Continuous Coverage Unwind Data Reporting

The Department of Health Care Policy & Financing (HCPF) is reporting its progress on “Unwinding” of the Public Health Emergency Medicaid continuous coverage requirement (PHE Unwind). Each month, data is submitted to CMS and is available on the PHE Unwind Reports page. Connect for Health Colorado also posts state-based marketplace information, according to their reporting schedules.

We will discuss Public Health Emergency Unwind insights and opportunities going forward as well as HCPF major initiatives for FY 2023-2024 and priority initiatives for FY 2024-2025 at our annual HCPF Webinar on August 27 from 8 to 11am. Please register here to attend this free event.

June 2024 Renewals

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Continuous Coverage Unwind Reports

Executive Summary

• The COVID-induced economic downturn caused hundreds of thousands of Coloradans to lose their jobs and with them, their employer sponsored health benefits. Health First Colorado (Colorado’s Medicaid program) rosters grew by 45%, one of the top states for membership growth during the PHE. We should all be proud that Coloradans were able to connect to our safety net coverage programs when they needed them. 
• While Colorado processed Medicaid and CHP+ member renewals throughout the pandemic, members did not lose coverage if they were no longer eligible because of the federal continuous coverage requirement. When the federal government called an end to the public health emergency 3+ years later, Colorado had to review everyone enrolled in Medicaid to determine if they still qualified. (PHE Unwind).
• HCPF and its contracted partners outreached more than 2 million times via text, email, mailings and phone calls to about 630,000 Colorado households as of May 2024 (up from 540,000 in March to 590,000 in April) to educate on what they needed to do to maintain their coverage. This outreach was in addition to a collaborative campaign with our partners who shared our toolkit messaging and a statewide Public Service Announcement campaign in English & Spanish to raise awareness of the need for Medicaid and CHP+ households to renew their coverage and update their contact information. 
• We took the time CMS provided - 12 months or 14 months including noticing - to do so. Notices began in March 2023 for members with renewals due in May 2023, while the last group of renewals in the PHE Unwind were due in April 2024. We aligned with existing member renewal dates to maintain member action consistency, to return to normal renewal processes in an equitable manner, to mitigate impacts to county and eligibility staff workloads, and align with tapering federal funding available to cover individuals during the PHE Unwind.
• The assumption was Medicaid and CHP+ would return to prepandemic enrollment levels through the PHE Unwind, and that is happening overall and across our 64 counties as well. Specifically, 31 counties had a slight decrease in enrollment and 33 had a slight increase.
• PHE Unwind renewals are tracking within 2% of prepandemic norms (55% vs 57%), and disenrollments are as well (43% vs 41%).
• For May and June 2024 renewals - the first two months after the PHE Unwind - 76% of those up for renewal were redetermined as still eligible for Medicaid or CHP+ coverage, a significant improvement over the 57% prepandemic and 55% PHE Unwind renewal approval rates.
• Automation is critical to improving the member renewal experience and reducing county workloads. About 57% of May and June renewals were completed through automation innovations (or ex parte). That’s a significant and meaningful improvement over the 33% average during the PHE Unwind. 
• Our procedural denials have also returned to prepandemic levels, at 12% for both May and June 2024 renewals. While we are not satisfied with this level and are continuing efforts to improve it, this is also welcome news.

Improving Performance Across Numerous Metrics

• Because these statistics change through the 90-day reconsideration period (the period after a person’s renewal when they can submit their paperwork late) and because there are still some pended PHE Unwind renewals that need to be processed by the counties, we won’t have the final PHE Unwind statistics until sometime in August.
• Accurate comparisons between states can not occur until all states' PHE Unwinding processes are complete, the 90-day reconciliation timeframes have elapsed, all pended applications are processed (many states have a much higher percent of renewals pended compared to Colorado), and all final reporting is available.

Work in Progress to Further Improve Eligibility Determination Performance

Though Colorado’s renewal performance metrics have improved significantly, there is still more work to do to the betterment of our members and county partners, and we are committed to completing that work.

Internal experts continue to collaborate with external consultants and other states to improve our renewal automation rates while additional enhancements are being made to PEAK (our member digital tool). These important advances are being tracked as a HCPF Governor’s Wildly Important Goal (WIG) for HCPF for FY 2024-25.

