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Families say Kansas Medicaid red tape cuts off kids from the medical equipment they need | KCUR 89.3

OLATHE, Kansas — It’s a typical Thursday evening in the Hoffman house.

The family hangs out in the living room for a small dance party. Then one of the kids reads a book to 18-month-old Miles.

Neil and Abby Hoffman make sure Miles, who has chronic lung disease and cerebral palsy, joins in with his three siblings while sitting in his positioning chair.

“He has some vision problems,” Neil Hoffman said. “He eats through a G tube (a gastrostomy tube used to deliver food and medication directly to the stomach), has a tracheostomy tube in his throat. (He’s) ventilator dependent. So he’s basically on life support. But he’s doing really well. He’s fighting through it all.”

The coat closet in the front hallway is filled with Miles’ medical supplies. He sleeps in the dining room.

“It’s just too hard to take him up and down the stairs,” Abby Hoffman said.

What their son really needs now is a standing frame to learn how to stand and build leg muscle. With that, Miles might walk one day.

But insurance won’t pay. Miles is covered by overlapping plans — his parents’ Blue Cross Blue Shield of Kansas City policy and a second one managed by Aetna from the Kansas Medicare program, KanCare.

Blue Cross says it doesn’t cover standing frames. That passes the buck to Aetna.

Aetna might pay the $5-6,000 cost for a standing frame. But only after Blue Cross puts its denial in writing. Blue Cross won’t. And that leaves Miles in limbo.

“It’d be nice if they just talk to each other and say, ‘Hey, we’re not going to cover this, so will you?’”

Families across Kansas find themselves in similar bureaucratic dead zones, unable to get critical medical devices. The denials can spoil chances to develop at home, at school and into productive adults. And in some cases, like Miles, that first step.

Doctors, therapists and advocacy groups say the denials of prescriptions for medical equipment come too often and appear to violate at least the spirit of federal law.

The Kansas Department of Health and Environment did not respond to questions about chronic delays and denials for physician-prescribed devices by KanCare insurance companies.

Instead, in an emailed statement, KDHE said it is working to get lawmakers to address low Medicaid reimbursement rates.

“The Medicaid program needs the Legislature’s approval to increase rates to the levels our providers are asking for,” the agency said.

Wait Times

A small closet door is swung open. On it hangs a clear plastic organizer stuffed with medical supplies. Inside the closet are more shelves and plastic drawers filled with medical supplies. — The Hoffmans’ entryway coat closet has been repurposed to hold Mile’s medical supplies.

Carrie Grosdidier, an early childhood intervention occupational therapist who works with the Hoffmans, said the absence of that standing frame could have profound consequences for Miles.

“That’s impacting his ability to move forward with his outcomes, his goals, and his independence,” she said.

Cases like his can prove complicated and mean navigating through red tape. The barriers cost families life-changing equipment. Elizabeth Edwards, an attorney with the health care rights group National Health Law Program, said bureaucracy too often gets in the way of care.

“People should not be waiting … an extremely long time to get these medically necessary devices,” she said.

The federal Early and Periodic Screening, Diagnostic and Treatment law, or EPSDT, mandates children on Medicaid receive access to comprehensive equipment and services they need.

“One of the things that comes up often is whether or not the state sets the definition of medical necessity, or whether or not managed care plans have more wiggle room to define what medical necessity means,” Edwards said. “That can really inhibit whether or not something is covered by a plan.”

The insurers

A young girl wearing a purple shirt and dark jeans sits in a wheel chair. A man, standing left and a woman are attending to her, getting her situated and prepared to roll out the door of a bedroom. — Dan and Kacy Seitz get their daughter, Hudsyn, ready for the day.

Kacy and Dan Seitz have learned to navigate the system over the years while taking care of their 12-year-old daughter, Hudsyn. She suffered a brain injury at birth. The Shawnee, Kansas, family has had to get a wheelchair, a bathing chair and a stairlift.

“We’ve been on this road for about 12 years, that process is more familiar to us,” Kacy Seitz said. “For new families, that’s pretty intimidating.”

Each month, Dan Seitz talks with insurers about what the family needs for Hudson. But insurance does not cover everything each month. Sometimes it depends on how much their claims add up to in a given month and whether KanCare, the state’s Medicaid program, will cover something or the family needs to pay for things on its own.

“These are not devices that are optional for our daughter,” Kacy Seitz said. “We have to have them.”

