When The Public Health Emergency Ends: What Will It Mean For Dually Eligible Individuals?

In response to the COVID-19 public health emergency (PHE), states have used a variety of federal policy flexibilities to stabilize their health care systems and maintain continuity of coverage for people. To comply with the Families First Coronavirus Response Act’s “continuous coverage” requirement and receive a temporary increase of 6.2 percentage points in their federal medical assistance percentage, states have had to maintain continuous Medicaid enrollment for nearly all program enrollees. This requirement has been largely responsible for a 20 percent increase in Medicaid and CHIP enrollment between February 2020 and September 2021.

In preparing for the end of the PHE, states should make policy and operational decisions that promote continuity of coverage for dually eligible individuals, as they could be disproportionately harmed by unnecessary disruptions in Medicaid coverage.

When The Public Health Emergency Ends…

When the PHE ends, states will have 12 months to initiate redeterminations of Medicaid eligibility for all of their Medicaid enrollees, roughly 12 million of whom are dually eligible for both Medicare and Medicaid. Over the past several months, the Centers for Medicare and Medicaid Services has worked with Mathematica and other contractors to release several tools to support states in “unwinding” PHE policies and restarting all eligibility redetermination processes. In this work, states, health plans, health care providers, and community-based organizations should focus on helping dually eligible individuals, for at least five reasons.

First, compared with people with disabilities who have only Medicaid coverage, dually eligible individuals are more likely to have three or more comorbid chronic conditions and to use long-term services and supports (LTSS). Losing Medicaid eligibility could mean losing critical services that help these individuals live in the community and prevent them from entering institutions.

Second, dually eligible individuals are also more likely to have Alzheimer’s disease or related dementia than people with only Medicaid. This means dually eligible populations might require more help navigating the process of renewing their Medicaid eligibility than other groups.

Third, dually eligible individuals have been hit hard by COVID-19. Their rates of illness and hospitalization were more than twice as high as those of people with Medicare benefits alone, and dealing with ongoing health issues related to COVID-19 could keep beneficiaries from responding to Medicaid eligibility renewal notices.

Fourth, although older adults and people with disabilities typically have slightly lower rates of Medicaid enrollment churn than the average enrollee, when dually eligible individuals lose Medicaid coverage, it is often because they do not respond to eligibility renewal notices, rather than because of any real change in eligibility.

Before the PHE, researchers found that 30 percent of dually eligible individuals lost Medicaid coverage within their first year, and 17 percent lost coverage within three years. In both studies, roughly 30 percent of the dually eligible individuals who lost coverage regained it within three months, meaning they likely had trouble responding to state administrative requests rather than genuinely losing eligibility. Expert interviewees also cited failure to comply with state administrative requirements as the most common reason full-benefit dually eligible individuals lose Medicaid coverage, rather than changes in income, assets, or functional status.

Finally, although states must use ex parte renewal processes whenever possible to redetermine Medicaid eligibility without requiring beneficiary input, states use these processes less frequently with older adults and people with disabilities due to problems verifying assets.

The net effect of these factors is that, compared with other Medicaid populations, states are more likely to ask dually eligible individuals to respond to requests to renew their Medicaid eligibility, even though they are less likely to be able to respond quickly and completely to those requests without help.

Medicaid Eligibility Churn Is Detrimental For Dually Eligible Individuals And State Medicaid Programs

Many dually eligible individuals who lose Medicaid coverage regain it quickly. Yet, periods without coverage disrupt access to critical health services and LTSS. Dually eligible individuals are at particular risk for adverse consequences from unmet LTSS needs. And because nearly half of dually eligible individuals receive LTSS, these disruptions can also significantly raise state Medicaid costs if they result in increased care needs over time.

Loss of Medicaid coverage for Medicare cost sharing can also lead dually eligible individuals to forgo medically necessary primary, acute, or behavioral health care in the short term. This short-term avoidance of care could increase states’ long-term costs as these individuals return to Medicaid benefits in need of higher-intensity, more expensive care down the road.

Finally, as people churn in and out of Medicaid coverage, states must often process multiple benefit applications for them, leading to unnecessary administrative burden for state Medicaid programs. 

How To Promote Continuity Of Coverage For Dually Eligible Individuals When The PHE Ends

States can take several policy and operational steps now to promote continuity of coverage for dually eligible individuals when the PHE ends.

1. Use Supplemental Security Income Redeterminations

About 34 percent of dually eligible individuals receive Medicaid benefits through a Supplemental Security Income (SSI) eligibility pathway. The Social Security Administration has special agreements with 34 states and the District of Columbia that allow it to determine Medicaid eligibility for people receiving SSI benefits. In those states, redeterminations for SSI eligibility also serve as Medicaid eligibility redeterminations, allowing the states to focus on improving redetermination processes for dually eligible individuals who do not receive SSI benefits.

