When the public health emergency related to COVID-19 ended, so did continuous Medicaid health insurance coverage for many vulnerable U.S. families. But in a process that has, as of March 19, dropped 11.19 million people, including 4.61 million children, many former beneficiaries may not know they’re losing coverage or that they may be eligible to get it back.

Utah at this point has the highest rate of “procedural” terminations, according to a state-by-state analysis by the Center for Children and Families at Georgetown University, which used national data reported to the Centers for Medicare and Medicaid Services. In Utah, 94% of the people dropped from Medicaid rolls recently lost coverage without any determination of being ineligible. Their application/review process had not been completed successfully for one reason or another.

The numbers are a moving target, with states at various stages of completing eligibility assessments. And to understand what’s happening, a bit of history is required.

Public health emergency begins — and ends

When COVID-19 raged hardest, families faced both a public health and an economic crisis. With unemployment shooting up and many lives in turmoil, the federal government issued a couple of moratoriums to help people in precarious financial situations. The eviction moratorium is among the best known. Another, tied to the public health emergency declaration, was continuous coverage for those on Medicaid. States were not allowed to just drop Medicaid beneficiaries while the declaration was in effect.

That continuous enrollment ended April 2023, but determination of eligibility has been done in phases in a process called “Medicaid Unwinding.” The public health emergency itself formally ended May 11, 2023.

Over the course of more than a year — unwinding is supposed to end this April 30 — all Medicaid beneficiaries were assigned an eligibility review month and their case was to stay open until then. In the Beehive State during that time, the Utah Department of Workforce Services was to review eligibility, which in some cases could be done without any action on the part of the person or family enrolled. Thus, a number of cases were automatically deemed eligible or ineligible.

Cases could be terminated one of two ways: By a finding of actual ineligibility or with what’s called a “procedural” termination. In the latter cases, more information was needed to decide if someone qualified and the Department of Workforce Services sent letters asking people to complete the process, said Kolbi Young, a spokesperson for Utah’s Department of Health and Human Services, which administers and oversees policy for the Medicaid program. She said a public education campaign to try to reach families that might not know has also been underway.

Young said Utah will complete its unwind by the end of April, on schedule.

Dropped, but maybe still eligible

Joan Alker, research professor and executive director of the Georgetown University Center for Children and Families, said there are many reasons that a procedural termination could happen. A family might decide not to be on Medicaid and not complete paperwork or they could have found better jobs, perhaps with health coverage for adults and children. That’s less likely for the children, though, Alker added, because many low-wage jobs don’t provide dependent coverage.

But it’s also more than possible, she said, that in many cases families never received the letter or didn’t understand what they needed to do or where to go for help. And call centers that are designed to help have had some backlogs and long wait times and delays — a problem nationwide. It’s also possible, she said, that paperwork didn’t upload properly in the system or that deadlines were missed.

Young said a lot of Utah enrollees moved in the pandemic or got new contact information, new jobs, “just a lot of change in the three years.” And in some cases, she said, folks have not been reachable. When eligibility staff reached out and has not heard back, “We don’t know why.” Some cases are still pending.

A report prepared by the U.S. Department of Health and Human Services projected that during the unwind, about three-fourths of the children that would be dropped would in fact still be eligible for Medicaid coverage, Alker said. “They’re losing it because of procedural terminations and the process going awry. And there are many, many ways the process can be going awry.”

Utah’s not the only state with a very high share of dropped coverage that falls under “procedural” termination. New Mexico at 93%, Washington, D.C, at 91% and California and Alabama, both at 88%, round out the top five. In the U.S., 70% of disenrollments are procedural, impacting millions, including kids.

Are children being covered elsewhere?

The question the Georgetown center asks is what has happened to the children who no longer have coverage. Some have likely moved to the Children’s Health Insurance Program (CHIP), which also serves low-income kids, but has different eligibility. But where are the others?

Utah even before the pandemic had a higher share of uninsured children than the national average at 8.3%, compared to the country’s 5.7%. The pandemic-era coverage dropped the share without insurance in Utah to 6.1%, compared to the national average of 5.1%, Alker said. “Utah’s was one of the biggest drops we saw in the country,” she said, calling the continuous coverage a win for Utah’s low-income children.

When it comes to health coverage, Alker said it’s important to think about children and adults differently, because children are more apt than adults to remain eligible for Medicaid.

“There’s really no excuse for children to be uninsured,” Alker said, calling it “problematic in many ways. Medical care is very expensive in our country. Everyone knows that. Unless you’re a millionaire, there’s no way to pay for it on your own. And with young children, you’re at the doctor constantly. They’re not expensive to cover, but they do utilize care regularly.”

She also notes that babies and toddlers, as they grow, need lots of care to do well, which is one reason many well-child visits are recommended for the youngest children. It’s important for development and to find and address any problems. All children need insurance, but it’s especially true for the very young.

Beyond that, any gap in coverage for children can turn into a family crisis. A simple fall and a broken bone can be devastating financially, said Alker.

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Health care coverage also offers benefits not only to families, but to society. When children are healthy, they do better in school. They develop better. They are more likely to graduate high school and have higher incomes as adults if they had health insurance when they were little. “Benefits immediately, and benefits long-term,” Alker said.

Waivers enable continuous coverage

Some states have received or are seeking Medicaid waivers to provide their own continuous coverage, including Oregon, which did so first, Alker said. A dozen states want to “completely re-conceptualize the eligibility system for children and even sometimes for adults,” she said, noting those states like the lack of churn, the stable and lower rate of uninsured and other benefits.

Who’s covered and for how long varies from state to state in the waivers. Once a young child qualifies for Medicaid in Oregon, for example, that child can stay enrolled to age 6. Children on CHIP also remain eligible. After that, programs check eligibility every two years, instead of annually. Washington and New Mexico have been approved for their waiver version to provide continuous coverage. California’s waiver targets small children ages 0-5. Ohio is targeting 0-3. And there are others, with their own formulas.

If you lost coverage ...

According to Young, those in Utah who were denied because they didn’t return paperwork have 90 days to restore coverage. But many have passed that 90-day window already and must start over. There’s also an appeals process. Those who don’t qualify have a 60-day special open enrollment period from losing coverage to apply in the federal health insurance marketplace.

Finally, nothing says those who lost coverage are barred from re-applying for Medicaid. That’s always an option.