Renewal automation, or ex parte, is the automation of renewal approvals. Increases in ex parte automation performance improves the member experience, reduces county workload and reduces inappropriate procedural denials. In April, HCPF implemented a process to increase the auto-renewal of all Coloradans with historic incomes less than 100% of the Federal Poverty Level when there is no conflicting data in our electronic data sources. We project this advance will increase our ex parte rates on income based individuals (MAGI) by about 5 percentage points. 

Post the PHE Unwind, May and June 2024 renewals show much higher levels of renewal automation at 59% in May and 56% in June versus an average of about 33% during the PHE Unwind. For households determined eligible based on income (MAGI population), renewal automation hit 67% in May and 66% in June. This is welcome news to our members and county processors as it improves the member renewal experience and decreases county workloads. 

In a shared effort to improve performance over prepandemic norms, HCPF is working in collaboration with the Colorado Department of Human Services (CDHS) and the counties on three long-term projects that better support our county eligibility partners, while improving the member experience and our overall eligibility performance.

• SB22-235 County Administration of Public Assistance Programs: A County Administration Long-Term Support Plan: provides recommendations to improve county administration of eligibility and enrollment related activities, including properly resourcing our state-county infrastructure, addressing county staff wage rate gaps, advancing the eligibility tools used by county workers, and more. Target Completion Date: report to the legislature is due  November 2024. 
• CBMS Vision & Strategy: driving alignment and clarity around CBMS operational advances, infrastructure, and priorities. CBMS is the state-owned eligibility system, which operates in conjunction with SalesForce, Amazon Web Services, and member applications (PEAK, PEAKPro) to make up the state’s eligibility infrastructure. Target completion date: June 2025.
• Joint Agency InterOperability (JAI): advances and creates consistency through the use of shared, universal tools that support counties and the state in eligibility task management, including new applications, renewals, case changes and other tasks; dashboarding; document capture; and related critical work. Target implementation date: Anticipated 2026 - 2027.

We are also updating our standard CBMS eligibility correspondence to improve clarity in 55 common Medicaid and CHP+ member eligibility communications, and ultimately eligibility renewal results. Forty-eight (48) of fifty-five (55) letters were updated in CBMS as of June 30. The other 7 letters, including the most complex communication, called the Notice of Action, will be updated by Dec 2024.

All of the above strategies will continue to drive down Colorado’s procedural denials, which 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 during the PHE Unwind were far higher than historic prepandemic levels, while our income-based and other qualified eligibility-based denials were far below historic (about half). This is not unexpected; 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. The good news is that the procedural denials during the months of May and June 2024 - post the PHE Unwind - have returned to the 12% prepandemic norm.

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The bar chart below illustrates that procedural denials after the 90-day reconsideration period also decline significantly (blue bar to the gold bars).The shaded area to the right represents the post-PHE Unwind period, May and June 2024.

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Where Are We Now? Returning to Prepandemic Enrollment Levels

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For each of the 3 years prior to the pandemic, Health First Colorado and CHP+ membership had been declining in aggregate by about 3% annually, reflecting Colorado’s strong economy. During the PHE, Medicaid and CHP+ membership grew by about 550,000. Through the PHE Unwind, we continue to track with the February 2024 estimate of a net enrollment reduction of 519,000 members.

Enrollment has dropped consistently each month through the twelve month PHE Unwind. As of May 2024, enrollment is about at prepandemic levels, reflecting the end of the Colorado’s PHE Unwind period, May 2023 to April 2024. However, the 90-day reconsideration period will continue through July, with reporting available in August. 

Enrollment is more closely resembling prepandemic 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. 

Enrollment Changes by County and Enrollment as a Percent of Population

To better understand the local impact of the end of continuous coverage and the PHE Unwind, the graph below depicts the percentage of the population, by county, that was enrolled in Medicaid or CHP+ prepandemic (January 2020 blue bar), directly before PHE Unwind began (May 2023 which was the peak of enrollment, rust colored dot), and at the end of PHE Unwind (April 2024 tan dot).  The chart below illustrates that counties are following the same trajectory as the state, which is also represented on the top left side of the graphic, reflecting a return to prepandemic enrollment levels.

