Overview: Resuming public health care program renewals

How to maintain coverage for Minnesotans when federal continuous coverage requirements end

Introduction

Like all states, Minnesota has maintained health care coverage for its Medicaid enrollees during the COVID-19 pandemic. Since March 2020, Minnesotans who newly gained eligibility or already had eligibility for Medicaid (called Medical Assistance in Minnesota) or MinnesotaCare have remained enrolled in the coverage regardless of most changes in their lives that previously would have affected their coverage.

Continuous coverage helped Minnesotans access care during a global pandemic and maintained high insurance coverage rates in the state. It also allowed the state to receive billions in additional federal funding under the Families First Coronavirus Response Act, the first major federal stimulus package passed by Congress. Those federal funds were used during the public health emergency to help pay for health care services, make COVID-19 testing and treatment accessible at no cost to Minnesotans, and help support the direct care workforce, however the majority went into the state’s general fund.

With these continuous coverage provisions in place, enrollment in Medical Assistance (Minnesota’s Medicaid program) and MinnesotaCare has grown by more than 360,000 people, or greater than 30%, to more than 1.5 million Minnesotans. One in four residents living in the state now get their health care coverage through these public health care programs.

Congress passed legislation requiring states to return to standard Medicaid eligibility procedures, which includes an annual eligibility review through a renewal process, in spring 2023. That means that most of the 1.5 million Minnesotans enrolled in Medical Assistance and MinnesotaCare will need to have their eligibility for these programs reviewed through the renewal process. Given the caseload growth, this represents a significantly larger volume of work than has ever occurred in the state’s public health care programs history. Experts across the country agree that the resumption of these renewal processes will create the biggest challenge to health care coverage since implementation of the Affordable Care Act.

The Centers for Medicare & Medicaid Services (CMS) has issued federal guidance outlining the expectations that states take all possible actions to maintain coverage for eligible individuals when renewal processes resume. States must conduct full eligibility reviews for most Medicaid enrollees before terminating coverage.

Challenges

Loss of coverage estimates
DHS is committed to ensuring that eligible Minnesotans retain their public coverage when renewal processes resume and that ineligible Minnesotans connect with other coverage options. This is a top priority for the State of Minnesota. The goal is for zero eligible enrollees to lose coverage.

Some enrollees will lose their Medical Assistance and MinnesotaCare coverage when renewals resume because their circumstances have improved and they no longer meet the program eligibility requirements. Safety net programs provide ladders up, so it is to be expected that some Minnesotans will lose eligibility because in the past three years they landed a new job, earn more money or gained employer-sponsored coverage. DHS will work with MNsure, Minnesota's health insurance marketplace, to help ineligible enrollees smoothly transition to a private health insurance plan if they don't already have other coverage.

However, some portion of enrollees will likely remain eligible for coverage and meet all of the requirements to keep it, but will lose their coverage due to barriers in the renewal process, including failure to receive notices or return paperwork, paperwork getting lost, and other issues unrelated to their actual eligibility status. DHS wants zero eligible enrollees losing coverage and aims to minimize administrative barriers to lessen their impact.

Nationally, estimates on the number of Medicaid enrollees who may be disenrolled remains highly uncertain. Estimates from the Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services have a loss-of-coverage rate of 17.4%:
- ~9.5% due to program ineligibility
- ~7.9% will lose Medicaid coverage despite still being eligible
The Department of Human Services estimates that 15-25% of people enrolled in Medical Assistance and MinnesotaCare may lose coverage when renewals resume. However, importantly, of those disenrolling, approximately 30-50% will likely re-enroll in their coverage within a short period of time. These numbers are initial estimates. Enrollee data has grown out of date during the pandemic. This is because continuous coverage requirements prevented eligibility workers from entering updated information into eligibility systems if it would negatively impact an enrollee’s coverage. The department will update disenrollment estimates when better outcome-based data is available from the first few months of resuming renewals.
Health and well-being impacts

When renewals resume, some enrollees will inevitably lose their public health care coverage because they no longer meet the eligibility requirements. Some portion of enrollees, however, will remain eligible for coverage but will lose it due to barriers in the renewal process, including failure to receive notices or return paperwork, paperwork getting lost, and other issues unrelated to their actual eligibility status. This is evidenced by the history of churn off and back on coverage over the years. “Churn” is when eligible people lose coverage and then re-enroll within a short amount of time.

