Eligible but unreachable: Medicaid unwinding ran on contact data
When continuous enrollment ended, states had about a year to redetermine eligibility for tens of millions of people. Outcomes turned less on eligibility rules than on whether agencies could renew people from data they held, reach the rest, and process their replies.
Looking Back revisits one week at a time, from January 2020 to today, and asks what it meant for the banks, health systems and public agencies we serve. The series was written in 2026, with the benefit of hindsight, and each article says which week it looks back on.
The week
On April 1, 2023, states could begin removing people from Medicaid for the first time since early 2020. During the COVID-19 public health emergency, states that accepted enhanced federal funding had to keep nearly all enrollees continuously covered. The Consolidated Appropriations Act, 2023, signed in December 2022, ended that requirement on March 31, 2023, separately from the end of the emergency itself, and phased down the extra funding over the year. States had up to 12 months to start renewals for everyone enrolled and 14 months to finish them, and had to report outcome data to CMS. A few states began terminating coverage in April; most started over the following months. Enrollment had grown substantially during the pause, and many enrollees had not been through a renewal in three years.
The unwinding was the largest eligibility operation in Medicaid’s history. Its rules were mostly familiar: income limits, household composition, residency. What was unusual was the scale and the gap. Three years without renewals meant that addresses, phone numbers and circumstances had changed for many enrollees, and agency records had not kept pace. Outcomes depended on three distinct capabilities, which some states had and others lacked: renewing people automatically, reaching the people who had to respond, and handling the response once it came.
Renewing people automatically
Federal rules require states to try to renew eligibility from information they already have before asking an enrollee to fill out forms. Sources include state wage records, other benefit programs and the federal data services hub. This is called ex parte renewal. When it works, an eligible person stays covered without doing anything. When it fails, the person receives a renewal packet and must respond.
Ex parte rates varied widely across states. They depended on whether the eligibility system could match records reliably across programs and how many data sources it could query in a batch. They also depended on how the rules engine handled edge cases such as mixed households, irregular income and people with no recent wage records. States with integrated eligibility systems for Medicaid, SNAP and other programs had an advantage, because income verified for one program could support another. States whose Medicaid systems had few data connections mailed far more packets.
The configuration detail that mattered most turned out to be the unit of renewal. Eligibility is determined person by person, but many systems processed renewals by household. If one adult’s income could not be verified, the whole household went to a packet, including children who qualified on data the state already held. That design choice, invisible to leadership, drove avoidable coverage losses.
For an agency director, the useful questions are operational. What share of renewals completes ex parte, by eligibility group and by county? Which data sources are queried, and which fail most often? Are rules applied to individuals or to households? A weekly dashboard of those numbers would have shown the problem early.
Reaching the people who had to respond
For enrollees not renewed automatically, the process depended on a letter reaching them and a reply arriving by a deadline. After three years, many mailing addresses were out of date. People who never received a packet could lose coverage for procedural reasons. That meant losing coverage not because the state found them ineligible, but because it could not confirm eligibility.
States had several tools to improve contact data. Federal guidance allowed them to update addresses using Postal Service change-of-address data, managed care plan records and other programs’ files. Many states partnered with managed care organizations, which often held more current phone numbers and emails, to remind members. Text messaging reached people who had moved but kept the same phone.
Each tool depended on groundwork. Agencies needed consent to text, data-sharing agreements with plans, and the technical ability to load updated contacts into the eligibility system. Without that, updated information sat in a spreadsheet. Message consistency mattered too. Enrollees who heard different instructions from the state, their health plan and community groups were more likely to wait or give up. The agencies that did best agreed on one set of messages with their partners and timed outreach to the renewal calendar. They also counted returned mail and acted on it.
Handling the response
The third capability was processing volume. Renewal packets went out in monthly batches that were large compared with normal operations. Enrollees who responded did so through online portals, call centers, mail and in-person offices. Each channel had capacity limits.
Call centers were the most visible pressure point. Long hold times and dropped calls meant people trying to comply could not complete renewal before the deadline. Portals that were hard to use on a phone pushed more people toward the phones. Paper documents mailed in had to be scanned, indexed and matched to a case by staff who were also handling new applications. Backlogs in any of these steps produced procedural terminations of people who had in fact responded.
Capacity planning for this kind of surge is well understood in other sectors. Forecast volume from the renewal calendar. Staff and contract for peaks. Offer callbacks instead of holds. Make the portal work on mobile devices, with document upload by phone camera. Measure time from receipt to processing, not only call answer times. States also used federal flexibilities to extend deadlines or pause terminations where backlogs built up. That was a reasonable choice, but it stretched the timeline and the workload.
Across all three capabilities, the measure that mattered was the share of people losing coverage for procedural reasons. A high rate means the agency could not complete the process. It does not mean those people were ineligible. Many returned to coverage within months, after a gap that cost them care and cost the agency a new application.
With hindsight
In late August 2023 CMS warned states that running automated renewals at the household level, rather than for each person, violated federal requirements. Dozens of states paused affected procedural terminations, and reports put the number reinstated at close to half a million people. By the time KFF stopped updating its tracker in September 2024, about 25 million people had been disenrolled, roughly 69 percent of them for procedural reasons. The unwinding was largely complete by mid-2024, and CMS rules finalized that year streamlined enrollment and renewals. The 2025 budget reconciliation law then required six-month redeterminations and work requirements for many expansion adults, starting around the end of 2026. That turns the same three capabilities from a one-time surge into a recurring operation.