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As the public health emergency drags on (PHE) into 2023, payers dominating both Medicaid and exchanges will continue to win big as recipients navigate complex waters.

Since HHS first declared COVID-19 a PHE, government-sponsored health insurance has grown exponentially – Medicaid and Marketplace.

To preserve continued coverage in an uncertain economy, HHS suspended Medicaid eligibility checks. As this grace period draws to a close, states are in varying degrees of readiness to resume the new determinations. Several stakeholders are reaching out to help, including health plans whose losing Medicaid member can switch to their market plans.

Medical help the number of members has increased from 12.7 million to 18.7 million per year between July 2021 and July 2022. The exchanges reached a record 14.5 million subscribers, including nearly three million new customers. In January 2022, the number of marketplaces was nearly 17 million per Kaiser Family Foundation (KFF)counting non-subsidized plans and those purchased off-exchange.

A Changing Pandemic Deadline

The PHE has been in place since January 31, 2020. The last HHS renewal on October 13 required 60 days notice of the PHE expiration by November 11, which did not occur. As such, the PHE will remain in place until at least January 11, 2023, further extending the suspension of the state’s Medicaid determination.

When it expires, three issues are paramount:

  • How States Will Handle Redeterminations
  • How many people will lose Medicaid coverage when this happens
  • How many will choose (or be able to successfully navigate) a transition to Exchange coverage

“Estimates range from 5 million to 14 million people who will experience a loss of coverage,” says Ashley Perrydirector of strategy and solutions for socially determinedwhich measures the impacts of social determinants of health (SDOH) and also engages with Medicaid officials to ease redetermination burdens.

“The delta in the projections reflects the uncertainty around which ones are no longer of quality and how they may perhaps be brought into trades,” Perry says, adding, “It’s interesting to see the variation in the response of the Some are driven by political considerations. Some are dependent on a state’s preparedness to manage the redetermination process. There are also many challenges in terms of manpower and, from a political point of view, , states have different levers in place. Some already have continuing or presumptive eligibility, which gives them more work to do.”

The best positioned plans

In its 2022 analysis, the Robert Wood Johnson Foundation (RWFJ) noted that the new determinations represent “the most likely prospect for listing growth” for the Exchange in the short to medium term.

Health plans that operate both lines of business – Medicaid and Exchange managed care plans – are expected to see the biggest gains. A 2022 KFF analysis shows that six companies dominate both spaces:

  • centene – Medicaid plans in 24 states and Exchange plans in 28
  • UnitedHealth Group — Medicaid plans in 24 states and Exchange plans in 22
  • Elevance Health (formerly Anthem) – Medicaid plans in 21 states and Exchange plans in 14 states
  • Etnaa CVS Health company – Medicaid plans in 14 states and Exchange plans in 12 states
  • Molina – Medicaid plans in 12 states and Exchange plans in 14

Among these plans, Centene is the mainstay.

“During the years when the big national plans stayed off the exchanges, Centene became the big dog and grew organically in markets and counties,” says Bill Melville, Principal Market Access Insights Analyst at Clarivate. “They didn’t retreat when others did.”

Associated challenges

The ability of Centene or any plan to migrate members to the exchange, however, depends on education and awareness – two ongoing challenges for the Medicaid program whose members have frequent changes of contact information as well as multiple SDOH challenges.

Socially Determined is working with states to update contact information for Medicaid members with these challenges in mind.

“Typically, 25-40% of contact information is out of date,” Perry says, adding, “Subsets of people with health literacy and cultural challenges are at higher risk, not just in coverage navigation, but also in access to care. Socially determined plans can help identify these subsets.”

Caught off guard

A Medicaid population aware of upcoming redeterminations would help mitigate these risks, including loss of coverage and options available on the Exchange.

But this is not the case. Nearly two-thirds (62%) of adults enrolled in Medicaid, or with a family member who is, are unaware that their eligibility will be reassessed, according to a new Urban Institute Report, funded in part by RWJF. Additional data showed that only 21% of members notified that coverage renewal was necessary were told what to do next, and only 29% were told about their other options.

“Our research shows that there is low awareness of the future resumption of Medicaid renewals, indicating that state programs may face significant information gaps among enrollees about the impending change brought about by the end of PHE,” said Jennifer Haley, senior research associate at the Urban Institute, in a press release accompanying the report.

For earlier HealthLeaders coverage of the 2023 exchange plan developments, read Part 1 – The Growth Trajectory, here.

Laura Beerman is a staff writer for HealthLeaders.