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NY/ Expansion- ‘Medicaid for All’ is rapidly becoming a reality in New York

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[ MM Curator Summary]: Half the people in NY are on Medicaid now.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



Gotham enrolls an even higher share of its residents in Medicaid: more than 4 million people, or nearly half of the city’s 8.8 million people. Shutterstock

In New York, it looks like the Democrats’ dream of “Medicare for All” is rapidly becoming a reality. Or at least “Medicaid for All.”

Since COVID struck, enrollment in the government-funded health-insurance program has shot up by 1.5 million people, as The Post reported this week. And the numbers were soaring even before that: By January 2020, 6.1 million of the state’s 19.8 million residents were enrolled; now, health officials estimate 7.6 million people will be getting benefits by March. That’s nearly 40 percent of the state’s population.

Add in other state health programs, from Child Health Plus to the Essential Plan, and it comes to 8.4 million New Yorkers, or 42 percent of the population, getting aid, the Empire Center reports.

And this is supposed to be a backstop program for just the poorest New Yorkers.

Gotham enrolls an even higher share of its residents in Medicaid: more than 4 million people, or nearly half of the city’s 8.8 million people.

New York has long been a national leader, both in terms of the number of enrollees and how much it spends on them — around $75 billion last year, including federal, state and local funds. And as the Empire Center also notes, more New Yorkers above the poverty line qualify for Medicaid than those under it. Even as New York’s poverty rate declined, its Medicaid rolls grew by 1.4 million from 2010 to 2019.

Clearly, the state needs to better screen applicants. But it also needs to rethink how this program “for the poor” works. Because soon, the state won’t be able to afford anything else but this.


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Backlog of Medicaid applications spurs Arkansas lawmakers to concur with hiring contract help for $29M


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[ MM Curator Summary]: Maximus will get $29M to help Arkansas with its current eligibility processing backlog.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


Arkansas lawmakers endorsed a $29 million contract Tuesday that aims to address the state’s backlog of Medicaid applications.


  • Morning

About 50,000 Medicaid eligibility applications were backlogged as of mid-November, according to state Department of Human Services spokeswoman Amy Webb. Webb said that number is not unprecedented, but the main causes of the backlog are the coronavirus pandemic, which has resulted in worker quarantines and temporary office closures because of positive cases, and staff turnover that has led to vacancies the department is having difficulty filling.

“We are short-staffed as most public [and] private employers are right now, and we’ve got a backlog of applications to process,” Mark White, chief of staff for the Department of Human Services, told the Review Subcommittee of the Arkansas Legislative Council.

White said the backlog is primarily affecting long-term care facilities, which means nursing homes and assisted living facilities have to operate without payment.

“The issues that most affect the beneficiaries have been our long-term care, where we have seen applications taking a little longer to process,” he said after the meeting. “We know that’s a strain on nursing homes, so we’re working to address that.”

The Department of Human Services plans to hire the Reston, Va.,-based company Maximus Human Services Inc. to help with processing Medicaid applications as well as changes related to Medicaid eligibility, White said.

The company will bring in staff to help the department work through the backlog as well as “provide some ongoing surge capacity” by allowing the state to access the company’s capacity to augment its own staff to deal with an influx of patients, he added.

Maximus will recruit, hire and train contracted eligibility specialists, according to information about the contract provided to the committee. The Department of Human Services inked a larger contract with Maximus for staffing several years ago, Webb said.

When the contract goes before the Arkansas Legislative Council for approval on Friday, the department will present its full plan, at the request of Rep. Jeff Wardlaw, R-Hermitage, White said.

Wardlaw, along with fellow Legislative Council co-chairman Sen. Terry Rice, R-Waldron, said in interviews Tuesday they are concerned about the impact of the delayed payments on rural nursing homes.

Wardlaw said his area lost two assisted living facilities two years ago as a result of Medicaid reimbursement issues and that other legislators from rural areas share those concerns.

“Every time we lose one of these facilities, we can’t get them back,” he said.

Rice said the backlog issue has been going on for some time and, at one point, reimbursements were taking four to five months when they should take 45 days or less. It’s something he has been discussing with the Department of Human Services officials for a number of months, he said.

He added that nursing homes have already been struggling financially as a result of the pandemic and that some have taken out personal loans to stay afloat.

“There’s been some strain on that industry anyway,” he said. “DHS needs to get these people placed and get those back payments.”

Rice said the pandemic and staffing shortages are legitimate excuses, but said he expects the government to hold itself accountable like a private business would.

“When you’re talking about some of these homes going out of business, they will not be back, and I keep preaching that to them,” he said.

Webb said in an email that the contract, in addition to addressing the backlog, allows the department to “staff up and provide support” as it prepares to deal with the end of the public health emergency.

The federal government’s public health emergency declaration is set to expire at the end of March, but it could be extended.

Under that declaration, there are limited circumstances by which the Department of Human Services can remove someone from the Medicaid programs, such as death, Webb said, so there will be lot of casework and eligibility re-determinations once the public health emergency ends.

“Obviously, we don’t have to do it overnight or all at once. We would have six months to redetermine eligibility once it ends,” she said.

The Department of Human Services also recently launched a new eligibility system, which it piloted in a few counties in December 2020 and launched statewide in April 2021. Webb said the system is working well, and the department launched a pilot to include Supplemental Nutrition Assistance Program, or food stamps, cases in some counties in the new system.

There were 330,421 people enrolled in Arkansas Works, the state’s Medicaid expansion, as of November 2021. More than 1 million adults and children were enrolled in Medicaid programs overall. At the beginning of March 2020, prior to the onset of the coronavirus pandemic, Arkansas Works enrollment was 250,233 and overall enrollment was just over 903,000.

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Delaware- State auditor presses for Medicaid information



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The state auditor is being refused data needed to confirm the state has followed Medicaid eligibility determination laws.



The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



State Auditor Kathy McGuiness is seeking Medicaid information for a performance audit after the Department of Health and Social Services went to court to quash her request. FILE PHOTO

State Auditor Kathy McGuiness took on the Department of Health and Human Services Nov. 2 in her months-long attempt to audit Delaware’s Medicaid program.

