Lanigan, Lindsey
Lukanen, Elizabeth
Zylla, Emily

State-Based Marketplace Transition Data During the Unwinding (Cross-Post)

The following content is cross-posted from State Health & Value Strategies. 
Authors: Elizabeth Lukanen, Emily Zylla, and Lindsey Theis, SHADAC

This expert perspective (EP) will be updated by SHADAC experts as additional dashboards/reports go live. Please visit the State Health & Values Strategies webpage for the most recent version of this EP.

Original publication date: August 16, 2023. Updated: November 17, 2023.

As the unwinding of the Medicaid continuous coverage requirement progresses, SHVS is closely monitoring state reporting on the impacts of redeterminations and disenrollments. There is intense interest in data that monitors transitions between Medicaid and Marketplace coverage and, more importantly, the outcomes of those transitions. State-Based Marketplaces (SBMs) play a significant role, coordinating with Medicaid agencies using a number of different strategies to ensure a smooth transition for people who no longer qualify for Medicaid, but might be eligible for a qualified health plan (QHP) offered through the Marketplace. To date, 12 of the 18 SBMs are reporting data on Marketplace transition outcomes. (Virginia, which would be the 19th SBM, launched on November 1, 2023. Virginia is not included in the total number of SBMs since it was not operating as an SBM from the beginning of the unwinding.)

The Centers for Medicare & Medicaid Services (CMS) continues to release required state data reporting metrics. On October 31, CMS released a fourth batch of data which included detailed information on Marketplace enrollment transitions. CMS reported slightly different data for states that use HealthCare.gov compared to SBMs. And among SBMs, for states with an integrated system versus those who transfer accounts between Medicaid and the Marketplace. Broadly, these data include:

• Consumers who were transferred to or applied for Marketplace coverage.
• Consumers who were eligible for a QHP or Basic Health Plan (BHP) coverage (disaggregated by those eligible for financial assistance).
• Consumers with a QHP selection or BHP enrollment.

In all cases, CMS provides both counts and percentages. Among SBM states without an integrated system, CMS provides two percentage calculations – one where the denominator is applications and one where the denominator is account transfers. This distinction is important, because using the much larger account transfers number as a denominator makes the successful rate of transitions to QHP coverage seem much smaller. While the presentation of the CMS data is clear and the availability of counts and percentages is useful, it could leave room for misinterpreting the denominator.

Data reporting and interpretation have been complicated by the announcement from CMS that 29 states and the District of Columbia have been making ex parte renewal determinations on a household, rather than an individual level, as regulations require. This includes 16 of the 18 SBMs (California and Rhode Island are in compliance). This has caused some states to pause procedural terminations, reinstate coverage, and/or implement temporary extensions for renewal.

Given the ongoing data concerns and cautions regarding state comparisons, differences in how states are managing changes to ex parte renewals and potential confusion regarding the use of different denominators, it is more important than ever for SBMs to release their own data.

SHADAC will continue to update this expert perspective as more states publish their unwinding data.

SBMs Reporting Marketplace Transition Outcome Data
 

Note: In some cases, SBMs publish Marketplace transition outcome data in a more ad-hoc way (e.g., in a legislative report) or in administrative documents that are hard to access (e.g., board meeting minutes). Because these data are not being systematically reported and are more difficult to access, they are not represented in the map above. 

Variation in State Reporting

To date, 12 of the 18 SBMs that use their own eligibility platform are reporting outcomes for individuals who exited Medicaid and were transitioned to the Marketplace. In summary:

• Seven states are reporting whether individuals were eligible for a QHP.
• 11 states are reporting whether individuals selected a plan.
• Five states are reporting enrollment and/or eligibility broken down by whether the individual received financial assistance (e.g., advance premium tax credit or cost-sharing reduction payments).
• Three states are reporting on the demographics of people transitioning from Medicaid to Marketplace coverage.
• One state, Idaho, reports having completed its redeterminations.

Select Data Highlights
In addition to general information on transition outcomes, most of the states reporting outcome measures are providing additional information of interest, though this detail differs by state. Select data highlights are provided on the SHVS Expert Perspective .

