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.
Thank you to the 2100+ registrants and 1550+ individuals who joined HCPF leaders live for our Annual Stakeholder Webinar on August 27. This event reviewed HCPF major initiatives for fiscal year FY 2023-2024 and priority initiatives for FY 2024-2025. It also included a PHE Unwind panel discussion, with HCPF experts as well as representatives from our county partners, Connect for Health Colorado and the Colorado Health Institute. Materials are being posted on our Annual Stakeholder Webinar page.
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 2.4 million times via text, email, mailings and phone calls to about 680,000 Colorado households as of August 2024 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 (PSA) campaign (87,990 PSAs) in English and Spanish to raise awareness of the need for Health First Colorado and CHP+ households to renew their coverage through the PHE Unwind and to update their contact information to ensure their receipt of renewal information.
- We took the time CMS provided to do so - 12 months, or 14 months including noticing. 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 finance coverage for individuals during the 12 month PHE Unwind.
- In accordance with our February 2024 budget assumptions, membership has returned to pre-pandemic levels.
- This historic unwind has been challenging for many members, families and health care providers. Throughout, we have had a shared goal to Keep Coloradans Covered. Nevertheless, some people have experienced coverage loss, confusion, and difficulty. All post PHE Unwind metrics are reflecting advances made during the PHE and the PHE Unwind, to the betterment of the member experience and county eligibility processing workloads. While all metrics are improving, we still have work to do.
- Unwind renewal approvals were within 2% of prepandemic norms (55% vs 57%), and disenrollments were as well (43% vs 41%). Since then, renewals have improved significantly. May, June, July and August renewal approvals were at 76%, 76%, 78% and 76% respectively, measured at the end of the respective month. Incorporating the 90-day reconsideration period, when members and counties submit renewal information or process renewals late, all renewal approval rates increase:
- In May, 80% of renewals were approved (after the 90-day reconsideration period) compared to the initial 76%;
- In June, 79% of renewals were approved (after 60 days of the 90-day reconsideration period) compared to the initial 76%;
- In July, 80% remain covered (after 30 days of the 90-day reconsideration period) compared to the initial 78%
- Automation is critical to improving the member renewal experience and reducing county workloads. In May 59%, June 56%, July 62% and August 58% of household renewals were completed through automation innovations (or ex parte). That’s a significant and meaningful improvement over the 33% average during the PHE Unwind. (Note: ex parte is only on renewal approvals).
- Procedural denials are now below the 12% prepandemic levels, at 9% for May renewals (after 90 days), 9% for June (after 60 days) 9% for July (after 30 days) and 11% for August. While we still have a lot of work to do, this metric is moving in the right direction.
Improving Performance Across Numerous Metrics
As noted in the chart below, all metrics are headed in the right direction. Performance is getting better, but we still have a lot of work to do.
Prepandemic | Unwind | Post Unwind | ||||
|---|---|---|---|---|---|---|
CYs 2018- 2019 | May 2023- April 2024 | May 2024 | June 2024 | July 2024 | Aug. 2024 | |
62% - All **72% - MAGI | 58% - All **68% - MAGI | |||||
| 4% (after 30 days) | 5% | |||||
| 9% (after 30 days) | 11% | |||||
* July 2024 marked the implementation of additional automation for renewing members with incomes at and below the federal poverty level. This additional automation is due to a temporary flexibility (known as an e14 waiver) allowed by the federal government through June 2025. HCPF has urged the federal government to make this waiver permanent as it improves the member experience by reducing paperwork needed for renewals and reduces associated county workloads.
** MAGI is Modified Adjusted Gross Income or income based populations. In August 2024, MAGI accounted for 77% of total enrollment.
We continue to see improvements after the 90-day reconsideration period. For example, renewals have improved over the 90-day reconsideration period: In May, 76% of those up for renewal were approved and still eligible for Medicaid/CHP+. This number increased throughout the reconsideration period as people completed late renewals, reaching 80% after 90 days. June’s renewals have also increased from 76% to 80% after 60 days and July’s renewals have increased from 78% to 80% after 30 days. In August, 76% remain covered, and we anticipate this too will increase over the next 90 days.
Given the renewal volume, the processing backlogs that evolved through the PHE Unwind, our state supervised-county administered structure, and the investments needed in our eligibility systems and staffing to improve capacity and processing time, this 90-day reconsideration period is an important metric for Colorado.
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. Major initiatives designed to improve the eligibility process include:
- Senate Bill 22-235 County Administration of Public Assistance Programs: A County Administration Long-Term Support Plan that provides recommendations to improve county administration of eligibility and enrollment and related activities, including properly resourcing our state-county infrastructure, addressing county staff wage rate gaps, advancing the eligibility tools employed by county workers, and more. This report is due to the legislature in November 2024.
