After a year of ‘unwinding,’ Maryland Medicaid rolls drop from 1.8 million to 1.69 million

The Maryland Department of Health is reevaluating the eligibility of 1.8 million Marylanders on Medicaid in a phased process after a COVID-era policy that didn’t require annual reenrollment expired. Photo by Danielle E. Gaines.

In March 2023, the Maryland Department of Health began the laborious process of evaluating the eligibility of 1.8 million Marylanders who had Medicaid coverage, many as a result of pandemic-era policies designed to boost enrollment.

A year after that “unwinding” began, a total of 1,687,343 Marylanders still had health care through Medicaid, according to department data released Thursday.

“We are very proud of the work and the efforts to ensure we did everything that we possibly could to ensure that every single eligible Marylander remained covered,” said Ryan Moran, the health department’s deputy secretary for health care financing. “Today does mark a monumentous effort.”

The new numbers come one day after Gov. Wes Moore (D) proposed $150 million in cuts to the fiscal 2025 budget, in large part because higher than expected Medicaid participation is costing the state more than was budgeted. In February, it was announced that technical errors and faulty projections resulted in a $236 million shortfall for covering Medicaid expenses.

Moran said health officials are “still working to refine projections” on how the new baseline of 1.7 million Medicaid recipients will affect future budget considerations. But he added that those 1.7 million Medicaid enrollees will “yield long-term impact into the state’s future.”

“We know that when children are covered under Medicaid, it’s linked to lower mortality rates and longer lives,” Moran said. “We also know Medicaid coverage of kids increases rates of high school graduation, college enrollment and then it also provides intergenerational mobility for families as well.”

While the current Medicaid enrollment is down from the pandemic high of 1.8 million, it is well over the 1.4 million Marylanders who were enrolled at the outset of COVID-19.

Medicaid is a joint federal-state program that provides a health care plan to low-income households. Prior to 2020, Medicaid coverage needed to be renewed every year. But Medicaid terminations were paused during the pandemic in order to ensure people were covered during a global health crisis.

That changed in 2023, when Medicaid re-enrollments were no longer automatic, and people had to reapply to the program to continue coverage, beginning the period that became known as the “Medicaid unwinding.”

Maryland opted to work through the 1.8 million Medicaid recipients over a the course of year, reaching out to 100,000 to 160,000 enrollees every month to let them know it was time to renew their coverage. Recipients then had two months to reapply. If they still qualified, their coverage was continued for another year.

It wasn’t all smooth sailing: Over the course of the year, more than 340,000 Marylanders were taken off the rolls, even if they may still have qualified for the coverage that is aimed at assisting low-income families.

Many of those rejections were for procedural issues, with recipients who missed the deadline to apply or filed an incomplete application. The 340,000 is a rolling number gathered over 12 months: It is not clear how many of them were able to correct their applications and regain coverage in a later month.

However, about 94,000 Marylanders were rolled off of Medicaid coverage because they were no longer eligible for the program, the state data shows. Those individuals were encouraged to purchase an individual health care plan on the Maryland Health Connection, the state marketplace for health insurance plans.

Back in May 2023, the Maryland Department of Health anticipated that one of the main hurdles in the unwinding process would be ensuring that those who had Medicaid knew to reapply. They issued an information campaign to get the word out, which included billboards, social media posts, radio ads and informational flyers.

Part way into the unwinding process, the department increased its outreach efforts after finding that certain ZIP codes appeared to have higher rates of procedural termination.

Of all the people who saw rejections over the course of the year in Maryland, about 70% were terminated due to procedural reasons, opposed to 30% who were deemed ineligible for the program, according to KFF , a nonprofit health policy research and polling organization. That’s slightly higher than the national average of 69% that were disenrolled for procedural reasons.

Kate McEvoy, executive director of National Association of Medicaid Directors, said that overall, about 50 million people were renewed for Medicaid over the course of the unwinding period across the United States. There are still six states that have not finished determining Medicaid eligibility.

“What we’ve seen across the county is huge effort around outreach and engagement. Maryland is a great example among peer states, that have that kind of multimodal statewide education campaigns, working with lots of partners, alerting people that this is occurring,” McEvoy said.

She also appreciated Maryland’s use of federal waivers to help make the reapplication process smoother and help some Medicaid recipients renew automatically through existing state and federal data, referred to as ex parte renewals.

“When we look at best practices, easing the federal flexibilities, improving ex parte renewals, the outreach campaigns and also the connections to the (state health insurance) marketplace, Maryland does stand out among peers,” McEvoy said.

The Maryland Health Department has been releasing monthly data since the unwinding began, and Thursday’s data included results from April, the last month of redeterminations. Of the 103,727 people who applied in April, 75,694 retained Medicaid coverage and 4,575 were determined ineligible. Another 20,127, or about 20% of the April applicants, were terminated for “procedural reasons,” meaning they did not complete the reapplication process in time.

There were still 3,330 applications being processed as of Thursday, according to the data.

Over the course of Medicaid unwinding, the state health department faced some hurdles. In September, the Centers for Medicare and Medicaid Services told states to suspend “procedural reasons” terminations after it learned that some enrollees were inappropriately losing coverage. As a result, CMS also instructed states to reinstate Medicaid coverage for some who had lost theirs. The pause on procedural terminations lasted for three months, resuming in December.

Moran said the lessons learned along the way will also help the department work through future Medicaid renewals, now that recipients again have to re-enroll annually.

“Just because we went through the process once, it is here to stay, it will happen on an annual basis,” Moran said. “We are shifting our focus with our partners and organizations to remind people that they have to go through this process every year.

“So, we’re sort of back to regular operations,” he said.

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