Knowing the lengthy wait times and potential denials that can routinely come with durable medical equipment means trying to prepare well in advance.

“You almost have to think about it a year ahead of time in order to follow the existing process and get equipment on time,” Kacy Seitz said.

And sometimes they just make something themselves. They’ve placed a La-Z-Boy recliner on a wooden platform with wheels and fashioned a paper towel holder to station one of her pumps by her bed.

“Kacy’s first thought is how do we get something paid for,” Dan Seitz said. “My first thought is, ‘How can I just make it, because I already know it’s probably not gonna get paid for.’”

National Health Law Program senior policy analyst David Machledt said few people appeal their denials. It’s even more difficult for those that do not have extra support systems to help.

“(It) exacerbates some of the health disparities and access that we are seeing for people with disabilities, for people from different cultural backgrounds,” he said.

A Strained System

A small room with white walls and patterned rug has a wooden crib in it with many medical accessories like oxygen tank, chart with medical information, latex gloves, stethoscope and hand sanitizer. — The Hoffmans’ formal dining room has been converted to a bedroom for Miles.

Federal law promises children on Medicaid the equipment they need to thrive. Critics say routine delays and denials of medical equipment suggest KanCare does not live up to the law’s intent.

Disability Rights Center of Kansas executive director Rocky Nichols said the issue got worse when Kansas privatized Medicaid 10 years ago and handed over management to insurance companies.

“There’s been a lot more problems,” he said. “It’s a lot more difficult for people with disabilities or parents of kids with disabilities, to frankly get what they need under Medicaid.”

Kansas has three managed care organizations, known as MCOs, that operate KanCare.

Aetna, UnitedHealth and the Centene subsidiary Sunflower all received contracts with the state starting in 2019. Those contracts were automatically renewed last year for two years and won’t expire until the end of 2024.

“The managed care company gets paid upfront,” Nichols said. “So it creates a real problem.”

He said that cuts into incentives to insurers to cover more expenses.

Sheila Simmons operates a sort of stop-gap library of medical equipment in Parsons, Kansas. It checks out items including wheelchairs, crutches and beds.

Wheeled metal chairs made with metal tubing and other plastic parts are shown sitting on a carpeted floor. They are mobility devices for impaired children. — Some standing frames sit in the lobby area at the Assistive Technology for Kansas facility in Parsons. The location includes a variety of medical equipment able to borrowed as needed.

“The process is almost designed to be disheartening in some ways, if you ask a parent,” she said.

State negotiations

Advocates for those families want to make Medicaid work with fewer delays and denials.

Simmons, for instance, said more training for insurance companies on federal rules like EPSDT could help children access care they need.

“Kansas Medicaid needs to reassert that EPSDT is how they’re supposed to be operating,” she said. “And reminding (insurers) that if you’re able to document the child’s need — medically, physically — that equipment should be purchased.”

Alliance Rehab owner Scott Lopez finds himself regularly lobbying to get KanCare payments for equipment that doctors have prescribed.

“I’ve been trying to get a kid a bath chair since July,” Lopez said. “And we still don’t have that with them.”

That bath chair was finally delivered six months later. He said he has seen some progress.

“We’ve had some wins, we’ve had some kids get equipment that I didn’t think they’d get, it took a long time, we’re getting better at it, the state’s getting better at it,” he said. “But we just got to keep working to make it better.”

A woman leans over the back of a padded chair stroking the arm of a young girl sitting. She is covered with a blanket. Behind them a man is holding a coffee cup and looking on. — Dan and Kacy Seitz with their 12-year-old daughter, Hudsyn.

But the reimbursement through KanCare is still too little. If that doesn’t change, Lopez said, he is going to have to stop accepting Medicaid patients from Kansas.

With the current contracts to run KanCare ending next year, Nichols with the Disability Rights Center of Kansas, said the state can force insurance companies to deny less and pay for medical equipment more quickly.

“We don’t have the right incentives in the contract that the state controls to ensure that things are provided promptly,” said Nichols. “And the state needs to fix that.”

Other states, including Iowa, publish quarterly performance reports showing the rate of denials for each of the MCOs and what is being appealed the most by each insurer.

Frustrations

Dana Peterson is mom to a 20-year-old son, Charlie, with a chromosome abnormality. A few years back, she had to work to get a toilet adapter and wheelchair for him. They were custom-made, but the wrong sizes. So the family faces another long wait for the custom-made gear to be manufactured.

