Health department provides redetermination data, but glaring questions remain

Mar 28, 2024

Victoria Eavis and Nora Mabie, Mar. 26, 2024 - State News Bureau

After acknowledging at least 100,000 Montanans lost Medicaid coverage in a "redetermination" effort last year, state health officials still won't confirm the total number of people who were put through the process.

Montana legislative staff requested records from the state health department last fall, but went through multiple contentious discussions about fulfillment of that request, followed by a second records request from legislative leadership. Lawmakers finally got with what appears to be some of the illustrative data on Medicaid “redetermination” earlier this month.

This data may be the most in-depth look at which groups were hit hardest by redetermination, but major questions remain about the integrity of the numbers, and the department of health has not clarified the apparent discrepancies. More than 100,000 Montanans lost health insurance in the process.

The Medicaid “redetermination” process in Montana spanned 10 months from April 2023 until Jan. 31. During the federal government’s public health emergency for the COVID-19 pandemic, people previously approved for coverage stayed on Medicaid regardless if they no longer qualified under metrics, such as income. With the end of the official public health emergency in the spring of 2023, the feds ordered states to reconfirm residents’ eligibility for the program. This revamp has led to droves of people being removed nationwide.

In a Children, Families, Health and Human Services interim legislative committee (CFHHS) earlier this month, the Department of Health supplied lawmakers with point-in-time demographic data through March 4 on how various populations across Montana were impacted by the redetermination process.

According to the data provided to the committee, 76,867 adults and 35,798 children were terminated since the start of redetermination. It remains unclear what proportion of the total Medicaid population (before redetermination began) those disenrolled Montanans make up, and DPHHS has not provided clarification on the numbers despite multiple requests from Lee Montana.

“Huge chunks of the folks who were disenrolled [were] kids, American Indians and seniors and I think that was entirely predictable,” said House Minority Leader Kim Abbott, D-Helena, the author of the records request. “That’s either incompetence or it’s malicious.”

There is some indication that the department may have disenrolled more people than it originally predicted it would.

According to the most recent DPHHS quarterly financial report, there were roughly 19,000 fewer people enrolled in Medicaid in December 2023 than the department projected there would be at that time.

Tribal communities hit hard

As of early March, 12,781 Native Americans were terminated from the healthcare program, according to data from DPHHS. When broken down by age, that’s 4,137 children and 8,644 adults.

While the health department issued letters in the mail and attempted to reach people by phone about the redetermination process, experts say Native Americans faced unique barriers in navigating the complex system.

People who live on reservations in Montana often don’t have traditional mailing addresses. It’s not uncommon for several families to share one P.O. box. And not everyone has access to internet, a computer or phone to receive information from the health department. A deep-seated mistrust in Western health systems means some people in tribal communities may feel uncomfortable walking into a state health office.

While the redetermination process was intended to kick out people who no longer needed Medicaid, tribal experts say when it comes to Native communities, it’s likely that most people lost coverage because they never received information about the update in the first place.

Lesa Evers, who is Little Shell and Blackfeet descendant, worked as the tribal relations manager for the state health department for more than a decade.

“People live differently in reservation areas,” she said. “My grandpa would get the mail and throw it on the dashboard. It didn’t matter if it was from the Department of Health and Human Services.”

Widespread Medicaid disenrollment in tribal communities, experts argue, will have far-reaching consequences — not only limiting individuals’ ability to access care, but also further burdening Indian Health Service, tribal health programs and Urban Indian Organizations that rely on third-party billing to build important services.

Anna Whiting Sorrell, a citizen of the Confederated Salish and Kootenai Tribes, previously held leadership roles in the state health department and federal Indian Health Service, and she served as an administrator for the tribal health department on the Flathead Reservation. She said when people who rely on this care are disenrolled from the program, the consequences can mean the difference between life and death.

“If people can’t go on (Medicaid), they don’t get care, and they die,” she said. “If you don’t get health care, you die.”

recent Lee Montana series revealed that Native Americans in Montana die, on average, 17 years sooner than their white neighbors. Whiting Sorrell said limiting people’s access to care will only exacerbate existing disparities.

