The Impact of Outreach and Assistance from Navigators on Medicaid Renewals in the United States
- Adults
- Take-up of program/social service/healthy behavior
- Information
- Nudges and reminders
In 2023, over 9 million US residents lost Medicaid coverage during the renewal process for procedural reasons (i.e., because they did not submit renewal paperwork or the submitted paperwork was not correct or complete). Challenges with completing renewal processes may arise for a variety of reasons, including confusion about the rules, information barriers, or lack of internet access. Researchers assessed the impact of outreach on Medicaid retention; outreach messages provided a reminder to renew as well as information about how to obtain free one-on-one assistance with renewal processes from health insurance navigators. Outreach using pre-recorded calls prevented denials due to procedural reasons and increased Medicaid renewal rates by 1.0 percentage point across the full study population, by 4.0 percentage points for Tribal members, 2.1 percentage points for children, and 1.9 percentage points for people with chronic conditions. The study results provide new insights on the value of outreach and assistance from navigators to prevent avoidable denials.
Policy issue
Medicaid is an entitlement program that provides free or low-cost comprehensive health insurance to certain eligible adults and children with low income. Yet many eligible people cannot enroll or lose coverage due to “administrative burdens”1 associated with Medicaid, such as information inaccessibility and complicated application and renewal processes. The Medicaid renewal process requires certain beneficiaries to recertify eligibility with documentation within a specified deadline. A recent national survey found that 17.4 percent of beneficiaries lost Medicaid coverage in 2023 due to their inability to complete the renewal process, rather than voluntary dropout or ineligibility.2 Latino/a and Tribal community members may be disproportionately likely to lose coverage at renewal deadlines.3
Prior evidence suggests that written outreach messages with reminders disproportionately benefit enrollees with relatively higher income or better health conditions, while telephone assistance providing one-on-one support can better support low-income individuals and those who speak other languages, but is more labor- and cost-intensive. With funding for Medicaid navigator programs frequently fluctuating, it is important to determine what methods are most effective at supporting individuals renewing their Medicaid coverage. This study is the first randomized evaluation to answer the question, “Can automated outreach and the offer of live assistance increase Medicaid renewal rates, and which are the most effective outreach methods?”
Context of the evaluation
Researchers partnered with the Wisconsin Department of Health Services and Covering Wisconsin, Wisconsin’s Affordable Care Act Navigator program. The study focused on Wisconsin Medicaid enrollees whose coverage was not automatically renewed and who received fee-for-service benefits. Fee-for-service enrollees represent about one-third of Medicaid beneficiaries nationally and 19 percent of total beneficiaries in Wisconsin. Fee-for-service enrollees are not enrolled in a Managed Care Organization (MCO), which is the predominant delivery system in Medicaid. The fee-for-service population includes Medicaid members in their 90-day enrollment period who have not yet selected a Health Maintenance Organization (HMO), members with other limited exceptions to managed care enrollment (for Tribal members, or for people with only one HMO offered in their county), and many Medicaid members enrolled through elderly, blind, or disabled eligibility categories. Covering Wisconsin conducted outreach to all fee-for-service enrollees, while MCOs handled additional outreach efforts for their members beyond the standard communications from the state.
The study participants included 80,016 households comprised of 92,957 fee-for-service Medicaid beneficiaries who faced coverage renewal deadlines from June 2023 to June 2024. The pre-recorded call arm of the trial was stopped early so the intervention could be delivered to everyone when it was shown to be effective, yielding a sample size of 55,310 households or 62,499 individuals for whom receipt of the pre-recorded call was randomized. All study participants spoke either English or Spanish; half of the participants identified as female (52 percent), and the average age of the participants was 47. Ten percent of the participants identified as Black, 8 percent as Latino/a individuals, 12 percent as Tribal community members, and 1 percent as Asian or Pacific Islander.