“It’s like starting all over again,” Peterson said. “If I have to pay out of pocket, I’m going to, because he needs something that works for him and that fits him.”

A temporary standing frame sits in the corner of Miles Hoffman’s room. His therapist, Grosdidier, has been able to loan it to the family until Miles gets his own personalized one. Neil Hoffman is grateful to have one, but he fears there will come a day when they lose it.

“I’m already pretty frustrated about it,” he said. “But I’d be pretty furious if we didn’t have one already.”

Samantha Horton reports on health for the Kansas News Service. You can follow her on Twitter @SamHorton5.

The Kansas News Service is a collaboration of KCUR, Kansas Public Radio, KMUW, and High Plains Public Radio focused on health, the social determinants of health and their connection to public policy.

Kansas News Service stories and photos may be republished by news media at no cost with proper attribution and a link to ksnewsservice.org.

California Looks to Spend Some Medicaid Money on Housing

SACRAMENTO, Calif. (AP) — At the commence of 2022, Thomas Marshall weighed 311 lbs .. He experienced been hospitalized 10 moments in five several years, like six surgical procedures. He had an open wound on his remaining leg that refused to recover — produced even worse by living in a dirty, moldy home with 5 other people today, two ball pythons, four Chihuahuas and a cage whole of rats.

A lot more than a 12 months afterwards, Marshall has missing just about 100 lbs .. His wound has healed. His blood pressure has returned to typical stages. His foot, which experienced nerve destruction, has enhanced to the place he goes on frequent walks to the park.

Lots of components are at participate in in Marshall’s dramatic turnaround, but the one he credits the most is lastly owning secure housing, just after the nonprofit Sacramento Covered assisted him get a a single-bedroom, 500 square-foot (46.4-sq.-meter) apartment in a downtown higher increase. He has hardwood floors, white pine cabinets and a glass jar on the counter stuffed with Bit-O-Honeys.

“To me it really is the most crucial 500 sq. toes I have ever experienced,” he explained. “Living listed here has just enhanced my well-getting in each individual feasible way.”

Marshall’s story is aspect of a radical rethinking of the partnership concerning housing and wellness care in the U.S. For decades, Medicaid, the joint point out and federal wellness insurance policy program for persons with disabilities or very low incomes, would only pay back for healthcare expenditures. But very last yr the Biden administration gave Arizona and Oregon permission to use Medicaid income for housing — a nod to reams of research demonstrating men and women in secure housing are healthier.

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California Looks to Spend Some Medicaid Money on Housing

Now California wants to be part of individuals states, creating on the good results of programs like the a person that bought Marshall housing. Gov. Gavin Newsom has proposed shelling out a lot more than $100 million for each year in the state’s Medicaid method to pay out for up to six months of housing for men and women who are or risk starting to be homeless are coming out of jail or foster care or are at possibility for hospitalization or unexpected emergency space visits.

It would be the biggest examination nevertheless of employing Medicaid dollars for housing. California has the nation’s major Medicaid system, with much more than 13 million sufferers — or about a 3rd of the state’s populace. California also has approximately a third of the nation’s homeless population, according to federal data.

“It’s a substantial phase towards breaking down the silos that have gotten in the way of having treatment of the total particular person alternatively than limb by limb and disease by illness,” claimed Anthony Wright, govt director of Health and fitness Obtain California, a customer advocacy group.

It would also be an expensive action. California is anticipated to have a $22.5 billion spending budget deficit this year, and it could get bigger in many years to appear. Meanwhile the state’s Medicaid paying out is projected to improve by $2.5 billion around the upcoming three years, according to the nonpartisan Legislative Analyst’s Office environment.

“What we are really performing is expanding the welfare condition, which is likely to come to be just a substantial money trouble,” explained Wayne Winegarden, senior fellow at the Pacific Analysis Institute, a team that advocates for free-current market guidelines.

California experimented with applying Medicaid cash for some housing-similar charges in 2016 when it introduced a pilot challenge in 26 counties. Though Medicaid did not shell out for hire, it paid for items like safety deposits and furniture.

In Marshall’s case, he pays his possess lease, making use of some of the $1,153 for every thirty day period he gets from Social Safety and Supplemental Stability Income. But Medicaid paid out for his stability deposit, bed, sofa, table, chairs and approximately 3 1/2 gallons of Pine Sol. Marshall explained preserving his condominium cleanse is one particular factor that assisted his leg wound to lastly recover.