“We die at such younger ages,” she said. “My mom died at 57. My grandma at 42. And I don’t see the world changing much. It’s still happening. You can’t get through the grief.”

Indian Health Service, the agency responsible for providing health care to federally recognized tribes, is chronically underfunded, understaffed and under-resourced. IHS leaders say it can take years to hire doctors or nurses, and patients subsequently face long wait times to access appointments.

But leaders say Medicaid has eased the burden on this fractured system of care. When IHS, for example, is able to bill Medicaid for certain services, the agency brings in revenue that can be used to support other programs.

But when people lose coverage and IHS is unable to bill Medicaid, experts say the agency will suffer and instead be forced to prioritize which services it can provide with limited funding.

The same goes for tribal health departments and tribal health programs statewide. When tribal health departments bill Medicaid for services, they can use the revenue to grow new programs or hire more people. On the Flathead Reservation, CSKT Health Department used some Medicaid revenue, in part, to support the new health clinic in Ronan, to hire clinical pharmacists and bring care to smaller communities, like Hot Springs and Dixon. On the Rocky Boy Reservation, the health center used some Medicaid revenue to offer preventive services, like cancer screenings and colonoscopies.

Urban Indian Organizations, which provide access to health care in larger population areas, receive about 1% appropriated IHS funding and therefore must rely heavily on grants and third-party billing.

Todd Wilson, executive director of the Helena Indian Alliance, said the organization has already seen a dip in its third-party revenue because people were disenrolled from Medicaid.

IHS funding, he said, mostly supports the organization’s clinical services, primary care providers and nurses. Whereas third-party revenue supports things like the behavioral health department, which currently employs 15 people. If Urban Indian Organizations can no longer rely on critical funding, Wilson said tribal health leaders may have to start prioritizing certain personnel or services over others.

“If Medicaid expansion isn’t authorized or it sunsets, all the Urban Indian Organizations and all the tribes are going back to a 2013, 2014 or 2015 operational style,” he said. “We looking at basically backtracking 10 years.”

Highly eligible populations

As of early March, nearly 36,000 children have been kicked off Medicaid.

While other populations saw larger proportions disenrolled from Medicaid, children have a high eligibility threshold that other groups do not have.

“Some of those [children] are potentially aging out of the Healthy Montana Kids program, but the eligibility is higher for children and so to see these levels of disenrollment of children is pretty alarming,” said Heather O’Loughlin, executive director of the Montana Budget and Policy Center.

Since the beginning of this process, there has been confusion among parents about how their eligibility impacts their children. Many parents, for example, incorrectly believe that if they lose their Medicaid coverage, their children automatically do as well.

Of the 36,000 children who have had coverage terminated, 27,000 of those were a part of households where parents also lost coverage, according to the data provided to the committee. The data did not break down the reasons for termination among that group of children.

The federal government sent a letter in December addressed to Gov. Greg Gianforte because Montana had the fourth-largest percentage drop nationwide — 18% as of the fall — in the number of children who lost coverage since the process began and urged the state to take measures to correct its course. Federal Secretary of Health and Human Services Xavier Becerra wrote he was “deeply alarmed” in the letter.

“Children are more likely than their parents to qualify for Medicaid due to higher income eligibility thresholds for children in Medicaid and CHIP. This means that as children go through the renewals process, many children should still be Medicaid- or CHIP-eligible and should not be getting disenrolled,” Becerra wrote. “Many states have already taken steps to ensure eligible children stay enrolled.”

Many of the details of how DPHHS executed dis-enrollment remain unclear to this day.

“We've been seeing high numbers in kids since the beginning,” said Dr. Aaron Wernham, CEO of the Montana Healthcare Foundation and a family physician. “I don’t think we have a good explanation for it.”

Seniors are another demographic group, like children, who are likely to continually be eligible. So far, roughly 7,600 seniors have been disenrolled according to the state’s data.

