Continuous Coverage Unwind Data Reporting
The Department of Health Care Policy & Financing (HCPF) is reporting its progress on “unwinding” the continuous coverage requirement. Each month, data is submitted to CMS and is available on the PHE Unwind Reports page. Connect for Health Colorado will also post state-based marketplace information, according to their reporting schedules.
Health First Colorado Enrollment Forecast February 2024 Update
Updates to our fiscal years 2023-24 and 2024-25 enrollment forecasts were released on February 15, 2024, leveraging a more expansive PHE-unwind period of insights based on actual renewal data. This updated forecast includes assumptions and learnings on Health First Colorado and Child Health Plan Plus (CHP+) member demographics and costs.
The updated forecast for FY2023/24 estimates a net 519,000 member enrollment reduction, reflecting the net of individuals losing coverage for Health First Colorado or CHP+ during the continuous coverage unwind and those who newly enroll into coverage. Providers and other partners should plan on a post unwind enrollment that more closely aligns with pre-pandemic levels. As you may recall, we began our PHE Unwind process with March notices for May 2023 renewals, meaning April 2024 reflects the last month of the 12-month unwind period.
We anticipate that the PHE unwind will cause the emerging, aggregate composition of our members to more closely resemble pre-pandemic norms, where historically eligible members with higher medical needs stay covered, while the vast majority of those who enrolled during the COVID-induced economic downturn - a generally healthier population - no longer qualify.
Understanding the Context - Economic Environment Impacts Enrollment
As a result of Colorado’s outstanding, collaborative efforts to get Coloradans covered during the COVID-induced economic downturn, when so many Coloradans lost their employer-sponsored coverage, Colorado had higher enrollment rates during the pandemic. Medicaid enrollment grew by more than 40% in Colorado compared to national growth of about 31%, as measured through January 2023 results, before the PHE Unwind began.
As well, Colorado’s unemployment rate has been lower than the national average through the pandemic and to date, indicating the state recovered faster than the nation from the COVID-induced economic downturn. As of December 2023, the state's unemployment rate of 3.4% continues to perform better than the national unemployment rate of 3.7%. As people regain employer-sponsored coverage through the economic recovery, Medicaid disenrollment will increase.
Additional Insights Since the November Forecast
For the last several months, the Department has underscored the importance of analyzing the 90-day reconsideration period, as covered members leverage this period to submit their renewal information late. Our November estimates had insights into only 1 month of mature information; this February forecast considers information through December, while relying heavily on the data through September, which incorporates the impact of this 90-day period.
We have also been tracking PHE Unwind data compared to historic norms (2018 & 2019 calendar years). That analysis shows that the PHE Unwind renewals are tracking within 2% of pre-pandemic norms, while disenrollments are within 3% of pre-pandemic norms.
Last, the Colorado economy has recovered faster than anticipated, and faster than national norms. This directly impacts our program enrollment, as individuals secured employment, which typically includes employer-sponsored coverage and incomes that exceed safety net program criteria.
In sum, this updated forecast takes into account the actual enrollment changes we have experienced and evaluated thus far, comparisons to historic norms, and economic insights, in complement to our traditional forecast methodologies.
January Renewal Insights
Based on point in time information reported to the federal government eight days after the close of the month, 50% of members were renewed in January, with about half being automatically renewed through advances in ex parte processing technology. The other half were renewed after completing their renewal packet. 14% were disenrolled due to income or other eligibility requirements, while 30% were disenrolled for procedural reasons. This includes 3% who voluntarily disenrolled, 73% failed to return their renewal, 17% who failed to provide verification. The charts at right provide January details.
Renewals and Denials Year To Date and Compared to Historic
Importance of the 90 Day Reconsideration Period
The monthly data reported to the federal government represents a specific point in time within eight days after the close of the respective month. However, we know from historic trends that many members who still qualify leverage the 90-day reconsideration period to submit their renewal late to remain covered. The reconsideration period provides an additional 90 days for individuals to turn in needed documentation or a completed renewal. This colorful chart shows renewals by month, incorporating the impact of the 90 day reconciliation period (gold bar). It also shows what was reported to CMS (blue bar, within 8 days of the end of the month) as well as progress 30 days after the end of the month (orange bar) and after 60 days (gray bar). The national averages are represented by the dotted line.
This chart shows that the percentage of members renewed grew by an average of 7 percentage points and as much as 10 percentage points over the 90 day reconsideration period as people continued to complete and turn in their renewal packets. Colorado’s 57% pre-pandemic (calendar years 2018 and 2019) average renewal rate closely aligns with Colorado’s PHE Unwind average renewal rate of about 55% (based on May 2023 through October 2023 data, including the 90 day reconsideration period).
