Last week we started a conversation regarding the impact of the CMS’ new Medicaid/CHIP Unwinding program. If you didn’t read our initial update, I’ll briefly walk through the program details at a high level or you can access the CMS Unwinding article from last week here.

Back in March 2020, because of the profound impacts of COVID, then President Trump declared a National Health emergency that’s commonly referred to as the PHE or the Public Health emergency and a declaration that’s been extended multiple times over the long, windy & complicated road through COVID.

Following the PHE declaration, the Family First Corona Response Act (FFCRA) issued a continuous coverage requirement for individuals using Medicaid or CHIP (Children’s Health Insurance Program) healthcare programs. What exactly did that mean for recipients and States?

  1. It means that States did not have to require revalidation of eligibility for Medicaid and CHIP recipients to continue using the programs
  2. During the declared PHE period, states were also disallowed to cancel services for program recipients, and
  3. Each state would receive up to a 6.3 increase in funding to cover costs required to provide continuous coverage

Huge Numbers of Enrollees; Huge Concern?

Since that time, as we noted in last week’s CMS Unwinding article (focused on the impact and implications Healthcare Providers will face because of the new mandate), the increase in recipients grew somewhere between 17 and 25%. I say somewhere in between because it really depends on which data source you’re using to determine the total number of Medicaid/CHIP recipients. Many sources point to a total enrollment of 87 million people while other data points will tell you it’s 89 million. A swing of 2 million recipients has a meaningful impact on the increased enrollment growth range, but really, at those numbers, it comes down to a rounding error. I’ve done the research and spoken with other experts who know the landscape even more deeply than I do; I’m comfortable stating an increased enrollment range of 17-23% growth.

But let’s be real here; whether it’s 17% or 25% enrollment growth, we’re talking millions and millions of human lives, human needs & a very real public health crisis on the horizon.

Think about that; since February 2020, approximately 17.7 million more people have enrolled in state-funded health coverage. It’s worth mentioning that the individuals at risk for losing coverage now are disproportionately skewed young. Young children and young adults are most at risk of losing their health benefits and I’m sure I don’t need to belabor the reasons why that’s such a terrifying prospect.

It all begins in a matter of days. CMS first gave a date of October 13th for this unwinding to begin and unwinding means that each State’s department of Health and Human Services are responsible to contact every program enrollee and revalidate their eligibility. Yes, every enrollee which, as a reminder, are documented at a staggering 87-89 million participants.

As of today, CMS has not provided updated guidance, but we fully expect that in the next few days, they’ll announce they’ve committed to a 60-day notice period. For example, if they were to announce this week that they were going to retract the PHE. The 60-day program kick-in mark would be mid-December.

With CMS regulations, you often experience a “kick the can” scenario, right? The folks responsible for action and next steps, well, they wait…and wait…and wait. No action, no movement, just waiting until it’s infeasible to wait any longer.

Don’t Kick This Can

We’ve done extensive research and forecasting related to the impact of waiting to action the Unwinding mandate and I say with confidence and conviction that this is the wrong can to kick.

Because we are talking about millions of people.

In a recent brief that was done in August by the US Department of Health and Human Services (issue brief from the Office of Health Policy), it states:

…the best-case scenario during the Unwinding process is that 8.2 million individuals will lose coverage (that’s 684,000 people a month— best case)

It’s what I call Lake Woebegone. Everybody’s bright and the kids are cute. But when’s the last time a best-case scenario materialized in the U.S. healthcare system? And the worst case? It’s called the “high churn model”:

…. the worst-case forecast estimates 18.4 million people losing coverage,
a rate of 1.5 million people per month

Sheer magnitude of these numbers propels our belief and guidance that kicking this can is the wrong thing to do. We realize states have been burdened by the great resignation and staff shortages like every other industry. No one believes there’s excess people waiting around to take on the kind of workload required to action the CMS mandate, the first step being one of monumental effort: actually locating enrollees (just a breezy 87-89 million of them), and then of course, communicating vital eligibility/revalidation information to them. Anyone who’s minimizing the enormity of this effort is kidding themselves because it’s going to be challenging at best.

Kaiser Family Foundation Steps Ups

What I find concerning and quite frankly, troublesome, is how little mainstream attention this issue has received. I, like many of my peers, was pretty happy to see that the Kaiser Family Foundation (KFF) has taken on this issue. They published a deep dive brief at the very end of September: “10 Things to Know About the Unwinding of Medicaid Continuous Enrollment Requirement”.  It’s a thorough document. I would encourage everybody to review what the KFF is saying about this and recognizing this as a potential second public health emergency.

If you’re a state Department of Health and Human Services, you (should) have received your CMS Medicaid Unwinding Kit. If you did, then you know one of the first recommendations in that kit is to implement a direct mail campaign to attack the impending enrollee outreach. I’ll be candid because there’s not much time to waste getting prepared for the Unwinding program kick off date:

Direct mail for required outreach is laughable & misguided for 3 key reasons:

  1. Total program cost
  2. Sheer Ineffectiveness
  3. Total cost + ineffective effort = major waste of money & time, the latter exacerbating the health crisis factor

Perspective Via Macros & Micros

Let me offer macro & micro numbers to put this in perspective (keep in mind the numbers I’m using are approximates but paint a realistic picture):

  • The ballpark cost to send a direct mail campaign, including postage paper processing, the return address requirement (called the forwarding address requirement) and the full list of line items needed to get a piece of direct mail sent is about $4.50 a unit.
  • Working from the 86 or 87 million individuals who are to be contacted nationwide, at $4.50/letter, you’re looking at a total spend of ~$391 million.