When a senior is covered by Medicaid, they often live in skilled nursing facilities or receive in-home care and rarely have changes in income or assets at that point in their lives, explained Rose Hughes, executive director of the Montana Health Care Association. In other words, it’s highly likely that many of those who had their care terminated are still eligible.

'It’s reckless’: Montana Medicaid revamp kicks off most at-risk, forces debt on providers

“[This] tells me that the process didn’t work very well knowing that these folks probably remain eligible and also knowing that they’re elderly and often have difficulty taking care of things,” Hughes said. “We should’ve dealt with those individuals differently … there should’ve been more conversations with the facilities.”

According to a previous Lee Montana report, there is evidence that many Montanans who likely have ongoing eligibility — whether they were in a nursing home, in the care of child protective services, on a disability waiver or something else — did not have their healthcare coverage reevaluated differently than those who may have had a change in eligibility.

Medicaid Expansion

The Medicaid Expansion population, on the other hand, is far more likely to include people who became ineligible for the healthcare program while the public health emergency was in effect.

Of the total adults that went through the redetermination process, the majority were covered by Medicaid Expansion. Medicaid Expansion covers adults who are not eligible under traditional Medicaid due to income thresholds and the expansion population tends to be covered for only a couple years, O’Loughlin explained. This population gained coverage when the Legislature expanded Medicaid via the Affordable Care Act in 2015 and has renewed the expanded program once since then.

Nearly 69,000 people covered by Medicaid Expansion had their coverage terminated through the process. About 65,500 people in the expansion program had coverage renewed, according to the data provided to the committee.

Medicaid expansion is back on the chopping block in the 2025 legislative session, and particularly because of the unwinding process, it’s likely to be one of the defining issues of the next session.

Outstanding questions

When the pending, renewed and disenrolled groups are summed for certain demographic groups (like children, for example), the number is drastically different than the total number on DPHHS's Medicaid dashboard. In theory, those numbers should be close to identical, but the department has not clarified those discrepancies. 

While the outstanding questions about the data make it difficult to calculate what proportion of the total Montana Medicaid population these disenrollments account for, Department of Health Director Charlie Brereton did give a presentation with some proportions.

The 36,000 children account for about 35% of the total number of children who were enrolled in Medicaid before redetermination started, according to the director’s presentation given at an interim committee meeting. The same presentation stated that 50% of children were renewed and 15% are still pending. It remains unclear how the department calculated those proportions.

Roughly 40% of adults were terminated from coverage, according to the same presentation, with 44% being renewed and 16% still pending.

Top Democrat reprimands health dept director, questions Medicaid data

Days after the demographic redetermination data was provided to the CFHHS committee, Abbott sent Brereton a forceful letter asking multiple questions about discrepancies in the data that she identified. In response to the letter, the agency’s legal counsel requested that the minority leader submit an official records request.

“We understand the March 13, 2024 letter to be a request for additional information from the Department — and, thus, is a new public records request. As of October 1, 2023, all agencies that report to the governor are required to respond to public information requests through the Office of Public Information Requests located in the Department of Administration,” DPHHS legal counsel Paula Stannard wrote to Abbott. “This email does not constitute acknowledgement of your request. Please visit OPIR’s website ( to submit your request.”

Pending cases

While no new people will be roped into the redetermination process, many cases are still classified as “pending” in the data provided to the committee, so the final number of terminations and renewals remains unknown.

“I think we’re still several months away from really understanding the full impact and where enrollment will ultimately be in part because folks are going to have to go through the reapplication process when it is entirely possible that they were eligible all along,” said O’Loughlin.

According to the data provided to the interim committee, there are tens of thousands of people whose cases are still pending: 15,079 kids and 29,436 adults.

“I think that there's a significant amount of work that’s going to have to go into reenrolling Montanans who are still eligible,” O’Loughlin said.

While the official end date for redetermination passed over a month ago, the effects of the process will continue to ripple across Montana for months to come.

Montana Budget & Policy Center

Shaping policy for a stronger Montana.

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.