Lukanen, Elizabeth
Zylla, Emily

States Reporting of Medicaid Unwinding Reinstatement Data (SHVS EP Cross-Post)

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The following content is cross-posted from State Health & Value Strategies. 
Authors: Emily Zylla and Elizabeth Lukanen, SHADAC

States, the federal government, advocates, and the media have all been closely tracking and monitoring the impacts of eligibility redeterminations during the unwinding of the Medicaid continuous coverage requirement. While there has been a strong focus on disenrollment data, recently, several states have also voluntarily begun reporting Medicaid reinstatement (also sometimes referred to as “re-enrollment” or “re-opening”) data. Medicaid and Children’s Health Insurance Program (CHIP) reinstatement data (especially when paired with enrollment data) allows states to tell a more complete story about what happens to individuals after they are disenrolled.

Individuals can be reinstated in Medicaid or CHIP for a variety of reasons. Recently, the Centers for Medicare & Medicaid Services (CMS) directed 29 states and Washington D.C. who self-identified as conducting ex parte renewal processes at the household level, rather than at the individual level, to reinstate coverage for at least 500,000 individuals whose coverage was terminated inappropriately.^[1] Individuals may also have their coverage reinstated as a result of fair hearing cases, or as a result of re-enrolling in Medicaid or CHIP within the 90-day reconsideration period.^[2]

This expert perspective reviews current state reporting of reinstatement data and provides recommendations for the reporting of such data. To facilitate transparency, states are encouraged to report data for at least 90-days, disaggregate data by race, ethnicity, age and other population characteristics and provide additional information to contextualize reinstatement data.

States’ Reporting of Reinstatement Data

SHADAC’s review of public unwinding data identified nine states that report some type of Medicaid reinstatement data:^[3]

• Arizona
• Connecticut
• Kentucky
• Massachusetts
• New Hampshire
• New Jersey
• New York
• Pennsylvania
• Virginia

 The federal government does not require states to report reinstatement data as part of their Monthly Unwinding Data; and, while CMS could presumably leverage Transformed Medicaid Statistical Information System (T-MSIS) data to track whether Medicaid or CHIP members who are disenrolled are later reinstated, the availability of such data is delayed. Without a standardized national approach, each of the nine states are reporting a measure with a slightly different definition. Specific differences include the population being counted within the “reinstatement” category and the timeframe being reported and tracked (Table 1).

Table 1. States Reporting Medicaid Unwinding Reinstatement Data*

Variation in Reinstatement Measures

As seen above, there is wide variation in the definitions, timeframes, and amount of detail provided in the reinstatement data that states are reporting. For example, New York only reports the number of individuals reinstated in accordance with the CMS Ex Parte Renewal Guidance (Figure 1).

Figure 1. New York Medicaid Unwinding Data – Reinstatements

Screenshot: 10/31/2023

In contrast, Massachusetts reports the number of members who have departed and regained MassHealth benefits for any reason over the past 12 months (not just those reinstated due to CMS guidance) and for every month since the unwinding began (Figure 2). (Note, however, that Massachusetts does not provide a breakdown by the specific reinstatement reason.)

Figure 2. Massachusetts Unwinding Data – Re-Openings

Screenshot: 10/31/2023

Arizona reports a cumulative total of reinstatements for those individuals who were procedurally disenrolled since the unwinding began in April (Figure 3).

Figure 3. Arizona Unwinding Data – Renewals After a Procedural Discontinuance

Screenshot: 11/16/2023

Best Practices for Reporting Reinstatement Data

Although it is not required, reporting Medicaid and CHIP reinstatement data publicly promotes transparency. Like the reporting of closure reason or transition outcome data (i.e., whether individuals who were disenrolled transitioned to coverage through a Marketplace plan or an employer-sponsored plan), reporting Medicaid reinstatement data (especially when paired with enrollment data) allows states to give the full picture about what happens to individuals after they are disenrolled. Being more transparent about who is coming back into Medicaid can help provide additional context about the impact of unwinding processes on populations.

Tracking and reporting Medicaid and CHIP reinstatement data over a 90-day period at a minimum is highly recommended. States that have reinstatement periods longer than 90 days can consider tracking and reporting data over both a 90-day period and the longer, state-elected period. If possible, states should also provide a breakdown of the type of reinstatements. For example, the number of individuals who were procedurally disenrolled and reinstated, the number of individuals who lost coverage due to an erroneous ex parte redetermination and were reinstated in accordance with the CMS Ex Parte Renewal Guidance, etc. While these standards are best, state reporting systems may have different functionality.