“We have been doing performance audits for decades,” McGuiness said during a hearing in Superior Court in opposition to DHSS’s attempt to avoid a Medicaid audit. “By limiting information, it hinders the auditor’s ability to do the job.”

In May, McGuiness began seeking information from DHSS to determine the eligibility of people who are receiving Medicaid. DHSS has pushed back, saying the auditor has no right to personal identifiable information, and it went to court to quash the auditor’s request.

McGuiness appealed the motion to quash, and both sides were heard by Superior Court Judge Jan Jurden.

Deputy Attorney General Annie Cordo said McGuiness is seeking to do an audit that is beyond the realm of her duties, even though McGuiness said previous auditors have conducted performance audits.

“Just because something happened once and one state administrator permitted it to happen does not necessarily mean it falls legally within the authority of what the auditor is permitted to do,” Cordo said. “We need to look at what is in the Delaware Code, which is a post audit of financial transactions, not a performance audit of how the program is in fact run, looking for efficiencies and weaknesses.”

McGuiness said her office is not seeking the entire Medicaid database, but income information would be needed to determine the eligibility of Medicaid recipients.

In a June 30 audit conducted by independent auditor CliftonLarsonAllen, the audit found DHSS’s Medicaid program did not consistently follow procedures to determine and monitor provider eligibility. The audit also found the program is unable to support provider eligibility, which may result in un-allowed costs.

Jurden will decide whether the state auditor can proceed with a performance audit with access to Medicaid information.


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Florida prepares for Medicaid disenrollment as end of PHE remains unclear

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Florida is in the planning phases of dealing with the more than 1M members who joined its rolls as part of the pandemic.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



Nicole Pasia | Nov 2, 2021 | Florida

Over one million Floridians have enrolled in Medicaid over the course of the pandemic. However, this large influx of beneficiaries may shift as the federal public health emergency (PHE) declaration — and the accompanying Medicaid disenrollment freeze — could end as early as mid to late January 2022.


The latest enrollment numbers from the Agency for Health Care Administration (AHCA) show an overall increase of 32.3% across the state since March 20, 2020. The only program with a significant drop in enrollment is the Florida Healthy Kids program. Audrey Brown, president and CEO of the Florida Association of Health Plans (FAHP), said that the drop reflected a transfer of those beneficiaries to Medicaid.


Image: Agency for Health Care Administration


Floridians under Medicaid are currently protected from being disenrolled due to the Families First Coronavirus Response Act. However, once the PHE ends, the Department of Children and Families (DCF) will need to redetermine each member’s eligibility. Conditions that lead to ineligibility for Medicaid include turning 65 and needing to transfer to Medicare, pregnant people reaching the end of the postpartum coverage period, and changes in circumstances, such as increased income.

The Centers for Medicare and Medicaid Services (CMS) have released guidance for states as they begin the redetermination process, but have not announced exactly when the PHE will end. The most recent PHE renewal will expire on Jan. 16, 2022.

Brown said that state Medicaid agencies will receive a 60-day notice prior to the end of the PHE declaration. Until then, the best they can do is coordinate with other state agencies to prepare for the redetermination process.

“I think the agency, with our health plans as partners, have been as transparent as they can possibly be. But obviously, the unknown is when that state of emergency at the federal level will be ending. And so for all of our purposes, we just continue the dialogue. We talk regularly with AHCA and the DCF to find out from them if they’ve heard anything new, and I know that the agencies are prepared to reach [the determinations] as quickly as possible.” 

Once the agencies inform the health plans of a member’s change in eligibility, the plans (FAHP has 18 member health plans across the state) will notify them in advance of the end of their services, as well as other options for health coverage. Florida is one of 14 states that has not yet expanded Medicaid since it became available in 2014. Because of this, people may go on the state exchange to look for coverage from private plans. 

Brown says that the exchange is still an affordable option for Floridians.

We have a very competitive, large group of health plans that participate on the exchange, [which is] heavily federally-subsidized. Even though people may not be qualified for Medicaid because of their financial eligibility, there are a lot of people that will pick an exchange policy and will even be up to 100% federally subsidized.”

Florida led the nation with the highest number of newly enrolled members in the state marketplace during the summer Special Enrollment Period (SEP). A CMS report stated over 487,000 Floridians participated in the SEP.

The 2022 open enrollment for the federal health insurance marketplace kicked off Nov. 1, and will continue until Jan. 15, 2022, the day before the PHE declaration expires. Participants who sign up by Dec. 15, 2021 will have coverage take effect on Jan. 1, 2022. 


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Medicaid Enrollment & Spending Growth: FY 2021 & 2022

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The latest survey of Medicaid directors suggests that 2022 enrollment growth will slow from 10% in 2021 to 4.5% in 2022.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


Key Takeaways

In March 2020, the COVID-19 pandemic generated both a public health crisis and an economic crisis, with major implications for Medicaid – a countercyclical program – and its beneficiaries. During economic downturns, more people enroll in Medicaid, increasing program spending at the same time state tax revenues may be falling. While state revenues have substantially rebounded after dropping precipitously at the onset of the pandemic, the public health crisis has continued as a new surge of COVID-19 infections, hospitalizations, and deaths, fueled by the Delta variant, began to take hold in the U.S. in late July and August 2021. To support Medicaid and provide broad state fiscal relief, the Families First Coronavirus Response Act (FFCRA), enacted in March 2020, authorized a 6.2 percentage point increase in the federal Medicaid matching rate (“FMAP”) (retroactive to January 1, 2020) if states meet certain “maintenance of eligibility” (MOE) requirements. Since then, the MOE requirements and temporary FMAP increase have been the primary drivers of Medicaid enrollment and spending trends. The fiscal relief and the MOE requirements are tied to the duration of the public health emergency (PHE).

