Holly Michels Jul 28, 2023
Even more people were removed from Medicaid coverage in Montana during the second month of a massive process to re-determine the enrollment qualifications of everyone on the program.
The pace of removals and data showing most of those who lost coverage ended up there because they failed to provide requested information to the state health department triggered two groups to ask the federal government to address their concerns and push the state to consider pausing or slowing the rate of the process called "unwinding."
The state health department reported that 19,244 people were removed from Medicaid in May, compared to 14,960 in April when the unwinding started. That means nearly half of those in the first two rounds of reviewing coverage qualifications have lost their health insurance, or a total of 34,204 people.
The removals are happening as part of a process going on nationwide. During the federal public health emergency declared for the COVID-19 pandemic, people who were approved for Medicaid coverage remained on the program regardless of fluctuations in their income or other metrics used to determine qualifications. But with the end of that emergency status earlier this year, states began the process of reviewing those qualifications.
More than 64% of those who lost coverage did so not because the state determined they were ineligible, but because they failed to return information asked for by the Department of Public Health and Human Services. It's unclear how many of those people would have remained qualified for Medicaid if they returned the paperwork. About a quarter of the population reviewed so far (that the state was able to gather information for) was determined ineligible for continued coverage. The unwinding process is set to take 10 months total.
Jon Ebelt, a spokesperson for the state health department, said in an email this week the department started the process with populations more likely to lose coverage because they were previously qualified based on income or other things more likely to have changed over the last three years. It will then move to review coverage for the aged, blind and disabled populations in the fourth month of unwinding.
“DPHHS expects these initial months to have a higher closure rate as a result of this population-based approach,” Ebelt wrote. He added people can still re-apply for coverage and appeal decisions about ended coverage, and that the department has worked with partners to inform people about other options for health insurance like the federal marketplace.
Earlier this month the Montana Budget and Policy Center and Montana Women Vote sent a letter to the federal government expressing "deep concerns about the process and outcomes of the Medicaid unwind in Montana."
“Though still in the early stages, we have encountered many issues that seem at odds with the shared goals of the state, advocates, and providers — to ensure that people can move through the process fairly and without undue hardship and to minimize, to the extent possible, unnecessary coverage loss,” the letter reads.
The letter referenced a backlog of renewals submitted before the end of May but still pending and terminated coverage for those stuck in that process, as well as excessive call center wait times — from between two to eight hours.
In a response this week, Ebelt wrote that the state is following requirements in law to re-evaluate if people are qualified for coverage.
“With the federal pandemic health emergency now over, DPHHS is exercising its statutory responsibility to verify the eligibility of Medicaid recipients. This includes recipients who may have enrolled in Medicaid during the pandemic and no longer qualify for coverage, including those who reentered the workforce and have employer-sponsored health care coverage,” Ebelt wrote.
The letter also raises concerns about how fast the state is moving through the reviews. Though the federal Centers for Medicare and Medicaid suggest states process no more than one-ninth of their Medicaid population every month, Montana is attempting more than that over five of the first six months, the letter points out.
“In total, the state will initiate 75% of renewals in the first six months of the unwinding. Given the stories we have heard from Montanans, we are concerned the state is attempting a renewal pace which exceeds its ability to provide people with accessible and accurate renewals,” the letter reads.
Ebelt wrote that the state is processing Medicaid redetermination cases “in a timely and accurate manner, and in accordance with a plan submitted to and reviewed by the U.S. Centers for Medicare & Medicaid Services.”
He added that the department is “leveraging a variety of communications tools and operational flexibilities offered by CMS.”
“To date, over 30,000 Montanans have been redetermined eligible for Medicaid, with more renewals on the way as our 10-month process steadily continues,” he wrote, adding that the department when possible tries to verify who is qualified for coverage through an automatic electronic process.
But the letter says there are issues with enrollment for people getting information from the state and trying to provide what's asked of them.
“We have heard many anecdotes of individuals who followed instructions, believed they were still covered, and did not receive notice that they had been disenrolled until they were turned away at the pharmacy or clinic," the letter read.
Additional problems the letter notes include a non-functioning virtual chat assistant on the health department's website, the application portal being overly complicated and logging out people who are trying to work through the application process, and the helpline disconnecting people during long wait times.
“Given the serious and endemic nature of these issues, we believe that the large number of Montanans being unenrolled includes a high percentage of people who have not had a fair and timely redetermination process and who may still be eligible for coverage,” the letter reads.
Ebelt said the department is working to address wait times.
“DPHHS is exploring ways to simplify the phone tree options, increase speed of answer, and resolve questions quickly. The department is dedicated to serving each and every client,” Ebelt wrote. “To best serve those calling the helpline, staff spend as much time as necessary with clients to ensure their case is properly processed, their questions are answered, and next steps are clearly communicated.”
Skye McGinty, the executive director of All Nations Health Center in Missoula, said her organization has been using a $1 million grant the center pursued to help connect people with health insurance. The focus groups include kids, pregnant people and the Native populations.
The center works with about 2,000 active clients, about 70% of which are eligible for Medicaid, McGinty said, and eligibility specialists work with them to apply for and keep coverage.
While people may mistakenly think the Indian Health Service is synonymous with health insurance, it’s not. And with about 40% of the state’s Native population living off reservations, care is frequently accessed elsewhere. All Nations also serves the entire Missoula population, not just Natives.
Additionally, people often need specialized or additional care beyond what the clinic can offer, such as a podiatrist or asthma specialist, services that can be expensive without insurance.
Having continuous eligibility on the program during the pandemic was dramatically helpful to reliable access to health care, McGinty said.