Medicaid and CHP+ Member Enrollment as Percent of County Population
Expand Graphic	County Start of PHE, January 2020 Start of Unwind, May 2023 Current Enrollment, April 2024 Enrollment Difference (April 2024 minus January 2020) Adams 27% 39% 28% 1% Alamosa 44% 54% 42% -2% Arapahoe 21% 32% 23% 2% Archuleta 26% 35% 25% -1% Baca 41% 52% 39% -1% Bent 33% 42% 32% -1% Boulder 15% 22% 15% 0% Broomfield 10% 16% 11% 1% Chaffee 20% 28% 20% 0% Cheyenne 30% 39% 32% 2% Clear Creek 15% 23% 14% -1% Conejos 45% 55% 43% -2% Costilla 57% 70% 53% -4% Crowley 26% 31% 24% -2% Custer 20% 27% 20% 0% Delta 32% 42% 30% -2% Denver 28% 37% 28% 0% Dolores 29% 37% 29% 0% Douglas 8% 12% 8% 1% Eagle 12% 20% 13% 1% El Paso 24% 33% 23% -1% Elbert 12% 16% 12% -1% Fremont 28% 36% 28% -1% Garfield 22% 32% 22% 0% Gilpin 18% 25% 18% 0% Grand 12% 19% 13% 1% Gunnison 19% 26% 16% -3% Hinsdale 20% 25% 20% 0% Huerfano 44% 51% 38% -6% Jackson 24% 28% 16% -7% Jefferson 16% 22% 16% 0% Kiowa 32% 44% 35% 3% Kit Carson 31% 41% 29% -1% La Plata 22% 31% 21% -1% Lake 22% 32% 20% -2% Larimer 18% 25% 18% 0% Las Animas 42% 52% 37% -5% Lincoln 25% 37% 26% 0% Logan 25% 34% 26% 1% Mesa 28% 37% 27% -1% Mineral 20% 28% 21% 1% Moffat 28% 39% 28% 0% Montezuma 37% 48% 36% -1% Montrose 29% 40% 29% -1% Morgan 30% 43% 30% 0% Otero 43% 55% 43% 0% Ouray 14% 19% 13% -1% Park 18% 24% 17% -1% Phillips 25% 33% 25% 1% Pitkin 9% 14% 8% -1% Prowers 41% 55% 42% 1% Pueblo 40% 50% 39% -1% Rio Blanco 22% 31% 22% 0% Rio Grande 39% 50% 37% -2% Routt 13% 19% 11% -3% Saguache 36% 49% 38% 2% San Juan 26% 32% 21% -5% San Miguel 13% 22% 13% 0% Sedgwick 31% 41% 33% 1% Summit 12% 20% 13% 1% Teller 22% 30% 21% -2% Washington 27% 37% 27% 1% Weld 21% 31% 23% 2% Yuma 29% 40% 29% 0% Percentages in this chart are rounded.

Colorado’s Historic Approach to Unwind

The continuous coverage requirement locked individuals into coverage during the COVID-19 public health emergency (PHE).  At the conclusion of the PHE, the federal government required all states to return to normal eligibility operations and review eligibility for members enrolled in Health First Colorado (Colorado's Medicaid program) and Child Health Plan Plus (CHP+) within 12 months. 

HCPF and its contracted partners outreached more than 2 million times to about 630,000 Colorado households as of May 2024 (up from 540,000 in March and 590,000 in April) to help members understand what they needed to do to retain Medicaid or CHP+ coverage, if that was their goal. The outreach leveraged health plan partners, providers and others to reach members via email, phone, text messages and mailings based on member communication preferences when it was their time to renew.  Along with a statewide PSA campaign in English and Spanish, community partners accessed and helped distribute materials in 11 languages to raise awareness of renewals and encourage members to update their addresses.  Thank you to the many community partners, advocates, health plan and other partners who did their part to help further raise awareness of the renewal process and for your direct member engagement throughout the renewal cycle to achieve shared goals. 

Colorado opted to take the full 12 months (14 months including noticing) to review individuals enrolled by their renewal anniversary.  This approach aimed to reduce member disruption and increase renewal results once the PHE Unwind began by continuing to align with Colorado’s ongoing practice to renew on a member’s coverage anniversary date, which Colorado continued throughout the PHE. The approach also ensured an equitable means of returning to business as usual renewal processing. It further recognized the impact to county and eligibility partner workload, given Colorado’s state supervised, county administered structure. 

The twelve month approach also aligned with federal funding allocated to states to finance the cost of coverage during the PHE Unwind.