This brief analyzes Medicaid enrollment and spending trends for state fiscal year (FY) 2021 and FY 2022 (which for most states began on July 1)1 based on data provided by state Medicaid directors as part of the 21st annual survey of Medicaid directors in states and the District of Columbia. Forty-seven states2 responded to the survey by mid-September 2021, although response rates for specific questions varied. In their survey responses, most states anticipated that the fiscal relief and MOE would end in December 2021 and that had major implications for enrollment and spending projections. The PHE was recently extended to mid-January 2022, which would affect these projections and possibly delay anticipated effects of slowing enrollment and spending currently assumed in state budgets for FY 2022. The methodology used to calculate enrollment and spending growth and additional information about Medicaid financing can be found at the end of the brief. Key survey findings include the following:

  • Enrollment growth: After increasing sharply in FY 2021 (10.3%) due to the MOE requirements and the pandemic’s economic effects, responding states expect Medicaid enrollment growth to slow to 4.5% in FY 2022, based largely on the assumption that the PHE and the related FFCRA MOE requirements will end in FY 2022 (most states assume mid-way through FY 2022).
  • Total spending growth: FY 2022 state budgets for responding states assume total Medicaid spending growth will slow to 7.3% compared to 11.4% in FY 2021. States identified enrollment growth as the primary driver of FY 2021 expenditure growth and assume slower enrollment growth will result in lower total spending growth in FY 2022.
  • State spending growth: While states reported that the state (nonfederal) share of Medicaid spending grew by 4.0% in FY 2021, they projected sharper FY 2022 growth of 14.0% based on the assumption that the PHE and related enhanced FMAP would expire in mid–FY 2022, shifting the state and federal spending shares even though total Medicaid spending growth is expected to slow.

As in 2020, the 2021 survey was fielded during a time of great uncertainty. State fiscal conditions had improved, but the rate of recovery varied across the states and employment indicators had not yet reached pre-pandemic levels. After COVID-19 infection rates dropped to encouragingly low levels in the late spring of 2021, a summer surge driven by the Delta variant was generating more uncertainty around the PHE end date, to which the MOE requirements and enhanced FMAP are tied. In their survey responses, most states projected slowing Medicaid enrollment growth and total spending growth along with increases in the share of state Medicaid spending in FY 2022 due to the assumption that MOE requirements and the enhanced FMAP would end in December 2021, half-way through the fiscal year for most states. However, the PHE was recently extended to mid-January 2022 and may be extended further if cases and deaths from the Delta variant remain high or increase heading into the winter. Extensions of the PHE would likely delay state projections/trends for spending and enrollment growth depicted in this report (for FY 2022). How states respond to the eventual end of the PHE and the unwinding of their MOE will have significant implications for enrollment and spending.


Following declines from 2017 through 2019, total Medicaid and CHIP enrollment nationwide began to grow following the onset of the COVID-19 pandemic. Between February 2020 and April 2021, enrollment grew to 82.3 million, an increase of 11.1 million or 15.5%. In 2020, Medicaid (together with CHIP) provided coverage to nearly one in five Americans. This enrollment growth reflects both changes in the economy, as people enrolled following income and job losses, as well as the FFCRA MOE provisions that require states to ensure continuous coverage for current Medicaid enrollees to access a temporary increase in the FMAP rate. Total Medicaid spending was over $662 billion in FY 2020 with 67.4% paid by the federal government and 32.6% financed by states. Medicaid accounts for one in six dollars spent in the health care system and more than half of spending on long-term services and supports.3

States experienced a dramatic and rapid reversal of their fiscal conditions when the pandemic hit in March 2020. Before the pandemic, unemployment was low, states expected revenues to grow for the 10th consecutive year, and state general fund spending was on track to grow by 5.8%. In this context, governors developed FY 2021 budget proposals that reflected continued revenue and spending growth. The pandemic began during the second half of FY 2020 and quickly reversed state fiscal conditions. Early estimates projected state budget shortfalls of up to $555 billion for fiscal years 2020 through 2022, and states experienced their first general fund revenue decline in FY 2020 since the Great Recession, though some declines in revenue can be attributed to states delaying their 2020 income tax collections from April to July (the start of FY 2021 for most states). Faced with continued uncertainty regarding the course of the pandemic, ongoing revenue collections, and additional federal fiscal relief, states adopted conservative FY 2021 budgets. Unlike the federal government, states must meet balanced budget requirements. To address budget shortfalls heading into FY 2021, states used strategies such as layoffs or furloughs for state workers, hiring freezes or salary reductions, across the board spending cuts, or one-time use of rainy day funds.

State economic conditions have since improved mitigating the need for widespread spending cuts last year. National economic indicators have moderated in recent months. For example, September 2021 saw a national unemployment rate of 4.8% across all states including DC, below the peak of 14.8% in April 2020 but still above the February 2020 rate of 3.5% right before the pandemic. State revenue collections have rebounded
due, in part, to federal aid provided to states, improved state sales tax collections on online purchases, and smaller personal income tax revenue declines due to the disproportionate impact of the pandemic on low-income workers. While state general funds are estimated to have grown by 3% in FY 2021, general fund spending in FY 2021 remained 2% below spending projections made before the pandemic. In FY 2022, however, general fund spending is expected to grow by 5%. In contrast to budgets adopted for FY 2021, proposed FY 2022 state budgets did not include general fund spending decreases, and most states enacted FY 2022 budgets with increased state spending and revenue.

Viewed nationally, state fiscal conditions have improved, but pandemic-related economic impacts vary by state. The severity of the pandemic-induced economic downturn and speed of recovery varies by state depending on state characteristics such as tax structure, industry reliance, social distancing policies and behaviors, and virus transmission. Economic indicators are improving across states, with indicators for some states returning to pre-pandemic levels while others remain distressed. For example, in September 2021, Nebraska saw an unemployment rate of 2.0%, which is below their pre-pandemic rate of 3.0% in February 2020, while Nevada’s unemployment rate was 7.5%, well above their pre-pandemic unemployment rate of 3.7%. While state revenues overall appear to have surpassed pre-pandemic levels, there is variation across states. Also, this data pre-dates the recent Delta variant fueled COVID-19 surge and is volatile due to most states delaying their income tax filing deadlines for 2020 and 2021.

