Since March 2020, a patient with Medicaid has stayed on Medicaid. The Families First Coronavirus Response Act gave states extra federal matching funds on the condition that they not disenroll anyone during the public health emergency, and enrollment in Medicaid and CHIP grew to more than 90 million people. For practices this meant the Medicaid eligibility check was the one that almost never came back negative. That ends in nine days.
The Consolidated Appropriations Act, 2023, signed on December 29, 2022, separated the continuous enrollment condition from the public health emergency and set its end date: March 31, 2023. Starting April 1, states may resume terminations for people who no longer qualify or who do not complete a renewal. HHS estimated last year that around 15 million people could lose Medicaid or CHIP during the unwinding, and that roughly 6.8 million of them would still be eligible but would lose coverage for procedural reasons: a renewal packet sent to an old address, a form not returned, a document not uploaded in time.
Key takeaways
- Continuous enrollment ends March 31, 2023. From April 1, states may terminate coverage, and each state sets its own schedule over the following 12 to 14 months.
- Most early terminations will be procedural, not eligibility findings, so many terminated patients will be reinstated, often with retroactive coverage, once paperwork arrives.
- Check Medicaid eligibility before and at every visit, and read the coverage end date and plan name in the 271, not just the word "active".
- Hold claims for terminated patients in a dedicated coverage-gap queue with a 30-day recheck; do not write them off or bill the patient until the date of service is confirmed uncovered.
- Patients who lose Medicaid because income rose have a Marketplace special enrollment period through July 31, 2024. Have the information at the front desk.
The timeline, state by state
The federal law sets the start. States set the pace. Each state has up to 12 months to begin renewals for everyone on its rolls and 14 months to finish them. Some states will send their first termination notices for April; most will begin in May, June or July. The enhanced federal match phases down through December 2023, which gives states a reason not to wait. Your state Medicaid agency has published an unwinding plan, and it will tell you which month it starts and whether it is renewing people by anniversary date, by likelihood of ineligibility, or by some other order.
For a practice, the practical implication is that eligibility for a Medicaid patient can now change in any month, and often will change without the patient knowing. A patient who was covered at the visit in March may be terminated on April 30 for a renewal form they never received.
A fictional timeline shows how this plays out for one patient. The state mails a renewal packet on April 3 to the address it has on file, which is two moves old. The response deadline is May 3. Nothing comes back, and coverage ends May 31. The patient has a visit with you on June 12 and the check shows inactive. On June 20 the patient calls the state, learns about the packet, and submits the renewal online. The state processes it on July 10 and, because the patient responded within the 90-day reconsideration period and still qualifies, reinstates coverage back to June 1. Your June 12 claim is payable, but only if it is still sitting in a hold queue and not in a write-off bucket or a patient statement cycle.
What it looks like on the remittance
| Denial | Meaning | What usually happened |
|---|---|---|
| CO-27 | Expenses incurred after coverage terminated | The patient was disenrolled before the date of service and nobody checked |
| CO-31 | Patient cannot be identified as our insured | The patient moved to a different managed care plan, or lost coverage and the ID no longer resolves |
| CO-109 | Claim not covered by this payer or contractor | Claim went to the old Medicaid managed care organization after the patient was reassigned |
| CO-26 | Expenses incurred prior to coverage | Patient regained coverage after a gap and the effective date is later than the visit |
These denials are often not the end of the story. Many states allow retroactive eligibility for a period before the application, and people terminated for procedural reasons who return their paperwork within 90 days can be reinstated without a new application. A claim denied CO-27 in May may be payable in July if the patient is reinstated with a retroactive date. That means holding those claims with a follow-up date, not writing them off.
Front desk: five changes to make now
- Check Medicaid eligibility at every visit, not once a year. Run the batch 270 check two business days before the appointment and a real-time check at arrival. The 271 response shows the coverage dates, the managed care plan and, in many states, the assigned primary care provider. All three can change.