Enhanced Federal Matching Funding Reductions from the PHE Level of 6.5%
5%: April - June 2023
2.5%: July - September 2023
1.5%: October - December 2023

States have approached the PHE Unwind differently, making state to state comparisons difficult. Accurate comparisons between states can not occur until all states' Unwinding processes are complete, all pending applications are processed, the 90-day reconciliation timeframes have elapsed, and all final reporting is available. 

Colorado’s Economic Environment and Enrollment Impacts

There are a variety of strong Colorado economic factors that are impacting Colorado’s eligibility redetermination results. 

Since Health First Colorado and Child Health Plan Plus (CHP+) are income-based programs, wage increases can have a direct impact on an individual’s eligibility as well as Colorado’s overall program enrollment.  

• Colorado’s minimum wage grew by 20% from 2020-2024 ($12.02 to $14.42).
• Our minimum wage is higher than most other states (8th highest in nation).
• At the same time, Denver’s minimum wage increased by 42% from $12.85 in 2020 to $18.29 in 2024. 

Second, Colorado’s unemployment rate has also been stronger than the national average throughout the PHE, though that gap has continued to shrink through the PHE Unwind period. In December 2019, the prepandemic unemployment rate in Colorado was 2.8%, while the national unemployment rate was 3.5%. In May 2023, at the start of the PHE Unwind, Colorado’s unemployment rate was 3.1% in comparison to the higher national unemployment rate of 3.7%. As of May 2024, our state’s unemployment rate of 3.8% is slightly better than the national unemployment rate of 4.0%. 

To qualify for Medicaid, a single person has to make less than about $20k annually and a family of four has to make less than about $40k. For children to be eligible for CHP+, household income can be about double those figures. Given that criteria, Coloradans are less likely to qualify for Medicaid through the PHE Unwind if they secured a job as Colorado’s economy bounced-back that provided income similar to the job they lost during the COVID-induced economic downturn.

Renewal and Disenrollment Historic Comparison

We have also been tracking PHE Unwind data compared to historic norms (based on 2018 & 2019 calendar years). That analysis shows that the PHE Unwind renewals are tracking within 2% of prepandemic norms (55% vs 57%), while disenrollments are within 2% of prepandemic norms (43% vs 41%). That final PHE Unwind approval rate will change through the finalization of the 90-day reconsideration period and the impact of pending renewals yet to be completed.

Importance of the 90-Day Reconsideration Period, Plus Emerging Data

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. Again, the reconsideration period provides an additional 90 days for individuals to turn in needed documentation or a completed renewal. The chart below 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 horizontal dotted line. Note the rising renewal rates for May and June 2024, (76% and increasing through the 90-day reconsideration period) post the PHE Unwind period. 

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This chart shows that the percentage of members renewed during the PHE Unwind grew by an average of 7 percentage points and as much as 10 percentage points (removing May, which included a late first submission) over the 90 day reconsideration period as people continued to complete and turn in their renewal packets.

Emerging Colorado disenrollment analysis also indicates that 33% of the Medicaid population disenrolled during the PHE Unwind have already requalified for Medicaid and has been re-enrolled. That compares to 42% returning prepandemic.

Transitioning to Other Coverage and the Associated Risks

Our shared goal has been to Keep Coloradans Covered. We are thankful for the many contracted partners, advocates, providers, insurance carriers, employer chambers, sister state agencies and other community partners who have collaborated on this important work.  

The most popular types of coverage most Americans connect to outside of Medicaid are Employer Sponsored, Medicare and Individual coverage. Since losing Medicaid coverage is a “qualifying event,” one can seek other coverage without having to wait until “open enrollment” through an employer, Medicare, or the Connect for Health Colorado marketplace exchange. 

Prepandemic, and typically, about half of Coloradans get their health insurance coverage through Employer sponsored coverage. During the Public Health Emergency, most people enrolled into Medicaid after losing their job (and their employer sponsored coverage) during the COVID-induced economic downturn. So, the vast majority of people disenrolling from Medicaid during the PHE Unwind should be returning to employer-sponsored coverage. Unfortunately, most of those disenrolling from Medicaid throughout the PHE Unwind did so outside of their employer’s typical open enrollment period, which is generally 6-8 weeks of the year, meaning those employees do not have the support they typically would have to enroll in coverage. Further, if the employee missed the window to enroll after their qualifying event, they may have been prohibited to do so by their employer. 