The loss of eligible coverage from churn when renewals resume may be higher than pre-pandemic years. Enrollees likely experienced many changes in the last three years that will complicate their renewal and make it harder to get in touch with them, including moving, changing jobs or experiencing an illness. A loss of coverage for Minnesotans creates barriers to accessing needed care, including COVID-19 vaccinations and treatment, other immunizations, preventive screenings, prescription drugs, management of chronic conditions, and mental-health and substance-use-disorder treatment.

These negative impacts could worsen existing health disparities in Minnesota. Public health care program enrollees are, by definition, low income. They are also disproportionately Black, Indigenous and people of color compared to the general population. Medical Assistance and MinnesotaCare also support people during some of the most critical times in their lives; in Minnesota, public health care programs cover more than 40% of children, 4 out of 10 births, approximately half of nursing home costs and about half of substance-use-disorder treatment.
Workload issues
Minnesota’s public health care programs have complex, paper-based renewal processes that require the partnership of DHS; processing entities, such as counties and Tribal Nations; navigators; and the enrollees themselves. An unprecedented volume of renewals that need to be completed combined with a tight labor market that has produced worker shortages — echoed in industries across the state — have the potential to create bottlenecks in renewal processing that cause gaps in coverage for some Minnesotans.

Since the pandemic began, the number of enrollees has grown, and so has the work necessary to complete renewals. With the continuous coverage requirements in place, the law required workers to refrain from acting on many changes that could negatively affect eligibility so these changes were not entered into the state’s eligibility systems. As a result, the data on file in the eligibility systems has grown outdated, making the number of cases that automatically renew based on data retrieved from electronic databases drop significantly. Consequently, this adds to the volume of renewals that workers must manually process. Meanwhile, the workforce in some counties to complete this renewal work is understaffed and already overworked.

Resuming the renewal process will be particularly difficult, since:
- Many enrollees are likely to have moved, changed jobs or experienced other changes that must be considered in the renewal process.
- Those who gained coverage during the pandemic are unfamiliar with the renewal process.
- New workers have never processed renewals and it has been about three years since experienced workers have processed renewals.

Mitigation plan approved by the Centers for Medicare & Medicaid Services

The Department of Human Services will use these CMS-approved strategies to help eligible Minnesotans keep coverage and secure another $300 million in federal funds for the state during the resumption of renewals.

Add more user-friendly ways to complete the renewal process, including by phone or by submitting documents online
- Learn more about the new ways to provide renewal information at mn.gov/dhs/renewmycoverage.
- Enrollees can still choose to submit their renewal form in person, by postal mail or fax.
Make it easier to complete the paper-based renewal forms
- Remove questions unlikely to change about enrollees from the renewal form, e.g., Social Security Number.
- Add a question that allows enrollees to select that they have no income.
- Train eligibility workers to continue renewal determinations when certain questions are left blank.
- Add how navigators and contracted health plans can help submit completed forms or documentation.
Renew coverage automatically for more enrollees, allowing them to skip the paperwork and renew their coverage based on trusted data sources that show they continue to qualify
- Add automatic renewal processes for enrollees who get their coverage on the basis of having disabilities, being blind or being age 65 or older by assuming their continued eligibility when they either:
  - Continue eligibility for other low-income programs, e.g., Supplemental Security Income, Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) at 100% of federal poverty guidelines.
  - Have stable income from Social Security or Railroad Retirement income or disability benefits.
  - Had no income when they applied for the program or at their most recent eligibility review.
Maintain coverage for enrollees who have disabilities, are blind or are age 65 or older and in the first batch of enrollees due for renewal – the July 2023 cohort – for all reasons other than an ineligibility determination
- Continue coverage if they fail to submit or complete their paperwork. Reschedule their renewal for later.
Minimize unnecessary hurdles to the renewal process that cause enrollees to temporarily lose program eligibility, reapply for it and regain eligibility in a short amount of time
- Waive the asset test at renewal for enrollees who have disabilities, are blind or are age 65 or older by disregarding assets above the asset limit until their next renewal after renewals have resumed.
- Verify program eligibility for enrollees who have disabilities, are blind or are age 65 or older after they submit their renewal form through manual back-end data checks.
- Permit enrollees to submit renewal paperwork up to four-months after their coverage closes if it closed for failure to return renewal paperwork.
Work with contracted managed care health plans to maintain coverage for eligible enrollees
- Provide health plans lists of enrollees due for renewal, and request they communicate with enrollees whose coverage will not automatically renew.
- Request that the health plans incorporate renewal-related information into customer-service interactions.
Check enrollees losing coverage for eligibility under other eligibility categories
- Train workers to check for eligibility under other categories when enrollees lose coverage.
- Add screening questions to renewal forms received by enrollees to detect when they may meet another eligibility category. Send enrollees who will lose coverage under their current category a supplemental form to complete within 30 days when screening questions indicate possible eligibility under another category.
Other renewal requirements: Consolidated Appropriations Act, 2023
Ensure up-to-date enrollee contact information.
- Develop and promote a statewide address update campaign with media, social media, text messaging, digital and print communications materials, and direct engagement by stakeholders serving enrollees. Share the resources to promote the campaign with partners and stakeholders, including counties, tribes, managed care organizations, navigators, providers and community organizations.
- Partner with managed care organizations to update address information for enrollees.
- Update enrollee addresses from other DHS programs, including SNAP and TANF.
- Accept in-state address updates from the U.S. Postal Service.
- Mail enrollee notices early to help identify wrong addresses.
Make extra effort to reach enrollees before closing their coverage for returned mail.
- Correct addresses for enrollees when renewal forms get returned in the mail due to bad addresses.
- Contact enrollees through multiple means before closing their coverage due to bad addresses.
- Give enrollees more time to complete their renewal when their renewal forms get re-mailed to new addresses.