Over five several years the system has lowered high-priced medical center stays and unexpected emergency room visits for individuals on Medicaid, preserving taxpayers an normal of $383 for every affected person for each calendar year, in accordance to an examination by researchers at UCLA.

Now California would like to go even further by utilizing Medicaid income to directly shell out some people’s hire. Democratic Assemblymember Joaquin Arambula, who chairs the price range subcommittee that will vet Newsom’s proposal, stated lawmakers are supportive. Arambula expended a 10 years as an unexpected emergency home health practitioner.

“I became pretty great at staying in a position to get cockroaches out of people’s ears,” Arambula claimed. “The residing situations of lots of of our communities, specifically in our rural communities, genuinely can impact a person’s capacity to get sufficient rest, to be well prepared for the up coming day and to stay healthful.”

Advocates for homeless individuals say they welcome these systems but expending much more funds on hire isn’t sufficient, noting the point out even now has a significant scarcity of cost-effective housing.

Kelly Bennett, founder and CEO of Sacramento Protected, reported that in the course of California’s first experiment with applying Medicaid revenue for housing companies, it would normally just take up to eight months for workers to place a patient in an condominium. In some cases, men and women have waited for yrs to locate a spot.

“Even when you have the deposit revenue and you have some rental subsidy, it is nonetheless pretty, quite demanding to obtain models — and to discover units wherever the landlords will lease to our purchasers,” Bennett said.

Marshall claimed he grew up in Sacramento and obtained a degree in dietic technological innovation and culinary arts. But a 30-yr dependancy to meth landed him on the streets from the late 1990s by means of about 2006. He camped at an old landfill, usually feeding on leftovers from people’s picnics at a close by park.

He utilized for residences at various sponsored housing structures, but in no way manufactured it off the wait checklist. It took him about a year to get his recent condominium, where by he pays $186 for every thirty day period with the aid of a subsidy.

“I really feel like I’m electric. … I have electric power and means to do points that I could not do for a incredibly prolonged time,” Marshall, 64, mentioned. “Whatever decades I’ve acquired left now, I am going to spend them up below in the glass tower.”

New report shows Medicaid expansion narrowed racial disparities in health insurance

Medicaid enlargement has not only diminished the in general variety of folks in the U.S. without having wellbeing insurance policies — it has also narrowed racial gaps in wellness insurance protection.

According to a new report from The Commonwealth Fund, well being coverage coverage for Black, Hispanic/Latino, and white older people enhanced amongst 2013 to 2021. Furthermore, the protection gap among Black and white grown ups and involving Hispanic/Latino and white older people shrank.

In 2013, in advance of Medicaid growth went into influence, 40.2{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of the Hispanic/Latino inhabitants, 24.4{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of the Black inhabitants, and 14.5{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of the white populace ended up uninsured. By 2021, these quantities fell to 24.5{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f}, 13.5{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f}, and 8.2{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f}, respectively.

“A whole lot of the progress in uninsured premiums going down and these disparities narrowing [is] certainly stemming from the Inexpensive Treatment Act protection expansions,” Jesse Baumgartner, co-author of the report and senior investigation associate at The Commonwealth Fund, instructed Yahoo Finance. “Those took impact in 2014. So you see major drops concerning 2013 and 2016 as the market subsidies arrived on line, [and] a large amount of states expanded their Medicaid systems at that time. So that is of course a enormous driver for that progress then.”

Growth vs. non-growth

Medicaid was expanded in 2013 via the Inexpensive Treatment Act (ACA) — commonly known as Obamacare. The provision will allow homes whose profits falls below 138{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of the federal poverty degree to grow to be suitable for Medicaid.

Following a Supreme Court ruling, nevertheless, it was left up to each and every condition to make your mind up no matter whether or not to adopt the expansion. As of March 2023, 39 states and the District of Columbia have expanded Medicaid.

According to the Commonwealth Fund report, amongst 2013 to 2021, states that adopted the Medicaid enlargement noticed greater fees of coverage coverage and wellbeing care accessibility than non-enlargement states. They also saw smaller disparities between racial and ethnic groups.

When just about every racial and ethnic team has designed significant strides in well being care protection given that 2013, the get in health treatment coverage for the Hispanic/Latino inhabitants has been specifically noteworthy: Its uninsured rate shrunk by 15.7 share factors concerning 2013 to 2021, the most of any demographic.

