3 Lessons States Can Learn From Medicaid Unwinding: Self-service, Automation, and Integrated Eligibility

By Walt Sedlazek, Product Strategy Manager, Cúram by Merative    January 19, 2024

The government’s declaration of the end of the COVID-19 public health emergency (PHE) this year set off a ticking clock for state HHS agencies around the country to evaluate their Medicaid rolls and “unwind” those no longer eligible for the program.

During the three years that federal pandemic policy allowed Medicaid beneficiaries to stay enrolled, states did not decertify or renew their enrollees. Now, states and their beneficiaries are working through a massive enrollment challenge.

This initiative, known as Unwinding, is complicated by several factors. First, there is a high volume of renewals to be processed amid a staff shortage. Second, policy, workflow, and system changes are being implemented with caseworkers hired since the pandemic who have never processed a renewal before. Citizens are challenged, too. Many are not aware they are required to recertify. Nor are they familiar with how to renew their benefit and update their information, if required.

Unwinding offers a unique opportunity to evaluate what technology investments can help address the same core challenges across multiple states. It enables us to identify lessons learned and apply them to future eligibility and entitlement modernization initiatives with similar challenges to those in Medicaid, SNAP, and TANF.

Expand and Encourage Self-Service

Perhaps one of the most important system capabilities identified in Unwinding was the creation of more citizen engagement via the existing self-service channel to provide citizens with a larger role in the eligibility and enrollment process and more effective ways to manage their information.

Giving citizens the ability to renew their eligibility online without (or with minimal) caseworker involvement has enabled agencies who made this investment to better utilize their staff and scale to meet their Unwinding enrollment goals. A similar benefit was seen with another important self-service feature offering Medicaid enrollees and applicants the ability to update and verify their information via document uploads.

Making citizens aware that there are digital alternatives to paper–so that eligible citizens can more quickly update their information online and put themselves on track for a speedier renewal process–is integral to a faster, automated renewal process. It’s no coincidence that North Carolina, which achieved the highest rate of automated Medicaid renewals in a recent Kaiser Family Foundation (KFF) analysis, also allows citizens to engage in the renewal process and change their information online. Maximizing what you can automate for citizens and caseworkers while enabling citizens to do more via a self-service channel is an important lesson that states should apply to managing other benefits programs.

Automate Key Processes From End-to-End

Manual renewals for Medicaid eligibility are extremely time-consuming and resource-intensive–neither of which HHS agencies could afford as they worked toward their expected 2024 Unwinding deadlines. With the limited time available to them, the only realistic path forward for agencies–which need to review and update enrollment data for current Medicaid beneficiaries, make a determination of their current eligibility, and execute that decision–is to automate key processes, where appropriate, from end to end. This means not only automating workflows but also the interactions that can help expedite a process like renewals. Such interactions include integrating electronic data sources or adding more self-service capabilities for citizens.

In our Unwinding experience, we’ve seen our agency partners make significant investments in automating the renewal process and creating a no-touch, frictionless integration between the renewal workflow, eligibility and enrollment policies, and beneficiary data. Some made these investments months in advance of the Unwinding process, and that forward planning has paid off. For example, in the aforementioned North Carolina, a state that made those investments early on, they have achieved a 99% ex-parte (auto) renewal rate for those citizens retaining coverage. Other states that did not make these investments until later are now attempting to catch up. Consequently, these states have experienced lower levels of ex-parte renewals, down to 40% or lower. That means over twice as many renewals had to be manually processed when compared to a state like North Carolina.

Streamlining Traditional Benefits With Integrated Eligibility

How can post-pandemic Medicaid Unwinding inform states’ initiatives for streamlining other complex major programs like Traditional (non-MAGI) Medicaid, SNAP, and TANF? With Traditional Medicaid streamlining next on CMS’ major program improvement docket for 2024, it’s critical that states begin to plan their investments in end-to-end automation and an expanded self-service channel for Traditional Medicaid and their other major benefits programs.

Integrated eligibility–integrating multiple benefits programs into a common system–provides a path forward on this front. In a 2023 survey, KFF found approximately a dozen states did not have Traditional Medicaid as part of their streamlined Medicaid eligibility engine. About 20 other states didn’t have SNAP or TANF either. States may benefit from federal funding to integrate these programs into the same streamlined Medicaid eligibility system. CMS has signaled potential support for funding these improvements with their federal partners at FNS and ACF if they are part of their core Medicaid eligibility and enrollment platform. By investing in streamlined processes and modernizing their legacy infrastructure, states can not only consolidate their benefits eligibility capabilities but also get a jump on streamlining benefits eligibility for other programs down the line.


At the end of the day, technology follows policy and process. The right policy precipitates the right technology, which in turn precipitates success. And that success is critical to the well-being of millions of people on benefit programs. To date, in Unwinding, 70% of people who have been disenrolled in Medicaid lose coverage not because they are ineligible based on their circumstances but for arbitrary procedural reasons, like missing a deadline for returning paperwork. To prevent this, a strategy of self-service, automation, and integrated eligibility is essential to help keep eligible citizens on programs like Medicaid, SNAP, and TANF and receive the benefits they’re entitled to.

What we see so far in Unwinding is that the states most successful at reviewing and processing eligibility renewals quickly are the ones that invested in streamlined policies, processes, and technology ahead of time. There was a belief that timely investing in major capabilities like program-specific automation, expanded citizen self-service, and integrated eligibility would be beneficial for Unwinding. That belief has been validated by the real progress we’ve seen in states nationwide that have done exactly that. When embedded in your eligibility and entitlement platform, these capabilities can make a noticeable difference in reaching your program’s modernization goals and ensure as many eligible citizens as possible retain their benefits.

About the Author

Walt Sedlazek

Product Strategy Manager
Cúram by Merative

3 Lessons States Can Learn From Medicaid Unwinding: Self-service, Automation, and Integrated Eligibility

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