- Ask every Medicaid patient to confirm their mailing address and tell them to update it with the state agency. The renewal packet goes to the address on file with the state, not with you. Most states have a website or phone line for this and many have created a short URL for the unwinding.
- Put up the state's renewal notice in the waiting room and on your website. CMS and the states have published toolkits with posters and text in multiple languages. This costs nothing.
- Add a line to your appointment reminder for Medicaid patients: "Medicaid renewals have restarted. Watch your mail and respond to any letter from the state."
- Prepare the self-pay and Marketplace conversation. CMS announced in January a special enrollment period on HealthCare.gov for people who lose Medicaid or CHIP between March 31, 2023 and July 31, 2024. Patients who lose Medicaid because their income rose may qualify for subsidized Marketplace coverage. Have the HealthCare.gov information and your local navigator's contact ready. If the patient is uninsured on the day of the visit, the No Surprises Act good faith estimate rules for uninsured and self-pay patients apply.
Billing: what changes in the queue
Create a hold reason specifically for Medicaid coverage gaps and separate it from the general eligibility hold. Set the follow-up interval to 30 days and recheck eligibility before each release. Track the count and dollar value in this hold weekly; it is your early warning that terminations have started in your state. When a patient regains coverage with a retroactive date, release the held claims and correct any that were already denied.
Watch managed care plan changes separately. In states where terminated people re-enroll later, they are often auto-assigned to a different plan. A claim to the old plan comes back CO-109 and the new plan's timely filing clock has been running since the date of service. Some plans have 90-day or 180-day limits. The 271 response tells you the current plan; use it before you bill, not after the denial.
Finally, remember that Medicaid enrollees cannot be balance billed beyond the cost sharing the state allows, and a patient who was covered on the date of service and is terminated later is still a Medicaid patient for that visit. Collections staff should have a clear rule: verify coverage on the date of service before any patient statement goes out for a Medicaid patient.
Numbers to watch from April
- Share of Medicaid appointments where the pre-visit check returns inactive coverage, weekly.
- Dollar value in the Medicaid coverage-gap hold, weekly.
- CO-27 and CO-109 denials for Medicaid and Medicaid managed care payers, monthly, compared with the first quarter of 2023.
- Medicaid share of total visits, monthly. A steady fall with a rise in self-pay tells you which patients are losing coverage.
Set the first-quarter numbers as your baseline this week, while the rolls are still frozen. In a fictional practice with 600 Medicaid visits a month, an inactive rate that moves from under 1% in March to 8% in June is 48 visits a month that need a phone call before the appointment and a hold afterward. That is a workload change the front desk should see coming, not discover.
Questions we hear
Can we see a patient whose coverage shows inactive?
That is the practice's decision, and it should be made ahead of time, not at the front desk with the patient standing there. Many practices will see established patients and hold the claim pending reinstatement, while explaining the self-pay position in writing. Whatever you decide, write it down so the front desk applies it the same way every time.
Will our state tell us when our patients are terminated?
Not directly. Some managed care plans send member rosters to assigned primary care practices, and those rosters will show drops. Otherwise your eligibility checks are the only signal. This is a good time to make sure the batch eligibility process actually runs every day and that someone reads the exceptions.
Where does this fit with our quality programs?
Patients who lose coverage also drop out of your care gap reports and your attribution lists. If you are in a Medicaid value-based contract or working on PCMH, the outreach you do to keep patients covered also keeps them in the denominator. Our closing gaps in care team is building the unwinding outreach into the same call lists, and the eligibility steps above are part of the daily routine in Revelrex billing.
What to do this week
- Read your state's unwinding plan and note the month renewals start and the order the state is using.
- Confirm the batch 270 eligibility check runs for every scheduled Medicaid patient two business days out, and that the 271 display shows coverage end dates and the plan name.
- Create the Medicaid coverage-gap hold reason in the practice management system with a 30-day recheck.
- Record the first-quarter baseline for the four numbers above.
- Print the state's renewal poster, add the reminder line to Medicaid appointment texts, and give the front desk the state's address-update phone number and the HealthCare.gov special enrollment information.