“There have been huge gains,” Baumgartner said, despite difficulties stemming from fewer entry to employer-sponsored insurance policy and regulations connected to immigration position that impression Medicaid eligibility.

Still, the Hispanic/Latino population has the maximum uninsured charge in the U.S., which Baumgartner claimed is “a substantial remaining inequity” and a person that “needs the most do the job shifting ahead.”

‘A apparent, huge threat to the development that’s been made’

As of October 2022, additional than 91 million Individuals had been enrolled in Medicaid and the Kid’s Overall health Insurance policy System (CHIP).

There ended up significant enhancements between 2019 to 2021, which Baumgartner attributed to federal policy steps taken in response to the coronavirus pandemic, particularly the Families Initial Coronavirus Reaction Act and American Rescue Strategy.

“What the info in this report indicates is that the federal coverage steps through the pandemic… designed a large influence in not only halting protection losses but in fact ensuing in some gains of protection for all of individuals teams through that time,” he claimed.

The Families First Coronavirus Response Act, which was signed into legislation in March 2020, allotted $3.5 trillion in funding for factors like coronavirus tests, diet expert services, and the General public Wellbeing and Social Providers Crisis Fund.

The American Rescue Strategy, passed a year afterwards, expanded the eligibility for ACA subsidies and amplified the sum of money support for those people presently eligible for the ACA. These subsidies have been prolonged right up until 2025.

“The details in this article truly speaks to the impression of those expanded subsidies and how they’ve built protection far more cost-effective,” Baumgartner explained. “Moving ahead, the issues we believe policymakers ought to continue to keep in brain is the extension of that earlier 2025 as unquestionably a different choice that this data highlights.”

Beginning on March 31, on the other hand, a provision of the federal coverage reaction to the pandemic — constant Medicaid enrollment — might occur to an conclude, removing health care coverage for millions of People.

In accordance to the Kaiser Household Foundation, “states that acknowledge the improved federal funding can resume disenrollments commencing in April but must meet up with sure reporting and other requirements for the duration of the unwinding course of action.”

That could affect some of the modern development on insurance coverage coverage, particularly for Black and Latino family members.

Among 2019 and 2021, uninsured costs for Black adults dropped by at the very least two share factors in 14 states, although fees for Hispanic/Latino adults fell by the identical total in 19 states, according to the Commonwealth Fund report.

“The even larger question is: What can states and the federal authorities do to lessen coverage decline and swap individuals who will inevitably be moved off Medicaid?” Baumgartner stated. “It’s a clear, massive chance to the progress that is been created simply because clearly these insurance policies, and the continual enrollment policies, in certain, feel to have had a really big affect.”

New report shows Medicaid expansion narrowed racial disparities in health insurance — Previous President Obama waves as he comes to provide remarks on the Very affordable Care Act and Medicaid at the White Dwelling on April 5, 2022. (Photo by MANDEL NGAN/AFP)

Until finally that distinct problem can be tackled, Baumgartner stated federal policymakers really should aim on developing a federal fallback choice for non-enlargement states.

“The problem gets to be: How are states heading to be equipped to get persons onto other coverage, to go them above to market coverage that they may possibly be qualified for, to seriously decrease the disruption and preserve the progress going and not have a backsliding?” he stated. “That’s the authentic vital.”

—

Adriana Belmonte is a reporter and editor covering politics and health treatment plan for Yahoo Finance. You can follow her on Twitter @adrianambells and arrive at her at adriana@yahoofinance.com.

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Medicaid Clinical Research Coverage Update | Ankura

On January 1, 2022, the new Medicaid research coverage regulation went into influence. The rule is portion of the H.R. 133 – The Consolidated Appropriations Act. The Medicaid exploration protection info is discovered in SEC. 210. Promoting Obtain TO Lifestyle-Saving THERAPIES FOR MEDICAID ENROLLEES BY Ensuring Protection OF Regime Affected person Fees FOR Goods AND Solutions FURNISHED IN Relationship WITH PARTICIPATION IN QUALIFYING Medical TRIALS. The rule calls for just about every state Medicaid to address certain charges related with sure medical trials. See for a much more in-depth overview of the precise necessities and likely operational problems. The New Medicaid Scientific Investigation Coverage Regulation: What you Want to Know and Do Now, Sarah Couture (ankura.com) for a much more in-depth overview of the unique specifications and probable operational difficulties.

