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Longest. Unwinding. Ever. The Continuous Wind Down of Continuous Enrollment

912 days sit between the beginning of the Public Health Emergency (PHE) and today, July 26, 2022. The PHE has been renewed 10 times, with the latest extension set to expire on October 13, 2022. There has been no shortage of speculation around the last two extensions, especially after the Biden-Harris administration committed to providing states with at least a 60 day notice prior to its plans to terminate or allow the PHE to end.

In March of 2020, the Families First Coronavirus Response Act (FFCRA) was signed into law. This particular piece of legislation focused on many programs impacting children and families, including but not limited to Supplemental Nutritional Assistance Program (SNAP), the Women Infants and Children (WIC) program, family and medical leave, school lunch, emergency paid sick leave, and state based programs for Medicaid and Children’s Health Insurance Program (CHIP) eligibility and enrollment requirements. The latter of these provisions effectively froze Medicaid disenrollment during the PHE allowing for continuous coverage for current beneficiaries. Prior to the pandemic, states were required to reprocess eligibility for most of its enrollees on an annual basis, this process is referred to as redetermination.  

Medicaid and CHIP enrollments have increased by approximately 19% or 13.6 million enrollees between February 2020 and September 2021 with an additional 1.2 million enrollees added to the roster since the September report. To offset increased program spending coupled with decreased state tax revenue, the FFCRA authorized a 6.2 percentage point increase in the Federal Medical Assistance Program (FMAP) and in return expected continuous enrollment. This FMAP bump will continue through the end of the first quarter in which the PHE ends. 

When the End Comes…

Now that we’ve covered some of the basics, let’s look what it means for the plan when the PHE and continuous enrollment ends, and redetermination resumes for its beneficiaries. The end of continuous enrollment is expected to create the single largest health coverage transition since the first Marketplace Open Enrollment. Due to the high volume of unprocessed eligibility renewals and the increase in membership, states have been given a 12-month unwinding period to manage this administrative task. The Department of Health and Human Services (HHS) has issued an Unwinding Toolkit and CMS has encouraged states to only process 1/9 of its total caseload in a single month; processing more than this creates an increased risk of people falling through the cracks and being unnecessarily disenrolled resulting in a loss of coverage and potential increase of additional administrative work to bring them back in.  

Keep in mind each state will have its own pathway and plan to work through this transitional phase. For example, some states have indicated they will target enrollees who appear to no longer be eligible first and others plan to conduct renewals on a monthly basis based on the individual’s initial enrollment month and some states have also reported they plan to process the backlog as soon as 3-6 months with others using the full 12 plus months.  

Projections for total Medicaid and CHIP growth during the pandemic and scenarios calculating total loss of coverage continue to shift and grow with varying levels of certainty and range from 5 to 14 million enrollees losing coverage. Even at the lowest end of the loss projections, five million people is an awful lot! While some loss may not be preventable, complete, and total disruption can be avoidable for those who be eligible for coverage on a Marketplace (aka Affordable Care Act or ACA) plan. This shift to retention will be more bearable and less burdensome if American Rescue Plan Act (ARPA) subsidies continue for the estimated 13 million Marketplace enrollees currently receiving a premium reducing subsidy.  

Planning for the Unwinding of Continuous Enrollment

So, we’ve covered some basics on what it means for the plan (a lot of work ahead), what it means for the member (a lot of uncertainty still remains), and now about what it means to everyone in between which in this instance is us, mPulse and that’s where I start to get excited. There are phased approaches and best practices from our friends in California who have been given the green light to reach members in just about any way possible even allowing plans to solicit opt-in consent for future updates by text message to the East coast where communications to CoverVA enrollees in Virginia are being encouraged to update their contact information by signing up for email or text alerts and following via social media.  

I’m no math whiz, but this one is easy: X + 14 = Regular Redetermination Resumes 

With X being the unknown number of additional PHE extensions and 14 the number of total months allowed to manage the backlog at the end of the PHE you’ll find yourself back where you were before COVID-19 was a household name. Regardless of where you are in your own state’s phase approach, you can count on trusted partners like mPulse to engage the unengaged and reach the unreachable in your membership. Not sure where to start? Reach out to learn more about the power of SMS and find out how many of your contact numbers are mobile vs. land lines.

CMS 2023 Ruling’s Impact on D-SNP Populations, Part 1

The Centers for Medicare & Medicaid Services (CMS) released the Contract Year 2023 Medicare Advantage and Part D Final Rule. The ruling places a spotlight on the vulnerable D-SNP population, and places health plans in a challenging yet opportunistic position to engage these notoriously difficult-to-reach members.

2023 Ruling’s Impact on D-SNP at a Glance 

Enrollee Participation in Plan Governance 

MA organizations offering a D-SNP must establish at least one enrollee advisory committee in each state to solicit input from member experiences. The sample must include those enrolled in D-SNP and garner input from members regarding access to services, coordination of services and health equity. 

Opportunity: Feedback will help identify and address barriers to care, which will allow plans to further assess their series and processes to ensure a better member experience, while also collecting valuable data regarding their unique member population.

Standardizing Housing, Food Insecurity, and Transportation Questions of Health Risk Assessments (HRAs)

Initial and Annual assessments will be conducted to evaluate each member’s physical, psychosocial, and functional needs. HRAs must include one or more questions on housing stability, food security, and access to transportation.  

Opportunity: Visibility of member needs will enable plans to address the unique needs of each member, allowing better access and resource allocation of plan offerings and services.

