Medicaid unwinding
Medicaid programs nationwide resumed eligibility reviews in April 2023 ahead of the end of the COVID-19 public health emergency (PHE) on May 11.
The U.S. Department of Health and Human Services declared a COVID PHE in January 2020. And, from January 2020 to February 2023, the PHE was renewed a dozen times.
For three years, until April 2023, people who were enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) at any time during the PHE got to keep their coverage without having their eligibility reviewed. This is because all states, Washington, D.C., and five U.S. territories were required to provide continuous coverage during the PHE.
Now that the PHE has ended — and COVID is considered a public health priority, rather than emergency — an estimated 8 million to 24 million enrollees nationwide are expected to lose coverage as Medicaid renewals resume. This return of eligibility reviews, also known as the redetermination process, is being called the unwinding of Medicaid.
It’s important for your state Medicaid agency to have your current contact information. If you can’t be reached or no longer qualify for Medicaid, you could lose your health insurance coverage.
Alternatives to Medicaid
If you lose your Medicaid coverage but you believe that you still qualify, you can reapply. If you choose not to reapply or no longer qualify for Medicaid, you may be able to take advantage of other low-cost or free healthcare options. You can also use GoodRx coupons to save on your prescription medications.
In addition, you may be able to find alternative health insurance coverage and care through:
Affordable Care Act (ACA) marketplace plan: Through your state ACA health insurance marketplace or the national exchange, you may be able to find an affordable health plan for $10 or less per month if you qualify for a premium subsidy. If you lose Medicaid coverage, you can purchase a plan during the unwinding special enrollment period from March 31, 2023 to July 31, 2024.
Employer plan: If you have a job, you may be able to get employer-sponsored health insurance.
Medicare: If you have a qualifying disability or condition — such as end-stage renal disease or ALS (amyotrophic lateral sclerosis), commonly referred to as Lou Gehrig’s disease — you can enroll in Medicare at any age.
Partner’s plan: If you have a spouse or domestic partner who has health insurance, you may be able to join their plan during an open enrollment or special enrollment period.
Special plans: Short-term insurance can be a great choice if you anticipate that a better option, like job-based health insurance, will be available soon. You may also consider alternative and limited-benefit plans, which include fixed indemnity, accident, cost-sharing, and catastrophic insurance plans.
Student health plan: If you’re enrolled in a college or university, you may be eligible for a campus health plan.
U.S. Department of Veterans Affairs (VA) benefits: If you are an active-duty service member or a veteran, you may qualify for TRICARE coverage or VA benefits and services.
History
Medicaid is a public health insurance program that provides coverage to families and individuals with low incomes. Medicaid programs are operated in all states, Washington, D.C., and five U.S. territories:
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
U.S. Virgin Islands
Medicaid is jointly funded by the U.S. government in each of the states and territories. The federal government sets the guidelines, but each state or territory operates its own Medicaid program. Because of this, eligibility and benefits can vary greatly from state to state.
President Lyndon Johnson signed Medicaid into law in 1965, along with Medicare. At first, Medicaid provided health insurance to people receiving cash assistance. The program now covers more groups of Americans, including pregnant people, individuals with disabilities, and those who need long-term care.
Medicaid has gone through many policy changes over the decades. In 2010, for example, the Affordable Care Act (ACA) became law. The ACA expanded income limits to include even more people in Medicaid coverage.
Coverage
The federal government sets top-level requirements for what Medicaid must cover and leaves the rest for each state or territory to determine. The mandatory benefits that each state and territory is required to offer include coverage for:
Inpatient and outpatient hospital services
Physician services
Laboratory and X-ray services
Home health services
Nurse midwife services
Family planning services
Nursing facility services
Transportation to medical care
Optional benefits that Medicaid programs may cover include:
Prescription medications (currently covered by all)
Optometry services, including eyeglasses and basic vision care
Dentures and dental services
Case management
Physical and occupational therapy
Podiatry services, or foot care
Costs
States have the option to charge Medicaid enrollees premiums and other cost-sharing expenses. Some out-of-pocket costs may include copayments, coinsurance, and deductibles.
States can charge higher amounts for enrollees with higher incomes. But there is a maximum out-of-pocket cost-sharing limit set by the U.S. government.
The federal government has also decided that certain vulnerable groups should not have any out-of-pocket Medicaid costs, including:
Children under age 18 (or any cut-off between age 18 and 21 that states choose)
People receiving hospice care
People living in an institution who spend nearly all their income paying for their care
American Indians and Alaska Natives who have received services from the Indian Health Service or tribal health programs
For all enrollees, there are no out-of-pocket costs for:
Emergency services
Family planning
Pregnancy-related services
Preventive services for children of Medicaid enrollees
Eligibility
Generally, you can qualify for Medicaid at any time as long as you meet financial and/or non-financial eligibility requirements. Requirements differ among states and territories, but there is one constant: You must be a resident of the state or territory where you’re applying for Medicaid.
