Keila Szpaller, Daily Montanan 12/7/23
Some Montanans are finding out they’ve lost Medicaid coverage while in a waiting room.
Agencies are seeing clients who lost insurance and may end up costing them money. Some Montanans, including children, are waiting months to know whether their reapplications with the state are approved.
At least one clinic has laid off workers, and families are trying to figure out how to make their monthly budgets work to pay for private health insurance.
As an example, a family of four in Missoula County might qualify for a plan that costs $400 a month — $4,800 a year — with a deductible of $9,100, according to an option on Healthcare.gov.
That’s some of the fallout Montanans and the healthcare industry are experiencing in the throes of changes to Medicaid, according to professionals and policy analysts in the field.
But the Montana Hospital Association anticipates Montanans won’t understand the full impacts of the coverage losses until later in 2024.
In an email, Department of Public Health and Human Services spokesperson Jon Ebelt said the agency’s processing time for applications is currently within the 45-day requirement by the Centers for Medicare and Medicaid Services.
He also said the state is obligated to ensure people receiving taxpayer-funded health care coverage are in fact eligible for it.
In an interview this week, Mary Windecker, executive director of the Behavioral Health Alliance of Montana, said it’s an understatement to say Montana Medicaid has a lot on its plate with the Medicaid redetermination process underway and new provider rates in the works.
However, Windecker said Montana is getting a look at what might happen if Medicaid expansion goes away in 2025.
“This is an excellent preview of how bad it would be for the state if we lost Medicaid expansion,” Windecker said.
As of last week, more than 100,000 Montanans had lost coverage in the Medicaid redetermination process, according to a state health department dashboard.
By comparison, in April, when the redetermination process started, 302,812 people were enrolled, and as of September, the most recent month data is available, 246,469 people were enrolled, according to the dashboard.
The loss of coverage and rocky application process coupled with delays in getting health care providers increased rates is having ripple effects.
Jackie Semmens, a policy analyst with the Montana Budget and Policy Center, said it’s not too late for the state to make improvements, but both patients and providers are experiencing setbacks because of the disruption in coverage.
“Montana chose to move faster than nearly every other state, and our number of backlogged cases shows that the capacity to handle the high volume of redeterminations every month wasn’t there,” said Semmens. “This has resulted in thousands of people waiting for their case to move forward, people being unable to get the answers they need in order to return their information, and at worst, people losing coverage incorrectly.”
Pam Liccardi, clinical director at Oxytocin in Kalispell, said her clinic has 174 clients on its roster. Oxytocin does intensive outpatient services, including for patients who need help with addiction and mental health issues.
Of the total, Liccardi said the clinic can’t bill for 42 people who are waiting on Medicaid; in the past, the clinic might have had just three or four people who didn’t have insurance.
It also can’t bill for 26 clients who were trying to get Medicaid but have since left treatment because the clinic doesn’t know where they are in the process.
“I would be surprised if we didn’t lose a lot of good smaller clinics because they’re waiting to get paid,” Liccardi said.
Olivia Riutta, director of population health with the Montana Primary Care Association, said the open enrollment season is busy, and people are trying to understand their options if they no longer qualify for Medicaid.
“The costs of other goods and services have gone up,” said Riutta, also with Cover Montana. “So just because they’re not eligible for Medicaid doesn’t mean they have a lot of extra income to spend on health care.”
As of this week, she said the association saw a roughly 16% increase in marketplace enrollments this year compared to last year.
Recently, Republican Montana candidate for the U.S. Senate Tim Sheehy’s comments suggesting people simply pay their doctors drew some backlash. At an event in Glasgow earlier this year, the Bozeman businessman said healthcare worked before insurance and healthcare networks existed, according to Semafor, a media outlet focused on transparency in journalism.
“Each town had a doctor that would drive to your house, take care of you, and you’d pay him,” Sheehy said, according to audio Semafor obtained. “And guess what? It worked. It worked when you actually paid a doctor for services provided. And then we started getting into this HMO, insurance, mega-conglomerate structure.”
Sheehy’s campaign did not respond Wednesday or Thursday to a question from the Daily Montanan about his plan to deal with people who don’t have the cash to pay 100% of their health care bills up front.