Details of the intervention
Researchers conducted a randomized evaluation to assess the impact of reducing administrative burdens through outreach methods offering information and assistance on Medicaid renewal. Medicaid recipients nearing their renewal deadlines were contacted with outreach information an average of 28 days before their deadline.
All members of the study population received written outreach in their preferred language. For a randomly selected subset of the population, this was supplemented with phone-based outreach (a pre-recorded call).
The researchers tested both the impact of sending this supplemental pre-recorded call as well as the impact of variations in the modality, frequency, and content of the written outreach. Fifty percent of the study population was randomly selected to receive a pre-recorded call. To test the effects of different forms of written outreach, 40 percent of the study population was randomly selected to receive postcards and the other 60 percent to receive text messages. Within the text message group, researchers randomly varied the calls to action (connecting with a webchat tool or calling a hotline) and the number of messages they received (one or two). Due to confidentiality rules, postcards could not mention Medicaid or renewal dates and only provided general guidance on navigator assistance with health insurance. The text messages and pre-recorded calls specified that the recipient must renew their Medicaid by a specific deadline to avoid losing coverage, while the webchat tool, accessible online or via SMS, provided Medicaid eligibility details and connected users to live assistance upon request. Enrollees who received only a postcard served as the comparison group.
The primary outcome was Medicaid renewal, defined as continued enrollment in a full-benefit Medicaid program the month after the renewal deadline, while the secondary outcome of interest was the lack of a Medicaid renewal due to a procedural denial. The study also assessed engagement with the hotline and webchat tool, as well as the impact of outreach methods on various demographic groups. Data collected through the field experiment were merged with Wisconsin administrative records.
Ethical Considerations:
For ethical reasons, all study participants received written outreach. After an interim analysis found that the pre-recorded call was effective in increasing Medicaid renewal, such calls were delivered to everyone. The analyses of the impact of the pre-recorded call used data from the period when it was randomized.
Results and policy lessons
The pre-recorded call increased Medicaid renewal rates by preventing procedural denials. This finding held for the full population, as well as in key sub-populations of interest such as children, Tribal members, people with chronic conditions, and adults with low-income. In contrast, variations in written outreach methods (postcard or text) did not affect Medicaid renewal outcomes.
Renewal of Medicaid coverage
Participants in the pre-recorded call group had a 1.0 percentage point increase in Medicaid renewal rates from a baseline of 67.8 percent (a 1.5 percent increase) and a 1.1 percentage point decrease in procedural denials from a baseline of 22.3 percent (a 5.0 percent decrease) compared to the group that were not sent pre-recorded calls. Sending a pre-recorded call had the largest effect on Medicaid renewal rates for Tribal members (by 4.0 percentage points or 7.0 percent); the intervention also increased Medicaid renewal rates for children (by 2.1 percentage points or 2.5 percent), adults aged 50-64 (by 1.5 percentage points or 2.1 percent), people with chronic conditions (by 1.9 percentage points or 2.5 percent), and people with income below the sample median of 82 percent of the federal poverty level (by 1.4 percentage points or 2.3 percent).
Variations in the modality of written outreach methods (postcard, text message with or without a webchat option, and reminder texts) did not impact Medicaid renewal or procedural denial rates. The timing of calls and texts (afternoon or evening, weekend or weekday) made no significant difference in Medicaid renewal rates, although calls sent during the afternoon had a smaller effect on procedural denials than calls sent during the evening (a reduction in procedural denials of 0.59 percentage points and 1.6 percentage points, respectively, compared to a baseline procedural denial rate of 21.3 percent, p=0.03).
Outdated contact information
Due to outdated personal contact information, some individuals might not have received the outreach method they were assigned. Although the study population only included people with a complete address and phone number, data from a contact information search vendor indicated that only about half of the phone numbers or addresses could be confirmed as likely correct. Combined with vendor reports of undeliverable postcards, bounced texts, and pre-recorded calls that could not be successfully connected (for example, no one picked up, and the voice mailbox was full), the researchers estimated that at most 78 percent of postcards, 72 percent of text messages, and 61 percent of pre-recorded calls were received by the correct person.
