Roughly 200,000 Nevadans’ health care coverage is likely to be affected by the March 31 end of a pandemic-era federal policy requiring states to keep Medicaid recipients continuously enrolled in the health care program for low-income people.

It’s a change that will take place over the next year and one that officials warn if done recklessly could potentially lead to hundreds of thousands of Nevadans without the coverage they have come to rely on. Through the pandemic, Nevada Medicaid saw a historic rise in enrollment leading to about one in three Nevadans being covered under the joint federal and state program.

As part of the shift from continuous enrollment and back to annual eligibility checks, states have a 12-month “unwinding period” of checking the beneficiaries on Medicaid rolls for eligibility compliance, removing those who no longer qualify based on income or other factors. 

A Medicaid enrollment and unwinding tracker from health policy research group KFF indicated that as of late June, Nevada has a 59 percent disenrollment rate for completed reviews (pending renewals are excluded), placing the Silver State in the top five highest disenrollment rates across all reporting states. 

However, officials with Nevada Medicaid and the state Division of Welfare and Supportive Services said in a joint statement to The Nevada Independent that a state-by-state comparison of disenrollment rates is not an apples-to-apples comparison because each state has different starting dates for unwinding, various numbers of members coming on to Medicaid during the pandemic and different methods of approaching the unwind. 

“Each month different states are likely to have different disenrollment rates,” state officials said.

As of the latest reports, nearly 41 percent of Nevada’s renewal applications due at the end of May have been approved for renewal, 17 percent have been determined to no longer qualify for Medicaid and a little more than 40 percent have not been renewed for “procedural reasons.” That can mean the individual or family did not respond to a Medicaid renewal notice, or their contact information was outdated and they could not be reached. 

Individuals have 90 days after disenrollment to reapply for Medicaid if they think their disenrollment was a mistake or were unable to get their information back to the state in time to renew.

State officials say the greatest priority is ensuring people continue to receive health care coverage if they no longer qualify for Medicaid or end up being disenrolled. 

“So far, the numbers are in line with what we expected as Medicaid returns to normal operations,” officials said.

During a press briefing on June 27, Centers for Medicare and Medicaid Services (CMS) Deputy Administrator and Director of the Center for Medicaid & CHIP Services Daniel Tsai described the policy shift as the “most significant health care coverage topic” in the country. He said it’s vital states make every effort to keep people insured and “not rush the process.”

“We are seeing large numbers of disenrollments across the country,” Tsai said.

Though “unwinding” refers to decoupling continuous coverage from the public health emergency, the abundance of administrative burdens and poor execution of the redetermination process could result in lost gains in health care coverage across the state and country.

CMS officials are also concerned because many people are unaware that the Medicaid renewal process is restarting. They also said that many parents may not realize that even if they are no longer eligible for Medicaid because their income has changed, it is very likely that their children might still maintain Medicaid eligibility. 

Health care advocates, Nevada Medicaid and the Biden administration want to ensure as many people stay covered as possible — and use a variety of strategies to overcome the administrative burdens that power frequent churn, a persistent pre-pandemic problem for Medicaid.

As part of efforts to inform Medicaid recipients of the renewal process, Nevada Medicaid sent messages to them to update their contact information and has aimed to connect with people via calls and text messages along with printed notices. The Division of Welfare and Supportive Services also implemented a process to automatically renew eligibility for people on Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF). But for cases where people report no income or there is no way to verify income, the division sends an application for renewal in the mail.

Nevada Medicaid Administrator Stacie Weeks said in a press release on June 23 that responding to the demand for Medicaid during the pandemic required strong partnerships between state and federal agencies, health plans and providers.

“We are leveraging these partnerships once again as we unwind from the pandemic with the goal of helping those who no longer qualify for Medicaid find affordable options for health insurance,” Weeks said.

Growth under continuous enrollment policy

Under the continuous enrollment policy, Medicaid enrollment grew rapidly in Nevada and across the country. From February 2020 to December 2022, Medicaid and Children’s Health Insurance Program enrollment grew 39.2 percent in the Silver State, with the vast majority of that growth attributable to the continuous enrollment policy, KFF reported using data from the CMS. Nearly a quarter-million Nevadans enrolled in Medicaid since the onset of the pandemic.

“It really created stability for folks,” said Jennifer Wagner, the director of Medicaid eligibility and enrollment at the Center for Budget and Policy Priorities, a progressive think tank. “Oftentimes, people come on and off of coverage frequently. That might be because they have some income fluctuations, or because they remain eligible, but red tape barriers cause them to lose coverage and come back on.”

She said the policy eased the workload for state agencies.

“If this provision hadn’t been in effect, it would have crumbled and been unable to handle the workload amid their own change rates,” Wagner said.

Nationally, the policy proved enormously effective — and expensive. At a dire time for the state of public health and the economy, the government kept more Americans insured than ever before and kept low-income beneficiaries from the cumbersome renewal process that has led to persistent turnover in the Medicaid population. With more Americans covered than ever before, Medicaid spending rose at the state and federal levels, peaking at a 12.5 percent total growth rate in 2022.

But Nevada Medicaid expects enrollment to shrink back to near-early 2020 levels with the expiration of the continuous enrollment provision at the end of March. 

So far, officials with Nevada Medicaid and the Division of Welfare and Supportive Services said the disenrollment numbers are in line with expectations and Nevada Medicaid is “returning to normal operations.”

“While some may no longer qualify for Medicaid, the hope is that by this time next year, more Nevadans are insured than before the pandemic,” officials said.

