Millions of Americans may be on their way to losing Medicaid coverage as a COVID-era continuous enrollment provision falls by the wayside.

As of April 1, five states — including Arizona, Arkansas, Idaho, New Hampshire and South Dakota – began disenrolling residents from Medicaid. 

What happens in those states is the first part of what’s being called the “Medicaid unwinding,” as 14 more states will begin dropping newly ineligible residents from the health program in May.

During the pandemic, Congress passed the Families First Coronavirus Response Act (FFCRA), which required Medicaid to allow people to remain continuously enrolled until the end of the public health emergency

Partially driven by that provision, enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) soared since COVID-19 hit — increasing by more than 23 million people.

Anywhere from 5 million to 14 million people are now expected to lose coverage, according to the Kaiser Family Foundation (KFF)

The process is expected to hit children and young adults, as well as Latino and Black populations, the hardest. According to federal data, about 9.5% of current Medicaid enrollees will lose coverage. One-third of the people expected to be dropped from the rolls are Latino and 15% are Black.

The Department of Health and Human Services (HHS) noted the grand unwinding “presents the single largest health coverage transition event since the first open enrollment period of the Affordable Care Act.”

Now, it’s up to state Medicaid agencies how to handle the unwinding and decide how long it will take to review eligibility for millions of people. 

While about half of the people expected to lose coverage will no longer be Medicaid-eligible, a large amount will be disenrolled even though they are still eligible.

In a statement, Melanie Fontest Rainer, director of the HHS’ Office for Civil Rights (OCR), pointed out that states will have to manage the mess to ensure certain groups of people — including people of color and people with disabilities — don’t lose coverage suddenly.

“OCR is deeply committed to helping states ensure that eligible individuals with limited English proficiency and individuals with disabilities are provided with meaningful language access and effective communication to ensure they do not experience an otherwise unnecessary lapse in coverage,” Rainer said.

Going forward, how states will communicate the process to residents will be crucial. 

In Arizona, for example, the state Medicaid agency has begun sending text messages, letters and phone calls to enrollees encouraging them to update contact information — and plans to roll out another text message campaign to follow up. 

States will also need to partner with community leaders and health centers to reach people impacted by the policy rollback. 

Still, some experts are concerned that large swaths of people may find out they no longer have Medicaid coverage unexpectedly. 

“We are very concerned about families, and particularly children, losing health coverage without their knowledge – that they will find out when they show up to the doctor,” Hillarie Hagen, a health policy associate at Idaho Voices for Children, told CNN.

Each state’s approach will also vary depending on its system capabilities, data processing, staff capacity and communications strategies, KFF noted. It’s important to note that some states have more comprehensive approaches than others.

The HHS’ OCR outlined several best practices for states to adopt, like properly funding and staffing call centers and providing information in accessible ways, like large-print or Braille when needed. The OCR also recommends making sure websites and other communications channels are accessible to people with disabilities.

Yet as most states begin the disenrolling process this May and June, the full impact is remains to be felt. 

“We go to sleep at night thinking about this and wake up in the morning thinking about this,” Daniel Tsai, Medicaid director at the Centers for Medicare and Medicaid Services, told The Washington Post.