Colorado’s 41% pre-pandemic (calendar years 2018 and 2019) average disenrollment rate also closely aligns with Colorado’s PHE Unwind average disenrollment rate of about 44% (based on May 2023 through October 2023, including the 90 day reconsideration period), meaning Colorado’s PHE Unwind denial rates after more than a 3-year pause are within 3% of pre-pandemic norms.
That said, we are not satisfied with pre-pandemic norms, so we are implementing short term and long term solutions to improve the overall eligibility process. We appreciate your partnership on this important work.
Improving Eligibility Performance - Understanding Procedural Denials
A top priority for improving eligibility performance is to reduce inappropriate procedural denials. Procedural denials are administrative denials for issues other than income and other eligibility requirements. It also includes individuals voluntarily opting out of Medicaid coverage because they no longer need safety net coverage.
Our data indicates that our procedural denials are higher than historic, pre-pandemic levels, while our income based and other qualified eligibility based denials are far below historic (about half). This is not unexpected; in fact, we expected that individuals who regained employment and the related employer-sponsored coverage during the PHE, would not consistently respond to our renewal inquiries, or our requests to verify income. All should expect Colorado’s procedural denials to be far higher than historic after a three year pause for this reason.
As well, to verify income, Colorado sends a renewal packet to all individuals who did not meet eligibility income criteria through the ex parte process. If the recipient does not verify their income through this added process, it is considered a procedural denial. This will make our procedural denials appear higher, though the root issue is that the individual is over income and simply not verifying this fact - not responding to our inquiries. The colorful bar chart illustrates that procedural denials after the 90 day (gold) bars are averaging about 25%.
The two tone green chart below illustrates, through the bars on the right, that the average 25% PHE Unwind procedural denial rate, after the 90 day reconsideration period, is about double historic norms. Related, the middle bars illustrate that current denials due to income and other eligibility criteria are about half of historic; this is largely because individuals are not verifying their “over-income” information as part of the current PHE Unwind renewal process. If that verification information was submitted, the income based eligibility denial would go up and the procedural denial rate would go down. Added together, the PHE Unwind disenrollment percent of 44% is within 3% of the 41% rate, pre-pandemic, as reflected in the bars on the left.
Reducing Inappropriate Procedural Denials
Our shared goal continues to be to mitigate procedural denials on those members who should be retaining Medicaid coverage. Below are short term, waiver related, and long term solutions in process to do just that. We are very appreciative of all who are collaborating with us to mitigate inappropriate procedural denials.
Short term, Colorado has implemented several state-specific and federal measures to mitigate procedural denials. We have shortened the renewal packet by 33%, created an escalation process for individuals who should be covered but have lost coverage, are leveraging our Overflow Processing Center (OPC) to assist counties and are actively working on correspondence clarity. In September, Colorado implemented two additional projects. The first is a 60-calendar-day extension to complete the renewal process, available for our vulnerable populations, including long-term care (LTC), members on waivered services, and buy-in recipients who have not returned their renewal packet on time. The second is a change to how the ex parte process occurs. As a reminder, “ex parte” means the automation of renewals using third party data sources. These two projects resulted in an increase in pending renewals and a decrease in procedural terminations.
In addition, we are working on the following short term solutions to mitigate procedural denials and improve the overall renewal process.
- In February, we are implementing a waiver to permit the designation of an authorized representative for the purposes of signing an application or renewal form via the telephone without a signed designation from the applicant or member.
- In April, we will implement a process to auto renew all Coloradans with historic incomes less than 100% of the Federal Poverty Level.
- We are collaborating with counties on longer term strategic advances
- We are actively working to improve eligibility correspondence to members
- We are also working on implementing a waiver to automatically (without member action) reinstate members back to their renewal date when they submit and are approved during their 90 day reconsideration period (Date TBD)
Recently, CMS extended flexibilities (or waivers) through December 2024 to assist states with processing renewals, which is welcome news. Longer term, we are working with CMS to make several of these waivers permanent, which include the following:
- Renew Medicaid eligibility based on financial findings from the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), or other means-tested benefit programs.
- Delay procedural terminations for beneficiaries for one or more months while the state conducts targeted renewal outreach, which is currently operational for long-term care renewals.
- Renew Medicaid eligibility for individuals through Ex Parte (automated renewals) with income at $0 (currently operational) or below 100% Federal Poverty Level (operational in April) when no data is available through electronic interfaces.