Now consider the critical issue of widespread relocations (this is covered in more detail in last week’s article). During the pandemic, relocations were at their highest levels ever; around 22 percent. So, 22% of people relocated over the last few years, which means there’s a high likelihood your direct mail never even makes it to the intended recipient…

MEANING: $86 million of the $391 million spent on direct mail is met with no discernible outcome, simply none. The letter will just sail around the world, the US, wherever it goes. Where does physical mail go these days? A deep abyss of unopened, unmet, unheard, unappreciated, unread communication. Sad but true.

Let’s take this scenario a step further into a micro-level view:

Take the state of Texas; they’re estimating 5,000,000 total individuals receiving Medicaid and CHIP services. FIVE MILLION pieces of direct mail; five million hope & a prayer chances to reach the right person with life-changing information. Literally.

  • They’re going to mail a letter to the 5 million people; using the same $4.50/unit, the spend for Texas alone is $22.5.
  • Assuming the same 22% relocation rate, the wastage on relocation misfires alone is $4.95 million, let alone the wastage potential tied to guessing whether recipients actually read the information.

Doom and Gloom for Days, But Also a Silver Lining

It’s not a pretty picture, but there’s optimism for States who sidestep the ridiculousness of relying on direct mail to accomplish enrollee outreach. We’ll use Texas to illustrate a better, alternate way for States to approach the CMS Unwinding.

If Texas chose to use technology instead of snail mail, and omnichannel technology at that, they’d could leverage outbound IVR (Interactive Voice Response), email, & SMS/text campaigns to reach enrollees with vital details about the new eligibility requirements and how to act.  

  • The cost of sending a multi-channel email & text? Barely or just touching a dollar per individual.
  • For Texas, you’re talking a total cost of around $5 million, versus a total cost of $22.5 million for direct mail. Is there some wastage in digital outreach efforts? Sure, but nothing remotely close to 22%+.

It’s hard to argue with those numbers; it’s undeniable that digital methods of outreach are just a smarter way to approach this.

Another alternative route is voice calls, but we all know most people won’t answer them and that’s assuming the States even have current or mobile phone numbers for enrollees. You could try it; it’s certainly not a wasted effort, but it will likely cost somewhere around $17-18 million dollars. If you look at the state of New York, with 7.4 million individuals who received Medicaid and CHIP services, that’s breaks down to one in three residents in the state of New York. Staggering numbers, and it’s just an enormous number of people to contact.

And if the proverbial can keeps getting kicked, and States don’t start the outreach as soon as CMS says it’s time (remember, we’ll know CMS’ decision on this date within the next few days), we’re looking at a decreased timeline to complete all this. Even with a 12-month runway the outreach is daunting, but with less time, it’s borderline unmanageable. Especially when compounded by the Department of Health and Human Services’ forecasting an extremely high percentage of administrative errors.

So, we’re thinking ahead to a laundry list of challenge points:

  • we can’t reach the people because the system is overloaded,
  • because people don’t answer their telephone,
  • and because people have moved
  • an enormous amount of money will be spent, and yet…

It must be done and if it’s not done correctly, with precisions, proactivity and logic, individuals will lose coverage at a rapid clip. Children will lose coverage.

There’s something I haven’t addressed; many current enrollees will still be eligible, but still, if you can’t get in touch with them and you can’t get them reenrolled, they will be dropped. Perfectly eligible enrollees without access to health coverage due to administrative and logistical complexity. Who’s going to end up without health insurance? Some of the most vulnerable people in our country. The people who need it the most.

Hopefully these people will seek out coverage, but if they don’t, that opens the door to a whole host of Provider-side problems; claim denials being the big one. But take a step back and think about the digital-first world we’re living in, and the fact that email, SMS & text aren’t affected by broad-scale relocations. Now there’s a brighter view in sight, a better/best case scenario where we reach millions and millions of enrollees, enroll them, and if they’re not eligible, proactively point them to the marketplace where they can find affordable health coverage for themselves and their families. It’s not a rainbows & unicorns scenario; it’s realistic. Modern technology can make it happen.

Acqueon’s Conversational Engagement Platform is built to tackle outreach and omnichannel campaigns of this magnitude. It was built for exactly this level of proactive communication with capabilities for voice, callback options, IVR campaigns, e-mail & SMS outreach. Not only is our platform equipped to tackle CMS Unwinding, we’ve also built the infrastructure to support this specific initiative:

  • It can be tailored for any/every State
  • It can be built & operational in under 60 days
  • It will work with your current contact center solution
  • There’s no hardware required
  • There’s no additional investment in people.

What we’re going to do is build the campaigns to make your contact center act as the trusted advisor, increasing your ability to reach this high-risk & vulnerable group of people and guide them through the re-enrollment process.

Trite as it may be to end this article with a “Don’t Wait” message, I can’t overemphasize the need for States to act quickly. There’s not a day to waste. Acqueon has the solution to address your needs, it’s already built, and we’ve actively helping tackle the CMS Unwinding Program requirements.


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