CMS halted Medicaid coverage redeterminations in six states due to procedural issues leading to improper disenrollments. States violating federal requirements faced suspension, and CMS directed reinstatements for those impacted. Efforts to raise awareness among beneficiaries are ongoing. The pause aims to rectify wrongful termination, potentially reducing the predicted 8 to 24 million coverage losses. Backlogs and staffing challenges add to state struggles. CMS remains committed to reinstating eligible beneficiaries in the next 12 months.
Medicaid coverage redeterminations have resulted in unintended disenrollments in certain states due to procedural issues. In response, the Centers for Medicare and Medicaid Services (CMS) has implemented a pause on coverage redeterminations in at least six states, nearly four months after the Medicaid continuous enrollment provision ended.
Reasons for the Pause
During a press call on July 19, CMS Administrator Chiquita Brooks-LaSure and Deputy Administrator Dan Tsai discussed the factors leading to the suspension. The primary concern was that most Medicaid coverage losses occurred due to procedural reasons. States faced challenges in identifying ineligible beneficiaries because of issues such as a lack of awareness, incorrect addresses, and beneficiaries not receiving Medicaid renewal forms.
Identified Procedural Barriers
CMS examined six states and found violations of federal requirements in handling redeterminations. Consequently, CMS suspended procedural terminations for impacted populations who were unable to follow the regulatory process fully. States were directed to reinstate individuals who were improperly disenrolled, leading to the reinstatement of tens of thousands of people in some states. Discussions with another 12 states about potential issues are ongoing.
Common Issues Discovered
CMS identified system glitches that hindered states from using electronic data matching for automatic renewals. The matching process, using income data on record, would have confirmed the continued eligibility of beneficiaries. However, this system failure resulted in eligible beneficiaries not receiving notices of coverage renewal.
Duration of the Pause
The duration of the redetermination pauses varies by state, with terminations delayed for up to 90 days to allow time for system corrections. The length of the pause depends on how quickly the states can address the issues identified by CMS. Failing to rectify the errors and resume appropriate redeterminations may result in the loss of enhanced federal funding for state Medicaid programs.
Efforts to Reinstate Coverage
CMS is collaborating with stakeholders in the private sector, including health plans and providers, to raise awareness among Medicaid beneficiaries about the renewal process. Retaining coverage for eligible beneficiaries has proven challenging due to a 28 percent increase in Medicaid enrollment during the COVID-19 pandemic, mainly driven by the continuous enrollment provision introduced by Congress. However, CMS remains committed to reinstating eligible beneficiaries who lost coverage over the next 12 months.
Proposed Solutions During the Pause
Jen Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities (CBPP), highlighted varying strategies for preventing wrongful termination of Medicaid coverage. Some states chose to delay redeterminations by 30 days to conduct additional outreach to overcome administrative barriers. For states found in violation of regulatory requirements, stronger oversight is necessary, with more personnel on the ground to observe violations and provide feedback to CMS for timely resolution.
Projected Impact of the Pause
The procedural termination pauses have different implications for beneficiaries and states. Beneficiaries who were mistakenly disenrolled have the opportunity for reinstatement and to complete the renewal process. The delays may also indicate improvements in disenrollment issues for future beneficiaries. However, the pauses may add to the challenges faced by state Medicaid programs, as they must now reprocess cases and manage backlogs, given existing staffing challenges.
Overall, the pause on Medicaid coverage redeterminations aims to address the improper disenrollment of eligible beneficiaries in several states. By identifying procedural barriers and working with stakeholders, CMS endeavors to ensure a smoother and fairer redetermination process for Medicaid beneficiaries, reducing the risk of coverage losses for millions of individuals.