Refining Definitions for Fully Integrated and Highly Integrated D-SNPS 

Beginning in 2025 and in years following, FIDE SNPs will have aligned enrollment and cover Medicare cost-sharing and Medicaid benefits for home health services, medical supplies, and behavioral health services between the state and the MCO, with the same legal entity as the FIDE SNP. Additionally, HIDE SNPs have service that overlaps the plan’s Medicaid managed care plan with the state. This rule will organize Medicaid long-term services while supporting Medicaid behavioral health services affiliated with FIDE SNPs and HIDE SNPs.  

Opportunity: Create better integration between FIDE SNPs and HIDE SNPs, whose definition and intricacies have previously lacked consistency.

Additional Opportunities for Integration Through State Medicaid Agency Contract

D-SNP contracts will be required through the state agency to provide benefits/ arrange a provision of benefits. New pathways will require aligned enrollment and establish contracts that only include one or more D-SNPs within a state and use integrated materials and notices for members. 

Opportunity: Members have clarity of their coverage and benefits. Star Ratings are assigned at the contract level, which means this rule provides greater transparency on D-SNP quality ratings and will allow CMS to identify disparities between beneficiaries and interventions. This will improve federal and state oversight and scale information sharing.

Attainment of the Maximum Out-Of-Pocket (MOOP) Limit

Plans must establish a limit on beneficiary cost-saving for Medicare Part A and B services after the plan pays 100% of the costs. Current guidance allows MA plans, including D-SNPs to not count Medicaid-paid amounts or unpaid amounts towards the MOOP limit, which results in increased state payments of Medicare cost-sharing and disadvantages providers serving D-SNP members. The MOOP limit within the plan will be calculated based on total cost sharing, regardless of whether it was paid by the beneficiary, Medicaid, secondary insurance, or left unpaid. 

Opportunity: More equitable payments for providers serving D-SNPs. This will result in increased bid costs, and increased Medicare spending, which will be offset by lower federal Medicaid spending. The net federal 10-year cost is estimated at $614.8 million. 

As plans heighten their attention and focus on D-SNP members with the new ruling in mind, several opportunities surface and a more robust engagement model that provides an exceptional experience becomes critical. Look out for Part 2, D-SNP Spotlight: Engagement Opportunities within the 2023 Ruling, to learn how plans can upgrade their engagement strategy to drive proven outcomes with D-SNP members. 

Frictionless Healthcare, Part 3: The Power of Reciprocity in Healthcare

Don’t forget to catch up with Part 1 and Part 2 of this blog series first!


So, readers, let’s talk more about theory and research. Robert Cialdini has been studying the science of persuasion for over forty years. In 1984 he wrote Influence, which reveals 6 principles of persuasion. It was an instant success and sits on the desks of advertising executives, copywriters, and marketeers everywhere, and reciprocity is the first of Cialdini’s six universal principles of persuasion. Why? Because the evidence shows that it works. 

Free coffee and donuts help car salespeople close deals. A couple of unexpected candies in the check at a restaurant gets the server a bigger tip (particularly if they come back to the table and hand deliver the second candy to “you lovely, special people”). When the hotel donates to charity on your behalf, you reuse a towel that you’d normally throw on the floor.  

Reciprocity in Healthcare

You are probably thinking to yourself, Cool, but what the heck does this have to do with healthcare?” Healthcare organizations have a real need for information or action from members, and it’s not always easy to get. By using a value first design to your approach (which means you provide the member with something valuable first and ask for the return favor later), you increase the likelihood of success.

We don’t just think and talk about these concepts, though. We put it into practice, and the Health Outcomes Survey (HOS) for Medicare beneficiaries is a perfect example of a healthcare initiative in which reciprocity can play a big role.  

We innovated on the standard HOS solution by applying value first design, so instead of asking members to answer a questionnaire by telling them that it’s very important (it’s important to the health plan, not the member, by the way), we first provide them with a fun, engaging digital experience designed to be valuable, personal, and unexpected. Most importantly, it includes changes members can make easily and quickly in their own lives. It’s only after we provide this experience that we ask members to provide their feedback, allowing us to identify high risk members so the plan can act.

Useful tip: Don’t only give first (it isn’t enough). Aim to also give a gift unexpectedly. In a study, customers who were given surprise discount coupons upon entering a shop spent on average 11% more than those who were given the coupons in advance. The unexpected nature of the gift amplified customer responses. Ensure that what you give is unexpected relative to the norm of what’s expected. 

Want to learn more about using reciprocity in healthcare? Watch the on-demand webinar » 

Something Unexpected 

Enter streaming health content. It’s something unexpected from healthcare but familiar to the member because it resembles media they consume every day, such as Tik Tok and Instagram stories. In this HOS example, the unexpected and helpful gifts are Fotonovelas, which are stories told through auto-advancing images (much like the snapchat or Instagram story experience). 

One of the biggest mysteries of neuroscience is how we create meaning out of the world. Stories are deep-rooted in the core of our nature and help us create this meaning.

Information presented in a story-based format is more easily remembered than plain statistics or facts. According to Stanford Graduate School of Business’ research, stories are 22 times more memorable than facts alone. This is likely because stories universally activate brain regions dealing with emotional processing and memory.

A powerful communication tool, stories can capture attention, build trust and credibility, and deliver messages and insights with impact. In the next installment in our Frictionless Healthcare blog and webinar series, we will go more in depth into storytelling effect, the psychology behind storytelling, and how to leverage it within your organization, so stay tuned and maybe sign up for our newsletter below (nudge nudge). 

Speaking of attention, dear readers, I’m probably losing yours. So, let’s wrap things up with some key takeaways about reciprocity.   

  • It’s how relationships are built ​ 
  • It’s not a trade or negotiation​ 
  • Follow the order of events: give, then ask​ 
  • Give something unexpected, personal, and valuable to increase the impact 

To learn more about using reciprocity in healthcare outreach, watch the full webinar below.

Read part four of this blog series!