For example, some states are counting reinstatements for individuals who were terminated for procedural reasons as new applications, making those cases more difficult to track. Regardless of system capacity, states are encouraged to report at least some of the number of people who are reinstated, using whatever definition is feasible for ongoing reporting. Even limited reporting can be paired with state context to help shed light on the larger impact of unwinding.  

Reporting reinstatements by enrollee characteristics, such as age, race or ethnicity, or on the basis of eligibility (i.e., MAGI, CHIP, and non-MAGI if applicable) might also help provide insights into where barriers might exist, enabling states to target outreach. For example, New Hampshire reports the number of Medicaid cases that are reopened and provides breakdowns by both age (adults and children) and for individuals in long-term care (LTC) and disability categories (Figure 4). Virginia also reports reinstatements for individuals with a procedural closure that can be broken down by eligibility category (e.g., individuals who are blind or disabled, children, enrolled due to pregnancy, etc.) and by program type (i.e. fee-for-service versus managed care) (Figure 5). Connecticut provides detailed breakdowns showing where individuals who have been disenrolled have regained coverage and by what type (i.e., whether they have enrolled in a qualified health plan with advance premium tax credits, transitioned to a non-MAGI Medicaid program, or regained active Medicaid coverage) (Figure 6).

Figure 4. New Hampshire Unwinding Reopening Data – Children and Individuals who Are Disabled or in Long-Term Care

Screenshot: 10/31/2023

Figure 5. Virginia Eligibility Redetermination Tracker – Procedural Closure Tab

Screenshot: 11/14/2023

Figure 6. Connecticut Unwinding Data – Renewal Post-Disenrollment Tracking

Screenshot: 10/31/2023

Finally, states are strongly encouraged to include data labels, detailed definitions, and context for reinstatement data. Describe population numerators and denominators if relevant. And, if the format allows, link to information that can help contextualize the data, such as overall application or enrollment data or comparisons to a previous time period that might help a user understand the historical context of the data.

Conclusion

While Medicaid churn remains a challenge, states are working hard to maintain Medicaid enrollment for eligible individuals, and they should present data that provides a more complete picture of their efforts and impacts on coverage. Renewals and disenrollments remain important measures of successful unwinding, but there is a growing need for states to provide more information to tell the whole story. To convey a more nuanced narrative, states should provide information on Medicaid and CHIP reinstatements, in whatever form is most feasible. This approach ensures that states effectively keep the public, policymakers, and advocates informed of their progress.

[1] See SHVS’ expert perspective, CMS Guidance on Conducting Eligibility Redeterminations at the Individual Level, for additional information.

[2] During the reconsideration period, states must reconsider eligibility without requiring the individual to fill out a new application if the renewal form or documentation is returned within 90 days after the date of the MAGI enrollee or CHIP enrollee’s termination. States have the option to (1) adopt a reconsideration period of longer than 90 days for MAGI enrollees, and (2) provide a 90-day (or longer) reconsideration period for individuals enrolled on a non-MAGI basis.

[3] No states reporting separate CHIP reinstatement data were identified—only New Hampshire and Virginia report reinstatement data by age.

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

State Dashboards to Monitor the Unwinding of the Medicaid Continuous Coverage Requirement (Cross-Post)

The following content is cross-posted from State Health & Value Strategies. 
Authors: Elizabeth Lukanen, Emily Zylla, and Lindsey Theis, SHADAC

This expert perspective (EP) will be updated by SHADAC experts as additional dashboards/reports go live. Please visit the State Health & Values Strategies webpage for the most recent version of this EP.

Original publication date: March 16, 2023. Updated November 15, 2023.

As the unwinding of the Medicaid continuous coverage requirement continues, both states and the federal government are tracking and monitoring the impacts of the resumption of eligibility redeterminations and disenrollments. To-date, the Centers for Medicare & Medicaid Services (CMS) has released three batches of required state data reporting metrics; most recently on September 29th. However, given the time-lags and caveats of the CMS data, many states have decided to also publish their own state data dashboards. Releasing data in this format allows states to follow some specific best practices, including providing additional detail about definitions, timeframes, and state context that are important for communicating the unique and specific circumstances that states are experiencing during unwinding. Colorado’s state dashboard, for example, highlights the state’s lower unemployment rate and provides context around the state’s reconsideration period in order to help users understand the CMS data reports.

