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This spring, millions of people could lose health insurance coverage as a pandemic rule for Medicaid ends. As NPR's Selena Simmons-Duffin reports, the first step in that process began this week.

SELENA SIMMONS-DUFFIN, BYLINE: Medicaid is a lifeline for low-income people across the country. It provides health insurance coverage often without any premium costs or co-pays. Usually, states require Medicaid recipients to fill out forms every year proving they still qualify, but one of the first COVID relief bills allowed people to stay on without filling out any forms. So for three years, new people enrolled, but no one disenrolled. An astounding 91 million people now have coverage through Medicaid or the Children's Health Insurance Program. That's more than 1 in 4 Americans. But things are about to change.

ROBIN RUDOWITZ: As a result of the Consolidated Appropriations Act that passed at the end of the year, there's a set time frame for these provisions to end. So they will expire at the end of March, and then individuals could be disenrolled as of April 1.

SIMMONS-DUFFIN: Robin Rudowitz of the Kaiser Family Foundation explains February 1 was the day states could start sending out letters to people warning them that they need to reapply to keep their coverage. Some states wasted no time, including Arkansas.

JENNIFER PERKINS: We have heard that those are being sent out, that the patients will start receiving letters to let them know that those renewals will be coming.

SIMMONS-DUFFIN: That's Jennifer Perkins. She helps patients with Medicaid applications at 1st Choice Healthcare, a clinic in Pocahontas, Ark.

PERKINS: I think initially, it's going to be probably a little bit of a panic just because people don't want to lose their coverage that they've had for the last couple of years. They're comfortable with it. But I think once they get in there and realize that there are other options, it'll be OK.

SIMMONS-DUFFIN: Options for people who now make too much money to qualify for Medicaid include employer health plans or insurance you can buy on healthcare.gov. One concern is that people won't realize they need to fill out these forms to keep Medicaid, so lots of different folks are trying to get the word out with public service announcements, including state health departments...

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UNIDENTIFIED PERSON #1: If you receive Medicaid coverage in Idaho, I have some important information to share with you.

SIMMONS-DUFFIN: ...Nonprofits - this is from North Texas Food Bank...

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UNIDENTIFIED PERSON #2: It is so important for you to turn in your renewal packets. We are here to help you.

SIMMONS-DUFFIN: ...Even the Federal Health agency in charge of Medicaid, the Center for Medicare and Medicaid Services.

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UNIDENTIFIED PERSON #3: Make sure you get your Medicaid renewal letter so you're not left out in the cold.

SIMMONS-DUFFIN: For all these efforts, some estimates suggest things might not go well. A federal analysis estimated 15 million people could lose coverage during this unwinding process. Nearly half could lose coverage because of paperwork problems, even though they're still eligible. Experts like Rudowitz say if you or a loved one receives Medicaid, make sure your mailing address and email and phone are all up to date, and keep an eye out for that renewal notice. Selena Simmons-Duffin, NPR News.

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