Keeping people insured

Officials with the Division of Welfare and Supportive Services said they have been verifying eligibility electronically, determining those who could be automatically renewed and those who needed to provide more information. 

All enrollees who needed to provide more information received a renewal packet in the mail in April, with a response required by May 31 at the latest. Beneficiaries who failed to return their packet or update their information digitally were deemed ineligible and were removed from the rolls beginning June 1.

A May report from the state indicates 53,932 people on Medicaid had a renewal application due May 31. Of those, more than 22,000 people — or nearly 41 percent — renewed and remained on Medicaid or CHIP. 

About 9,330 people (17 percent of renewal applications) were determined to be ineligible for Medicaid, and roughly 21,840 people (a little more than 40 percent) were “terminated for procedural reasons.” 

Nevada Medicaid says eligible beneficiaries are at risk of losing coverage because the agency does not have a current address. 

“The transient nature of Nevada’s population means that maintaining proper contact information has been difficult,” the agency wrote.

For those who are no longer eligible, other sources of coverage — including Medicare, the Children’s Health Insurance Program or marketplace plans from Nevada Health Link — are expected to close some gaps, though the full extent of how the unwinding will affect the uninsured rate will not be known for several months. KFF estimates that people who have moved, people with limited English proficiency and immigrants are most at risk of slipping through the coverage gap. 

Officials with Nevada Health Link said that Nevadans who are ineligible for Medicaid benefits will have a special enrollment period from when they are notified of eligibility loss to enroll in a plan through Health Link. 

Between April and May, reports from Nevada Health Link indicate that 94 percent of those who applied for health coverage after being transferred to Nevada Health Link from Medicaid were found eligible to enroll in a Qualified Health Plan (QHP), or an insurance plan that meets Affordable Care Act requirements, and 74 percent of those who applied were also eligible for financial assistance.

In a June 23 press release, Deputy Administrator of the Division of Welfare and Supportive Services Kelly Cantrelle said the members of the division are available to help, including at 184 sites within at-risk communities..

“We are working with our sister agencies and community-based partners to prevent any Nevadan from slipping through the cracks,” she said

Meanwhile, health care advocates and members of Congress aim to deploy every tool they have to ensure patients retain coverage, including following long-standing legal guidance from the Department of Health and Human Services that states have been slow to implement. 

As chair of the Congressional Black Caucus, Rep. Steven Horsford (D-NV) led a March letter to HHS Secretary Xavier Becerra detailing how people of color are at greater risk of slipping through the coverage cracks. Horsford and his colleagues asked HHS to emphasize various “legal obligations” state agencies have in providing guidance and resources in order to “prevent a new epidemic of paperwork-driven terminations.”

Specifically, they called on state agencies to use data matching — or automatically renewing beneficiaries or updating their contact information with data they have already provided to other programs such as SNAP. 

The members also asked HHS to emphasize that state agencies fully staff call centers, provide information about unwinding in multiple languages and permit beneficiaries to update their address information online or by phone. Finally, they asked for states to upload data about unwinding at the end of each month so that Congress and HHS can best understand how it proceeds.

“To prevent a major civil rights and health equity disaster, we believe that you should set the bar high in clearly defining and enforcing states’ and territories’ legal obligations to prevent eligible beneficiaries from losing coverage,” the members wrote. 

A test of resources

Experts worry about several drop-off points in which someone could lose coverage.

Among those who are no longer eligible, transitioning to either Medicare or the exchanges can be confusing, even though the federal government extended Affordable Care Act subsidies for those purchasing plans on Nevada Health Link. 

Beneficiaries who reapply and learn they are no longer eligible receive a special notice explaining how to transition to the marketplace. But for those who do not bother to reapply, suspecting they no longer qualify, they never receive that information. And for beneficiaries who are eligible but whom the agency is unable to contact, they may not know they have lost their insurance until they attempt to pay for a doctor’s appointment or a prescription.

Anne Reid, a policy and health equity adviser at advocacy group Protect Our Care, said nationally, half of the beneficiaries that agencies will need to contact are estimated to still be eligible for the program, but would not automatically requalify because of administrative red tape. And in Nevada, Medicaid is uniquely valuable to the workforce.

“There’s some major employers within the state that rely heavily on Medicaid — Amazon, Walmart, Clark County School District, three top Strip resort companies,” Reid said. 

The ability of the agency to keep as many beneficiaries insured as possible may come down to the capacity of its staff. The Division of Welfare and Supportive Services, which processes the renewal applications, has a vacancy rate of 18 percent. Officials with the division said that with the cost-of-living increases approved for state workers by Gov. Joe Lombardo, DWSS “is looking forward to reducing the vacancy rate with upcoming recruitments for open positions.”

Asked whether the vacancy rate will negatively affect the division’s ability to help beneficiaries, officials responded that the average processing timeframe for Medicaid applications is less than 14 days, which is well under the federal guideline of 45 days.

“DWSS has no concerns with continuing to meet the needs of our customers,” officials said. 

Wagner said workforce challenges are also exacerbated by inexperience — given that redeterminations have not taken place in three years, many caseworkers have never conducted one.

Officials with Nevada Medicaid and the Division of Welfare and Supportive Services said that the new partnerships created during the pandemic with health insurers, hospitals, providers, community partners, schools, employers, pharmacies and Medicaid members themselves will help ensure coverage is not lost.

“Overall, enrollment in health insurance (whether Medicaid or private health insurance) is expected to be strengthened by the efforts and the new partnerships that have been built,” officials said.