States Publicly Posting Unwinding Data

To date, 45 states including the District of Columbia (D.C.) have publicly published their own unwinding data in some format (this does not include states with pre-existing enrollment dashboards that don’t specifically identify unwinding cohorts). In most cases, state Medicaid departments are releasing those data, although some State-Based Marketplaces (SBMs) are also publishing unwinding data (see the SHVS expert perspective on SBM Marketplace Transition Data During the Unwinding). Of the 45 states currently reporting data:

• 23 are releasing state unwinding data online in either an interactive dashboard or static pdf format.
• Two states have only released copies of their required CMS Monthly Unwinding Data.
• 20 states are releasing both state data and their CMS Monthly Unwinding Data reports.

In some cases, states are publishing unwinding information in an ad-hoc way—such as by a press release. Because these data are not being systematically reported, they are not represented in the map above. As unwinding has progressed, the number of new states reporting unwinding data has slowed significantly and states are updating their data less frequently. Eight states have not updated their state unwinding data reports since August. Arkansas and Idaho report to have completed all redeterminations and are no longer reporting through their unwinding dashboards (Arkansas continues to make monthly reports to CMS publicly available).

The public release of unwinding data has proven to be a valuable tool in understanding who is losing Medicaid coverage and why. States and advocates have successfully used the data to both monitor outcomes and adjust strategies. Although CMS has indicated they only plan to continue reporting unwinding data through June 2024, we encourage states to continue to make detailed disenrollment, renewal, and call center data (in addition to the enrollment data most states already report) available publicly on an ongoing basis.

SHADAC will continue to update this expert perspective as more states publish their unwinding data.

Variation in States’ Reporting of Indicators

There is a wide variation in the indicators that states are reporting on their state data dashboards and reports. Of the 44 states reporting publicly, most are now reporting renewal and termination data. Some states are also reporting other interesting indicators such as:

• Reasons for procedural denials (see Colorado example below).
• Number of cases terminated that are re-enrolled or reinstated in Medicaid (see Massachusetts example below).
• Qualitative data from individuals about reasons why they did not renew Medicaid (see New Hampshire example below).
• Enrollment in CHIP (see Utah example below).

It’s important to note that states use different terminology, definitions, population denominators, and timeframes on their dashboards making it difficult to compare one state’s data to another. In some instances, the data displayed on state dashboards also varies from what states include in their monthly reports to CMS (see Georgetown’s State Unwinding Renewal Data Tracker for a summary of states’ monthly CMS reports).

Another cause of variation in the types of indicators reported across states is that states began disenrolling people from Medicaid in different months. For example, Arkansas resumed eligibility determinations in April 2023, and as of October 9th, the state indicated that it had fully completed its statutorily required six-month unwinding process. In contrast, Oregon started initiating procedural terminations in October and plans to take 10 months to complete eligibility redeterminations. Data reporting and interpretation across states is further complicated by the announcement from CMS that 29 states and D.C. have been making ex parte renewal determinations on a household, rather than an individual level as regulations require. This has caused some states to pause procedural terminations, reinstate coverage and/or implement temporary extensions for renewal. 

Unwinding Indicators & Disaggregated Data Reported by States

Few states are reporting disaggregated data on their dashboards. The most common breakdowns that states are providing are by program and geography (typically by county). Although CMS only asks states to report data by modified adjusted gross income (MAGI) and non-disability applications, versus disability applications, additional data breakdowns by age, race, ethnicity, and program type can elucidate important trends about the disproportionate impact of unwinding on groups that have been economically or socially marginalized. (See Arizona, Minnesota, Oregon and Washington’s dashboards below for additional examples of disaggregated data reporting). 

Visit the SHVS Expert perspective to view examples of state unwinding dashboards in the following states: Arizona, Colorado, Indiana, Massachusetts, Minnesota, New Hampshire, Oregon, Utah, and Washington.

Health Equity Measurement: Considerations for Selecting a Benchmark (SHVS Brief)

September 2023:

The following content is cross-posted from State Health & Value Strategies. 

Authors: Emily Zylla, Andrea Stewart, and Elizabeth Lukanen, SHADAC 

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As states look to advance health equity, they need ways to measure whether their efforts result in improvements. Benchmarking can be used to identify health disparities and establish a standard for evaluating efforts to address health inequities.

