Administrative hurdles drive Medicaid losses during redeterminations

Hundreds of thousands of people are losing Medicaid coverage because of procedural hurdles in states that have begun eligibility redeterminations during the early phase of a nationwide process of culling the program's rolls.

An estimated 15 million Medicaid beneficiaries are projected to exit the program as states unwind a federal policy requiring continuous coverage during the COVID-19 pandemic. Although the aim is to disenroll people who no longer qualify for Medicaid, others are getting caught up as states require beneficiaries to affirm that they remain eligible.

A state-by-state look at the impact of Medicaid determinations

In Arkansas, Florida and Indiana, more than 80% of those losing benefits so far are being removed from the program because of administrative reasons, such as not having current contact information on file.

“These are red flags here, and pretty soon we're gonna have more states coming online, and we don't want this to spiral out of control. It's going to be very important for the Biden administration to take action sooner rather than later,” said Joan Alker, executive director of the Georgetown University Center for Children and Families.

Although states must report monthly enrollment data to federal authorities during Medicaid redeterminations, most are not disclosing how many people are losing coverage for procedural reasons. The Consolidated Appropriations Act of 2023 requires the Centers for Medicare and Medicaid make enrollment information public, but the agency hasn't said when it will publish the data or whether it will differentiate between people determined to be ineligible based on income and those disenrolled for other reasons.

“While states are responsible for determining whether people should be enrolled in Medicaid, CMS takes our monitoring and oversight role incredibly seriously and is doing everything in our power to help states to go above and beyond the minimum requirements to keep people covered," Center for Medicaid and Children's Health Insurance Program Services Director Dan Tsai said in a statement. "No one is more concerned than this administration, from the president on down, to making sure people have the coverage that’s right for them.”

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Among the 21 states that have begun redeterminations, Arkansas, Florida, Indiana, Iowa, Pennsylvania and South Dakota are the only so far to release data on so-called procedural disenrollments, according to the Center for Children and Families. The Health and Human Services Department projects that 46% of those who will lose Medicaid during redeterminations, or 6.9 million people, will do so due to procedural reasons.

Arkansas removed more than 72,000 people from Medicaid in April, the first month states could begin trimming program rolls. People affected by this who believe they still qualify for coverage can provide the state with missing information to retain or restore benefits, an Arkansas Department of Health Services spokesperson wrote in an email.

In Florida, nearly 250,000 Medicaid enrollees lost coverage last month, more than 82.2% of them for procedural reasons. The Florida Agency for Health Care Administration did not respond to interview requests.

Indiana boasts the highest rate of procedural denials to date at 88.5%. The state's Medicaid rolls swelled to 2.2 million during the pandemic, a spokesperson for the Indiana Family and Social Services Administration said in an email. Some enrollees likely did not respond to state requests because they know they are no longer eligible, the spokesperson said. In addition to mailing notices, sending text messages and making telephone calls to beneficiaries, the agency is conducting a paid advertising campaign, the spokesperson said.

States are investing in new technology systems, training an army of brokers and partnering with health insurance companies and providers to reduce coverage losses.

In spite of this effort, most Medicaid beneficiaries are unaware that states have resumed eligibility checks, according to survey results the Kaiser Family Foundation published Wednesday. Sixty-five percent of respondents did not know about Medicaid redeterminations and another 7%—disproportionately Black or Hispanic—incorrectly believe states are not allowed to cut people from the program. Nearly 30% said they didn't know where to obtain replacement coverage and 15% expect to become uninsured.

CMS should require states with high levels of procedural denials to submit corrective action plans or pause redeterminations, said Lucy Dagneau, senior director of state and local Medicaid campaigns at the American Cancer Society Cancer Action Network. “What we are worried about is that it doesn't seem clear that states know necessarily why their rates of procedural denials are so high,” she said.

Long call center wait times, mail delays and fraud reporting further complicate the process for enrollees.

West Virginia, for example, is reviewing other states’ Medicaid systems to see if their residents are covered elsewhere. If an enrollee has an open file in another state, West Virginia removes them from Medicaid and initiates a fraud investigation, said Miriam Delaney Heard, a senior attorney at the National Health Law Program. To reinstate West Virginia Medicaid coverage, beneficiaries must close their files in other states and prove they were not committing fraud, she said.

“They're requiring a person to close a case out in another state. How is that even possible?” Delaney Heard said. “You call into these call centers and can’t get anyone and, even so, whatever state they came from is also going through redeterminations. How high is this going to be on their radar?” The West Virginia Bureau for Medical Services did not respond to interview requests. The state has not released updated enrollment data.

In South Dakota, more than 1,700 people lost Medicaid coverage in April who will become eligible when the state's Medicaid expansion takes effect July 1. The South Dakota Department of Social Services declined to comment.

North Carolina also is poised to expand Medicaid after the state enacted the policy in March. North Carolina will begin redeterminations in July, months ahead of the expansion taking effect, said North Carolina Medicaid Deputy Director Jay Ludlam. In the meantime, the state is making plans to assist those who leave Medicaid with finding replacement coverage and then enrolling eligible people into expanded Medicaid when it becomes available, he said.

“They don't have to fill out any paperwork. It will be seamless to them. They will become enrolled in the expansion population,” Ludlam said.

Arizona Medicaid, known as the Arizona Health Care Cost Containment System, disenrolled 33,705 people who signed up for Medicaid during the federal public health emergency and 6,126 people who had Medicaid prior to the COVID-19 pandemic, spokesperson Heidi Capriotti said.

Arizona continuously tracked enrollee information during the pandemic, which enables the state to more easily assess what beneficiaries are most likely to no longer qualify, she said. In addition, state employees didn't require training or retraining to carry out redeterminations, Capriotti said. “I would say the process is going as smoothly as expected,” she said.