What To Know About Enrollment Transitions in Medicaid

What To Know About Enrollment Transitions in Medicaid

A recent Wall Street Journal story ignores the facts and presents a deeply flawed viewpoint on enrollment and coverage changes for Medicaid beneficiaries.

Here are the facts:

• Robust coverage and satisfaction: More than 70 million Americans rely on Medicaid for affordable, high-quality health care coverage, and Medicaid plans work closely with states to ensure the accuracy of enrollment data.
• Despite the story’s generalizations, Medicaid concurrent enrollment is a rarity.
  • Less than 0.5% of Medicaid enrollees are concurrently enrolled, according to the U.S. government.
  • While very rare, concurrent enrollment can occur if a beneficiary moves states without closing their previous Medicaid coverage and subsequently enrolls in the program in their new state, or if there is a temporary lag in enrollment data.
• Medicaid plans strongly support program integrity and accuracy.
  • Medicaid plans coordinate with state and federal policymakers to maintain the integrity of and stability of the Medicaid program.
  • Many states have robust processes in place to recover premium costs associated with potential concurrent enrollees, including through program and payment audits, rate-setting and/or recoupments through contracting requirements. These mechanisms ensure Medicaid plans do not benefit from rare and temporary instances of concurrent enrollment.
• It can be difficult to 100% eliminate concurrent enrollments for several reasons, including:
  • Complex individual circumstances can result in multiple residence changes for some beneficiaries.
    • For example, people experiencing chronic homelessness or in unstable housing situations, seasonal employees, people with frequent job changes, and/or people suffering from illnesses may relocate more often, resulting in lags to updated data.
  • From 2019-2021, COVID-19 created a higher-than-average level of movement among beneficiaries, both across states lines as well as between and among coverage markets, straining states’ administrative resources. Pauses on routine eligibility redeterminations further contributed to temporary instances of concurrent enrollments.
  • Brief overlaps between the termination and initiation of coverage can also lead to short periods of concurrent enrollment for a small portion of the Medicaid population.
• Federal medical loss ratio requirements place strict limits on Medicaid plans’ profits and administrative costs, ensuring that states receive value from their Medicaid partnerships.
  • States use the claims and enrollment experience of contracted MCOs to set monthly capitation rates year over year, which should account for concurrent enrollments.
  • States can also impose contractual requirements on MCOs for premium recoveries related to concurrent enrollees if they deem it necessary and appropriate given the very small numbers involved and the other protections noted above.