Starting April 1, California began unwinding the federal Medicaid continuous coverage requirement. Created by the federal government to help people keep their health coverage during the COVID-19 pandemic, this policy provided increased Medicaid funding to states, with the agreement that states refrain from disenrolling Medicaid enrollees. When the provision expired on March 31, states were required to resume their regular Medicaid renewal processes and complete them within 14 months. This will be a daunting task for California, which has over 15 million Medi-Cal enrollees (PDF), the largest enrollment of any state Medicaid program.
As I have previously described, California researchers project that most of the two to three million enrollees who are expected to be disenrolled from Medi-Cal (PDF) will be eligible for other sources of coverage. Avoiding unnecessary Medi-Cal disenrollment for those who remain eligible and smoothing transitions to other types of coverage for those who are no longer eligible will be critical to maintaining access to care for Californians with low incomes.
Communities of color and Californians whose primary language is not English are especially at risk. Researchers note that those who enrolled during the pandemic may be more likely to be disenrolled from Medicaid. Among those newly enrolled in Medi-Cal in 2021 and 2022, less than one-quarter who self-reported their race identified as White. Approximately 30% of those who self-reported their primary written language identified it as Spanish or another language other than English. Moreover, national research indicates that enrollees who are Black, Latino/x, or Asian, Native Hawaiian, or Pacific Islander are more likely than their White counterparts to be disenrolled despite being eligible. Confusing and punitive federal immigration rules (PDF), language barriers, and other administrative obstacles to enrollment are burdens not equally shared.
Preparing for This Moment
Fortunately, California has been preparing for this moment in multiple ways. Some highlights include:
Reaching enrollees. Continuing to build on their statewide Coverage Ambassadors campaign and Phase 1 Toolkit (PDF), the California Department of Health Care Services (DHCS) has launched a push to educate enrollees about the return to regular renewal processes and the actions required of them to maintain coverage. The department has created a consumer-facing website and new toolkit materials in 18 languages in addition to English for use by health care and community partners. Paid media, videos, and direct texts from Medi-Cal will be used to disseminate critical information to enrollees.
Preventing avoidable coverage gaps. California made two particularly important adjustments to the unwinding plan that are expected to help Californians avoid disruptions to their Medi-Cal coverage. DHCS shifted Medi-Cal redetermination dates to the end of the unwinding period to maintain continuity of coverage for people who otherwise would have aged out in advance of California’s January 2024 expansion of eligibility to all 26- to 49-year-olds, regardless of documentation status. In addition, California will maintain continuity of coverage for seniors and persons with disabilities by disregarding increases in assets until the asset test is eliminated in January 2024. Meanwhile, Covered California, the state’s health care marketplace under the Affordable Care Act, is launching its auto-enrollment plan to more seamlessly transition eligible individuals losing Medi-Cal into Covered California, with a targeted communications plan (PDF) that will soon begin.
Promoting retention. California has adopted numerous policies and practices – some temporary, others permanent – that make it easier to hold onto Medi-Cal. For example, during the unwinding period, there is a more flexible “reasonable compatibility” threshold for some eligibility groups, which will allow more people to have their Medi-Cal coverage automatically renewed without completing extra paperwork. Similarly, Medi-Cal now allows an individual to provide a reasonable explanation to satisfy income verification requirements, which will help prevent unnecessary disenrollment. (This change is set to remain in place indefinitely.) In addition, a new round of state funding has been granted for Medi-Cal Health Enrollment Navigators to provide direct assistance with applications and renewals.
These are just some examples of the many changes that have been made. More information on the overarching DHCS unwinding plan (PDF) and California’s commitments (PDF) to the US Centers for Medicare and Medicaid Services are available to the public. The nonprofit Health Consumer Alliance also offers practical resources and information for assisters, navigators, and consumers.
Key Metrics to Watch For
As the unwinding begins, these key areas need California’s continued attention:
Prioritizing equity. California has made huge strides in reducing language barriers in Medi-Cal. We need to ensure that all Medi-Cal materials, including renewal forms, are sent in all Medi-Cal threshold languages and that enrollees can easily get help in their preferred language. The state should keep improving and prioritizing multilingual and culturally appropriate messaging, and should refine it based on direct feedback from the Californians it strives to reach. Further bolstering community and provider-based outreach and enrollment assistance efforts would make it more likely that people will get assistance from trusted sources in their own language and targeted to their specific needs.
Ensuring county capacity. Counties will face an unprecedented workload as Medi-Cal enrollees are directed to them for eligibility redeterminations. California needs to ensure its counties have the capacity, resources, training, and support to avoid backlogs and redistribute workloads as needed; be prepared to further streamline administrative processes; and ensure effective collaboration occurs between counties and partners such as Medi-Cal managed care plans, providers, and community organizations in all 58 counties.
Using data transparency to flag problems. California has committed to producing (PDF) a public facing Medi-Cal Eligibility Unwinding Dashboard on a monthly basis that will include state- and county-level data on enrollments and renewals. DHCS says it is considering implementing an “early warning/trigger” mechanism that will raise flags when a large number of individuals lose or are slated to lose coverage due to a lack of response or missing paperwork. Ensuring data is timely and granular enough to identify issues and patterns will be critical to spotting problems swiftly. This means tracking customer service metrics like wait times and call disconnects from counties; monitoring outcomes at the county level by age, aid code, language, and race and ethnicity; and producing robust pre-unwinding baseline information to use for comparisons.
The federal continuous coverage requirement helped millions of Californians keep their coverage during the pandemic. California has put numerous policies and practices in place to prevent avoidable coverage loss during the unwinding period. In the weeks and months ahead, we will also have the opportunity to assess what works so we can build on and extend the best policies and practices to ensure that the Medi-Cal eligibility and enrollment system always prioritizes keeping Californians covered.
CHCF is grateful for research contributions on this topic from Lauren Block, managing principal, and Leah Montgomery, associate director, of Aurrera Health Group, a mission-driven national health policy and communications firm based in Sacramento.
Authors & Contributors
Jessica Brandi Lifland
Jessica Brandi Lifland is a freelance photographer, instructor of journalism at City College of San Francisco, and mother. Her work with publications and nonprofits such as Operation Smile, Tostan, and the California Health Care Foundation has taken her all over the world, including West Africa, the Middle East, Kosovo, Burma, Haiti, and South America.
For two decades she has been photographing the National Cowboy Poetry Gathering and has been working on a long-term project documenting the lives of the cowboy poets of the American West in affiliation with the Western Folklife Center. She plans to make her project into a book.
