Medicaid ‘unwinding’ complete in Montana, nearly 24,000 people still pending

Medicaid illustration by Nick Youngson (CC BY-SA 3.0)

Medicaid redetermination is officially done, but more than 23,000 people are still waiting to find out whether they qualify, according to a final report discussed Wednesday in a legislative committee.

And the head of the Montana Health Care Association said its members are still waiting on $8.8 million in delayed payments for 25 nursing facilities — roughly half in the state — for both redetermination cases and new Medicaid applications.

Charlie Brereton, head of the Montana Department of Public Health and Human Services, said it’s a two-way street when it comes to delayed payments, and providers need to “proactively communicate.”

However, he said the state considers redetermination to be complete — with some lessons learned for the future. Redetermination is the process to review whether people using Medicaid still qualified for it after the COVID-19 pandemic.

“There is a silver lining in this redetermination process, and that is that it shed light on some cracks in our public assistance delivery system,” Brereton said. “And we are committed to addressing those cracks and improving the client or customer experience for Montanans.”

Earlier estimates put the number of people who lost coverage for procedural reasons — or paperwork — at 64% . The Health Department said at times it waited for necessary documents from applicants, but Medicaid members also reported repeatedly turning in the same paperwork.

The report compared the Health Department’s own projections for enrollment after redetermination with actual data. It said traditional Medicaid enrollment was declining prior to the public health emergency and was at 136,017 in March 2020; in March 2024, it was at 134,899.

“This compares to DPHHS’s projection that enrollment would be 138,814 at the end of the redetermination process,” it said.

It’s a difference of 2.8% and does not consider “bounceback” applications from people who lost coverage, reapplied, and were determined to be eligible, the report said.

In the standard redeterminations, the health department assessed eligibility for 280,180 individuals, the report said. (It assessed another 20,000 special cases that undergo a separate process, such as foster care cases.)

Of the standard redeterminations, 51% were renewed, 41% were disenrolled, and 8% remain pending, according to the final report on “Medicaid Unwind” with data as of June 27, 2024.

“Among the individuals whose coverage closed, 69% were adults aged 19 and older, and 31% were children,” the report said. “Proportionally, there were fewer children disenrolled than adults. This is expected because income limits are higher for children coverage programs.”

In a previous analysis, the American Academy of Pediatrics found Montana had the highest portion of children who lost coverage in the U.S. from April through December 2023, a 26.6% loss based on federal data.

A separate campaign is underway by Cover Montana, a program of the Montana Primary Care Association, to reregister people, including children, who don’t have coverage but might qualify.

Pending cases

In response to a question at the Children, Families, Health and Human Services meeting, Brereton said the pending applications are complex cases and “medically needy” ones, which require a lot of communication between the Medicaid member and the health department.

“We do have teams with our Human and Community Services Division dedicated to those cases,” Brereton said. “They are aggressively working through them as quickly as possible.

“But we expect to see movement here over the next couple of months, and eventually we’ll close all of those out.”

Vice Chairperson and Rep. S.J. Howell, who had asked about the plan to close out the pending cases, also requested a timeline for that work. Of the roughly 23,662 pending cases, 7,921 are children, according to data in the report.

Administrator Jessie Counts said she anticipates the bulk of them will be completed in the next three months. In many cases, the department is waiting for information that’s difficult to gather, said Counts, head of the Human and Community Services Division.

Chairperson and Sen. Dennis Lenz said he wanted to confirm the estimate was realistic given the remaining cases are challenging ones.

“By your own admission that we’ve moved into cases that are a lot more difficult, is that a realistic timeline at this stage?” said Lenz, a Billings Republican.

Counts said the Health Department has dedicated teams for both “medically needy” cases and long-term care nursing home cases that are pending, and she believes it has adequate resources as it moves into a more normal cycle of processing applications.

Nursing homes still waiting

In public comment, Rose Hughes, executive director of the Montana Health Care Association, said her members are still reporting long delays in getting applications processed.

She said among 25 facilities, 261 applications were still pending, and they estimated the state owed them a total $8.8 million based on information collected from July 8 to 15.

Hughes, who spoke at the meeting and in a phone call, said people whose coverage has been dropped then reapply, but facilities have to wait for those applications to be processed, sometimes as much as a year, often six months.