This issue brief summarizes the advantages and disadvantages of four common approaches to health equity benchmarking:

1) Using the best-performing group as a reference

2) Using the most socially advantaged group as a reference

3) Comparing against a population average 

4) Comparing against a set target or goal

Key Findings

• There is no single ideal benchmark for health equity measurement and it is important to weigh the advantages and disadvantages of each before selecting an approach.
• The rationale for selecting a benchmarking approach should be thoroughly explained and accompanied by detailed context and interpretation, acknowledging the role of societal inequality and structural racism in driving disparities to prevent the perception that individual subgroups carry responsibility for the observed disparities.

Conclusion

There is no universal “best” approach to selecting a benchmark for health equity measurement. Ultimately, careful and detailed documentation of benchmarking methodology and other choices made in health equity measurement, paired with a discussion of the root causes of inequities, connects the dots between disparate outcomes and the disparities in power and privilege in which they are rooted to maintain the focus on the goal of advancing health equity.

To read the brief in its entirety click here.

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About the Author/Grantee:

State Health and Value Strategies (SHVS) assists states in their efforts to transform health and healthcare by providing targeted technical assistance to state officials and agencies. The program is a grantee of the Robert Wood Johnson Foundation, led by staff at Princeton University’s School of Public and International Affairs. The program connects states with experts and peers to undertake healthcare transformation initiatives. By engaging state officials, the program provides lessons learned, highlights successful strategies and brings together states with experts in the field. Learn more at www.shvs.org.

This issue brief was prepared by Emily Zylla, Andrea Stewart, and Elizabeth Lukanen. The State Health Access Data Assistance Center (SHADAC) is an independent, multi-disciplinary health policy research center housed in the School of Public Health at the University of Minnesota with a focus on state policy. SHADAC produces rigorous, policy-driven analyses and translates its complex research findings into actionable information for states. Learn more at www.shadac.org.

Lukanen, Elizabeth
Planalp, Colin

Using Surveys to Monitor Coverage Transitions During the Unwinding of the Medicaid Continuous Coverage Requirement (Cross-Post)

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The following content is cross-posted from State Health & Value Strategies. 
Authors: Elizabeth Lukanen and Colin Planalp, SHADAC, and Kevin Caudill, GMMB

The unwinding of the Medicaid continuous coverage requirement represents the largest nationwide coverage transition since the Affordable Care Act. Not surprisingly, policymakers, advocates and the media are watching coverage transitions closely and many states have released Medicaid administrative data documenting their progress. While state and federal administrative data can quantify the number of successful Medicaid renewals and coverage terminations, they typically cannot provide details on what happens to people leaving Medicaid. For instance, are people gaining employer-sponsored insurance (ESI) upon leaving Medicaid coverage, or are they becoming uninsured? Those administrative data also are limited in their ability to tell us why patterns are occurring. For instance, among people who remained eligible for Medicaid coverage, why were some successfully renewed while others were not?

Individual-level surveys of people who were enrolled in Medicaid during the continuous coverage requirement can help to answer such questions. The federal government’s Household Pulse Survey, which the U.S. Census Bureau established during the COVID-19 pandemic, serves as one key example of how surveys can fill critical data gaps to answer questions during unique circumstances. Similarly, states may consider conducting their own survey of consumers.

Motivation for Conducting a Medicaid Consumer Survey

Targeted surveys of people who have been enrolled in health coverage (referred to as “consumers” in this expert perspective), can be a relatively inexpensive and quick way for states to obtain information on coverage transitions and consumer experiences. In the context of unwinding, surveys would target Medicaid enrollees who recently went through the redetermination process. These surveys could be leveraged by officials in Medicaid or the Marketplace to:

• Better understand coverage transitions.
  • Did an enrollee transition to employer-sponsored coverage, some other source of coverage, or become uninsured?
  • Why did the enrollee exit Medicaid if they were still eligible?
  • If they were eligible for a qualified health plan (QHP) but didn’t enroll, why?
• Gather information on what messages and message strategies resonated with consumers.
• Assess what shopping, assistance and customer service tools were used.
• Educate people on tools, resources, or coverage options available to them.
• Serve as a final nudge to consumers that they need to take action to stay covered or transition to new coverage.
• Inform future research, such as longer targeted surveys, user experience testing or consumer focus groups.

Survey Mode

Given the dynamic nature of the unwinding, surveying consumers quickly is important. For this reason, states should consider short surveys that are distributed by email or text message using a convenience sample (i.e., Medicaid disenrollees for whom the state has contact information). For the sake of administrative ease, states could work with a web survey vendor that offers a user-friendly interface and (if possible) with whom they have an existing subscription or contract.

