Lessons from the Medi-Cal Unwinding: How California Protected Coverage and Policy Options to Improve Renewals

The COVID-19 pandemic triggered unprecedented growth in Medi-Cal enrollment, fueled by the federal continuous coverage requirement that prohibited disenrollments during the federal public health emergency. The end of the requirement in March 2023 marked the beginning of the “unwinding,” during which California resumed regular Medi-Cal redetermination processes.

During the unwinding, California processed 11 million redeterminations, the most of any state in the nation. Roughly two million people were disenrolled, and 66% of these disenrollments were due to procedural reasons (e.g., missing paperwork rather than a determination of ineligibility).

This report examines California’s approach to the unwinding, highlights key successes and challenges, and identifies opportunities to improve Medi-Cal renewals going forward. These lessons take on new urgency as Congress (at the time of publication) considers a reconciliation bill that could add even more administrative hurdles to Medicaid enrollment and renewals. Hundreds of thousands of eligible Medi-Cal enrollees (possibly more) would lose coverage because they have difficulty navigating an even more burdensome renewal process.

In the face of this federal threat, California must do what it can now to streamline and improve the process.

Successes:

• Adoption of federal flexibilities. California adopted over a dozen federal flexibilities to minimize inappropriate disenrollments, improve contact information accuracy, and streamline eligibility verifications.
• Increased ex parte renewals. California’s ex parte renewal rate more than doubled during the unwinding, rising from 31% to 63%, reducing administrative burdens and preventing unnecessary coverage losses.
• Robust outreach and communications. A statewide multimedia campaign, multilingual materials, and community-based partnerships helped inform members about renewal requirements.
• Data transparency. California provided detailed, disaggregated unwinding data through an interactive public dashboard, enabling stakeholders to track trends and target approaches.
• Stakeholder engagement. Regular collaboration between the state, counties, managed care plans, and community-based organizations improved coordination and messaging.

Notable challenges:

• Eligibility worker capacity and training. Counties faced workforce shortages and long call-center wait times, creating barriers for members attempting to renew coverage.
• Operational inefficiencies. Manual data entry and system issues, including the simultaneous implementation of a new statewide eligibility system, slowed processing and led to avoidable procedural disenrollments.
• Member confusion and outreach limitations. Some enrollees reported not receiving renewal notices, while others were overwhelmed by redundant or confusing outreach messages.
• Variability in county-level coordination. Collaboration between counties and community-based organizations was inconsistent, with some organizations struggling to obtain necessary case information to assist members with the renewal process.

Future opportunities:

• Extend or permanently adopt key federal flexibilities to maintain high ex parte renewal rates and reduce administrative burdens.
• Enhance training and capacity for eligibility workers through improved funding, technology adoption, and interactive learning opportunities.
• Streamline application and renewal processes with simpler forms, better data integration, and automation of eligibility verifications.
• Improve member outreach and accessibility by identifying enrollees’ preferred communication methods and collecting data on outreach effectiveness to better target messaging.

Explore a companion CHCF research paper, Lessons from the Medi-Cal Unwinding: Enrollee Experiences and How They Would Fix Renewals, for more recommendations on improving renewal processes, outreach and communication, and customer service.