Maryland has begun an unprecedented effort to renew Medicaid coverage for nearly 1.8 million adults and children for the first time since the start of the COVID-19 pandemic.

States were required to provide uninterrupted coverage for those enrolled in Medicaid, the public health insurance program for low-income people, throughout the pandemic in exchange for increased federal funding. But the public health emergency is set to end on May 11.

Maryland officials have said renewal notices will be mailed to beneficiaries over the course of the next year in the same month that their coverage began, regardless of its duration. People must then turn in requested documents within 45 days after they receive notice.

The first notices were sent in April, and coverage losses will start as early as June. Marylanders whose income now exceeds eligibility thresholds — set at 138% of the federal poverty level, or $41,400 for a family of four — will be referred to apply for health coverage on the state exchange, where they may still receive income-based subsidies to help with costs, said Ryan Moran, deputy secretary of health care financing and Medicaid director at Maryland Department of Health.

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He said there’s no estimate of the number of people who stand to lose coverage because of the many variables that determine Medicaid eligibility.

Organizations like Health Care for the Homeless help patients through the process of re-enrolling in Medicaid, which can include creating email addresses, locating necessary paperwork to enroll, and selecting insurance. (Julia Reihs for The Baltimore Banner)

Even under ordinary circumstances, though, some people who remain eligible for Medicaid still lose it when renewing coverage, typically for “procedural” reasons — they may not receive or understand notices informing them of the need for renewal, may not provide requested documents in time, or might experience a short-term fluctuation in income that renders them temporarily ineligible. About two-thirds of people were uninsured for a period of time after losing their Medicaid benefits, according to a study using pre-pandemic data, and 40% re-enrolled in Medicaid within a year.

These are the coverage losses that the Centers for Medicare and Medicaid Services want states to avoid. The agency is requiring states to submit plans detailing how they will “promote coverage retention and prevent inappropriate terminations of coverage” among people with Medicaid.

Here’s what to know about Maryland’s plan.

How will Medicaid enrollees know when to renew?

A statewide campaign called the “Medicaid Check-In” encourages beneficiaries to update their contact information so that they will receive notices when it’s time to renew coverage. The state is reaching out to beneficiaries via mail, text and robocalls, urging them to update their information, said Moran. It has also launched an outreach campaign on TV, radio, and social media, and partnered with community organizations to get the word out, he said.

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“We’re laser-focused on our efforts to ensure that we get people covered,” Moran said.

Unlike some other states, Maryland is requiring Medicaid enrollees to update their contact information directly with state agencies. Although over 30 other states will obtain information from the United States Postal Service change of address database or the Medicaid managed care organizations tasked with administering benefits, Maryland has not followed this trend.

That means that while managed care organizations, in partnership with the Maryland Health Benefit Exchange, will be contacting beneficiaries to tell them to update their contact information, that’s where their job ends.

The state has elected to automatically renew coverage for people who have active SNAP benefits, also known as food stamps, if they do not respond to renewal requests.

What challenges are people on Medicaid anticipating?

Beneficiaries will need to update their information with the right agency, which varies according to their age and disability status. Contact information can be updated online, but for the roughly 20% of people living near the poverty line who lack access to the internet or who have a question about their enrollment, this could necessitate spending hours on hold.

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To enroll, they must provide documents proving citizenship, state residency and income. State workers match reported income with state and federal data sources and compare it with expenses listed for basic needs such as rent, utilities and transportation. They’ll question applicants and sometimes deny coverage if amounts don’t match.

“It’s like this compounding headache of finding paperwork to prove that you are sufficiently poor,” said Dr. Andrey Ostrovsky, managing partner at Social Innovation Ventures and former chief medical officer of the U.S. Medicaid program under President Obama, who also previously operated a series of methadone clinics in Baltimore.

Disjointed and inefficient processes make reapplying for Medicaid “logistically very difficult,” even under normal circumstances when most people are required to re-enroll annually, Ostrovsky said.

John Bell, a 46-year-old patient at Health Care for the Homeless in Baltimore who receives Medicaid benefits, recently received three emails from the state, warning him that coverage renewal was “not automatic” and he would need to reapply.

But because he receives Supplemental Security Income due to a disability, he does not have to renew. The email was phrased in a way, Bell said, that made him afraid he was about to lose coverage.

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“I need my health care,” he said. He uses Medicaid for “my medication, my glasses, everything.” His Supplemental Security Income pays only $914 per month.

He went to the Maryland Health Connection office in downtown Baltimore, where staff reassured him that, despite the emails, he does not need to renew. Bell then spent 20 minutes on hold with a different office to make sure his contact information was updated.

Muhammed Mamman, director of client access at Health Care for the Homeless, said some patients have received mailed notices warning them of impending disenrollment if they do not reapply by their renewal date. The letter’s wording unfortunately “led many people to incorrectly believe that they had to reapply by May,” Mamman wrote in an email.

Muhammed Mamman, director of client access at Health Care for the Homeless, helps patients through the process of re-enrolling in Medicaid, which can include creating email addresses, locating necessary paperwork to enroll, and selecting insurance. (Julia Reihs for The Baltimore Banner)

How will the state manage this enormous effort?

“States have gotten out of practice with doing enrollment and eligibility,” Ostrovsky said, as those processes have been suspended for over three years. States have also lost staff who previously did that work, he said.

Conducting a wholesale review of coverage is also unprecedented “in terms of magnitude,” Moran said. “We have not gone through a process like this before across the country.”

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The federal government is requiring states to submit data on how their renewal process is going, including measures such as the number of enrollees who have lost coverage, reasons for coverage loss, and call center wait times and abandonment rates. States were given the option to make this data public and Maryland will do so, said Chase Cook, acting director of communications for the Department of Health. Officials have not yet announced which of several data points will be publicly available.

Moran said health officials “are going to be watching that data very closely,” and will use it to guide renewal efforts.

What’s at stake for people who lose their health insurance?

Gaps in health insurance coverage can lead to worsening of new or chronic health conditions when people don’t visit the doctor or fill prescriptions due to financial concerns, Ostrovsky said, and states incur higher administrative costs when Medicaid enrollees churn in and out of the program.

For low-income people, gaps in coverage can mean losing any chance to escape poverty, Ostrovsky said, if a medical crisis leads them to visit the emergency room or to be hospitalized.

“If you’re already poor and you’ve got a $50,000 debt sitting on top of you, you’re done. You’re not ever going to get out from under that,” he said. Unpaid debt also ruins credit scores and causes toxic stress, Ostrovsky said, which can impact people’s lives for years to come.