While the FFCRA FMAP increase currently continues to support Medicaid programs and provide broad fiscal relief to states, states are preparing for the FMAP increase to end in FY 2022. In the past, federal fiscal relief provided through Medicaid FMAP increases during significant economic downturns has helped to both support Medicaid and provide efficient, effective, and timely fiscal relief to states. FFCRA uses this model as well by providing a temporary 6.2 percentage point increase in the Medicaid FMAP from January 1, 2020 through the end of the quarter in which the PHE ends. The current PHE declaration expires in mid-January 2022, meaning the enhanced FMAP will remain in place until the end of March 2022 unless the PHE is extended further. This FMAP increase does not apply to the Affordable Care Act (ACA) expansion group, for which the federal government already pays 90% of costs. To be eligible for the funds, states must meet certain MOE requirements that include not implementing more restrictive Medicaid eligibility standards or higher premiums and providing continuous eligibility for enrollees through the end of the PHE. Though the recent rise in COVID-19 cases and deaths due to the Delta variant cast uncertainty on the duration of the PHE, states are beginning to prepare for the end of MOE requirements, and new guidance from CMS gives states 12 months to address Medicaid eligibility renewals and redeterminations following the end of the PHE.

Key Findings

Trends in Enrollment Growth FY 2021 and FY 2022

Medicaid enrollment growth peaked in FY 2021 and is expected to slow in FY 2022 (Figure 1). Medicaid enrollment growth peaked in FY 2015 due to ACA implementation and tapered thereafter. Enrollment actually declined in FY 2018 and FY 2019 and was relatively flat in FY 2020. Enrollment rose sharply, however, in FY 2021 (10.3%), and is projected to continue to grow, though more slowly, in FY 2022 (4.5%). Many states noted uncertainty in their projections due to the unknown duration of the PHE and related MOE requirements. Following the end of the MOE requirements, redeterminations will resume, and eligibility will end for beneficiaries who are determined to no longer meet eligibility standards. For budget projections, a majority of states were assuming the MOE would end as of December 31, 2021. This assumption was contributing to slowing enrollment growth in FY 2022; however, states also identified challenges to resuming normal eligibility operations such as the need for system changes, staffing shortages, and the volume of new applications and redeterminations.

States largely attributed enrollment increases to the FFCRA’s MOE requirements. All responding states reported that the MOE requirements were a significant upward pressure on FY 2021 enrollment. Over two-thirds of responding states reported that the MOE was likely to be a significant upward driver of FY 2022 enrollment, though some assumed that this upward pressure would end mid-year. In the absence of the MOE, individuals may lose Medicaid coverage because they have a change in circumstance (such as an increase in income), because they fail to complete renewal processes or paperwork even when they remain eligible, or because they age out of a time- or age-limited eligibility category (e.g., pregnant women or former foster care youth). In FY 2021, only about a quarter of states noted that the economy was a significant upward pressure on enrollment. Conversely, signs of economic improvement at the time of the survey likely contributed to some states citing economic conditions as a downward pressure on enrollment in FY 2022. Among Medicaid expansion states that responded to the survey, expansion adults were the most frequently mentioned eligibility group with notably higher rates of enrollment growth relative to other groups.  States also reported that groups more sensitive to changes in economic conditions (e.g., children, parents, and other expansion adults) grew faster than the elderly and people with disabilities.

Trends in Spending Growth FY 2021 and FY 2022

FY 2022 state budgets for responding states assume total Medicaid spending growth will slow to 7.3% compared to a peak of 11.4% in FY 2021 (Figure 2). High rates of enrollment growth, tied first to the Great Recession and later to ACA implementation, were the primary drivers of total Medicaid spending growth over the last decade. Following ACA implementation but prior to the pandemic, declining or slowing enrollment growth resulted in more moderate spending growth. In prior surveys, states noted that spending growth in FY 2020 (prior to the major effects of the pandemic) was tied to increasing costs for prescription drugs (particularly for specialty drugs), rate increases (most often for managed care organizations, hospitals, and nursing facilities), overall medical inflation, pressures from an aging state population, and a higher acuity case-mix.

FY 2021 spending growth increased sharply, primarily due to enrollment growth. Some states noted upward pressures from increased COVID-19 related expenditures, but half of states reported pandemic-related utilization decreases for non-COVID care as a downward pressure on overall spending. A majority of states reported acute care utilization on a per member basis decreased in FY 2021, but most of these states expect a full rebound in acute care services utilization in FY 2022 (most states were responding to the survey before a new surge in cases from the Delta variant were emerging). Most states indicated nursing facility utilization decreased in FY 2021; however, a majority of states noted the decreased utilization was partially or fully offset by utilization in home and community-based services (HCBS). Among states seeing decreases in nursing facility utilization, only a small number expect nursing facility utilization to fully rebound in FY 2022. Changes in payment rates and utilization patterns for acute and long-term care services may have contributed to states reporting that per enrollee spending for the elderly and people with disabilities was growing faster relative to other groups in FY 2021.

For FY 2022, a majority of states expect enrollment growth trends to be a primary factor driving total spending growth.  While a majority of states cited enrollment as an upward pressure, over a third of states expect enrollment to become a downward pressure in FY 2022, assuming that the MOE requirements end midway through FY 2022 and states would resume redeterminations resulting in slower enrollment growth. Beyond enrollment, states reported additional upward pressure coming from provider rate or cost changes and increased utilization driven by a return to pre-pandemic utilization levels or by pent up demand resulting from pandemic-related delays in care.

Assumptions about the duration of the PHE and the expiration of the enhanced FMAP affected state Medicaid spending growth assumptions (Figure 2). The state share of Medicaid spending typically grows at a similar rate as total Medicaid spending growth unless there is a change in the FMAP rate. During the Great Recession, state spending for Medicaid declined in FY 2009 and FY 2010 due to fiscal relief from a temporary FMAP increase provided in the American Recovery and Reinvestment Act (ARRA). State spending increased sharply when that fiscal relief ended.

This pattern has repeated during the pandemic-induced economic downturn, with state Medicaid spending declining in FY 2020, increasing but at a slower rate than total spending in FY 2021, and then projected to increase sharply to surpass total Medicaid spending in FY 2022 due to assumptions about the expiration of the fiscal relief. More than three-quarters of responding states assumed the enhanced FMAP rate would end December 31, 2021, half-way through the state fiscal year, with only two states assuming a later date. The spike in state spending growth reflects these assumptions. However, the recent PHE extension to mid-January 2022 extends the enhanced FMAP through at least March 2022, which will mitigate the state spending increase observed here. Of course, a further extension of the PHE due to the Delta variant or other factors could mean that the enhanced FMAP would be in place through June 2022 (the end of the state fiscal year for most states), meaning the spike in state spending would not occur until the following fiscal year.