Whilst most states have now amended their point out plans to protect required medical analysis solutions, very handful of state Medicaid programs have offered advice to provider businesses with regards to operationalizing the rule, including instructions for submitting the demanded attestation form (medicaid-attest-form.docx (are living.com)). Other concerns abound from companies linked to the rule by itself. In their State Prepare Amendments (SPA), states could have clarified certain phrases or protection ways, but most have adopted the language of the rule itself which poses considerable issues:

What constitutes a “serious or lifetime-threatening” ailment or situation?
Is typical treatment protected similar to Medicare protection (for each NCD 310.1)?
How is the rule used to gadget scientific studies?

As states finalize their SPAs and condition Medicaids establish their precise approaches for the attestation and other compliance expectations, provider companies keep on to battle with the deficiency of clarity and subsequent issues in operationalizing the necessities. We keep on to advise the subsequent:

Stay informed as condition Medicaid strategies build and roll out their methods, which include achieving out to those options for assistance on the procedure
Advocate with point out legislatures regarding problems and problems that might be impacting people or the corporation
Proceed doing a Medicare-primarily based coverage investigation, then overlay Medicaid particulars
Continue on demanding indigency clauses in sponsor contracts as not all studies will be qualifying, and not all expert services within just a qualifying examine will be billable

This write-up was co-authored with Cassie Cruz-Montez, MHA, YCCI Exploration Billing Compliance Analyst, Yale College of Medication, Yale Centre for Scientific Investigation.

Idaho dropped Medicaid recipients instead of trying hard to track them down : Shots

Idaho removed nearly 10,000 people from Medicaid in the pandemic’s first years when enrollees couldn’t be reached. The episode previews what could occur in other states after April 1, when a COVID-era coverage mandate ends.

Eric Harkleroad/KHN

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Eric Harkleroad/KHN

During the first two years of the COVID-19 pandemic, while the federal government was trying to prevent people on Medicaid from losing health coverage, Idaho dropped nearly 10,000 people from the safety-net program.

Federal law generally banned states from dropping people, and federal officials said Idaho acted improperly. Idaho officials, however, said they didn’t think they did anything wrong.

The episode, revealed in documents KHN obtained through a public records request and in interviews with state officials, offers a preview of what could soon unfold across the United States for millions of people covered through Medicaid, the federal-state health insurance program for people with low incomes.

It shows how easily state bureaucracies can disenroll people they shouldn’t be disenrolling, leaving those people in financial and medical jeopardy. It also illustrates the potential for confusion and disagreement over what procedures states should follow before cutting off anyone’s benefits, particularly when enrollees can’t be reached.

Why millions on Medicaid are at risk of losing coverage in the months ahead

Why it could happen in other states starting April 1

A COVID-19 relief law Congress enacted in 2020 prohibited states from removing people from Medicaid except in a few narrow circumstances, such as if an enrollee died or moved out of state.

On April 1 of this year, after the prohibition expires, states will resume removing people who no longer qualify or do not furnish needed information. That process has come to be known as “the unwinding.” Some states see the end of the mandate as a chance to quickly winnow Medicaid rolls that have grown to record levels.

Idaho Gov. Brad Little was among 25 Republican governors who told President Joe Biden in a December letter, that, by keeping ineligible people on the Medicaid rolls, the mandate was “negatively affecting states.”

Idaho’s Medicaid program had nearly 450,000 enrollees at the start of this month. The state said about 150,000 of them no longer qualified or had not been in contact with the program during the public health emergency.

By the time recipients notice, ‘the damage will be done’

Nationally, as disenrollments ramp up, many officials are predicting a mess. The Department of Health and Human Services has predicted that nearly 7 million people still entitled to Medicaid benefits will lose coverage because they fail to complete renewals or state governments won’t be able to contact them.

People may not realize they’ve been dropped until they seek care.

6.8 million expected to lose Medicaid when paperwork hurdles return

Why pediatricians are worried about the end of the federal COVID emergency

“The damage will be done,” said Tricia Brooks, a research professor with Georgetown University’s Center for Children and Families.

Idaho terminated Medicaid benefits for more than 9,800 beneficiaries during the pandemic after mail the state sent them was returned as undeliverable and other attempts to confirm that they still resided in Idaho failed, according to emails obtained by KHN between the Idaho Department of Health and Welfare and the U.S. Centers for Medicare & Medicaid Services.

