Background
To date, the Centers for Medicare & Medicaid Services (CMS) has approved nearly 400 section 1902(e)(14) waivers that 52 states (including Washington D.C.) and territories are employing to support the return to regular eligibility and enrollment operations following the expiration of the Medicaid continuous coverage requirement. These waivers, authorized under section 1902(e)(14)(A) of the Social Security Act, are intended to help states increase ex parte renewal rates,1 support enrollees with updating their contact information and completing the renewal form, and facilitate the reinstatement of eligible individuals who were disenrolled for procedural reasons.
While CMS has encouraged state take-up of unwinding-related section 1902(e)(14) waivers since March 2023, recent data concerning Medicaid and Children's Health Insurance Program (CHIP) disenrollment and procedural disenrollment among children has reignited CMS' focus. With CMS' December release of Medicaid unwinding-related guidance and the United States Department of Health and Human Services' targeted letters to states, federal partners are urging states to take advantage of the flexibilities at their disposal to prevent eligible individuals, particularly children, from losing coverage. As part of this push, CMS announced an extension of all unwinding-related section 1902(e)(14) waivers through December 31, 2024 (or a later date approved by CMS)2 and offered new operational considerations and illustrative scenarios to assist states in implementing the waivers.
This issue brief is intended to help states evaluate whether to take up additional section 1902(e)(14) waiver flexibilities and determine which to explore further based on emerging evidence of their effectiveness.
Promising Linkages Between Section 1902(e)(14) Waivers and Renewal Outcomes
States differ substantially in the number and type of section 1902(e)(14) waivers they are adopting, ranging from zero to 15 (with a national average of seven). Varying state uptake can be attributed to a number of unique state factors, such as ability to nimbly update eligibility and enrollment systems, competing policy and operational priorities, and a need to come into compliance with federal renewal requirements.
Emerging evidence indicates a positive linkage between state take-up of these waivers and renewal outcomes during the unwinding period. Recent findings from CMS demonstrate that higher state uptake of unwinding-related section 1902(e)(14) flexibilities is associated with a smaller percent change in Medicaid and CHIP child enrollment (see Figure 1 below). States that availed themselves to 11 or more section 1902(e)(14) flexibilities experienced only a 3% average change in Medicaid/CHIP child enrollment, as compared to states that adopted up to two flexibilities, which translated to a 13% average change in Medicaid/CHIP child enrollment during the same time period. This data suggests that state uptake of section 1902(e)(14) waivers impacts continuity of Medicaid and CHIP coverage among children.
Figure 1: Average Percent Change of Medicaid Child and CHIP Enrollment by the Number of Section 1902(e)(14) Waivers Adopted Between March and September 2023
Source: CMS Medicaid and CHIP Enrollment: Child and Youth Data Snapshot, December 18, 2023. See slide 14
Insights Into High-Value Section 1902(e)(14) Flexibilities
Section 1902(e)(14) waivers mitigate coverage loss by increasing rates of ex parte renewals and assisting individuals in updating contact information and completing renewal forms. For example, higher rates of ex parte renewals are significantly correlated with lower rates of Medicaid and CHIP disenrollment among children.3 Through a recent qualitative assessment, State Health and Value Strategies and Manatt Health analyzed anonymous insights from states and identified strategies that states consider to be most impactful. Notably, states expressed substantial interest in making permanent flexibilities that increase ex parte rates and provided anecdotal insights establishing the effectiveness of such flexibilities. States also indicated that they would like to permanently maintain certain flexibilities to support enrollees with the renewal process. Table 1, below, compiles high-value section 1902(e)(14) strategies that states may want to implement to promote continuity of coverage and care.
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Footnotes
1. "Ex parte" refers to verifying eligibility based on a review of available data sources without needing to send a renewal form and request information/ documentation from the enrollee.
2. CMS will also allow states to request new waiver authorities through this same time period.
3. States with the lowest rates of ex parte renewals (between 0% and 15%) experienced a nearly 10% average decrease in Medicaid/CHIP child enrollment, as compared to states with the highest rates of ex parte renewals (between 41% and 91%), which experienced on average about a 2% average decrease over the same time period
Originally Published by State Health & Value Strategies
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