longer qualify for Medicaid, but might be eligible for a qualified health plan (QHP) offered through the Marketplace. To date, 11 of the 18 SBMs are reporting data on Marketplace transition outcomes. (Virginia, which would be the 19th SBM, launched on November 1, 2023. Virginia is not included in the total number of SBMs since it was not operating as an SBM from the beginning of the unwinding.)

The Centers for Medicare & Medicaid Services (CMS) continues to release required state data reporting metrics. In December, CMS released a new batch of data which included information on Marketplace enrollment transition data as of September 2023. CMS also continued to point to the increase in Marketplace enrollment (an increase of 1.5 million people between March and September 2023) as a signal of strong transition rates. CMS continues to report slightly different data for states that use HealthCare.gov compared to SBMs. And among SBMs, for states with an integrated system versus those who transfer accounts between Medicaid and the Marketplace. Broadly, these data include:

  • Consumers who were transferred to or applied for Marketplace coverage.
  • Consumers who were eligible for a QHP or Basic Health Plan (BHP) coverage (disaggregated by those eligible for financial assistance).
  • Consumers with a QHP selection or BHP enrollment.

In all cases, CMS provides both counts and percentages. Among SBM states without an integrated system, CMS provides two percentage calculations – one where the denominator is applications and one where the denominator is account transfers. This distinction is important, because using the much larger account transfers number as a denominator makes the successful rate of transitions to QHP coverage seem much smaller. While the presentation of the CMS data is clear and the availability of counts and percentages is useful, it could leave room for misinterpreting the denominator.

Data reporting and interpretation have been complicated by several factors causing delays in renewal processing and changes to states’ timelines. First, the announcement from CMS on August 30, 2023 that 29 states and the District of Columbia had been making ex parte renewal determinations on a household, rather than an individual level, as regulations require. This included 16 of the 18 SBMs (California and Rhode Island were in compliance). This caused some states to pause procedural terminations, reinstate coverage, and/or implement temporary extensions for renewal. Second, CMS offered states the option of delaying procedural disenrollments while they conduct targeted renewal outreach. To date, 15 states have opted to take advantage of this flexibility. 

Given the ongoing data concerns and cautions regarding state comparisons, differences in how states are managing changes to ex parte renewals and potential confusion regarding the use of different denominators, it is more important than ever for SBMs to release their own data

SHADAC will continue to update this expert perspective as more states publish their unwinding data.

SBMs Reporting Marketplace Transition Outcome Data

 

Note: In some cases, SBMs publish Marketplace transition outcome data in administrative documents (e.g., board meeting minutes and legislative reports). Because these data are more difficult to access, they are not represented in the map above.  

Variation in State Reporting

To date, 12 of the 18 SBMs that use their own eligibility platform are reporting outcomes for individuals who exited Medicaid and were transitioned to the Marketplace. While most of these states continue to update their data frequently, three states haven’t released updated data since October 2023. In summary:

  • Seven states are reporting whether individuals were eligible for a QHP.
  • 11 states are reporting whether individuals selected a plan.
  • Five states are reporting enrollment and/or eligibility broken down by whether the individual received financial assistance (e.g., advance premium tax credit or cost-sharing reduction payments).
  • Three states are reporting on the demographics of people transitioning from Medicaid to Marketplace coverage.
  • One state, Idaho, reports having completed its redeterminations.

 

Select Data Highlights

In addition to general information on transition outcomes, most of the states reporting outcome measures are providing additional information of interest, though this detail differs by state. Select data highlights are provided below.

Covered California Medi-Cal Transitioner Profile

California provides detailed data on Californians who have transitioned from Medi-Cal to Covered California. The Excel file has multiple tabs and contains counts, percentages, and detailed methodological and definitional information. It starts with a tab containing summary information on transitions by month (called “key performance indicators”). The following tabs contain detailed demographic information for: individuals who lost Medi-Cal and who were eligible for Covered California; those who lost Medi-Cal, were eligible for Covered California and received an auto plan selection; and those who effectuated QHP coverage. Demographic data includes:

  • Age
  • Gender, including transgender identification
  • Income
  • Race and ethnicity (in combination and separately)
  • Written language
  • Service channel used (i.e., Certified Insurance Agent, Certified Enrollment Counselor)
  • Geography (i.e., region, county)
  • Financial assistance

Screenshot: 1/10/2024

 

New York State Public Health Emergency Unwind Dashboard

New York provides both summary information in the form of a “snapshot” and goes on to provide more detailed information on renewals, transitions and transition outcomes by various demographic breakdowns. Specifically, the state provides information on transitions to the Marketplace based on which program an individual was previously enrolled in (e.g., did they transition to the Marketplace from CHIP or Medicaid). Notably, New York presents both counts and percentages related to transitions, making it easy to contextualize and understand the scale of transitions compared to the program as a whole.