2. Maximize Use Of Ex Parte Reviews With Dually Eligible Populations

• Analyzing data from past ex parte reviews to identify factors that have prevented successful renewal of coverage for dually eligible individuals based on ex parte data and strategizing ways to increase the rate of ex parte renewals for these individuals
• Expanding the number and types of data sources used for ex parte reviews
• Creating a data source hierarchy to guide ex parte verification, prioritizing the most recent and reliable data sources
• Using reasonable compatibility thresholds for income and assets and adjusting those thresholds to reflect the circumstances of dually eligible populations
• Building enough time into the ex parte review process to use data from the state’s asset verification system
• Requesting 1902(e)(14)(a) waiver authority to use data from ex parte reviews to renew eligibility for people who have attested to having zero income or for whom the state’s asset verification system does not return asset information within a reasonable time

3. Extend Protections For MAGI Eligibility Groups To Dually Eligible Individuals

State Medicaid agencies must extend certain protections to Medicaid beneficiaries whose eligibility is determined using modified adjusted gross income (MAGI) methods. States may extend those protections to Medicaid beneficiaries in non-MAGI eligibility groups, including dually eligible individuals. Examples of these protections include:

• 12-month renewal timelines: States may not redetermine eligibility for Medicaid beneficiaries in MAGI-based eligibility groups more than once a year, unless the state learns of a change in a beneficiary’s circumstances. This 12-month renewal timeline can be extended to dually eligible individuals, a group whose income and assets tend not to change dramatically over time.
• Pre-populated renewal forms: Pre-populating eligibility renewal forms can simplify eligibility redeterminations and improve the likelihood of renewed coverage. In 2019, 30 states sent pre-populated Medicaid redetermination forms to older adults and people with disabilities.
• 30-day response period: Giving dually eligible individuals 30 days or longer to respond to renewal notices can reduce the number of people losing coverage merely due to lack of response. Lengthy response periods are especially helpful for people who receive renewal notices during short-term hospital stays and those who need help responding to renewal requests.
• 90-day reconsideration period: Given the large proportion of dually eligible individuals who regain coverage within 90 days of losing it, extending a 90-day reconsideration period to these individuals can prevent gaps in coverage and unnecessary reapplication burden.
• Waiver of in-person interviews: Waiving in-person interviews can enhance actual and perceived safety for dually eligible individuals during the renewal process, given their high rates of chronic disease and susceptibility to COVID-19.

4. Facilitate Access To Medicare Savings Program Benefits

Before terminating someone’s Medicaid coverage, states must consider whether the person could qualify through other eligibility pathways. These pathways include Medicare Savings Programs (MSPs), partial-benefit Medicaid programs that provide help with monthly Medicare premiums and, in some cases, Medicare cost sharing.

As the PHE ends, facilitating access to MSPs will be especially important for Medicaid expansion adults who became newly eligible for Medicare during the PHE—a group that states could choose to prioritize in processing pending eligibility actions, while deprioritizing other dually eligible individuals. Because of differences in state eligibility criteria for the adult expansion group and groups for older adults and people with disabilities, some of these individuals might lose eligibility for full-benefit Medicaid coverage at the end of the PHE but remain eligible for MSP benefits.

To facilitate access to MSPs after the PHE ends and ease the transition of Medicaid expansion adults into MSPs, states should build consideration of MSP eligibility into their eligibility renewal processes for Medicaid. States can also make policy changes now that will make it easier to streamline MSP access. For example, states can update the criteria with which they evaluate MSP eligibility to align with processes used to assess eligibility for the Medicare Part D Low-Income Subsidy (LIS) program; they can then use LIS data from the Social Security Administration to automate or otherwise support enrollment into MSPs. States can also use federal authority to increase income or asset limits for MSPs, eliminate MSP asset limits altogether, or adjust how income or asset disregards are applied.

5. Partner With Dual Eligible Special Needs Plans (D-Snps) To Maintain Continuity Of Care For D-SNP Enrollees During Temporary Lapses In Medicaid Eligibility

Besides partnering with Medicaid managed care plans to share updated beneficiary addresses, conduct outreach, and help members with Medicaid renewal, states can also partner with D-SNPs—specialized Medicare Advantage plans that serve only dually eligible individuals—to promote continuity of care for their members as the PHE ends. In February 2022, more than four million dually eligible individuals nationwide (one-third of the dually eligible population) were enrolled in D-SNPs.

In particular, D-SNPs can implement eligibility “deeming periods,” which enable members who lose Medicaid eligibility to maintain D-SNP enrollment, as long as those members are expected to regain Medicaid coverage within six months. D-SNPs can choose to offer this continued coverage for 30 days to six months, and states can use their contracts with D-SNPs to require deeming periods of a particular length. For example, some states require D-SNPs to implement deeming periods of 90 days to align with Medicaid benefit reinstatement periods. During deeming periods, D-SNPs can help members regain Medicaid eligibility while providing continued access to care coordinators and the D-SNP’s network of providers—all critical tools for ensuring that members receive necessary medical and social supports while they are temporarily ineligible for Medicaid.

Act Now

Loss of health coverage for anyone with an illness can be difficult. For dually eligible individuals with complex health and functional needs, low incomes, and few (if any) assets, loss of coverage for even a short time can be life threatening. State policy makers and Medicaid agency staff should act now to maintain continuity of coverage, save costs, and improve health outcomes for dually eligible individuals as the COVID-19 PHE ends.