Text Messaging: An Important Communication and Outreach Strategy as States Unwind the Federal Medicaid Continuous Coverage Requirement
Kinda Serafi, Alex Dworkowitz, and Michael Budros, Manatt Health
As state Medicaid and Children’s Health Insurance Program (CHIP) agencies develop their strategies for unwinding the federal Medicaid continuous coverage requirement under the Families First Coronavirus Response Act (FCCRA), many are looking to text messaging as a mechanism for outreach to their Medicaid and CHIP enrollees and communicating important information. Generally, states rely heavily on communicating with enrollees through mail when sending program updates and requests for information. When states resume standard redetermination processes at the end of the public health emergency (PHE) and are unable to renew an individual’s eligibility using available data sources, Medicaid/CHIP programs will send paper notices requesting that the enrollee provide documentation or additional information that will help to verify continued eligibility. However, the PHE has exacerbated housing instability, and many individuals have moved, leaving Medicaid and CHIP agencies without updated mailing address information. As a result, as they prepare for the end of the PHE and Medicaid continuous coverage, states are looking for additional and more nimble ways to reach Medicaid and CHIP enrollees, encourage them to update their contact information (i.e., phone, mailing address, email), and remind them to reply promptly to renewal requests.
States Have the Authority to Send Text Messages
Early and frequent reminders to update contact information and respond to requests from state agencies can help those who continue to be eligible for Medicaid or CHIP to maintain coverage. Ninety-seven percent of people with income less than $30,000 per year have a cellphone, the majority (76 percent) of these people are using smartphones. Some states have already implemented text messaging as a supplementary mechanism for communicating with their enrollees. Further, text messaging is quickly becoming the norm for how individuals want and expect to receive updates. Leveraging text messaging, in addition to communicating via mail, phone calls, email, and through an online account, is an efficient and effective way to communicate with Medicaid/CHIP enrollees.
Some text messages are subject to the Telephone Consumer Protection Act (TCPA), a federal law designed to protect consumers from unwanted phone calls and texts. In many cases the TCPA requires the sender of a text message to obtain the recipient’s prior consent before sending a text via an “autodialer.” Based on the Federal Communication Commission (FCC) interpretation of the TCPA, state Medicaid and CHIP agencies are not subject to TCPA text messaging restrictions meaning that state agencies can directly send text messages to their enrollees without prior consent. Current FCC guidance requires, however, that contractors of state agencies, which include Medicaid managed care organizations (MCOs) as well as counties and municipalities, are subject to the TCPA and therefore typically must obtain enrollee consent prior to sending text messages if they are using an autodialer. States that use contractors to send texts related to enrollment activities, or states that want their counties or Medicaid managed care plans to send such texts, must ensure TCPA compliance and obtain consent, assuming an autodialer would be used by counties/contractors and no consent exception to the TCPA applies.
The easiest way to obtain such consent would be to add a clause to the state’s application as part of the enrollment process. See Box A for sample consent language to add to the Medicaid and CHIP application. It should be noted that adding consent to a Medicaid and CHIP application is a best practice going forward but will not address states’ need to communicate with individuals who are already enrolled in coverage. In the short term, states can set up processes to send texts to its enrollees without consent, send auto-dialer texts to individuals seeking consent for its managed care plans to send texts, or have their managed care plans or other contractors solicit opt-in consent directly from enrollees.
|Box A. Sample Consent Language for Medicaid/CHIP Application
The information provided on this application, including your phone number(s), will be shared with any [county eligibility offices] and [MCO] to which you are assigned. You consent to being called or texted by the [county eligibility office] and [MCO], or any contractors acting on their behalf, at any phone number(s) you provide in relation to your application, now or in the future, including in regard to your healthcare needs and treatment, wellness services, plan benefits, eligibility, renewal and/or redetermination, and for any other communications relating to your relationship with the [county eligibility office] and [MCO] or concerning your [Medicaid] coverage. These calls/texts may be made using automated technology, such as with an automatic telephone dialing system or artificial or prerecorded voice message. Standard message and data rates may apply.