Nearly all responding states report using the federal fiscal relief to support costs related to increased Medicaid enrollment. About two-thirds of responding states also report using the fiscal relief to help address Medicaid or general budget shortfalls and mitigate provider rate and/or benefit cuts. Fewer states anticipate Medicaid budget shortfalls in FY 2022 (prior to the Delta variant surge) compared to last year’s survey, reflecting improving state revenues that allow states to fund their share of Medicaid spending increases. However, many states noted the importance of federal fiscal relief to avoiding a shortfall and uncertainty of a shortfall due to the unknown duration of the enhanced FMAP.

Conclusion and Looking Ahead

State economic conditions have improved, though the recovery varies across states and employment indicators have not yet reached pre-pandemic levels. Almost all states have adopted budgets for state fiscal year 2022 (which started July 1 in most states), and revenue and spending projections incorporated improvements in revenue reflecting increased economic activity due to COVID-19 vaccination efforts and eased restrictions, assumptions about the duration of the PHE, and federal stimulus funds that were part of the American Rescue Plan. A summer surge in COVID-19 cases, hospitalizations, and deaths driven by the Delta variant, however, has generated greater uncertainty regarding future state fiscal conditions.

The end date of the PHE remains uncertain and will have significant implications for Medicaid enrollment and spending. The recent COVID-19 surge casts further uncertainty around the duration of the PHE and the MOE requirements and enhanced FMAP that are tied to the PHE. The MOE requirements and enhanced FMAP have already been extended further than most states anticipated in their budget projections and may be extended even further if the current COVID-19 surge continues or worsens. If the PHE is extended beyond January, Medicaid enrollment growth will likely continue in FY 2022, but the expected increase in state Medicaid spending will be delayed while the enhanced federal fiscal relief remains in place. Regardless of when the PHE ends, most states will start to prepare for the eventual unwinding of their MOE policies and procedures, as resuming Medicaid eligibility renewals will be a large administrative task for states. Guidance from CMS gives states 12 months to complete renewals and redeterminations following the end of the PHE. Additional guidance and oversight from the federal government could help mitigate differences in how states approach the end of the MOE. With the unwinding, states are likely to face pressures to contain growth in state spending tied to enrollment, particularly after the enhanced FMAP ends, even as they work to overcome challenges with systems and staffing to ensure that eligible individuals remain covered by Medicaid or transition to other sources of coverage.


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DMAS prepares for post-public health emergency Medicaid disenrollment

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Virginia is gearing up for the disenrollment effort.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



DMAS prepares for post-public health emergency Medicaid disenrollment – State of Reform | State of Reform


The Department of Medical Assistance Services (DMAS) is currently preparing for the impending end of the federal public health emergency (PHE) declaration, which will instigate a lengthy eligibility redetermination process for one in five Virginians who currently benefit from Medicaid. 


DMAS Director Karen Kimsey provided an update on the organization’s preparation for potential disenrollment, or “unwinding,” and its impact on the state budget to the Joint Subcommittee for Health and Human Resources Oversight earlier this month. 

Medicaid enrollment has increased significantly in the state, with 373,634 new members enrolling in Medicaid since the beginning of the State of Emergency on Mar. 12, 2020. Over 116,000 of these were children. DMAS also implemented several policy changes this year, such as extending postpartum coverage and adding dental services, that are associated with added costs to the state budget. 

Kimsey was unable to provide exact spending numbers for the next fiscal year as DMAS is still preparing to submit its 2022 Medicaid forecast on Nov. 1. However, she said increased federal funding has saved the state an average of $133 million per quarter. DMAS will also reinvest additional state general fund savings into home and community-based services (HCBS), which stem from federal American Rescue Plan (ARP) funding

However, Kimsey said the agency must pay attention to potential changes in the state’s Medicaid population.


“While the longer PHE will continue to bring [general fund] savings from enhanced FMAP, if that happens, there is a cost for us, as the Commonwealth, in terms of keeping our populations on Medicaid, as well as what time we are going to need once it ends, to actually redetermine all those individuals’ [eligibility].” 


Virginians under Medicaid are currently protected from being disenrolled due to the Families First Coronavirus Response Act. However, once the PHE ends, DMAS will need to redetermine each member’s eligibility, a lengthy process that Kimsey said can take anywhere from six to 12 months. This is in part because eligibility may be determined at a local-level, case-by-case basis. 

The Centers for Medicare and Medicaid Services (CMS) have released guidance for states as they begin the redetermination process, but did not specify exactly when the PHE will end. The most recent PHE renewal will expire on Oct. 18, and the Department of Health and Human Services (HHS) expects to renew it one more time through the end of 2021, according to Kimsey. However, that means the PHE could expire as soon as Jan. 2022. 

The disenrollment freeze prevented an exact estimate of people who would lose Medicaid eligibility, although Kimsey said over 337,000 cases (equating to over 644,000 members) in the state may need to be redetermined. This included individuals who turn 65 and may need to transfer to Medicare, pregnant people who reached the end of the postpartum coverage period, and individuals with changes in circumstances, such as increased income.

Kimsey said DMAS is currently working with several partners across the state to provide navigation resources to disenrolled members. CMS is also employing marketing campaigns to encourage people to sign up for insurance through the market exchange, as well as extending open enrollment until Jan. 15, 2022.


“That’s going to be the most important part, is the messaging that we share with individuals to help encourage them along [in applying].”


One of DMAS’s partners is the Virginia Poverty and Law Center (VPLC). In a previous conversation with State of Reform, Deepak Madala, Esq., VPLC director of the Center for Health Communities and ENROLL Virginia!, mentioned the importance of making resources more accessible for underserved communities, such as providing limited-English proficiency (LEP) individuals with resources in their native languages. 

Aside from the redetermination process, Kimsey shared other updates with subcommittee members. During the August special session, the General Assembly approved a 12.5% increase in reimbursement rates for Medicaid providers. The funding has been available since July 31, although it has yet to be transferred to providers. Kimsey said DMAS would “ideally” have funds transferred by the end of this month.