Many web-based vendors can send surveys via email or text. When sent via email, these surveys can typically be distributed in two ways: 1) consumers are sent a generic survey—the same survey link goes to everyone on the distribution list; 2) consumers are sent a unique survey link—a unique survey link is distributed individually to everyone on the distribution list. These options entail trade-offs. A benefit of a generic link is that it can be sent using the state’s existing communication platform. This avoids the need to import consumer contact information into the survey vendor platform, which might raise privacy and other legal concerns. Alternatively, a benefit of using a unique, individualized survey link is the ability to connect survey responses to state administrative data on the respondent, notably, characteristics (e.g. income, age, race, household type, etc.). This reduces the need to collect demographic data via the survey, can result in richer demographic detail about survey respondents, and provides insights into those who did not respond to the survey.  

Text or SMS surveys can also be distributed in two ways. One option is to send a “2-way” survey, where respondents text their replies to each question (best suited for a one question survey). The second option is to distribute a link to the survey which is sent to the consumer’s phone and can be opened in a mobile browser. During the unwinding, states are often focused on very short surveys. In some cases, they might ask a single question (typically focused on assessing coverage transitions) or other very brief surveys (3 to 10 questions). In some cases, states might attempt both—starting with a single question survey to assess coverage transition, followed up by a longer survey that captures information about the consumer experience. While there is wide concern that state Medicaid programs might not have up-to-date contact information for Medicaid enrollees, especially in a time-sensitive situation such as the unwinding, it is likely most practical to reach out to people using contact information already on file—often including a cell phone number or email address.

The primary benefits of web-based surveys sent via text or email are speed and cost. If a state has in-house expertise, funding, and can leverage an existing partnership (e.g., a state–university partnership) or an existing survey effort, they could also consider a more robust, mixed-methods survey that supplements a mailed survey (and online option) with interviews. For example, New Mexico recently fielded the New Mexico 2023 Office of the Superintendent of Insurance (OSI) Health Access Survey, commissioned by the New Mexico OSI and conducted by the University of New Mexico. This was a larger and sophisticated effort—a statewide survey of 1,900 adults, conducted by a survey firm in both English and Spanish using multiple modes (telephone and online). While the focus of the survey was broad, to better understand the opinions and attitudes New Mexicans have regarding health insurance, the state recognized the opportunity to use this vehicle to gain insights into unwinding. The survey found that residents were generally aware that pandemic funding for Medicaid was ending, but this awareness was lower for Latino/a, Native American, Spanish-speaking and lower-income New Mexicans, which highlighted the importance of targeted messaging and outreach.

Target Population and Timing

During the unwinding, states should focus on consumers who are scheduled to be redetermined for Medicaid. Logistically, states could consider sending the survey in waves, aligning with unwinding cohorts. If state systems allow them to target more granular groups, the state could send slightly different surveys to different groups. For example, if a state is targeting those who exited Medicaid and shopped for plans in the Marketplace, they could send slightly different questions to those who ultimately selected a plan than to those who did not select a plan.

States should also carefully consider the timing of any consumer survey as they finalize their questions.  For example, questions about shopping and plan selection should happen fairly quickly, ideally within a couple of weeks of when consumers should have engaged in these activities. If a consumer can still submit redetermination paperwork or sign-up for a QHP, the questions and wording should make that clear and not imply the consumer has no option to take action. As mentioned above, given the nature of many states’ phased unwinding approach, states should consider sending surveys weekly or monthly based on renewal cohorts.

Questions of Interest

States considering consumer surveys related to the unwinding tend to be interested in a fairly narrow set of questions. They want to understand coverage transitions, specifically whether people enrolled in employer-sponsored or Marketplace coverage after leaving Medicaid, and the enrollee’s experience navigating the process. States might use these surveys to assess specific outreach methods (e.g. the impact of mailing campaigns to send people letters on colored paper). And for states with available customer service resources, they could use the survey to connect people with a customer service channel (for instance, asking respondents if they would like assistance with the application and enrollment process). By collecting demographic information along with these questions, states can also get a sense for whether there are population differences between those who successfully transitioned to another source of coverage and those who remain uninsured. 