During the COVID-19 pandemic, the federal government said people who had health insurance through Medicaid didn’t have to reapply to stay eligible. On April 1, that provision ended, and Montana started a process to ensure people who use Medicaid fit the requirements.
The process has been fraught. Earlier this year, the Centers for Medicare and Medicaid Services sent a letter to the Montana health department raising concerns about the number of people losing coverage and long hold times — 42 minutes on average — for phone calls.
At the time, spokesperson Ebelt said DPHHS was making improvements. He also said some of the long waits were because of the complexity of the issues people were dealing with as they received help.
In an email this week, he said processing times are currently within CMS’ 45-day requirement.
“DPHHS is committed to thoroughly reviewing and efficiently processing each redetermination and application,” Ebelt said. “Processing times can be impacted by a variety of factors including allowing adequate time for clients to follow up on requests for information from DPHHS.”
Riutta said some people who are losing coverage had Medicaid for a number of years because of the continuous coverage requirement, and the loss is a big shift now, as is understanding new cost-sharing structures.
“It’s different than what they are used to,” she said. “It’s often more expensive than what they’re used to.”
Windecker said some agencies are providing care to patients who are losing coverage and trying to help them re-enroll in Medicaid at the same time. But she said it’s an uphill battle because staff are not reimbursed for time they spend helping somebody reapply.
The revenue cycle has always been long in Medicaid, meaning a significant amount of time between billing and getting the money, she said: “But now it’s four or five months.”
In an email, Ebelt said providers have already started receiving rate increases. The new rule wasn’t approved until Sept. 8, but the new rates were uploaded into the system with an effective date of July 1.
“All claims that DPHHS could re-process have been completed,” Ebelt said.
A recent report to a legislative committee noted 67% of claims were adjusted and paid as of the week of Nov. 13, and the health department expects most claims to be adjusted by the end of 2023.
At some places, layoffs have already taken place, although how much is attributable to redetermination is hard to tell, Windecker said. She also said she doesn’t think she’s ever used the phrase “perfect storm” more since she’s worked in the field, with multiple significant initiatives underway at once at DPHHS.
Semmens, with the Montana Budget and Policy Center, said the center is concerned with the 41,513 people who are still waiting on their redeterminations to be processed — some since the process started.
“This backlog has put tens of thousands of Montanans in limbo,” Semmens said. “Montana is seeing such a high backlog due to the speed at which the state has attempted to move through redetermination.”
She also raised a concern with the reasons people are losing coverage. Just 31% have been found to be ineligible. The others, some 63%, have lost coverage because they failed to provide requested information.
But Semmens said people are still encountering long hold times and problems online, and the center is receiving reports of people who submit information only to receive a notice saying they never did so.
In the meantime, she said, the lack of insurance can have ripple effects across a person’s life, including on their health and their finances.
“Medicaid helps keep families and individuals financially stable by reducing the chances a medical emergency will result in bankruptcy or eviction,” Semmens said.
Katy Mack, with the Montana Hospital Association, said 2024 will reveal more of the impacts. In the meantime, hospitals will continue to treat all people who come through their doors.
“People who have lost coverage may be signed up again,” Mack said. “However, there may be a lapse in coverage that could result in interruptions to their care.”
She also said research shows a correlation between the rate of uninsured people and other health indicators for people and community.
“If there is an uptick in the rate of uninsured patients in Montana, it could lead to decreased access to services and poorer health outcomes for those Montanans, and increased financial strain for the local hospitals that provide services without receiving any payment for them,” Mack said in an email. “Providing charity care is an important role of Montana’s hospitals, but high levels of charity care could worsen the financial strain many hospitals are currently experiencing and weaken hospitals’ ability to sustain and invest in the various services needed by their community.”
Semmens said it’s not too late for the state to make improvements that would help people get coverage, such as upgrades to the website, increased options for in-person assistance, reduced wait times on the help line, and faster processing for applications.
“Redetermination has helped shed light on some of the difficulties people on Medicaid and other types of assistance face,” Semmens said. “We believe that when people are facing tough times in their life, they should be met with dignity and not left to face hours of red tape.”
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.