Kimsey also briefly spoke on DMAS’s Cardinal Care program, which will consolidate the agency’s managed care organizations with its fee-for-service programs in a single contract by July 1, 2022. DMAS plans to share a draft of the contract with relevant stakeholders in Spring 2022. 

A full recording of DMAS’s legislative update can be found here.





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Brooks-LaSure: ACA marketplace key to Medicaid redeterminations after COVID-19 PHE ends

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The CMS chief is pointing to the exchanges to deal with PHE-driven eligibility terminations.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



CMS Administrator Chiquita Brooks-LaSure is seeking to streamline enrollment between Medicaid and Affordable Care Act exchanges once states start to redetermine Medicaid eligibility after the public health emergency expires. (Getty/kroach)(Credit: Getty/kroach)

The Biden administration plans to lean heavily on the Affordable Care Act’s insurance exchanges to sign up people who may quickly drop off Medicaid’s rolls once the public health emergency ends, according to the head of Medicare and Medicaid.

Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure said that the agency realizes states have a pending dilemma with how to redetermine Medicaid eligibility after the end of the COVID-19 public health emergency ends, which could be some time next year. The emergency prevented states from dropping Medicaid beneficiaries from the program.

Brooks-LaSure spoke of the issue on Friday during the Medicaid Health Plans of America conference in Washington. The group represents the Medicaid managed care industry.

“We do understand the pressures that states are under,” she said during a virtual speech.

The agency also has concerns about how to maintain coverage levels for individuals who may lose Medicaid eligibility because they earn too much. CMS gave states a year after the emergency ends to restore normal income eligibility requirements.

Brooks-LaSure said that ACA marketplace coverage is going to play a key part in keeping people covered after the emergency ends.

“We are very focused on integrating as closely as we can Medicaid and marketplace coverage,” she said. “We actually have a unique opportunity to … streamline enrollment because of the American Rescue Plan.”

The administrator was referring to enhanced income-based subsidies passed under the law earlier this year and expire after the 2022 coverage year. Democrats in Congress are working to extend the subsidies past that date as part of a $3.5 trillion infrastructure package.

“We have people right about the Medicaid level who have much higher subsidies than they do normally,” she said.

CMS has also made moves to ensures signups on the marketplace are easier, including extending by 30 days the 2022 open enrollment period that starts in November.

There are also special enrollment periods for people to sign up if they lose coverage, Brooks-LaSure added.

“That is one way we can continue to ensure that people move into care if they are losing eligibility because of income,” she said.

The end of the public health emergency could affect coverage for millions of people, a recent study said.

The study conducted by the Urban Institute found that 15 million people could be dropped off the Medicaid rolls after the emergency ends. States will need to inform enrollees of other coverage options such as the ACA marketplace, researchers said.

Aligning care for duals

Brooks-LaSure also spoke about the need to improve integrated care between Medicare and Medicaid for dual-eligible beneficiaries.

“They are currently an underserved population,” she said.

CMS did create dual-eligible special needs plans which are Medicare Advantage plans available to duals.  

However, about 3 million dual-eligible beneficiaries are enrolled in such plans out of roughly 10 million dual eligibles.

“As we all know Medicare and Medicaid have different payment incentives and so it is so important to make sure that care is integrated,” Brooks-LaSure said. “One of the things we are also looking at is these times where people are enrolled in different managed care programs … and can we align there.”


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15 million people may lose Medicaid coverage when public health emergency ends

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Most who lose their Medicaid coverage are expected to have employer-based or subsidized exchange coverage when the PHE ends.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


By Maria Marabito



What will happen to unprecedented high Medicaid enrollment after the public health emergency? Published Sept. 15, 2021. Accessed Sept. 16, 2021.

Disclosures: Buettgens reports no relevant financial disclosures.


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A new report showed that about 15 million Americans who enrolled in Medicaid during the public health emergency could lose coverage when the emergency declaration ends.

Those at risk for losing coverage include almost 9 million adults and 6 million children, according to the analysis published by the Urban Institute with support from the Robert Wood Johnson Foundation.

aid coverage saves lives and increases families’ financial stability. Becoming uninsured would adversely affect both,” Matthew Buettgens, PhD, a senior fellow in the Health Policy Center at the Urban Institute, told Healio Primary Care. “Many of those losing Medicaid would be eligible for other types of health coverage, and states can substantially reduce the number becoming uninsured by providing effective outreach and assistance.”

Buettgens and coauthor Andrew Green, MSDSPP, a research analyst in the Health Policy Center at the Urban Institute, analyzed state enrollment patterns from February 2020 to January 2021 using Medicaid enrollment data from CMS and individual state Medicaid websites for all available months in 2020 and 2021. They projected possible disenrollment scenarios for 2022.

By the end of the second quarter of 2020, about 62.5 million nonelderly people were enrolled in Medicaid. Following this period, enrollment increased by about 1% each month. Buettgens and Green said they expect this trend to continue while the emergency declaration is still in place. By the second quarter of 2021, they approximated that 72 million nonelderly people were enrolled.

Moreover, Buettgens and Green estimated that 17 million more nonelderly people will be enrolled in Medicaid at the end of 2021 compared with enrollment prior to the pandemic. Overall, an estimated 76.3 million individuals aged younger than 65 years would be enrolled, according to Buettgens and Green.

In a scenario where the emergency declaration is lifted at the end of 2021, the researchers predicted that 15 million people would lose coverage in 2022, while one-third of adults would potentially qualify for subsidized private health coverage in the Healthcare Marketplace. The remaining individuals without coverage would likely have access to employer coverage through their family or be eligible for other sources of subsidized coverage, the authors wrote. If the American Rescue Plan Act is made permanent, one-third of adults losing coverage would be eligible for Marketplace premium tax credits.

Among the children losing coverage, only 57% would be eligible for the Children’s Health Insurance Program, and 9% would be eligible for Marketplace coverage with tax credits, according to the authors. These alternatives to Medicaid will likely cost families much more, Buettgens and Green wrote. They projected that 7 million people will become disenrolled in the first half of 2022.

However, the tax credits would make private health coverage more affordable, according to Buettgens.


