At the start of the COVID-19 pandemic (January 2020), a federal Public Health Emergency was declared, allowing the federal government to pass policies to increase public health preparedness and healthcare access for Americans facing new pandemic-related challenges. Among these policies was a “Medicaid Continuous Enrollment” requirement, in which state Medicaid programs were given increased financial support in exchange for maintaining continuous enrollment for individuals in their programs. As a result, Medicaid enrollments grew significantly as states could no longer disenroll members that would have previously lost coverage.
As the federal Public Health Emergency was nearing its end, the Consolidated Appropriations Act was passed in December 2022, allowing states to reevaluate the eligibility of their Medicaid populations–this was referred to as the “unwinding” process for re-assessing Medicaid eligibility.
The Iowa Medicaid program began its phased eligibility redetermination “unwinding” process in February 2023, continuing over the next 13-15 months. The redetermination process began with an administrative review to determine current eligibility status of Medicaid members by using existing administrative data (also known as “ex parte” renewals). Enrollees whose eligibility could not be determined “ex parte” were mailed renewal forms.
At the beginning of the public health emergency (January 2020), total Iowa Medicaid enrollment was 692,769.[1] During the continuous enrollment period, Medicaid enrollment increased by about 200,000, peaking at a high of 893,844 members in April 2023.
During the redetermination process (April 2023 to June 2024), about 67% of cumulative Iowa Medicaid members had their coverage renewed, while 33% were disenrolled.[2] This resulted in about 281,000 Iowans losing their Medicaid coverage.
Among those that were disenrolled, 28% lost their coverage because they were ineligible for coverage as indicated by either the “ex parte” review using administrative data or from information submitted by via information submitted by members on their renewal forms. The vast majority (72%), however, lost their coverage for procedural reasons (e.g., applicants did not finish the renewal process; contact information on file was no longer accurate). [3]
Thus, although there is a net gain in Iowa Medicaid enrollment since the beginning of the continuous enrollment period, the administrative process used to redetermine eligibility (the unwind) has had limited success reaching Medicaid members. As a result, the vast majority who have lost their eligibility have been removed due to procedural reasons.
Although some options exist for those who have lost coverage (e.g., health insurance marketplace, employer-based insurance, appealing Medicaid disenrollment), national data indicates nearly a quarter of those who were disenrolled from Medicaid due to the unwind remain uninsured.[4] Additionally, the CDC recently released a report indicating that the uninsured rate increased nationally following the unwind.[5] Due to the high proportion of Medicaid members who lost their coverage for procedural reasons and the national trends of increasing numbers of uninsured, some of those for whom Medicaid never received their forms may still be eligible and could return to the program when their Medicaid eligibility is evaluated, often in coordination with a future health care visit.
[1] Source: IA-HHS Medical Assistance Dashboard: Medicaid and COVID unwind.
[2] Source: KFF Analysis of State Unwinding Dashboards and Monthly Reports Submitted to CMS
[3] Source: IA-HHS Medical Assistance Dashboard: Medicaid and COVID unwind.
[4] Source: KFF Survey of Medicaid Unwinding, April 12, 2024
[5] Source: CDC Health Insurance Coverage Jan 2023-March 2024