As pandemic-era protections end, Maine has managed to keep almost 70 percent of people formerly relying on state healthcare on Medicaid, a rate better than the national average and many other states.

More than 300,000 Mainers have renewed their MaineCare coverage so far, according to the Maine Department of Health and Human Services. MaineCare is the state’s name for federal Medicaid, which provides health coverage to millions of low-income adults, children, pregnant individuals, elderly adults and people with disabilities.

Approximately 13 percent of all renewals have been terminated, either due to procedural reasons such as an incomplete form or missing information, or due to enrollees being deemed ineligible. The rest are applications pending manually or automatic renewals.

That amounts to an enrollment decline of 16,000 people from MaineCare, according to Georgetown University’s McCourt School of Public Policy, which tracks data from the Centers for Medicare and Medicaid Services on the Medicaid unwinding.

During the COVID-19 public health emergency, the federal government offered states extra benefits to keep people enrolled in Medicaid. So even if an individual’s income increased and they no longer qualified, they still retained free dental, mental and health care benefits.

That coverage, known as continuous enrollment, officially ended in March 2023. So starting in spring 2023, states had approximately a year to redetermine eligibility and terminate coverage for people who would no longer be eligible. Maine started unwinding last April, and the unwinding period ends this October.

States have had varying success rates retaining healthcare coverage for residents, with states such as Oregon and Arizona keeping more than 80 percent of enrollees covered with state Medicaid programs, while millions of Texans lost Medicaid coverage.

The national average was a 63 percent retention rate, according to Allie Gardner, a research fellow at Georgetown.

“Medicaid enrollees largely had greater protections from disenrollment in Maine than they did in other states.”

There is no one clear reason Maine successfully kept most people who need MaineCare enrolled in the program, according to John Gale, a senior research associate at the Maine Rural Health Research Center within University of Southern Maine.

“It’s a combination of factors, I think; manageable population, reasonable policies, a smaller number of enrollees to track down, and an accepting political climate,” he said.

“Part of it is we don’t see the same level of anxiety or anger towards people on Medicaid. I mean, we pretty much accepted that this is an important safety net program for people who don’t normally, who may not qualify for coverage under the marketplaces.”

Maine’s start to unwinding was with noncompliance

Despite this overall success, the state had an uphill battle to keep most eligible Mainers covered under MaineCare when unwinding began.

In April 2023, Maine was one of the only states not in compliance with CMS because it was not offering any passive renewals, called ex parte renewals, for people already on Medicaid. Through ex parte renewals, an existing member’s eligibility can be determined automatically through available data sources, such as income data, without requiring action by the enrollee, which saves time and paperwork for state employees.

Until August 2023, all MaineCare renewals had to be done manually, but when CMS did their review of state compliance of federal renewal requirements prior to the unwinding, they found that Maine was not in compliance, Gardner said. CMS then worked with the state’s health department to develop mitigation strategies until they were able to get their ex parte system up and running.

One of the included the state not being able to terminate any coverage until there was an ex parte renewal either automatically through the system, or through manual workarounds with employees replicating that ex parte process, Gardner said.

“Considering where Maine was at the start of the unwinding with no ex parte renewals, I’d actually say it’s pretty impressive where they are,” she said.

“Cumulatively, Maine’s ex parte rate is right around 25 percent, and there are states that were doing ex parte and had those systems in place that have far lower ex parte renewals throughout the unwinding.”

Lowest rate of procedural disenrollments across the country

There are two ways someone enrolled in Medicaid can lose their coverage during unwinding: if they are deemed ineligible based on the updated eligibility requirements, or if they are disenrolled due to a missing form or information.

Only 20 percent of Mainers who were up for renewal were procedurally disenrolled, according to Georgetown data, which is the lowest procedural disenrollment rate of all states. The vast majority of disenrolled people were not deemed eligible under the updated requirements.

Because Maine was not able during those first few months of unwinding to end someone’s coverage until they had an automatic system, Gardner said this basically meant that the first few months of Maine’s unwinding, no one was terminated from coverage if they had missing or incomplete information, or if they were unresponsive.