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“If a patient has lost Medicaid, a physician could suggest that they check with or their state Marketplace to see if they qualify,” he said.

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Montana’s plan to end continuous Medicaid coverage sparks objections

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MT lawmakers want to increase the frequency of eligibility determinations to reduce spending on ineligible members, but some advocates say the disruption to care is not worth it.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


HELENA — Some Montana Medicaid recipients are pushing back against plans to end 12-month continuous coverage for certain people enrolled in public health insurance programs as the state’s public comment period on the new policy draws to a close. If successful, the change would likely alter two Medicaid programs in Montana in significant ways, both for enrollees who rely on the state for health care coverage and for officials tasked with operating the new system.

The state will stop accepting public comment on its proposals on Aug. 31.

While the state Department of Public Health and Human Services estimates that ending continuous eligibility, or a year of uninterrupted health care coverage, will save the federal and state governments roughly $22 million a year in the cost of benefits, critics say the change could result in temporary lapses in coverage for more than 20,000 people in a given year. 

Inherent to opponents’ concerns is the prospect of Montanans losing coverage because of paperwork, communication and bureaucratic errors rather than true income ineligibility, an outcome DPHHS has said it would make every effort to avoid. 

“I’m still unclear as to what the outcome is that the department hopes to seek. But I am pretty sure that, whether intended or not, the outcome will be a reduction in the rolls.”

Rep. Mary Caferro, D-Helena

The department contends that checking eligibility on a more frequent basis will help ensure that people who don’t qualify for the public program won’t remain on the rolls, saving the state money in the process.

But vagueness about what might replace the state’s current system has sparked anxiety among some residents insured by the impacted programs, including single adults with incomes below 138% of the federal poverty level and people diagnosed with a serious disabling mental illness (SDMI). 

“I depend on Medicaid for my mental health problems, and when I have my medicine I feel normal. Please don’t make me worry about going without my medicine,” said one man in a written comment submitted to the department through the nonprofit Montana Women Vote. “Do not end continuous eligibility.”

Montana Free Press is not publishing the names of quoted commenters, who did not respond to interview requests, in order to protect personal medical information. Montana Women Vote estimated it has helped submit roughly 175 comments from individuals in the past month.

Another woman wrote to the department out of concern for her goddaughter, saying it would be “unfair and cruel to end continuous eligibility,” and that the change would make it “difficult or impossible” for her goddaughter to maintain health care coverage.

One recipient told state health officials he depended on Medicaid for “life saving” medicine for diabetes, and urged them not to alter the program’s verification process.

“Please don’t do this to the people that depend on this,” he wrote.


Montana and New York are currently the only states that permit continuous eligibility through an agreement with the federal government agency that administers Medicaid and Medicare. Ending continuous eligibility would happen through a waiver submitted to those federal officials, who may accept or reject the proposal. 

The draft waiver changes developed by DPHHS contain no details about what would replace Montana’s current process of vetting eligibility and income once a year. Department staff said deliberations about program logistics will likely continue between federal and state officials after the waivers are submitted.

“We are implementing this waiver change under the direction of the Montana state Legislature. The funding to pay for continuous eligibility was removed from our budget and there was clear language in directing us to pursue this policy.”

Marie Matthews, DPHHS

The department’s move comes in the wake of a legislative session in which lawmakers failed to pass a complex bill, Senate Bill 100, that would have ended continuous eligibility and made several other changes to how Montana verifies Medicaid eligibility.

Late in the session, lawmakers then passed a budget amendment authorizing DPHHS to end continuous eligibility for adults who are covered through the 2015 Medicaid expansion program. That group includes single adults whose income is up to 138% of the federal poverty level. Nearly 10% of Montana’s total population, or 101,484 enrollees, were covered by Medicaid expansion as of this July.

“We are implementing this waiver change under the direction of the Montana state Legislature,” DPHHS Medicaid and Health Services branch manager Marie Matthews said in an August hearing before lawmakers. “The funding to pay for continuous eligibility was removed from our budget and there was clear language in directing us to pursue this policy.”

Though not instructed to do so by the state Legislature, DPHHS has said it will also submit a waiver amendment to the federal government to end continuous eligibility for roughly 20,000 Montanans covered by the WASP (Waiver for Additional Services and Populations) program, which insures low-income families and caretakers as well as people 18 and older who are diagnosed with a serious disabling mental illness (SDMI). The department has said its reason for doing so is to avoid “significant additional administrative burden” if the state continues 12-month continuous eligibility in one program and not the other.

During the August meeting, department officials stressed that a person would be removed from the program only after verification that their permanent monthly income level has exceeded the eligible amount.

“If somebody makes enough income that they’re no longer eligible for Medicaid coverage, then the next tier is the subsidized [Affordable Care Act] plans on the exchange,” said DPHHS Director Adam Meier, who added that he would expect some residents’ health outcomes to eventually improve after leaving Medicaid, based on a presumption that they will have a larger income.  

“I would think that as people improve their economic situations, as they’re making more income, that would then be their impetus for no longer qualifying [for Medicaid], then we may see a corresponding increase or improvement in health outcomes,” Meier said.


None of the members of the public who testified before lawmakers in August voiced support for the proposed DPHHS waivers. 

Asked how many public comments the department had received so far, and whether those comments supported or opposed the proposals, a DPHHS spokesperson told MTFP that information will be available after public comment closes on Aug. 31 and the department has submitted its proposals to the federal government. 

Democratic lawmakers on the Children, Families, Health, and Human Services Interim Committee in August repeatedly asked members of the department to explain what they consider the benefits of discontinuing continuous eligibility, and how many people would likely be impacted by the change. 

“There’s lots of research that basically shows that by providing people more stable coverage, they end up being healthier. They are able to get primary and preventive care so that they don’t have a diabetic coma, so that if they have asthma, they don’t end up in the emergency room.”

Dr. Leighton Ku, Director of the Center for Health Policy Research at George Washington University

“I’m still unclear as to what the outcome is that the department hopes to seek,” said Rep. Mary Caferro, D-Helena. “But I am pretty sure that, whether intended or not, the outcome will be a reduction in the rolls.”

