Outreach and Maintenance of Medicaid Enrollment: Evidence from Wisconsin’s Navigator Program

This field experiment will test methods to increase maintenance of Medicaid enrollment by connecting beneficiaries with navigators, a group of professionals publicly funded since 2014 to help consumers enroll in coverage. The intervention will be implemented by Covering Wisconsin, a navigator grantee with a staff of more than a dozen professional assisters. Covering Wisconsin was contracted by the Wisconsin Department of Health Services (DHS) to conduct outreach to fee-for-service Medicaid beneficiaries after the end of the public health emergency.
The intervention arms will vary the frequency of outreach messages (1 or 2 repeated text messages) and the modality of assistance offered (texting with a chatbot vs. calling a hotline to speak with an assister); the chatbot can also be used to schedule a call with an assister. These interventions will be repeated after the renewal window closes for people who lost their coverage. All beneficiaries will also be mailed standard letters by DHS.

This is a four-arm research design. The experimental arms will vary the number of outreach messages (1 vs. 2) and the modality of the assistance offered (texting with a chatbox vs. calling a hotline to speak with an assister) to a list of beneficiaries whose redetermination window begins. Sample message content of the text messages is as follows, with the bracketed Call to Action text varying across arms: “Hi, this is nonprofit Covering WI, for the WI Dept of Health Services. Time to renew your BadgerCare or Medicaid! To get free, local help, [Call to Action] or visit www.coveringwi.org. STOP to end.” The treatment arms will be as follows:
Arm A: These consumers will receive one message connecting them with a chatbot. The Call-to-Action text will be “text COVER to 920-###-####.”
Arm B: These consumers will receive a message connecting them with a chatbot using the same Call-to-Action text as arm A. Two weeks after the initial message, they will receive an additional reminder message.
Arm C: These consumers will be prompted to speak with an assister by calling a hotline. The Call-to-Action text will be “call ###.”
Arm D: These consumers will be prompted to speak with an assister by calling a hotline using the same Call-to-Action text as arm C. Two weeks after the initial message, they will receive an additional reminder message.
There will be a second round of randomization for people who lost their Medicaid because of the redetermination process. These consumers will receive a message text such as the following: “Hi, this is nonprofit Covering WI, for the WI Dept of Health Services. Lost your health insurance? To get free, local help, [Call to Action] or visit coveringwi.org. STOP to end.” The group will be split into additional treatment arms with varied number of messages (1 vs. 2) and modality (texting with a chatbot vs. calling a hotline to speak with an assister), as in the first round of messaging.

2023-01-02

2023-12-30

The primary outcome is maintenance of Medicaid enrollment, measured on the individual level over the 12 months following each person’s redetermination deadline (e.g., at 1, 3, 6, 9, and 12 months; successful redetermination at 12 months). When analyzing data from the second round of outreach (i.e., for people who had already lost their coverage), outcomes will be measured at 1, 3, 6, 9, and 12 months after at the time of the receipt of outreach messages.

Secondary outcomes focus on application activities and outcomes, measured using the following categories: no application filed; application filed but denied due to lack of eligibility; application filed but denied due to administrative reasons; application accepted. Application outcomes will be measured at 1, 3, 6, 9, and 12 months after each person’s redetermination deadline.

The study population includes all fee-for-service Medicaid beneficiaries in Wisconsin, except those who prefer a language other than English or Spanish or who lack a cellular phone number.
Assignment to treatment arms will occur monthly over the 12-month period after the PHE, to ensure each beneficiary receives outreach at the beginning of their two-month redetermination window assigned by the state. Each month, Wisconsin DHS will provide Covering Wisconsin a list of the beneficiaries whose redetermination window begins. Randomization for people in each group of monthly renewals will be clustered by case (e.g., members of a household who applied for Medicaid together) to address potential spillovers. Cases will be assigned to treatment arms in equal numbers, with stratification on characteristics measured prior to randomization.
There will be a second round of randomization to determine outreach strategy for people who lost their Medicaid coverage during the redetermination process. As in the first round of randomization, cases will be assigned to receive outreach messages that vary in the calls to action (text vs call) and messaging frequency (1 vs 2 messages). The assignment process for this second round of randomization will follow the same process described above.

Randomization will be stratified by preferred language, Medicaid eligibility category at baseline (children, aged, SSI, pregnant, parents, adult without dependent children), whether there are enrolled adults over 50 or enrolled children at baseline, and tribal membership; for each stratification variable, missing data will be its own stratification category.

Randomization will be done in office using a computer.

Randomization for people in each group of monthly renewals will be clustered by case (e.g., members of a household who applied for Medicaid together) to address potential spillovers.

Yes

168,000

224,000

42,000 clusters in each of 4 treatment arms

The study has 80% power to detect a 0.66 percentage point change in enrollment rates due to changes in outreach repetition or suggested modality for contact.

Pre-analysis plan 07-14-2022.docx