- Partnering with National Change of Address (NCOA) Database and United States Postal Service (USPS) In-State Forwarding Address to Update Beneficiary Contact Information.
Also to improve eligibility performance longer term, HCPF is collaborating with counties on a study to identify areas of opportunity to improve the overall renewal process and the process for those accessing Long Term Services and Supports. We are looking forward to sharing these recommendations, once available, with stakeholders.
Caution in Interpreting Colorado’s Data in the National Context
During the public health emergency, Colorado made it a top priority to get people who lost their jobs, and related employer-sponsored coverage due to the pandemic-induced economic downturn, enrolled in Health First Colorado and Child Health Plan Plus (CHP+). As we returned to the regular renewal processes after the public health emergency and a three year pause, we anticipated that more individuals would be disenrolled from our programs compared to national norms for three basic reasons:
- Greater Comparative Medicaid Enrollment. As a result of Colorado’s outstanding, collaborative efforts to get Coloradans covered during the COVID-induced economic downturn, when so many Coloradans lost their employer-sponsored coverage, Medicaid enrollment grew by more than 40% in Colorado compared to national growth of about 31% (measured using the month of January 2023, before the PHE Unwind began). That means Colorado grew our Medicaid rosters by about 9 points and 29% more than the nation did.
- Lower Comparative Unemployment Rate. The unemployment rate has a direct impact on Medicaid enrollment. Colorado’s economy has rebounded better than the national average. As of December 2023, the state’s unemployment rate is similar to pre-pandemic levels, at 3.4% and better than the national unemployment rate of 3.7% (0.3 points or 8% better).
- Medicaid Expansion. Colorado expanded Medicaid as a result of the Affordable Care Act, meaning that adults under the age of 65 are eligible for Medicaid with incomes up to 133% of the Federal Poverty Level (FPL). That means more individuals were eligible for our safety net coverage during the PHE, and added to the Colorado Medicaid rosters, than states that did not expand Medicaid. Conversely, it also means that as people regain employer-sponsored coverage through the economic recovery, more will disenroll from Colorado Medicaid rosters.
Given these comparative metrics, we should expect Colorado’s overall disenrollments to be greater than the national averages.
The below chart illustrates national performance on unemployment rates as well as Medicaid enrollment growth on the left, compared to Colorado’s superior performance on the right.
We are also analyzing data by race/ethnicity, age and geographic region to help identify and mitigate any emerging inequities. Ongoing analyses are not indicating race related disparities in the tracked renewal metrics between white people and people of color.
To avoid health coverage gaps and disparities that historically impact communities of color, rural, people with disabilities, LGBTQ+, and non-English speakers, we all need to work together to Keep Coloradans Covered - a key health equity priority. Thank you for your continued partnership on this important health equity work.
Help Us Keep Coloradans Covered
Our top priority continues to be to Keep Coloradans Covered. Thank you for your active engagement with members, community partners, and advocates leading up to and during the unwind period and for your continued dialogue to improve the renewal process. Based on stakeholder feedback, we have made the following changes:
- Revamping Renewal Packets: renewal packets are 33% shorter, and a colored Colorado State seal has been added to help it from being mistaken for junk mail.
- Flexibilities to Protect Vulnerable Populations: HCPF is leveraging additional flexibility from the federal government to provide vulnerable populations with a 60-calendar-day extension to complete the renewal process through June 2024. This includes long-term care (LTC) members, those with waivered services and buy-in recipients who have not returned their renewal packet on time.
- Improving PEAK and the Health First Colorado App: We continue to improve the PEAK and Health First Colorado app user experience by making it easier to submit renewal materials and monitor the status of a submitted renewal.
- Reducing Whereabouts Unknown: We’ve implemented system and process improvements to reduce procedural denials due to “whereabouts unknown.” Procedural denials for members whose whereabouts are unknown decreased to 3% of procedural denials in November, reflecting a very favorable adjustment compared to historic norms.
- Creating Toolkits to Help Members: HCPF has created and distributed toolkits to help members complete the renewal process or transition to other affordable health coverage. These toolkits are available in the top 11 languages spoken by our members. Resources for partners and employers to assist in this process are also available in the PHE Resource Center.
Thank you again for your partnership in outreaching Health First Colorado and CHP+ members to complete their renewals. Those who no longer need Health First Colorado or CHP+ coverage should voluntarily disenroll at CO.gov/PEAK or by contacting their county Human Services Department. This will help all of us more efficiently target our shared outreach efforts to those who should be maintaining Medicaid coverage.