For three years, the Medicaid continuous enrollment requirement offered stability during a time of unprecedented disruption. Members stayed covered, health plans adjusted to record enrollment levels, and states paused routine eligibility terminations. That era has officially passed. As redeterminations resumed, millions of people have lost Medicaid coverage and are now searching for their next coverage option.
For managed care organizations, this moment presents both risk and opportunity. Members losing Medicaid are not disappearing. Many remain eligible for coverage through Affordable Care Act Marketplace plans, Basic Health Programs, or other subsidized options. The organizations that act early, coordinate across programs, and meet members where they are stand to retain lives, stabilize risk pools, and build long-term loyalty.
Understand how Medicaid unwinding is reshaping coverage transitions and what it means for retaining members moving to ACA options.
The Scale of Medicaid Unwinding
At its peak in March 2023, Medicaid and CHIP enrollment reached roughly 94 million people nationwide.¹ As states resumed eligibility reviews, enrollment declined sharply. By October 2025, total Medicaid and CHIP enrollment stood at approximately 76.8 million, representing a 19% decline from the peak.¹ Even after this drop, enrollment remains higher than pre-pandemic levels, reflecting expanded eligibility and improved renewal processes in many states.¹
More than 25 million people have been disenrolled since unwinding began.² Not all of these individuals lost coverage because they were ineligible. Administrative churn, outdated contact information, and process complexity played major roles.² For those who are no longer eligible for Medicaid, the ACA Marketplaces represent the primary pathway to continued coverage.²
Historically, this transition has been difficult. Before the pandemic, only a small fraction of people losing Medicaid successfully enrolled in Marketplace plans.² During unwinding, transition rates improved meaningfully, driven by increased outreach, policy flexibility, and targeted state initiatives.² Even so, the majority of disenrolled individuals still do not end up in ACA coverage, leaving significant room for improvement.²
Medicaid & Marketplace Transitions Are State Specific
Medicaid policy is state driven, and unwinding outcomes vary widely. That variation is especially important for organizations operating in Texas, Arizona, and California, where eligibility rules, system integration, and state programs differ substantially.
In Texas, the challenge is scale. Texas has one of the largest Medicaid populations in the country and has not adopted Medicaid expansion. Many adults losing Medicaid fall into coverage gaps or face affordability concerns when moving to Marketplace plans. Outreach, education, and simplified transitions are critical, particularly for families with children who may remain eligible even when parents are not.
Arizona presents a different picture. As a Medicaid expansion state with a relatively integrated eligibility system, Arizona has more structural pathways for Medicaid to Marketplace transitions. Even so, members often struggle with premium expectations, plan selection, and understanding cost sharing after years of Medicaid coverage.
California stands apart due to its policy innovation. Medi-Cal expansion, automatic plan selection, and strong premium assistance programs have driven some of the highest Marketplace transition rates in the country. Covered California’s automatic enrollment approach has helped roughly one third of eligible individuals effectuate ACA coverage after Medicaid termination.2 While not every state can replicate California’s model, the underlying principles are widely applicable.
Why Members Fall Through the Cracks
Losing Medicaid is rarely a single event. It is often a confusing sequence of notices, deadlines, and unfamiliar terminology. Members who were accustomed to zero premiums and minimal cost sharing suddenly face monthly payments, plan choices, and network considerations.
Several barriers consistently disrupt transitions:
- Limited understanding of ACA eligibility and subsidies
- Confusion about special enrollment periods
- Fear of premiums and out-of-pocket costs
- Language and accessibility gaps
- Fragmented eligibility systems between Medicaid and Marketplaces
When these barriers go unaddressed, members delay action or disengage entirely. From a health plan perspective, that means lost lives and increased uncompensated care downstream.
Capturing Members in the Moment of Transition
The unwinding period highlighted an important truth. Timing matters. Members are far more likely to enroll in ACA coverage when outreach happens immediately following Medicaid termination. Plans that rely solely on passive notices or expect members to self-advocate see far lower conversion rates.
Effective transition strategies share several characteristics:
- Early identification of members at risk of losing Medicaid
- Clear, simple communication about next steps
- Warm handoffs between Medicaid and ACA programs
- Support that reflects cultural, linguistic, and community realities
Clearlink has seen firsthand how alignment across clinical management and operational management functions can dramatically improve these outcomes. Eligibility data, call center workflows, care management teams, and community partners all play a role in keeping members connected.
Lessons from States That Moved the Needle
Data from state-based Marketplaces shows that integrated eligibility systems and facilitated enrollment programs produce stronger results.2 States that simplified plan selection or reduced administrative friction saw significantly higher ACA enrollment rates among former Medicaid members.2
Basic Health Programs also offer important insights. In states like New York and Minnesota, where BHPs function as a bridge between Medicaid and Marketplace coverage, enrollment rates among eligible individuals exceeded 50% and in some cases approached universal uptake.2 While Texas and Arizona do not operate BHPs, the lesson remains relevant. Transitions work best when coverage feels familiar and affordable.
California’s approach reinforces this point. Automatic plan selection, opt-out models, and premium assistance reduce decision fatigue and financial shock. Members are more likely to stay covered when the system does more of the work upfront.
The Role of Member Engagement During Redetermination
Retaining trust during redetermination lays the foundation for successful transitions. Members who feel supported during Medicaid renewal are more receptive to guidance when eligibility changes.
This is where proactive engagement makes a measurable difference. Clear communication, personalized outreach, and strong provider partnerships help members understand their options before coverage gaps occur. Community-based strategies, including collaboration with social service agencies and safety net providers, further strengthen these efforts.
Clearlink outlined many of these approaches in our free tip sheet, 5 Best Practices for Retaining and Engaging Your Members Amidst Redetermination. The guidance applies directly to organizations looking to improve Medicaid to ACA transitions. Downloading the tip sheet provides practical tactics teams can deploy immediately to support members at risk of losing coverage.
What This Means for Texas, Arizona & California Plans
For plans operating in these states, unwinding is not over just because redetermination timelines have ended. Member churn continues, and Marketplace opportunities remain underleveraged.
In Texas, success depends on outreach at scale and coordination with community organizations that already serve vulnerable populations. In Arizona, aligning Medicaid and Marketplace operations can reduce friction and improve conversion rates. In California, the focus shifts toward optimization and sustainability as automatic enrollment programs mature.
Across all three states, plans that integrate clinical insights with operational execution will outperform those that treat Medicaid and ACA as entirely separate worlds.
Turning Unwinding into Long-Term Growth
The end of continuous enrollment closed one chapter, but it opened another. Medicaid unwinding revealed how fragile coverage can be and how powerful smart systems and human-centered design can become when aligned.
Organizations that invest now in transition strategies will not only retain more members but also strengthen relationships that extend beyond a single program. That translates into more stable enrollment, better member experiences, and improved outcomes over time.
Clearlink partners with managed care organizations to bring clarity to this complexity. By aligning strategy, technology, and execution, we help plans capture opportunity in moments of change and turn disruption into durable growth.
Contact us to talk through your Medicaid and ACA strategy and learn how targeted operational and clinical support can help you retain members during transition points.
Sources:
1. Medicaid Enrollment & Unwinding Tracker, KFF
2. Unpacking the Unwinding: Medicaid to Marketplace Coverage Transitions, Georgetown University Center on Health Insurance Reforms