- Through the Joint Agency InterOperability (JAI) project, we will advance county consistency through the use of shared, universal tools that support counties 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.
- The Colorado Benefits Management System (CBMS) Vision & Strategy project is driving alignment and clarity around CBMS operational advances, infrastructure, and priorities. Target completion date: June 2025.
- Ongoing work to improve:
- Our renewal and new application automation (ex parte rates)
- PEAK performance, our member digital tool
- Eligibility correspondence clarity within 55 common member eligibility communications, and ultimately eligibility renewal results.
The above project solutions achieve shared goals prioritized between HCPF, CDHS, and our County partners. All of the above strategies will continue to improve the member experience and drive down Colorado’s procedural denials, which are administrative denials for issues other than income and other eligibility requirements as well as 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 through August 2024 - post the PHE Unwind - are now below the 12% pre pandemic norm.
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 through August 2024.
Where Are We Now? Returning to Prepandemic Enrollment Levels
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.
Note that the consistent downward trajectory in membership through the PHE Unwind has now leveled off. As of August 2024, enrollment is about at prepandemic levels, reflecting the end of the Colorado’s PHE Unwind period, May 2023 to April 2024, plus the 90-day reconsideration period.
Through the PHE Unwind, members with higher medical needs have remained covered or returned to coverage, while those disenrolling had lower medical needs. This is causing a significant increase in the average per member per month (per capita) cost of Medicaid membership, post the PHE Unwind — an increase that is above expectations and an over-expenditure against our FY 2023-24 budget projection of more than $150 million in general fund.
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 2.4 million times to about 680,000 Colorado households as of August 2024 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.
Qualifying for Medicaid
To qualify for Medicaid, in many cases, a single person has to make less than $20,028 annually and a family of four less than $41,496 annually. 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 rebounded that provided income similar to the job they lost during the COVID-induced economic downturn. Economic factors further impact enrollment, as a standard, such as changes to the minimum wage or the unemployment rate. For example, Colorado’s minimum wage grew by 20% from 2020-2024 ($12.02 to $14.42) and Denver’s minimum wage increased by 42% from $12.85 in 2020 to $18.29 in 2024.
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%). While we still have a lot of work to do to improve the state’s eligibility system, the below post PHE Unwind performance illustrates that performance is moving in the right direction.
May 2024-August 2024 numbers reflect the most recent data including changes during the reconsideration periods.
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 through August 2024, (76% and increasing to 80% for May through the 90-day reconsideration period) post the PHE Unwind period.
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. We are seeing an uptick of 2-3% points post unwind as individuals turn in their materials or counties work the renewals in the 90-day reconsideration period.
Colorado disenrollment analysis also indicates that 33% of the Medicaid population disenrolled during the PHE Unwind have already requalified for Medicaid and have 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. As employers begin open enrollment for their employees this month, it is more important than ever that they help employees navigate onto employer sponsored health benefits.
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.
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 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 about 45,000 in May 2023 to about 89,000 in August 2024, even above prepandemic enrollment of about 79,000.
Employer Sponsored Insurance: Traditionally, more Coloradans tend to 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.
Understanding the Medicaid Member Experience
HCPF partnered with the Colorado Health Institute (CHI) to conduct two surveys to capture experiential data from a subset of current and former Colorado Medicaid members. These subset populations do not comprise statistically representative samples; therefore, results cannot and should not be extrapolated as statistical representations of the PHE Unwind. As such, findings should be interpreted with caution and used to provide general or directional insights. They should not be extrapolated to represent the entirety of the disenrolling population, nor should they be used to establish normative rates such as the uninsured rate. Findings can inform opportunities based on the member experience feedback and help leaders frame strategies to address those opportunities. The CHI summary report, A Snapshot of Current and Former Medicaid Member Experiences, is published on our Annual Stakeholder Webinar page.
Point in Time: August 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 August, with over two-thirds (71%) of those approvals automatically renewed through advances in ex parte processing technology. 8% were disenrolled due to income or other eligibility requirements, while 11% were disenrolled for procedural reasons.
Supporting Member Renewals
Improvements Implemented:
- Enhanced Member Outreach
- Improved Automatic Renewals
- Shortened Renewal Packet
- Online Renewal Upgrades
- Improved Contact Info. and system changes to reduce Whereabouts Unknown denials
- Pause LTSS terminations for all reasons for two months (60 days) past the member’s original termination date (except for death and relocation out of state).
- NEW Webpage: Stabilizing Long-Term Services and Supports (LTSS)
- Automatically renew members earning less than 100% FPL when third party data sources return no information ($1,215/month individual, $2,500/month family of 4)
Improvements in Process (requires system updates and federal approvals):
- Automatically backdate coverage for those who renew during reconsideration period
- Enhanced outreach during reconsideration period
- Ongoing strategic advances in collaboration with counties and further improving member letters
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.
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.