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Who doesn't text in 2022? Most state Medicaid programs

States must reach out to all Medicaid enrollees to inform them that their eligibility will need to be reevaluated, but many of those states will not be employing one key strategy: texting.
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States must reach out to all Medicaid enrollees to inform them that their eligibility will need to be reevaluated, but many of those states will not be employing one key strategy: texting.

West Virginia will use the U.S. Postal Service and an online account this summer to connect with Medicaid enrollees about the expected end of the COVID-19 public health emergency, which will put many recipients at risk of losing their coverage.

What West Virginia won't do is use a form of communication that's ubiquitous worldwide: text messaging.

"West Virginia isn't set up to text its members," Allison Adler, the state's Medicaid spokesperson, wrote to KHN in an email.

Indeed, most states' Medicaid programs won't text enrollees despite the urgency to reach them about renewing their coverage. A Kaiser Family Foundation report published in March found just 11 states said they would use texting to alert Medicaid recipients about the end of the COVID public health emergency. In contrast, 33 states plan to use snail mail and at least 20 will reach out with individual or automated phone calls.

"It doesn't make any sense when texting is how most people communicate today," said Kinda Serafi, a partner with the consulting firm Manatt Health.

State Medicaid agencies for months have been preparing for the end of the public health emergency. As part of a COVID relief law approved in March 2020, Congress prohibited states from dropping anyone from Medicaid coverage unless they moved out of state during the public health emergency. When the emergency ends, state Medicaid officials must reevaluate each enrollee's eligibility. Millions of people could lose their coverage if they earn too much or fail to provide the information needed to verify income or residency.

As of November 2021, about 86 million people were enrolled in Medicaid, according to the Centers for Medicare & Medicaid Services. That's up from 71 million in February 2020, before COVID began to ravage the nation.

West Virginia has more than 600,000 Medicaid enrollees. Adler said about 100,000 of them could lose their eligibility at the end of the public health emergency because either the state has determined they're ineligible or they've failed to respond to requests that they update their income information.

"It's frustrating that texting is a means to meet people where they are and that this has not been picked up more by states," said Jennifer Wagner, director of Medicaid eligibility and enrollment for the Center on Budget and Policy Priorities, a Washington-based research group.

The problem with relying on the Postal Service is that a letter can get hidden in "junk" mail or can fail to reach people who have moved or are homeless, Serafi said. And email, if people have an account, can end up in spam folders, she noted.

In contrast, surveys show lower-income Americans are just as likely to have smartphones and cellphones as the general population. And most people regularly use texting.

In Michigan, Medicaid officials started using text messaging to communicate with enrollees in 2020 after building a system with the help of federal COVID relief funding. They said texting is an economical way to reach enrollees.

"It costs us 2 cents per text message, which is incredibly cheap," said Steph White, an enrollment coordinator for the Michigan Department of Health and Human Services. "It's a great return on investment."

CMS officials have told states they should consider texting, along with other communication methods, when trying to reach enrollees at the end of the public health emergency. But many states don't have the technology or information about enrollees to do it.

Efforts to add texting also face legal barriers, including a federal law that bars texting people without their consent. The Federal Communications Commission ruled in 2021 that state agencies are exempt from the law, but whether counties that handle Medicaid duties for some states and Medicaid managed-care organizations that work in more than 40 states are exempt as well is unclear, said Matt Salo, executive director of the National Association of Medicaid Directors.

CMS spokesperson Beth Lynk said the agency is trying to figure out how Medicaid agencies, counties and health plans can text enrollees within the constraints of federal law.

Several states told KHN that Medicaid health plans will be helping connect with enrollees and that they expect the plans to use text messaging. But the requirement to get consent from enrollees before texting could limit that effort.

That's the situation in Virginia, where only about 30,000 Medicaid enrollees — out of more than a million — have agreed to receive text messages directly from the state, said spokesperson Christina Nuckols.

In an effort to boost that number, the state plans to ask enrollees if they want to opt out of receiving text messages, rather than ask them to opt in, she said. This way, enrollees would contact the state only if they don't want to be texted. The state is reviewing its legal options to make that happen, she said.

Meanwhile, Nuckols added, the state expects Medicaid health plans to contact enrollees about updating their contact information. Four of Virginia's six Medicaid plans, which serve the bulk of the state's enrollees, have permission to text about 316,000, she said.

Craig Kennedy, CEO of Medicaid Health Plans of America, a trade group, said that most plans are using texting, and that Medicaid officials will use multiple strategies to connect with enrollees. "I do not see this as a detriment, that states are not texting information about reenrollment," he said. "I know we will be helping with that."

California officials in March directed Medicaid health plans to use a variety of communication methods, including texting, to ensure that members can retain coverage if they remain eligible. The officials told health plans they could ask for consent through an initial text.

California officials say they also plan to ask enrollees for consent to be texted on the enrollment application, although federal approval for the change is not expected until the fall.

A few state Medicaid programs have experimented in recent years with pilot programs that included texting enrollees.

In 2019, Louisiana worked with the nonprofit group Code for America to send text messages that reminded people about renewing coverage and providing income information for verification. Compared with traditional communication methods, the texts led to a 67% increase in enrollees being renewed for coverage and a 56% increase in enrollees verifying their income in response to inquiries, said Medicaid spokesperson Alyson Neel.

Nonetheless, the state isn't planning to text Medicaid enrollees about the end of the public health emergency because it hasn't set up a system for that. "Medicaid has not yet been able to implement a text messaging system of its own due to other agency priorities," Neel said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. It is an editorially independent operating program of KFF (Kaiser Family Foundation).

Copyright 2022 Kaiser Health News. To see more, visit Kaiser Health News.

Phil Galewitz