As states unwind the Medicaid continuous enrollment provision, they must comply with federal renewal requirements, including the requirement to conduct ex parte or automated renewals. Ex parte renewals can help to reduce administrative burdens for state eligibility workers and enrollees. Ex parte can also help to address longstanding issues with Medicaid enrollees losing coverage at renewal despite still being eligible by simplifying the process and eliminating the need for enrollees to complete and return a renewal form. States have taken steps to increase the share of ex parte renewals; however, with heightened focus on state renewal policies and procedures, the Centers for Medicare and Medicaid Services (CMS) identified a problem that led to hundreds of thousands of enrollees, many of whom are children, being inappropriately disenrolled from Medicaid. This policy watch explains what ex parte renewals are, examines variation in ex parte renewal rates across states, and discusses current issues as well as actions states are taking to increase ex parte rates.
What are ex parte renewals and how do ex parte renewal rates differ across states?
When conducting a renewal, states are required to first attempt an automated, or ex parte, renewal by checking data available to the state to verify eligibility before requesting enrollees complete a renewal form. States have access to several databases that can be used to verify eligibility. For example, to check financial eligibility requirements, states can access a state wage or tax database, information from other means-tested programs like the Supplemental Nutrition Assistance Program (SNAP), or federal data from the Internal Revenue Service (IRS). Ex parte renewals lessen the administrative burden on both enrollees and Medicaid staff by reducing the amount of paperwork that must be completed and processed. Strong ex parte processes also lower the risk of eligible people losing Medicaid if they do not receive or otherwise do not complete renewal paperwork (also known as procedural disenrollments).
Ex parte rates vary widely across states (Figure 1). Among individuals who have had their coverage renewed to date during the continuous enrollment provision unwinding process, 55% of people had their coverage renewed automatically via ex parte renewal. However, ex parte rates vary widely, ranging from 99% in North Carolina to 3% in Wyoming. Several factors contribute to differences in ex parte rates across states, including which data sources states use in ex parte reviews and the process states establish for reviewing data from multiple sources. Also, some states lack the system capability to conduct ex parte renewals for certain populations, particularly for Medicaid enrollees who qualify based on age or disability and have more complex criteria for determining eligibility.
What are current issues with ex parte renewals?
The focus on state renewal processes during the unwinding period has shed light on longstanding challenges with ex parte renewals. According to a recent report from the Medicaid and CHIP Payment and Access Commission (MACPAC), states face challenges conducting ex parte renewals related to the data sources they can access as well as competing priorities and resource constraints that delay needed systems upgrades. In addition, as noted above, some populations, particularly those that require verification of assets or functional assessments, can be more difficult to renew on an ex parte basis. While these challenges are not new, new reporting requirements have made data on ex parte rates available and led to greater scrutiny of state ex parte renewal processes.
Most states have adopted new policies or flexibilities to increase the number of ex parte renewals. Leading up to the start of the unwinding period, states implemented policies to increase ex parte rates, such as adding new data sources to their ex parte processes. Nevertheless, as of March 31, 2023, about half of states (26) were out of compliance with federal rules and were not conducting ex parte renewals for at least some enrollees. In most cases, states were not conducting ex parte renewals for some or all enrollees who qualify based on disability or age. CMS required these states to implement mitigation plans while making system fixes that would eventually bring the states into full compliance. In addition, nearly all states (47) have adopted 1902(e)(14)(A) waivers made available by CMS during the unwinding period to streamline ex parte renewals, and in some cases were used as mitigation strategies.
In September 2023, federal officials announced that 30 states had been incorrectly processing ex parte renewals. Federal rules require states to process ex parte renewals at the individual level and not the household level. However, if these states were not able to renew everyone in the household via ex parte, the states were sending renewal forms to all family members and then disenrolling everyone if the forms were not returned, even if the states had information to renew coverage for some family members, most often children. Income eligibility thresholds for children are generally higher than for adults. In total, states estimated that roughly 500,000 people were inappropriately disenrolled. States with this issue are required to pause additional procedural disenrollments until a mitigation plan is put in place and must reinstate coverage for affected individuals. While it is unclear how long the process will take, states are working quickly to reinstate coverage. Several states, including Nevada and Virginia, announced they have already reinstated coverage.
Despite recent challenges with ex parte renewals, steps taken by states to increase ex parte renewals will likely have a lasting effect on renewal processes and promote continuity of coverage for eligible Medicaid enrollees. Although most states have so far been identified as out of compliance with federal rules (either because they were not conducting ex parte renewals for all enrollees or because they were not processing ex parte renewals at the individual level), it is possible additional issues will be uncovered. There is also room for improvement in many states, particularly those with low ex parte rates, even in states meeting federal requirements. Many states have used the unwinding as an opportunity to implement new strategies for increasing ex parte rates, which may improve Medicaid renewal long-term, particularly if some temporary flexibilities like waivers prove effective and are extended beyond the unwinding or are made permanent.