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Preparing for the End of the PHE and the Beginning of the Unwinding

When a storm is approaching, it’s common sense to be as prepared as possible.

 In this case, the storm is the ending of the public health emergency (PHE) declared by the federal government during the pandemic — a storm that is headed directly for states across the nation. The PHE expiration and its accompanying effects could hit states hard as the enrollment renewal process resumes for millions of Medicaid recipients for the first time in years. At the same time, states will be losing the additional financial support provided by the Federal Medical Assistance Percentage (FMAP) funding.

While there is currently no definite date for the end of the PHE, the Biden administration has pledged to provide states with 60 days’ notice. The next renewal period ends in mid-July, which makes October 2022 the earliest cessation date.

During the PHE, states were prevented from dropping Medicaid and Children’s Health Insurance Program (CHIP) recipients from the rolls, and enrollment expanded dramatically. According to the Kaiser Family Foundation, 16.1 million people enrolled in Medicaid from February 2020 to February 2022, creating a total of more than 87 million Medicaid and CHIP enrollees as of February 2022.

As the process of redetermination begins—what is called “the unwinding”—states are likely to experience unprecedented challenges, from administrative backlogs to a record number of appeals and grievances. This will happen at a time when states are already grappling with employee burnout and staffing shortages, further stressing an already overburdened workforce.

Two phases, multiple difficulties.

According to the Centers for Medicare and Medicaid Services (CMS), the unwinding will happen in two phases:

Phase one: Preparing for the renewal process and educating recipients of Medicaid and CHIP about the upcoming changes.

Phase two: Making sure that recipients of Medicaid and CHIP take action to renew their coverage, or transition to other coverage if they are no longer eligible.

States are now developing multi-faceted plans to ensure continuity of coverage for those who remain eligible and seamless transitions to other coverage for those who do not. However, the volume of renewals is expected to create numerous challenges:

Communication with current enrollees. In the months leading up to the end of the PHE, it will be vitally important to let current enrollees know that renewals are coming, and that they must soon take steps to maintain their coverage. Many Medicaid recipients may have moved during the pandemic, so they should be reminded to update their mailing address and contact information. People who cannot be contacted could be in danger of losing coverage even if they remain eligible for it. Those who become ineligible for Medicaid need to know of other affordable coverage options that may be available to them, such as subsidized insurance through the Health Insurance Marketplace or state-based exchange.

Timely processing. Redetermination of millions of enrollees will require an enormous effort. Guidance from CMS gives states up to 12 months to initiate renewals for all enrollees and recommends that states handle no more than one-ninth of their total caseload of Medicaid and CHIP renewals in a given month. Because of the extraordinary scale of the event, processing delays will be likely, leading to coverage gaps for members and negative financial implications for states. Increases in applications, phone calls, hearings and other tasks will simply compound the problem.

Administrative shortages and resulting errors. According to the National Association of Medicaid Directors, 70% of Medicaid agencies feel “least confident” about building the workforce capacity needed to execute the unwinding. Employees who already feel overworked will face mounting obligations to complete the monumental task in the allocated 12-month period. An exponentially increased workload and pressure on states, combined with staffing shortages, could result in a high number of ineligible determinations due to administrative errors.

Worsening of health disparities. The Urban Institute estimates that as many as 15 million low-income people—including 6 million children—could lose health coverage during the upcoming redetermination process. Inevitably, this will have a disproportionate impact on an already vulnerable, marginalized population. 

What states can do to prepare for the unwinding.

At Gainwell, we share the concerns of CMS about the ending of the PHE and what it means for our nation’s safety net and those who rely on it. As states seek to manage PHE-related challenges, several steps can be taken now to meet at-risk individuals where they are while improving the process and mitigating complications on the back end.

Use social media to efficiently communicate with recipients. In addition to more traditional communication vehicles like direct mail, radio and television, states should take advantage of the popularity of social media platforms like Facebook, Twitter and TikTok to get the word out. Medicaid beneficiaries need to understand clearly that renewals are beginning and that it’s very important to update their mailing address and contact information. They also need to be informed that reenrollment information is coming in the mail, and that forms need to be completed in a timely manner. These campaigns should start as soon as possible after the announcement of the PHE end date. To enhance communication with recipients, CMS has created a useful toolkit.

Tap into the power of celebrity and influencers to spread the message. Sports, entertainment and business personalities can be used as public megaphones to amplify the renewal message and reach greater numbers of people. Politicians can also use their influence to inform constituents about the upcoming redetermination process.

Reach out to parents through schools. Parents are accustomed to regular communication from their children’s schools. Website bulletins, emails and printed communication can be used to make sure that state Medicaid programs have the most current mailing address and contact information for parents.

Reallocate resources to manage staffing problems. States should take a careful look at the administrative burdens and workloads of various departments and consider shifting some staffers to help with the unwinding. Once again, this should be happening now, so departments can be more fully staffed and employees can be better trained before the process begins.

Leverage contractors to fill gaps in staffing. With staffing shortages and employee burnout already a problem, think about turning to outside sources for support. Third-party companies could assist with tasks like data entry and phone assistance, and technology firms could provide new tools to automate manual processes.

Take advantage of emergency department visits. When Medicaid recipients visit an emergency room, healthcare providers will have the opportunity to assess the situation in a whole-person context that includes physical, mental and socioeconomic factors. Medicaid recipients can be informed about the upcoming need to renew enrollment, and providers can suggest wrap-around solutions for individuals and families while identifying those who could be at higher risk of losing coverage.

Break through silos. Many agencies within the state safety net—from human services to child welfare to education—work in silos, with little communication between them. However, these same departments often serve the same populations. As a result, beneficiaries must navigate a confusing range of websites, offices and applications to access their benefits. During the PHE and beyond, states must begin looking for ways to centralize key functions to increase efficiency, improve communication and make people aware of the benefits they qualify for. Even the simple act of recommending other healthcare options for families who are no longer eligible can be extremely helpful. By working more collaboratively, states can improve their operations while better serving their citizens.

Engage and coordinate with other stakeholders. States should encourage other organizations to communicate key messages and promote continuity of coverage. These include state and local health departments, Indian Tribal healthcare providers and social services agencies that routinely serve the same people. States should also coordinate closely with the federal healthcare marketplace to maintain coverage for those declared ineligible for Medicaid or CHIP.

The unwinding is coming, and big challenges are coming with it. Through careful preparation before the PHE ends and strong follow-through during the renewal process, states can help ease the administrative burden and ensure that vulnerable citizens continue to receive quality healthcare.

This unique situation can also be seen as a prime opportunity to take a closer look at the entire Medicaid ecosystem and make positive changes for the common good. We can begin to move from a siloed, program-specific view of services to an individualized, person-centric approach across multiple needs. Ultimately, we could create user-friendly web portals that combine all the eligibility rules for public health programs in one central place, where anyone—regardless of their age, their language or the device they use—could find the services they qualify for quickly and easily.

Technology enhancements like these could lead to a more centralized, equitable and efficient system of care and yield better human and financial outcomes for years to come.

Through our Whole Person Services, Gainwell Technologies is creating new recipient-centered assessment solutions and modular ecosystems to help states navigate the challenges of the PHE unwinding and deliver better health and human services outcomes over the long term. To learn more about our work in this area, visit or contact us here.