Recognizing this risk, CMS recommended that employers extend their special enrollment period (SEP) from 60 days to 1 year in a federal government’s letter to employers, plan sponsors and issuers. To mitigate the negative consequences of individuals being uninsured, and to help Coloradans navigate back onto employer-sponsored coverage, HCPF has created specific tools for employers and their HR departments. They are available at KeepCOCovered.com and Downloadable Resources: #KeepCOCovered. CDLE further partnered to remind employers to help navigate their employees who no longer qualify for Medicaid back onto employer-sponsored health insurance, in collaboration with our shared efforts to Keep Coloradans Covered. 

Those over 65, and not actively working, should be enrolling into Medicare. That might include Medicare Advantage, available through commercial carriers or traditional Medicare. 

Others may need to purchase individual or family coverage. The most affordable way to do so is through Colorado's Connect for Health marketplace exchange, which provides many options for health coverage as well as federal subsidies to make individual and family premiums and coverage more affordable.  To help disenrolling Coloradans to connect to the subsidies available through Connect for Health, HCPF provides customized files to Connect for Health Colorado to enable their outreach to disenrolling Medicaid members and to make sure those individuals know they are eligible for a subsidy. 

Coverage Options for Coloradans

CHP+: HCPF is auto-enrolling eligible kids as part of the Medicaid redeterminations process.  CHP+ enrollment has gone from a low of 45K in May 2023 to 83K in March 2024, even above prepandemic enrollment of 79K.

Employer Sponsored Insurance: More Coloradans get their coverage through employer sponsored plans - about 50% - than any other type of coverage. Employers have annual open enrollment periods, opportunities to sign up when new employees are hired. Some employers may also offer special enrollment periods.

Family Member Employer Sponsored Coverage: Spouses, dependents, and children up to age 26 can be on their family’s employer plan.

Connect for Health Colorado: The state’s ACA marketplace. Premium and cost sharing subsidies are available below certain income thresholds. 

OmniSalud: Coverage option for people who are undocumented or have DACA status.  Immigration status not asked as part of application. Less than 150% FPL may qualify for subsidies. Program has an enrollment cap - that enrollment has been met for this year.  

Medicare: Primarily for people over age 65. Penalties associated with late enrollment. People can qualify for Medicare and Medicaid (duals), where Medicare is main payor and Medicaid is payor of last resort and primary payor for long-term services and supports.

To apply for health coverage or programs, visit: colorado.gov/health

Understanding the Affordability Transition Challenge

Medicaid provides robust coverage for zero premiums, zero deductibles and zero copays, except for the inappropriate use of the emergency room.

This is not the case with employer-sponsored insurance. We are fortunate that Colorado has made health care affordability a top priority, so we are in a better place than other states. Still, there is still a wide gap between Medicaid affordability and employer-sponsored health insurance affordability.

That reality is a significant influencer in the household budget decisions many individuals and families have to make as they choose between paying for health insurance coverage or other basics like rent, groceries, a car payment, gas or utilities. 

In fact, our most recent insights into those disenrolling from Medicaid indicate that the older one is, the more they are prioritizing the purchase of health insurance while those who are younger are not connecting to coverage at the same rate. 

Point in Time: June Renewal Insights

Based on point in time information reported to the federal government eight days after the close of the month, 76% of Medicaid members were renewed in June, with about two-thirds (64%) of those approvals automatically renewed through advances in ex parte processing technology. 7% were disenrolled due to income or other eligibility requirements, while 12% were disenrolled for procedural reasons. Of the 12% disenrolled for procedural reasons, 1% voluntarily disenrolled, 8% failed to return their renewal, and 3% failed to provide verification.

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 PHE Unwind period and for your continued dialogue to improve the renewal process, as we seek for continuous improvement to our eligibility processes as a best-practices approach. 
Thank you for helping us collaborate with employers - directly and through their chambers - to expand the benefit enrollment period after a person experiences a qualifying event like the loss of Medicaid or CHP+ coverage. CMS and HCPF have asked employers to expand this period from the typical 60-days to 1-year, in order to ensure those disenrolling from Medicaid have time to complete this enrollment process, which is important given the lower level of support that typically occurs outside the standard, annual employer benefit enrollment period.  

And thank you for helping us raise awareness of all coverage options for which an individual may qualify, such as Medicare or Connect for Health Colorado’s marketplace exchange.  

Please continue to employ our 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. And 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, going forward.