Other factors that can determine eligibility are:
Income
Family size
Having a disability or other qualifying condition
It’s important to note that 40 states and Washington, D.C., have expanded Medicaid coverage through the ACA. This means that residents of those states and D.C. can qualify for Medicaid based on income alone — which includes higher incomes than the programs previously accepted. This has reduced the nation’s uninsured population and improved access to care.
If you are approved for Medicaid, your coverage will start on the date you apply or the first day of the month you applied. Additionally, Medicaid enrollment can be backed up to the 3 months prior to your application date, if you qualified during that time.
Coverage typically terminates at the end of the month in which you stop meeting the eligibility requirements.
How to apply
You can enroll in a Medicaid or CHIP program in two ways:
Through an ACA health insurance marketplace: Fill out an application on www.healthcare.gov or through your state marketplace. If anyone in your household qualifies for Medicaid or CHIP coverage, a representative for the marketplace will forward your application to your state agency so that you can enroll.
Directly through your state Medicaid agency: State Medicaid agencies usually have 45 days to process your Medicaid application, or 90 days if you’re applying due to a disability. Processing times vary by state and are reported by the federal government.
When applying for Medicaid, you may be asked for proof of eligibility. Some records you may need to provide include:
Proof of age, identity, and citizenship (such as a birth certificate, driver’s license, or photo ID)
Proof of residency (such as a lease, utility bill, or property tax record)
Proof of all sources of income
Medical records for proof of disability or pregnancy
Common concerns
U.S. citizens and nationals are eligible for Medicaid. According to the federal government, “qualified non-citizens,” such as green card holders, can generally become eligible for Medicaid coverage after a 5-year waiting period. However, certain states provide Medicaid coverage to children or pregnant women before the end of the 5-year waiting period.
In some cases, you may qualify for Medicaid and Medicare at the same time. This is called dual eligibility. When you have coverage through both programs, Medicare pays first and Medicaid pays second. Medicaid may also cover costs that Medicare doesn’t, such as nursing home and personal care services.
Coverage varies by state, but being dually eligible — or a “dual-eligible” — means you won’t have many out-of-pocket healthcare costs.
References
Administration for Strategic Preparedness & Response. (2020). Determination that a public health emergency exists.
Administration for Strategic Preparedness & Response. (2023). Renewal of determination that a public health emergency exists.
Centers for Medicare & Medicaid Services. (n.d.). Beneficiaries dually eligible for Medicare & Medicaid.
Centers for Medicare & Medicaid Services. (2021). History.
Centers for Medicare & Medicaid Services. (2023). Temporary special enrollment period (SEP) for consumers losing Medicaid or the Children’s Health Insurance Program (CHIP) coverage due to unwinding of the Medicaid continuous enrollment condition – Frequently asked questions (FAQ).
Guth, M., et al. (2020). The effects of Medicaid expansion under the ACA: Studies from January 2014 to January 2020. Kaiser Family Foundation.
Healthcare.gov. (n.d.). Medicaid & CHIP coverage.
Kaiser Family Foundation (n.d.). Status of state action on the Medicaid expansion decision.
Kaiser Family Foundation (2020). Premium and cost sharing requirements for selected services for Medicaid adults.
Medicaid.gov. (n.d.). Beneficiary resources.
Medicaid.gov. (n.d.). Benefits.
Medicaid.gov. (n.d.). Cost sharing.
Medicaid.gov. (n.d.). Cost sharing out of pocket costs.
Medicaid.gov. (n.d.). Financial management.
Medicaid.gov. (n.d.). Mandatory & optional Medicaid benefits.
Medicaid.gov. (n.d.). Medicaid and CHIP coverage of lawfully residing children & pregnant women.
Medicaid.gov. (n.d.). Medicaid eligibility.
Medicaid.gov. (n.d.). Medicaid MAGI and CHIP application processing times.
Medicaid.gov. (n.d.). Out-of-pocket cost exemptions.
Medicaid.gov. (n.d.). Program history.
Medicaid.gov. (n.d.). Renew your Medicaid or CHIP coverage.
Medicaid.gov. (n.d.). Unwinding and returning to regular operations after COVID-19.
Rudowitz, R., et al. (2019). 10 things to know about Medicaid: Setting the facts straight. Kaiser Family Foundation.
Tolbert, J., et al. (2023). 10 things to know about the unwinding of the Medicaid continuous enrollment provision. Kaiser Family Foundation.
U.S. Department of Veterans Affairs. (2022). VA & TRICARE information.