Common survey question domains include:
(A list of sample questions is included at the end)

• Current coverage/coverage transitions
• Reasons/motivations to have or not have coverage
• Experience shopping for insurance
• Establish who shopped (if this cannot be identified using administrative data)
• Outreach and assistance
• Impacts of uninsurance
• Demographics
• Did an enrollee transition to employer-sponsored

As states consider what questions to ask, they should take care to tailor their surveys to the strengths and limitations of this data collection method. Surveys are good at collecting information on people’s experience and impressions, but they are less useful for collecting specific, detailed and nuanced information (e.g. specific information about ESI cost-sharing, specific detail on what programs consumers qualified for). 

Another best practice is to ask questions that only require the respondent to reflect on one concept at a time. For example, when constructing questions about the shopping process, avoid phrasing questions that conflate opinions about the shopping experience and plan choice, which could pose a challenge to respondents if they found the online interface easy to use but the plan options to be underwhelming, or vice versa.

Finally, states should consider the goals of the survey and tailor the questions to those goals. Especially in the unique circumstances of the unwinding, states may be looking for ways to make their redetermination processes more user-friendly for Medicaid in the near-term, so they can maximize the number of eligible individuals reenrolled in the program. In that case, states should prioritize questions that are likely to yield data that are actionable in the coming weeks or months, rather than years. Relatedly, states should take care in how they interpret survey data collected during the unwinding and temper their expectations for the generalizability of the survey findings into the future. Because the current circumstances are so unusual, it is possible that the experiences of Medicaid enrollees going through the redetermination process today may not resemble the experience of people going through the redetermination process in a couple of years. However, if states find these survey data useful, they could incorporate similar surveys even after the unwinding, as part of their ongoing, regular course of business.

Communications Best Practices

As states are developing survey instruments, it is important to also keep in mind the surrounding communications to potential respondents to maximize participation, reinforce validity, and mitigate against concern about scams. Below are some helpful tips that states should consider when developing communications to support consumer research. While these apply primarily to email, they can also be applied to other mediums such as text messages. 

Establish your tone/voice. The tone of your subject line and email should reflect your Marketplace or Medicaid agency brand. Reinforcing your role as an official program is key. Determine where you will fall on the spectrum of conversational (e.g. “A few minutes to share your feedback?”) versus professional (e.g. “We’d appreciate your feedback to help us serve you better.”)

Personalize as much as possible. Personalizing is more than a name; it’s reflecting the experience you want feedback on. For example: “How did we do with Medicaid/Marketplace enrollment?” or “Did you have all the enrollment information you needed?”

Talk about the benefits of completing the survey. Explain up front why their participation matters. For example: “Help us make Medicaid enrollment better” or “Your feedback will make Marketplace enrollment better.” Within the body of the email itself, briefly explain how their feedback will be used and express appreciation for their time and input.

Ask a question in the subject line.

Try to keep subject lines under 50 characters. This is so participants can get the full headline on their mobile device.

States should consider these recommendations as they develop customized messaging for survey communications. These steps can help states get the most helpful information from their survey efforts. Ultimately, communications should reflect the unique goals that each state will determine for its research effort so there is no one size fits all approach.

Interpreting the Results

This type of consumer survey can be very useful to gather information on consumers’ experiences, identify areas where they are struggling with the process and which resources or outreach methods are resonating. In this case, it can also be useful for gaining some insights into coverage transitions outside of Medicaid or the Marketplace. That said, it will rely on a convenience sample, it is likely to have a low response rate and the results will not be representative of the target population as a whole. When interpreting the results, these limitations should be considered. States shouldn’t assume that survey results collected using a convenience sample during the unwinding represent everyone who experiences the Medicaid redetermination process. For example, consumers’ experiences might be different during a more typical renewal period and might be different for those who did not respond to the survey.

Agency Coordination

States considering these surveys should work closely with their legal, marketing, customer service and other relevant teams. Support and guidance from a legal team can be critical as states consider specific details about how the surveys are sent and distributed. For example, can the state send text messages to consumers and with what limitations? Can the state upload consumer contact information into survey vendor platforms for the purposes of distributing a survey? Involving the marketing and public relations team is also a good idea as they can ensure the terminology is consistent and that messages are aligned with what is being sent regarding redeterminations. And it is important to let customer service teams know when these surveys are going out, particularly if they are designed to spur final action or are directing enrollees to specific supports.

Sample Questions

A list of sample survey questions can be downloaded using the link below. The sample questions can be customized and used by states interested in conducting a consumer survey during the unwinding.

SHVS_Sample Consumer Unwinding Survey