“These facilities almost without fail continue to report that it’s three to six months to get this process done,” Hughes said.

In some cases, she said, people are even dying while waiting for their applications to be processed. Medicaid will still pay, she said, but families don’t have as much incentive to track down bank statements from, say, 2009, when they’re loved one has passed.

“The amount of time it’s taking is leading to those kinds of situations, and I’m hearing about that more and more often,” Hughes said in a phone call. “It’s just not something that I’ve heard a lot about in the past.”

Hughes also said members are reporting the Health Department is estimating it won’t even pick up applications for 30 to 60 days. She said the people at the agency are working hard, but more of them may be needed.

“There doesn’t seem to be a lot of movement in this getting better, in getting rid of the backlog and dealing with these applications in a timely fashion,” Hughes said.

Sen. Jen Gross, D-Billings, asked the Health Department what could be done to close the gap of 30 to 60 days, but Brereton said he considered that estimate “unverified” and a perspective from “one stakeholder” hearing from her members.

Brereton said the agency is seeing, in many cases, late applications, it often takes time to figure out who is authorized to speak on behalf of Medicaid members, and the issue is “multifaceted.”

He also said the agency is considering additional employees as part of the executive budget process, but it’s currently working within the resources the Montana Legislature granted.

“I don’t believe that it’s just the department being under-resourced and not having enough people or enough trained people,” Brereton said. “We are playing catch up right now. And like I said, it’s a two-way street.”

Speeding up reviews

In the discussion about pending cases, Howell, a Missoula Democrat, asked whether the Health Department has a plan to review them more quickly given data in the final report.

More than 45% of cases reviewed for income requirements were taking more than 45 days, the guideline for processing applications, according to the report. It sets 90 days as a guideline for other types of reviews.

“Obviously, I would like to see that number coming down,” Howell said of the income reviews; they asked if the Health Department was directing resources toward such an effort.

Brereton said the department agreed with Howell’s goal: “We’d like to reduce those figures.” He said he believes the slow increase in time to process applications was really the effect of redetermination on agency staff.

The final report shows a steady increase in the median number of days to process applications, and also a rise in the percent of applications where processing times exceeded the 45- or 90-day guidelines.

Counts said the Health Department expects timelines will shorten once it wraps up a backlog and as it trains new staff, especially to address the less complicated cases, such as the income based qualification applications.

In the meantime, the agency is working through a period where it’s seen multiple applications from the same person, she said. The duplicate cases stack up, and the Health Department has to close out all of them at once, which she said counts “multiple times against the timeliness.”

“We track it with our individual offices, as well as at the regional and at state level, to make sure that we’re properly deploying the resources where we need to,” Counts said.“And I’m expecting that those timelines will go down as we’re finishing up these final pieces and getting into a place where it’s much more of a typical pattern with Medicaid applications and redeterminations.”

The report notes Medicaid clients will now have federally required annual redetermination.

The report also discusses staffing and timelines. It said the Health Department made adjustments to onboarding during redetermination to train workers on Medicaid earlier, and it also said the vacancy rate in the division from March 2023 to February 2024 fell to 5% compared to 10% in fall 2022.

The report addressed upcoming deadlines as well: “It is important to note that no federal processing time requirements for redeterminations or case changes existed during the unwinding period. A new federal rule, however, will require timeliness standards within the next three years.”

More data

The Medicaid closeout report from the Department of Public Health and Human Services also noted the following:

• Current enrollment in traditional Medicaid is 1,118, or 0.8%, less than at the beginning of the pandemic.
• Medicaid Expansion enrollment was declining prior to the public health emergency and was at 86,788 in March 2020. In March 2024, it was 82,940, compared to the Health Department’s projection it would be 88,572, or a 6.3% difference.
• Current enrollment in Medicaid Expansion is 3,848, or 4.4%, less than at the start of the pandemic.

• Public assistance telephone hold times averaged 30 minutes “throughout the duration of the unwinding period.” The report said that wait was more than the Health Department wanted but was also in line with historic hold times for all programs. In summer 2023, the federal government found Montana had the second-to-longest hold times in the country at 42 minutes and requested a review of call center data and make necessary changes.

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