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2023 Marketplace Coverage: Part 2 — The Transition Arc

Analysis  |  By Laura Beerman  
   November 22, 2022

As the public health emergency extends (PHE) into 2023, payers dominating both Medicaid and the Exchanges will continue to win big while beneficiaries navigate complex waters.

Since HHS first declared COVID-19 a PHE, government-subsidized health insurance has grown exponentially—Medicaid and Marketplace.

To preserve continuous coverage in an uncertain economy, HHS suspended state Medicaid eligibility checks. With that grace period nearing its end, states are at varying degrees of readiness to resume redeterminations. Multiple stakeholders are reaching out to help, including the health plans whose Medicaid member loses may shift to their marketplace plans.

Medicaid membership grew from 12.7 million to 18.7 million per year between July 2021 and July 2022. The Exchanges reached a record 14.5 million enrollees, with close to three million being first-time customers. As of January 2022, the marketplace number was nearly 17 million per Kaiser Family Foundation (KFF), counting unsubsidized plans and those purchased off-Exchange.

A shifting pandemic deadline

The PHE has been in place since January 31, 2020. HHS' latest renewal on October 13 required a 60-day notice of PHE expiration by November 11, which did not occur. As such, the PHE will remain in place until at least January 11, 2023, further extending state Medicaid determination suspension.

When it does expire, three issues are paramount:

  • How states will manage redeterminations
  • How many people will lose Medicaid coverage when that happens
  • How many will choose—or be able to successfully navigate—a transition to Exchange coverage

"Estimates range from five to 14 million who will experience loss of coverage," says Ashley Perry, chief strategy and solutions officer for Socially Determined, which measures the impacts of the social determinants of health (SDOH) and is also engaging with Medicaid officials to ease redetermination burdens.

"The delta in the projections reflects the uncertainty about those who no longer quality and how they can maybe be brought into the Exchanges," says Perry, adding: "It's interesting to see the variation in state response. Some is politically driven. Some depends on how prepared a state is to manage the redetermination process. There are also a lot of workforce challenges and—from a policy perspective—states have different levers in place. Some already have continuous or presumptive eligibility, which gives them more to work with."

The plans best positioned

In its 2022 analysis, the Robert Wood Johnson Foundation (RWFJ) noted that redeterminations represent "the most likely prospect for enrollment growth" for the Exchange in the short-to-medium term.

Health plans that operate both lines of business—Medicaid managed care and Exchange plans—stand to see the greatest gains. A 2022 KFF analysis shows that six companies dominate both spaces:

  • Centene – Medicaid plans in 24 states and Exchange plans in 28
  • UnitedHealth Group — Medicaid plans in 24 states and Exchange plans in 22
  • Elevance Health (formerly Anthem) — Medicaid plans in 21 states and Exchange plans in 14 states
  • Aetna, a CVS Health company — Medicaid plans in 14 states and Exchange plans in 12 states
  • Molina – Medicaid plans in 12 states and Exchange plans in 14

Among these plans, Centene is the stalwart.

"In years when large national plans stayed out of the Exchanges, Centene became the big dog and grew organically across markets and counties," says Bill Melville, principal analyst of Market Access Insights with Clarivate. "They didn't retreat when others did."

Associated challenges

The ability of Centene or any plan to migrate members to the Exchange, however, depends on education and outreach—two abiding challenges for the Medicaid program whose members have frequent contact information changes as well as multiple SDOH challenges.

Socially Determined is working with states to update Medicaid member contact information with these challenges in mind.

"Typically, 25–40% of contact information is out of date," says Perry, adding: "Subsets of people with health literacy and cultural challenges are at greater risk, not only in coverage navigation but access to care. Socially Determined can help plans identify these subsets."

Caught unawares

A Medicaid population aware of upcoming redeterminations would help mitigate these risks, including loss of coverage and the options available on the Exchange.

But that's not the case. Nearly two-thirds (62%) of adults enrolled in Medicaid, or with a family member who is, are unaware their eligibility will be reassessed, according to a new Urban Institute report, funded in part by RWJF. Additional data showed that only 21% of members notified that coverage renewal was needed were educated on how to go about it, with only 29% informed of their other options.

"Our research shows there is low awareness about Medicaid renewals resuming in the future, indicating state programs may face significant information gaps among enrollees about the looming change brought about by the end of the PHE," said Jennifer Haley, senior research associate at the Urban Institute, in a press release accompanying the report.

For HealthLeaders' prior coverage of 2023 Exchange plan developments, read Part 1 — The Growth Trajectory, here.

“In years when large national plans stayed out of the Exchanges, Centene became the big dog and grew organically across markets and counties. They didn't retreat when others did. ”

Laura Beerman is a contributing writer for HealthLeaders.


COVID-19 has grown Medicaid and Exchange enrollment by the millions.

With suspended Medicaid redeterminations looming, as many as 14 million Americans could lose eligibility and be faced with Marketplace decisions for the first time.

States are approaching redeterminations in diverse ways, aided by the Medicaid plans and other organizations that have a stake in member coverage continuation.

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