Nearly half of the 15 million Medicaid patients across the U.S. at risk of losing coverage when the COVID-19 public health emergency (PHE) ends may fall prey to “administrative churning.” That is, they could lose coverage despite remaining eligible because of difficulties navigating the renewal process, address changes, and other administrative challenges.
This figure is among the key findings of a recent issue brief from the U.S. Department of Health and Human Services’ (HHS’) Office of the Assistant Secretary for Planning and Evaluation (ASPE).
Although the brief doesn’t include state-level estimates, previous analyses indicate Texas Medicaid patients are especially vulnerable to the post-PHE coverage cliff. The Texas Health and Human Services Commission (HHSC) estimates about 3 million Texans – predominantly postpartum women and children – have had their Medicaid coverage extended as a result of the PHE, which, as of this writing, has been extended to Oct. 13 and could get renewed once more.
Austin oncologist Debra Patt, MD, said Texas Medicaid places “a high administrative burden” on patients to maintain coverage, which often leads to lapses in care.
“Those care delays pose a risk to patients,” she added.
Texas is one of six states where children enrolled in Medicaid and in the Children’s Health Insurance Program (CHIP) are at high risk of falling into administrative gaps, according to a February report by the Georgetown University Center for Children and Families. According to those study authors, children are most vulnerable in states that:
- Have separate CHIP programs;
- Charge premiums for CHIP coverage;
- Don’t provide 12 months of continuous coverage for children in Medicaid; or
- Process less than half of their renewals using existing data sources.
Texas has all these risk factors.
In response to this potential loss of coverage, the Centers for Medicare & Medicaid Services in March issued guidance around unwinding continuous coverage, giving states 12 months after the PHE ends to initiate the eligibility process, plus an additional two months to complete any pending redeterminations.
HHSC then developed a three-phase plan to redetermine eligibility for an estimated 3.7 million Medicaid patients within eight months.
TMA and nine other Texas organizations dedicated to improving health care access have raised concerns about this timeline.
“According to a recent survey of state Medicaid programs, Texas will be one of only [eight] states attempting to unwind the PHE-related continuous eligibility provision without allowing up to a year” of follow-up coverage, the signatories wrote in a March 31 letter to HHSC. “Additionally, unwinding too quickly will result in human and financial costs not only to millions of Texans, but also the state’s safety net, already strained by the pandemic.”
TMA and the other organizations also offered a series of recommendations to prevent such an outcome, including urging HHSC to:
- Leverage data, automation, and flexibility to ease some of the burden on the eligibility system and workforce;
- Improve access to its “211” help program by increasing staff to address wait times, or by establishing a dedicated line for Medicaid patients to update their contact information; and
- Maximize patient outreach via text to ensure eligible Texans maintain coverage.
Dr. Patt says patient outreach is especially important given the limited capacity of practices like hers, which have taken on additional work during the pandemic: counseling patients about COVID-19 vaccinations, managing care that patients have let lapse, and dealing with increased mental health needs, for instance.
“And that’s in addition to the cancers we’re treating,” she said.
Regardless of how the unwinding process unfolds, many of the poorest Texas Medicaid patients deemed ineligible will not have another coverage option – largely because Texas hasn’t extended health care coverage to low-income working adults as allowed by the Affordable Care Act, says Helen Kent Davis, TMA vice president of government affairs.
The Inflation Reduction Act, which President Joe Biden signed into law last month, extended subsidies for federal marketplace health plans through 2025, which Ms. Davis says could help blunt the impact of the PHE’s end for some vulnerable Texans – so long as those who are eligible for marketplace coverage are connected to it.
Still, Texas physicians caring for Medicaid and CHIP patients face a potential increase in uncompensated care when the PHE does end. Between now and January, Ms. Davis encourages practices to prepare for this possibility by:
- Urging their Medicaid patients to complete their eligibility redetermination as soon as possible;
- Scheduling services for patients who may lose coverage and familiarizing themselves with potential coverage options for such patients; and
- Evaluating the financial impact of a potential increase in uncompensated care.
In addition, practices should expect to reverify patients’ Medicaid eligibility when the PHE ends, which can be done through:
The Families First Coronavirus Response Act increased federal Medicaid matching dollars for states that agreed to maintain Medicaid coverage for anyone enrolled in the program through the end of the PHE, including Texas. As of this writing, the PHE has been extended 10 times, most recently to Oct. 13. Because HHS has committed to giving states 60 days’ notice before ending the PHE, experts anticipate the PHE will be renewed for an 11th time, until mid-January.