“For three years we completely paused all of that and it had a huge, monumental, tremendous impact for our patients who aren’t having to think about it,” McGinty said.
“It meant a decrease in their anxiety and their fear about not being able to access health care at all. People don’t have as much fear as when they have to go through a redetermination process every year. It was a time when it was so uncertain and really scary for a lot of people, and at least there was a constant of ‘If we need medical help, if we need some amount of coverage, then we do have that through Medicaid.’”
Many people first gained coverage during the pandemic, so navigating the re-enrollment system is new to them, McGinty said.
“It’s no secret to everyone this system is really clunky and the application process is really esoteric,” McGinty said. “If you don’t have the right documents and you don’t have your taxes in order, there’s a lot of different delays that can happen. It’s pretty discouraging having to go through that system, especially by yourself.”
There are other challenges besides the complex paperwork process. For people who live in rural areas, they might not be able to check their PO Box every day and could miss deadlines to re-enroll. They might also not know what the mail coming from the health department is, or not have transportation available to make trips to a place to get help navigating the enrollment process or be able to take time off work or away from caregiving obligations.
For pregnant people, there’s additional racism in traditional western medical settings where value judgements are made about people of color expecting children. The additional pressures put on them to be high-performing parents and seen as doing everything possible for their children can make it a challenge to find capacity and time for other things.
Marilyn Gomez, an eligibility specialist with All Nations, said many of her clients arrive to her confused about paperwork they’ve received, perplexed by the forms the state needs filled out or after learning their coverage was already terminated.
“I’ve had multiple clients come in saying they verified their address and were waiting for paperwork in the mail and now in the month of June or July, they go to the pharmacy to pick up medications and they tell them you’re closed (meaning their coverage has ended),” Gomez said.
One of Gomez’s clients was caught in a complicated web when his coverage was terminated. He didn’t receive any of the mail to complete his redetermination process because his account was initially established under his now ex-wife and communication was sent to her. Though the man qualifies for benefits, he wasn’t able to get a warning about what was about to happen or send the state information to show he should receive them.
Then when he submitted a new application online, the system automatically associated him with his former wife’s account, further delaying the process.
“Because this patient had an urgent medical need with his medication, I was on hold for five-and-a-half hours and finally got an agent who said they couldn’t find his application at first,” Gomez said. Because his application was linked to someone else's with no way to correct that, the man needed to do another application over the phone again.
Other patients are waiting through the 45-day window for their reapplications to be processed after a denial.
“If somebody's diabetic and they need to get their medicine, I can’t tell them ‘Oh, Medicaid is pending but you can go get your insulin,’” Gomez said.
People can also be intimated by the sheer amount of information mailed to them, Gomez said, along with the process to apply online. There’s a dual-verification requirement to establish someone’s identity, and without a laptop or cellphone it’s not possible to submit.
“A lot of the people I’m working with are not technologically savvy,” Gomez continued. She had to get a work-issued smartphone to help people navigate the verification process, which requires the ability to take and submit a photo online.
Patients who lose access to health insurance are no longer able to keep seeing their doctors for chronic conditions that get worse without regular treatment, McGinty said, and can also lose access to medications.
“That’s been the biggest fear I’ve heard from our clients is the disruption,” McGinty said. “That’s huge and then the disruption for their children is huge, whether it’s physicals or sick child visits, there’s a big fear around losing that coverage for kids. It’s not healthy for our people to be cold-turkey stopping and restarting medication.”
By July 13, 13,748 children and teens under the age of 18 have lost Medicaid coverage through the unwinding process, Ebelt said.
“The number of children who have lost their health care in the past two months is concerning. It is more than every Montana public preschooler and kindergartener enrolled last year,” said Stephanie Morton, the executive director of Healthy Mothers, Healthy Babies Montana.
“Children need access to checkups and essential vaccinations. Those with chronic health conditions, such as cancer and diabetes, may miss medications that keep them alive. Administrative hurdles to keeping eligible kids and families covered are adding to the already difficult job of parents and caregivers in our state.”
Gomez, the enrollment specialist, said information coming from the health department doesn’t help parents understand that even if they exceed income limits for adult programs, their child still may qualify for Healthy Montana Kids programs.
“They’re not aware of the diversity of programs offered, so they go and search the income limits and it brings up the one for them as adults and they’re not interpreting the information correctly,” Gomez said.
People may also get denial letters for themselves but not realize it doesn’t necessarily apply to their children.
Families can be placed onto transitional Medicaid to offer some coverage while trying to get insurance elsewhere, but there’s minimal information provided about the program and people often don’t know if that means their child is still insured, Gomez said.
CMS has stopped the redetermination process in a dozen states, not including Montana. CNN reported earlier this month Daniel Tsai, director of the Center for Medicaid and CHIP Services, told reporters in a press briefing that “despite all the preparations and what we know has been a tremendous amount of work at the state level and in the community, we are very concerned about the level of terminations, meaning disenrollment, that we are seeing across the country.”
Outreach efforts in Montana have included approximately 100,000 text messages to households most likely to have new mailing addresses encouraging them to update their contact information, Ebelt wrote. The health department also plans a new public service announcement campaign about redetermination, to run through the rest of the process.
Still, groups like the organizations that signed the letter to the federal government and All Nations in Missoula worry about the pace of review and disenrollment.
“Those 10 months are going to go by really fast,” McGinty said.
Holly Michels is the head of the Montana State News Bureau. You can reach her at email@example.com
MBPC is a nonprofit organization focused on providing credible and timely research and analysis on budget, tax, and economic issues that impact low- and moderate-income Montana families.