Screenshot: 12/6/2023

 

Pennsylvania Unwinding Renewals Progress Tracker

Pennsylvania presents side-by-side renewal outcome metrics for Medicaid and the Marketplace, providing a holistic view of coverage transitions across the state. In addition, the state provides information on the outcomes of transitions to Pennie, the state’s official health insurance Marketplace, by county and ZIP code. 

Screenshot: 1/10/2024

 

Washington Health Benefit Exchange Medicaid Redetermination Data Snapshot

Washington has produced a Data Snapshot (available as a PDF) that includes summary information (called “data top lines”), a personalized coverage transition example illustrating an individual’s cost under a QHP, and detailed information on coverage transition such as the geographic distribution, carrier transitions, receipt of financial assistance, and demographics of transitioners (i.e., age, sex, race, and ethnicity). Washington provides both counts and percentages for most data points and provides a detailed appendix with information on data sources and definitions.

Screenshot: 10/11/2023

 

Considerations for Presenting Outcomes Data

  • Draw on existing reporting requirements. Because timeliness of this data is so important, SBMs should start by releasing the CMS-required Marketplace indicators—the number of individuals determined eligible for a QHP and the number who selected a plan. Beyond that, SBMs could release additional data related to process—such as whether the enrollment was active or passive—and outcomes—such as whether people qualified for financial assistance or whether they qualified for a zero-dollar plan.
  • Present Marketplace and Medicaid data together. The best data dashboards present Medicaid and Marketplace data side-by-side, offering a holistic view of the impact of unwinding. Several of the states who are currently reporting do this well, including Pennsylvania, featured above.
  • Publish disaggregated data. There is a great interest in understanding who is being impacted by the unwinding. At a minimum, we recommend displaying data breakdowns by:
    • Program type
    • Age (children versus adults)
    • Race/Ethnicity
    • Language
    • Geography (ZIP code is best, but by county or any other level lower than statewide is helpful)
    • Eligibility for or receipt of financial assistance (e.g., advance premium tax credit or cost-sharing reduction payments)
  • Provide context and transparency. There are many reasons that Marketplace transition outcome data reported by different states might be difficult to compare. CMS has outlined these data limitations and specifically cautioned against comparing data from HealthCare.gov to data from SBMs. States should address this in their reporting by clearly labeling data time periods and documenting data revisions, providing clear data labels and definitions, and including both proportions and counts so it easy to understand the group being reported on.
  • Make the data easy to find. Many SBMs release information and data via materials such as board meeting minutes (e.g., Colorado, Minnesota, and New Mexico). Unless you know where to look, these materials can be hard to find and often do not appear in a cursory Google search. If a state does plan to release unwinding data in this way, consider cross-posting in order to increase visibility. For example, data could also be released as a blog post, highlighted in an SBM newsletter, or put out as a press release. Alternatively, the state could post links to the materials on a highly trafficked part of the SBM or Medicaid website for more permanency.
  • Make the data easy to use. Consider reporting both counts and, where relevant, percentages (e.g., successful transitions to a QHP). While advocates and policymakers are interested in raw numbers, they are also eager to understand transition rates. Since the calculation of these rates can use different denominators, choose one that best tells the story of the state and note the denominator being used. For example, depending on a state’s operational processes and eligibility systems, an SBM that transfers accounts between Medicaid and the Marketplace may be able to present rates of successful transitions to QHP in a variety of ways (see example below). Regardless of how the state chooses to present rates or percentages, it is critical to provide notes and detail on how these statistics were calculated.

Example: Hypothetical SBM That Transfers Accounts Between Medicaid and the Marketplace

Transition Data:

Possible Statements About Transitions:

  • 10% transitioned to QHP Coverage
    • Statement about the largest/broadest group—total account transfers
    • 3,000 (QHP)/30,000 (AT) = 10%
    • Among those who were ineligible for Medicaid and were transferred to the Marketplace, 10% of consumers selected a QHP.
  • 23% transitioned to QHP Coverage
    • Statement limited to those who had an application
    • 3,000 (QHP)/13,000(A) = 23%
    • Among those who were ineligible for Medicaid, were transferred to the Marketplace and completed an application, 23% of consumers selected a QHP.
  • 25% transitioned to QHP Coverage
    • Statement limited to those who were found eligible for a QHP
    • 3,000 (QHP)/12,000 (E) = 25%
    • Among those who were ineligible for Medicaid, were transferred to the Marketplace, completed an application and were determined QHP-eligible, 25% of consumers selected a QHP.