The department, citing a 2013 study conducted by researchers from George Washington University, estimated that ending continuous eligibility would reduce months of coverage by 2.6%. Caferro said that calculation seems to use “sterile language” to avoid accounting for the impact on real Montanans.

“You know, when you say 2.6% of whatever, we’re talking about people,” she said. “WASP, for example, covers people who are seriously mentally ill and also the families who live in extreme poverty … we are talking about people’s health care and people’s lives.”

Pinpointing the number of people affected by the waiver change is difficult, said Dr. Leighton Ku of George Washington University, one of the researchers whose work DPHHS cited in its estimate of reduced coverage. 

In a written comment submitted to the department and in a later phone interview, Ku said a reduction of 2.6% covered months would likely be distributed across enrollees who would temporarily lose coverage for a short amount of time within a year. If enrollees had their coverage discontinued for roughly two months before they could re-enter the program, Ku said, the number of affected residents could reach as high as 15.6%, or roughly 21,500 people.

Ku said that “churn,” the process of people exiting public programs only to re-apply a short time later, can also create administrative strain on public health departments, on top of the increased vetting and communication demands on state employees. In its proposed waiver changes, DPHHS does not estimate the anticipated costs of running the program with more frequent eligibility checks.

If people fall through the cracks because of miscommunication with DPHHS about their income and eligibility, Ku said, their health care may also be more expensive when they come back to a public health insurance program. More importantly, he said, interrupted health care could have serious repercussions for some individuals.

“If you have diabetes, for example, that means that actually you want your insulin and your medications all year round,” Ku said. “You don’t want to say, OK, insulin for 10 months, two months I’ll go without. That’s how you end up having problems. Like you go into diabetic coma.”

Nationally, health care researchers have encouraged states to enact continuous eligibility policies for particularly vulnerable people with public insurance, such as children, because of improved long-term health outcomes. Ku said he and others are suggesting that states apply that perspective to their Medicaid policies for adults as well. 

“There’s lots of research that basically shows that by providing people more stable coverage, they end up being healthier. They are able to get primary and preventive care so that they don’t have a diabetic coma, so that if they have asthma, they don’t end up in the emergency room,” Ku said. “If there is someone who has, you know, a mental health problem, that they don’t go off their medications, they can still get counseling, so they don’t have a psychotic attack.”

After the close of public comment next Tuesday, DPHHS has until Sept. 3 to apply changes to the proposed waivers and submit them to the federal government. Before any waivers are approved, federal officials will open another 30-day public comment period and could enter negotiations with state officials on the details of proposed plans.

One other logistical reality hangs over Montana and other states looking to change their enrollment and eligibility processes for Medicaid. Given the federally declared public health emergency in place because of the COVID-19 pandemic, states must keep continuous eligibility in place or risk losing an enhanced federal match rate for Medicaid. 

In its presentations on the topic, DPHHS has said it will continue to follow the federal pandemic guideline so as not to sacrifice that boosted rate. The department has said the federal emergency declaration is expected to continue until Dec. 31, and could possibly be extended further, likely pushing the implementation of any changes to Montana’s Medicaid programs into 2022.

by Eric Dietrich 08.23.202108.23.2021


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Iowa in ‘uncharted territory’ as Medicaid numbers swell

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Iowa’s enrollment in traditional Medicaid has surged 16% while enrollment by the expansion population has surged 30%.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


COVID pandemic fuels surge in sign-ups for health insurance program



A stethoscope sits on an examination table in an exam room. (Bloomberg News)

DES MOINES — Enrollment in Medicaid and Iowa’s related Health and Wellness insurance programs saw double-digit surges in Iowa due to the COVID-19 pandemic, according to data compiled by a state forecasting group.

Since the pandemic hit Iowa in March 2020, Iowa’s regular Medicaid program added 64,134 individuals through last month while an additional 51,669 individuals enrolled in the Health and Wellness program that offers slightly fewer benefits for recipients between the ages of 19 and 64 who are not pregnant and do not earn more than 133 percent of the federal poverty level.

That represented a 15.56 percent increase when comparing July’s 487,193 Medicaid enrollees to the 423,059 enrolled when the pandemic began, said Jess Benson, a senior Legislative Services Agency fiscal analyst who provides data for the state’s Medicaid Forecasting Group.

The increase in the Health and Wellness program was even steeper, jumping 30 percent, from 176,903 participants in March 2020 to 228,572 last month.

Last month’s Medicaid total included 280,905 children, 90,436 adults, 83,231 disabled Iowans and 32,621 elderly residents.

“We’ve never experienced anything like this before so this is kind of uncharted territory for all of us,” Benson said.

The influx of more than 115,000 new enrollees gradually built as Iowans lost their jobs – and their employer-based health insurance – as the pandemic took hold. State officials project Medicaid and the Health and Wellness program will continue to add 3,000 to 7,000 individuals per month through December. At that point, the eligibility parameters may change, lifting a current prohibition on “dis-enrolling” individuals while a federal public health emergency is in effect.

The suspension of program dis-enrollments is a condition for Iowa receiving a 6.2 percent matching fund rate in federal assistance as part of the COVID-19 relief package. That adjustment of nearly $135 million in fiscal 2020 and $275.4 million last fiscal year enabled Iowa’s Medicaid program to amass “huge carry-forward” balances, Benson noted. Those balances are projected at $244 million for fiscal 2021 and $228 million in the current fiscal year that began July 1.

The matching federal funds helped provide some relief to states struggling to afford the increasing pace of sign-ups for Medicaid, a program for low-income and disabled people.

Once the state is allowed to drop individuals who no longer need or qualify for Medicaid, Benson said he expects enrollment will gradually decline by 100,000 or more. He said reviews will take place to remove people who “normally would have fallen off,” but he was not certain the numbers would settle back to the previous levels around 425,000 Medicaid participants.

“It seems like whenever we go through one of these massive expansions, when we pull back we never get back to that level that we were at before,” he said.

Earlier this year, the federal Centers for Medicare and Medicaid Services released data indicating that nearly 9.9 million people enrolled in Medicaid and the Children’s Health Insurance Program between February 2020 and January 2021 because of the COVID-19 pandemic – a 13.9 percent increase nationally. Iowa’s increase at that time was in the 12 percent range.

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