Supporting States in Prioritizing Coverage Retention and Health Equity When the Medicaid Continuous Coverage Requirement Ends

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A series from State Health and Value Strategies provides resources to support states in “unwinding” and prioritizing coverage retention when the Medicaid continuous coverage requirement ends.

The Issue

The Families First Coronavirus Response Act (FFCRA) Medicaid “continuous coverage” requirement has allowed people to retain Medicaid coverage and get needed care during the COVID-19 pandemic. When continuous enrollment is discontinued, states will restart eligibility redeterminations for nearly all 80 million people enrolled in Medicaid. While most people will continue to be eligible for Medicaid or Marketplace coverage, the potential for loss of coverage for millions of Americans due to “administrative” reasons is significant, and Black, Latino(a) and other people of color will be most at risk.

State Health and Value Strategies is developing a series of products and programming intended to serve as a resource for states in planning for and beginning to “unwind” the continuous coverage requirement. Materials will build on federal sub-regulatory guidance, best practices from states across the country, and the input from consumer advocates to provide resources for states seeking to optimize coverage retention for consumers who remain eligible for Medicaid or who are eligible for subsidized Marketplace coverage.

The latest brief in the series, "Medicaid Enrollment Trends During the COVID-19 Pandemic," examines how Medicaid enrollment growth has substantially outpaced pre-COVID-19 rates of growth in the program, particularly among non-elderly, non-disabled adults.

Key Findings

  • The Centers for Medicare & Medicaid Services (CMS) has released sub-regulatory guidance and tools to support state Medicaid and Children’s Health Insurance Program (CHIP) agencies in returning to normal eligibility operations once the unwinding period begins. The updated August 2021 guidance lays out a timeline of “up to 12 months” for completing pending renewals and redeterminations for changes in circumstances. This CMS “punch list” includes operational and policy strategies for states to maintain continuity of coverage, and this CMS issue brief highlights ways to improve outreach, enrollment, and renewal activities to ensure eligible individuals are able to enroll in and retain their health coverage.

  • People of color are overrepresented in the Medicaid program and are more likely to experience volatility and instability in employment and housing as a result of longstanding, structural racism, thus increasing the chances that these individuals could lose coverage for administrative reasons when the continuous coverage requirement ends. States therefore have a clear imperative to center health equity as they plan for the end of the continuous coverage requirement.

  • To ensure eligible individuals don’t churn off coverage once the continuous coverage requirement ends, states can take steps to improve consumer communications, partner with stakeholders, and ensure Medicaid/Marketplace coordination.

  • States can also strengthen eligibility and enrollment processes and implement information technology (IT) system, policy, and operational strategies to update contact information to ensure eligible enrollees are able to keep or transition to new affordable health coverage.

  • From February 2020 through November 2021, the median state among the 29 states with available data saw a total Medicaid enrollment growth of 23.2 percent, with the average state seeing monthly growth well above previous levels.


The end of the continuous coverage requirement will present the single largest health coverage transition event since the first open enrollment of the Affordable Care Act (ACA). Federal and state policymakers and other stakeholders will need to engage in robust planning efforts to prioritize continuity of coverage and ensure that the end of the continuous coverage requirement does not exacerbate already widespread racial and ethnic disparities in the American healthcare system.

About State Health and Value Strategies—Princeton University School of Public and International Affairs

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

About Manatt Health

Manatt Health integrates legal and consulting expertise to better serve the complex needs of clients across the healthcare system. Our diverse team of more than 160 attorneys and consultants from Manatt, Phelps & Phillips, LLP and its consulting subsidiary, Manatt Health Strategies, LLC, is passionate about helping our clients advance their business interests, fulfill their missions, and lead healthcare into the future. For more information, visit

Contributors to this series include: Georgetown University Health Policy Institute Center on Health Insurance Reforms; GMMB; Health Equity Solutions; Jason Levitis, Levitis Strategies; and the State Health Access Data Assistance Center (SHADAC).