Simple and Straightforward Texts are Efficient Ways to Communicate with Enrollees
Texts should use direct, plain language and guide Medicaid/CHIP individuals and families to more information. Text messages can remind individuals to update their contact information or reply to requests for information from the state Medicaid and CHIP agency. See Box B for sample text message language.
|Box B. Template Text Message
This is [STATE MEDICAID/CHIP AGENCY] with a reminder to make sure your current address is in our records. It’s important to keep your contact information up to date so we can reach you about any changes to your [MEDICAID/CHIP] coverage. Visit [URL] or call [NUMBER] to update your contact info today.
Estamos llamando de [AGENCIA ESTATAL DE MEDICAID/CHIP] para recordarle que debe asegurarse de que su dirección actual esté en nuestros registros. Es importante mantener al día su información de contacto para que podamos comunicarnos con usted sobre cualquier cambio en su cobertura de [MEDICAID/CHIP]. Visite [URL] o llame al [NÚMERO] para actualizar su información de contacto hoy.
Texting can be effective, especially when it comes directly from state agencies, who are seen as the official source of information for their program enrollees. For example, in December 2020, Montana launched an automated process that sends one-way texts to individuals for whom the state receives returned mail. (https://www.foleyengines.com)  If the program sees returned mail with an address that matches the address on file, the program will send a follow-up notice via mail and a text or email directing the enrollee to contact the state through the online portal or the public assistance hotline. If the addresses do not match, the program flags the case for manual follow-up. Montana received positive feedback and found that people who received a text message contacted the state at a 40 percent higher rate than those who did not. Other texting programs have shown promising results with supporting eligibility and enrollment processes. For example, the Michigan Primary Care Association launched a texting campaign in 2012, which increased Medicaid enrollment. Further, the Text4baby program, a text messaging service for pregnant individuals and new mothers, continues to successfully keep pregnant people and their families connected to health coverage.
With the end of the PHE fast approaching, states have an imperative to review their consumer outreach and communications strategies and modify existing language and modalities that are used to convey key messages about the end of the Medicaid continuous coverage requirement and the required renewal process.
States will be looking to the FCC and CMS for additional guidance on potential flexibility with respect to the TCPA consent requirements when texts are being sent by counties, state contractors or Medicaid managed care plans. Further, as states look to implement text messaging they will also need guidance on the Health Insurance Portability and Accountability (HIPAA) security rules that require state Medicaid programs and managed care plans to encrypt text messages sent to their enrollees in certain circumstances. Specifically, guidance advising states of their ability to send unencrypted texts that lack detailed health information will be critical in supporting states’ enrollee communication efforts.
Texting is one effective way to remind individuals to update their contact information and to respond to requests for information. With appropriate consent, managed care plans can be important partners to state Medicaid/CHIP agencies and can send text messages that align with the state’s communication plan. In addition to sending text messages, states should review all of the ways that they communicate with individuals—through notices, electronic accounts, state agency websites, and contacts through call centers and enrollment brokers—and strengthen their messaging in order to encourage individuals to maintain coverage. ,
For more information on state strategies to support Medicaid/CHIP coverage retention and plan for the end of the continuous coverage requirement, see the State Health and Value Strategies (SHVS) resource page.
 Families First Coronavirus Response Act, HR 6201, § 6008(b)(3).
 The TCPA regulates calls, including text messages, sent via an “automatic telephone dialing system,” also known as an “autodialer.” 47 USC § 227(b)(1)(A).
 47 USC §§ 227(b); 86 Fed. Reg. 9299 (Feb. 12, 2021).
 86 Fed. Reg. 9299 (Feb. 12, 2021).
 The FCC has promulgated some exceptions to the consent requirement, such as for texts made for emergency purposes. 47 CFR § 64.1200(f)(4).
 Medicaid and CHIP Learning Collaborative, “Ensuring Continuity of Coverage and Preventing Inappropriate Terminations for Eligible Medicaid and CHIP Beneficiaries: Part 2. Operational Strategies for States and Territories,” Center for Medicare and Medicaid Services, August 3, 2021.
 Centers for Medicare and Medicaid (CMS), The Coverage Learning Collaborative: Ensuring Continuity of Coverage and Preventing Inappropriate Terminations for Eligible Medicaid and CHIP Beneficiaries: Part 2.
 Kaiser Family Foundation, Profiles of Medicaid Outreach and Enrollment Strategies: Helping Families Maintain Coverage in Michigan.
 45 CFR § 164.312(a)(2)(iv) and (e)(2)(ii).