To Emergency and Beyond….

To Emergency and Beyond. From Pandemic to Endemic. Sounds like science fiction, but it is our reality and our future as we attempt to navigate through and beyond the COVID-19 virus our world has been plagued with for more than two years.


Record high Medicaid and CHIP enrollment

During these two-plus years, enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) has increased by over 14 million, a result of states’ response to the Families First Coronavirus Response Act (FFCRA).  This legislation increased a state’s Federal Medical Assistance Percentage (FMAP) by 6.2 percentage points so long as the state maintains “continuous eligibility” for their Medicaid beneficiaries. Continuous eligibility extends through the calendar month in which the Health and Human Services (HHS) declared Public Health Emergency (PHE) ends and the 6.2 percentage point FMAP increase through the calendar quarter in which the HHS’ PHE ends. The latter is a duration of approximately two and one-half months.


The PHE end date has been a source of angst for Medicaid beneficiaries, healthcare providers, health plans, and states. As of September 2021, nearly 85 million people were enrolled in Medicaid and CHIP. According to the Centers for Medicare and Medicaid Services (CMS), every beneficiary will be due for a renewal at the end of the PHE, currently set to expire April 16.



HHS must renew the PHE every 90 days. President Biden has committed to giving states 60-days’ notice before the end date of the final renewal. Notice has not been issued which leads us to believe the PHE will be renewed again, through at least mid-July. Some predict the PHE will be renewed until after the mid-term elections. Regardless, the time to prepare for “unwinding” Medicaid and CHIP continuous eligibility is now! A comprehensive Unwinding website has been established to guide states.


On March 8, 2022, CMS issued a 46-page State Health Official (SHO) letter #22-001 to assist states in their planning efforts. This SHO has two overriding themes: 1) promotion of coverage continuity and 2) guarding against inappropriate terminations.


SHO #22-001 give states 12 months to “initiate” their unwinding with an additional two months to “complete” it, for a total of 14 months. States may initiate their unwinding up to two months before the end of the PHE but no later than the month following the end of the PHE. They may not terminate coverage for any beneficiary until the first of the month following the end of the PHE without risking their 6.2 percentage point FMAP increase. The 14-month timeclock starts ticking the month a state starts its unwinding. CMS will gather baseline enrollment data for each state and then monitor ongoing. Of concern to CMS will be any state who processes more than one-ninth of their “total caseload” in any given month and could result in corrective action.


Operational plan

States will need to develop a comprehensive “unwinding operational plan” to restore routine operations, detailing how they will complete outstanding work and maximize uninterrupted coverage for eligible individuals. A state’s operational plan does not have to be reported to nor approved by CMS, except upon request. There is not a transparency requirement so accessing a state’s plan may prove to be difficult. State plans will be like snowflakes, no two will be alike. Depending on what actions and strategies a state chooses to deploy, there will be other documents that states may need to complete and possibly get approval on. These include State Plan Amendments, various waivers, verification plans, and more.



Federal rules for Medicaid renewals vary depending on whether a program of eligibility is or isn’t based on Modified Adjusted Gross Income (MAGI). States are required to use an ex parte process for MAGI-based renewals. This means they attempt to conduct the renewal using reliable information and electronic data sources, without requesting information from the beneficiary. If the agency can renew eligibility based on the available reliable information, the agency sends a notice to the beneficiary. The renewal is complete. No action is required by the beneficiary. If a state cannot renew on an ex parte basis, they will send the beneficiary a pre-populated form, wait for a response, and then act according to what they receive back. The reconsideration period allows the state to accept and process the renewal form as they would an application, without requiring a new application. In most states, eligibility can be retroactive, so it is possible for a lapse in coverage to be avoided. Less work for the beneficiary, less work for the state.


Below is a table illustrating some of the renewal differences between MAGI and Non-MAGI.



  • Children, newborns, pregnant women, parents and caretaker relatives, Group VIII “expansion adults” aged 19-64 with no other coverage
  • Aged (65+), blind, disabled, Medicare secondary payers (QMB, SLMB, QI-1), long-term care, many medically needy or spenddown programs
  • Income limit
  • Income and asset limits
  • Ex parte process required
  • Ex parte process not required
  • Pre-populated form with instructions
  • Form with instructions
  • 30 days to return
  • Return within “a reasonable period of time”
  • 90-day reconsideration period required
  • Reconsideration period optional


The new SHO is full of strategies for states to consider, too many to cover here. Several of the strategies include treating Non-MAGI renewals like MAGI renewals, either just during the unwinding or ongoing.


Having current beneficiary contact information is a huge concern. We know how transient the Medicaid and CHIP populations are. CMS is anticipating a lot of outdated beneficiary contact information and is using the SHO to suggest strategies and establish guardrails. The SHO suggests states work with their Managed Care Organizations (MCO) as one method to secure updated addresses. States should consider accessing the National Change of Address database and use other contact methods such as email, texting, and phone calls. How states handle address changes depends on whether one exists and if it is in-state or out-of-state.


Another set of strategies relates to MCOs. CMS is recommending states partner with their MCOs for more than just updated contact information. States should also work with their MCOs to conduct outreach. There are marketing rules MCOs have to follow, and the SHO offers some details around MCO dos and don’ts. Once a member loses coverage the MCO is greatly restricted, so it benefits everyone to involve the MCO early in the renewal process.


More work to do

I have focused on renewals, but that isn’t the only work a state will be doing during the unwinding period. States will continue to receive and process new applications, conduct redeterminations based on changes in circumstances, and request verifications to validate eligibility. The SHO offers a few strategies around this work as well. For example, holding off on a redetermination until the state conducts the full renewal.


CMS and the SHO encourage states to reach out to their partners for assistance. Centauri Health Solutions has decades of experience working with Medicaid and is qualified to partner with your hospital or health plan to help you navigate beyond the emergency.


Shanna Hanson, FHFMA, ACB
Manager, Business Knowledge
Centauri Health Solutions, Inc.