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The Dartmouth
May 22, 2024 | Latest Issue
The Dartmouth

New Hampshire undergoes “unwind” of Medicaid continuous enrollment policy

Following the 2023 Consolidated Appropriations Act, approximately 103,000 state residents may no longer be eligible for Medicaid.

NH State House Copy (w/out caption)

On April 1, the Medicaid continuous enrollment policy, which expanded coverage to thousands of U.S. citizens during the COVID-19 public health emergency, expired with the passing of the 2023 Consolidated Appropriations Act. 

New Hampshire Medicaid director Henry Lipman said that following the 2023 Consolidated Appropriations Act, state governments are mobilizing to redetermine which of their residents still qualify for federally funded health insurance. Those who no longer qualify will eventually be removed from the Medicaid rolls, reflecting what Lipman and other officials are calling “the unwind” of the Medicaid continuous enrollment policy. 

“Up until the point of the Consolidated Appropriations Act, the public health emergency worked in ninety-day increments,” Lipman said. “And so you didn’t know until December of this past year whether you were going to be subject to having to complete a redetermination.”

According to the Kaiser Family Foundation, a non-profit, health policy focused organization, an estimated 5 to fifteen million individuals nationwide might lose Medicaid coverage due to the unwind. Economics professor Douglas O. Staiger said immigrants and those dealing with housing instability are most vulnerable to facing challenges in the redetermination process. 

“When Medicaid is trying to find you to check on your status, if they can’t find you, the default is you’re off [Medicaid],” Staiger said. “The states have been working for a while now trying to try to update where people are, to try to figure out where everybody on their rolls are living, but this is a very mobile population.”

Congress initially passed the Medicaid continuous enrollment policy with bipartisan support at the beginning of the pandemic in March 2020 in the Families First Coronavirus Response Act (FFCRA). This expansion was sustained by an increase in the Federal Medicaid Assistance Percentage, also known as FMAP, which is the federal contribution to individual states’ Medicaid programs, said Congressional Budget Office associate analyst Nianyi Hong ’13.

According to Hong, the federal government increased states’ FMAP by 6.2 percent, which enabled people to remain on Medicaid.

“The federal government said, ‘We’ll give a 6.2 percentage point boost to your FMAP,’ so the percentage the federal government will contribute to each state,” Hong said.  “In exchange, you have to offer this continuous eligibility provision, so you have to essentially not kick anyone off of Medicaid.” 

According to Hong, the FFCRA brought the usual Medicaid “churn,” the cycling of individuals on and off the Medicaid rolls, to a halt. Medicaid enrollments continued throughout the pandemic without any removals to stabilize the total number of recipients, he added. 

“Once you had Medicaid during the coronavirus public health emergency period, no matter what your income became, you were allowed to stay on Medicaid,” Hong said. “If you had Medicaid during that period, essentially there were only two ways to become disenrolled from Medicaid: You either left the state or you passed away.”

Since failr, the number of individuals receiving Medicaid coverage in New Hampshire grew by over 40,000 between March 2020 and March 2023, Lipman said.

In anticipation of the end of the public health emergency, the New Hampshire Department of Health and Human Services has been preparing for the beginning of this Medicaid unwind since July 2020, according to Lipman. In their outreach campaign to redetermine who qualifies for Medicaid, the state department of Health and Human Services applied a “risk based strategy,” targeting those whose eligibility seemed most precarious in the first months of the unwind.

“We frontloaded the unwind with individuals [for whom] we had information that suggested they were over-income… certain people that we had lost contact with that [had not] consumed any healthcare services in the past year, and generally others who had indicators of ineligibility,” Lipman said. 

Efforts of the “risk-based strategy” also included phoning members of  the “protected class” —  the 103,000 people whose eligibility status was thrown into question – to encourage them to complete their Medicaid eligibility redeterminations, according to Lipman. Approximately 251,000 New Hampshire individuals are currently enrolled in Medicaid, he said. Lipman estimated that 33,000 individuals successfully completed their redeterminations in advance of the CAA taking full effect.

“We provided pre-populated forms to individuals who had missing information, so it was easier for them to complete the process,” Lipman said. “We also have a pipeline to refer people to the federal government… people who are over-income or potentially could be eligible for the exchange coverage.”

For those who no longer qualify for Medicaid, Lipman said that the New Hampshire DHHS is working with other healthcare actors to ensure that they still have access to alternative coverage.

“What we are doing is trying to connect them with other sources of coverage,” Lipman said. “…We’ve worked with the insurance department. We’ve worked with the navigators. We’ve also connected with employment security. We’ve connected with the Department of Education to help get the word out aside from all the stakeholder groups.”

As the redetermination process continues, the state department of Health and Human Services is keeping a close eye on the New Hampshire legislature, specifically the Medicaid Reauthorization Bill, SB 263, according to Lipman. If passed, the law would extend coverage for many of those at risk of losing it. However, according to Lipman, the House and Senate disagree on the length of the extension.

“We expect some time in the budget reconciliation process. At the end of the year, there will be a committee of conference that will figure out if [the extension is] going to be two years or permanent,” Lipman said. “If that doesn’t happen, coverage for all that expansion group — which at one point was 96,000 and today is closer to 83,000 — that coverage will go away at the end of the year.” 

Since both the Senate and House have approved versions of the bill, Lipman said that he is confident a final version will soon pass. The only question is how long its Medicaid protections will last.