Proposed Mitigation Plan 2.0

Review the draft of our most recent mitigation plan, with details about our strategy for conducting individual ex parte (automatic) renewals.

Strategies to maintain health care coverage

DHS is creating a comprehensive plan on how to complete the necessary work to resume eligibility reviews for a quarter of the state’s population, mitigate the loss of eligible coverage and help ineligible Minnesotans connect with other health care coverage options. DHS, working with many other partners, is committed to ensuring that eligible Minnesotans retain their public coverage when annual renewal processes resume and ineligible Minnesotans connect with other coverage options. Refer to the operational plan and renewal process playbook.

Enrollee-centered communications
Communications will be a core component in successfully restarting renewals. The agency will work with partners and stakeholders to amplify DHS messages. The department will focus on targeted outreach to enrollees at highest risk of losing eligible coverage, including Minnesotans with limited English proficiency and BIPOC communities. Outreach activities will include:
- Researching enrollee communication needs
- Creating campaigns to update enrollee addresses and phone numbers
- Revising call center scripts and hold messages to request updated enrollee contact information
- Sending multiple mailings to enrollees when it’s time for them to renew their coverage
- Sending text messages to enrollees to supplement mailed communications
- Launching a dedicated webpage in multiple languages about resuming renewal processes
- Partnering with trusted community leaders and community relations experts, including navigators and health care providers, and providing them with communications toolkits to further messages about restarting renewal processes
- Promoting accessibility through translations of highly-used resources
- Partnering with multicultural media outlets for paid and earned media opportunities
Coordination with state and federal partners

DHS regularly communicates with the Centers for Medicare & Medicaid Services to explore flexibilities that allow the state to maintain consistent coverage for enrollees while efficiently resuming renewal processes. Other State of Minnesota agencies will also be critical partners in this work. DHS will meet with these agencies regularly to identify possible points of collaboration, consistent communications and strategies, and support to reduce health disparities while maintaining access to affordable health care. DHS will work particularly closely with MNsure on seamless coverage transitions for enrollees found ineligible who seek coverage through Minnesota’s health insurance exchange.
Support for county and tribal eligibility workers

To better support counties and tribes, DHS regularly provides space for all to collaborate and will encourage counties and tribes to share best practices. The department will continue to offer several refresher trainings for eligibility workers with a plan for additional timely trainings for resuming renewals and other eligibility processes shortly before restarting renewals. DHS will provide counties and tribes with a toolkit of resources and regular updates on statewide trends in renewals.
Partnership with health plans

Contracted managed care plans provide coverage for approximately 85% of enrollees and will also serve as critical partners when renewals resume. DHS will provide these health plans with monthly rosters of the enrollees attributed to them who are due for a renewal and encourage the plans to conduct outreach with these enrollees, reminding them to complete their renewal paperwork and update their contact information. DHS will also offer toolkits to aid these communication efforts.
Project management support

DHS is contracting with an external vendor to primarily provide dedicated project management resources and strategic communications development and support. This investment helps ensure appropriate coordination, execution and tracking of renewal activities. Dedicated communications resources will help reach enrollees to ensure they know what they need to do to maintain coverage.
Capacity for appeals, disability determinations, ombudsman
Public transparency