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Headshot of author Kendra KuehnMedicaid Unwinding: What APS Should Know 

by Kendra Kuehn, MSW, NAPSA

During the COVID-19 public health emergency, Congress and the federal government worked to meet the nation’s needs with as much flexibility as possible. Now that the country is moving out of the crisis and into more normal operations, many of these accommodations will begin to fade or “unwind.” The unwinding of the Medicaid program flexibilities has the potential to impact many older adults and people with disabilities. Medicaid provides coverage to nearly 85 million eligible participants, including low-income adults, children, pregnant women, older adults, and people with disabilities. The program is administered at the state, DC, and territory (hereafter “state”) level with federal requirements. This blog will cover the national picture, but APS programs and workers should be sure to check in with their own state’s activities (see resources). 

How did Medicaid change?

In early 2020, the federal government declared a public health emergency for the COVID-19 pandemic. As part of the emergency, states submitted amendments and waivers to create flexibilities such as expanding telehealth options, increasing provider payments, or supports for home and community-based services.  

The largest flexibilities for Medicaid came as part of the Families First Coronavirus Response Act (FFCRA) passed in 2020. The law provided more funding to states through increasing the Federal Medical Assistance Percentage (FMAP). The FMAP is a formula based on state per capita income that determines the federal funding for Medicaid in each state. Increasing the FMAP was a quick way to both support the expected increase in Medicaid eligible residents and bolster state vaccination and testing efforts. 

To receive the increased FMAP states had to meet several conditions, including ones related to eligibility and services. While receiving the increased FMAP, states’ Medicaid eligibility standards could not be more restrictive than what was in place going into 2020. State programs were required to cover COVID-19 vaccines, testing, and treatment. The most significant requirement was that states must provide continuous eligibility for enrollees through the end of the public health emergency, unless the person is no longer a state resident or asks for coverage to end. States are also prevented from collecting any unpaid premiums due during this period. 

What is unwinding?

Medicaid unwinding is the process the federal and state governments are going through to return to normal operations. Under the Consolidated Appropriations Act passed in December 2022, the continuous enrollment requirements will start phasing out on April 1, 2023. The increased funding will also start phasing out April 1, 2023, through the end of the year, and states must enact certain protections for determining if enrollees are eligible to continue receiving Medicaid benefits.  

States submitted an operational plan for unwinding to the Centers for Medicare & Medicaid Services (CMS), including efforts to prevent improper terminations. They can start the process as early as February 2023 with terminations starting in April 2023. Programs have 12 months beginning in April to review eligibilities and 14 months to complete enrollment decisions. States are able to use existing data systems to verify eligibility. States are also able to de-prioritize, or leave until later in the process, groups of enrollees such as older adults and persons with disabilities. Plans vary, but all states have noted that they have alerted enrollees to update their contact information.

Who will be impacted? 

As of November 2022 CMS reported that nearly 85 million individuals were enrolled in Medicaid, nearly a 30% increase from February 2020. The Kaiser Family Foundation and U.S. Department of Health and Human Services estimate that 5.3 million to 15 million people will lose Medicaid benefits during the unwinding process. States will be working to support a smooth transition for those who may be eligible for marketplace plans or Medicare. Some beneficiaries may have become eligible for Medicare during this period but not have enrolled, or they may have lost eligibility for their Dual Eligible Special Needs Plan. The State Health Insurance Assistance Program (SHIP) can provide counseling in these areas. 

The Kaiser Family Foundation and Justice in Aging note that people with limited English proficiency (LEP) and persons with disabilities may be particularly at risk. People with LEP and persons with disabilities are the most likely to face access barriers in ensuring all information is accurate. Not all states provide online application translations or easy access to large print options. Dually eligible individuals (eligible for Medicare and Medicaid) could face significant consequences if they are improperly disenrolled, including loss of Medicaid services not covered by Medicare, loss of premium payments, and loss of eligibility for subsidies. The National Indian Health Board notes that American Indians and Alaska Natives may also face barriers to maintaining coverage primarily due to limited postal delivery and broadband availability on reservations. CMS has toolkits and communications materials available to engage community groups and the National Health Law Project has recommended questions for assessing available assistance. 

What should APS know?

APS workers and partners should know what Medicaid unwinding is and the impact on the older adults and people with disabilities they see day to day. APS programs may be involved in their Medicaid program’s unwinding plan, and others should ensure they are aware of what is happening in the state. Some states have online dashboards and resources available to the public, such as Minnesota’s Department of Human Services or Hawaii’s Med-QUEST Division. The specific unwinding procedure will vary from state to state, and updates from the state Medicaid agency are key. 

The Administration for Community Living fact sheet on Medicaid changes notes, “The upcoming changes to Medicaid are historic and the aging and disability networks are critical partners in ensuring older adults and people with disabilities can continue to receive the supports and services they need without disruption.” APS is a critical part of the system, ensuring that older adults and people with disabilities are empowered during the unwinding of the COVID-19 pandemic.


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