Successfully receiving a pre-recorded call increased Medicaid renewal rates by 1.6 percentage points from a baseline of 67.8 percent among people not sent a pre-recorded call (i.e., a 2.4 percent increase compared to people not sent a pre-recorded call) and reduced procedural denials by 1.8 percentage points from a baseline of 22.3 percent (an 8.1 percent decrease). Receiving a pre-recorded call had the largest effect on Medicaid renewal rates for Tribal members (by 7.7 percentage points or 13 percent). Receiving the call also increased Medicaid renewal rates for children (by 3.0 percentage points or 4 percent), adults aged 50-64 (by 2.4 percentage points or 3 percent), people with chronic conditions (by 3.0 percentage points or 4 percent), people with no recent successful Medicaid renewal (by 1.9 percentage points or 3 percent), and people with income below the sample median of 82 percent of the federal poverty level (by 2.3 percentage points or 4 percent).
Seeking help from navigators
Receiving a pre-recorded call led to a 1.2 percentage point (92 percent) increase in calls to Covering Wisconsin’s hotline compared to a baseline of 1.3 percent among those who did not receive the call. Additional analysis suggested that among those who sought assistance, calling the hotline reduced the risk of losing Medicaid for procedural reasons by 21 percentage points.
Cost-effectiveness
Postcards were the most expensive outreach method at 38 cents each, compared to 9 cents per text and 15 cents per pre-recorded call. Thus, texts were more cost-effective than postcards, given that text messages and postcards had equal impacts on Medicaid renewal rates. Sending pre-recorded calls costs $15 per successful renewal, though a full cost-effectiveness analysis would need data on navigator assistance time.
The results indicate that pre-recorded calls can reduce coverage loss during the renewal process. If all Medicaid enrollees nationwide responded to the intervention in the same manner as Wisconsin enrollees, then using pre-recorded calls to supplement typical postal mail outreach nationwide could lead to 700,000 more people renewing their coverage. Furthermore, the data on contact information accuracy suggests that updating contact information more frequently would enhance the effects of outreach.
Use of results
After researchers found that the pre-recorded call was effective in increasing Medicaid renewal, the calls were scaled up and sent to the full fee-for-service Medicaid population in Wisconsin up for renewal. This was maintained to help reduce procedural denials throughout a period when an unprecedented number of Medicaid enrollees had renewal deadlines in a short time because of a recent policy change (the unwinding of the Covid-19 era continuous coverage requirement). The results were also used as preliminary data for a new randomized study that will explore the impacts of live or pre-recorded phone call outreach to people who lost their coverage for procedural reasons. More broadly, the findings show that Medicaid agencies can fruitfully partner with navigator organizations to improve the retention of beneficiaries.
Myerson, Rebecca Mary, Allison Espeseth, and Laura Dague. 2025. Navigating Medicaid: Experimental Evidence on Administrative Burden and Coverage Loss. NBER Working Paper 34191. Cambridge, MA: National Bureau of Economic Research. https://doi.org/10.3386/w34191.
Herd, Pamela, and Donald Moynihan. "How Administrative Burdens Can Harm Health." Health Affairs Health Policy Brief, October 2, 2020. (https://doi.org/10.1377/hpb20200904.405159)
Rumalla, Kranti C., Daniel B. Nelson, K. John McConnell, and Jane M. Zhu. 2024. “Racial and Ethnic Disparities in Medicaid Disenrollment After the End of the COVID-19 Public Health Emergency.” JAMA Internal Medicine 184, no. 8: 987–89. (https://doi.org/10.1001/jamainternmed.2024.1503)
Dague, Laura, and Rebecca Myerson. 2024. “Loss of Medicaid Coverage During the Renewal Process.” JAMA Health Forum 5, no. 5: e240839. (https://doi.org/10.1001/jamahealthforum.2024.0839 )