The emails, sent last spring and summer, detail Idaho’s rationale for the terminations, CMS’ concerns, and the state’s efforts to restore benefits.

CMS officials maintained that, when Idaho’s mailings were returned with no forwarding address or an out-of-state forwarding address, the state didn’t do enough to make contact with the beneficiaries and ensure they no longer lived in Idaho.

“CMS appreciates the state’s efforts to come into compliance,” Sarah O’Connor, a CMS official, wrote on Aug. 18 of last year.

In meetings with CMS, Idaho officials were told the state could not kick people off if it didn’t make “physical contact,” Shane Leach, administrator of the Division of Welfare at Idaho’s Department of Health and Welfare, recounted in correspondence with CMS.

“What they were saying early on,” Leach told KHN, “is, basically, we didn’t do enough outreach to really prove that this person was no longer in Idaho and not eligible for Medicaid.”

He added: “My perspective is, we did our due diligence.”

Many calls and letters went unanswered, Idaho says

For the first two years of the pandemic, when Idaho received returned mail with an out-of-state forwarding address or no forwarding address — possibly indicating the enrollee no longer lived in Idaho — Leach said state officials would call them.

A lot of the calls went unanswered, he said.

“They’re really concerned about physically talking to the person or having them say, ‘Yes, I’m in another state,'” Leach said of CMS. “And so that’s where they said, ‘OK, well, you need to reinstate those individuals.'”

“We felt like we were following the guidance,” said Jennifer Palagi, a deputy director at the Idaho health department.

CMS guidance in August 2021 stated that returned mail alone was not reason enough to disenroll Medicaid beneficiaries during the public health emergency. But if CMS had issued a written version of the standard to which it was holding Idaho — in which disenrollments would be justified only if the state made contact with the enrollee — Medicaid consumer advocates and other specialists said they were unaware of it.

CMS declined to answer several questions about the Idaho situation.

“CMS is committed to working with states to ensure continuity of coverage for eligible individuals, including those for whom the Medicaid agency receives returned mail,” Bruce Alexander, director of CMS’ office of communications, said in a written statement to KHN.

According to the batch of emails obtained by KHN, Idaho in March 2022 did change the state’s procedures after discussions with CMS. By July, the state Medicaid agency had reinstated benefits for 6,400 people the state couldn’t get hold of.

In one of the emails the Idaho Medicaid agency sent to CMS last July, the state said it was reviewing the extent to which it needed to pay medical bills the program had originally rejected.

It’s a long-standing problem — and about to get bigger

The inability to reach Medicaid enrollees has been a long-standing problem. The paperwork that agencies send people to fill out often goes unreturned. Some ends up at the wrong address. Up-to-date phone numbers or email addresses may not be available to state and county workers.

Red and blue states look to Medicaid to improve the health of people leaving prison

“In a perfect situation, a member responds to give you their current address, a phone number, an email address, etc.,” said Jack Rollins, director of federal policy for the National Association of Medicaid Directors. “But that is not the case for a lot of situations.”

And that’s bound to become a larger problem, consumer advocates say, after the pandemic-era enrollment mandate ends this spring. On Jan. 27 of this year, CMS detailed to health agencies in all states the minimum they’ll need to do to reach a Medicaid recipient who hasn’t responded to a mailed form: Before ending benefits, a state must try to obtain up-to-date contact information and attempt to reach the person through at least two means, such as by mail, phone, email or text message, if those means are available.

Still, “there’s just a lot of variation in terms of what that could look like,” said Farah Erzouki, a senior health policy analyst for the Center on Budget and Policy Priorities, a think tank in Washington, D.C.

If any state isn’t following the rules, Georgetown University’s Brooks said, it can take months to fix the problems — all while people’s benefits hang in the balance.

“This is what we want to avoid,” Brooks said. “We don’t need to spend the next three years after ‘the unwinding’ trying to get people back on who should not have been disenrolled.”

KHN (Kaiser Health News) is an editorially independent, national program of KFF (Kaiser Family Foundation).

Bringing Medicaid behind bars has wide bipartisan support : Shots

When he was in prison, Lee Reed was in agonizing back pain. His doctors there told him he needed back surgery, but because he was so close to his release date, they said he’d have to get it done on the outside. Reed saw that surgery as his ticket to being able to get a job and effectively reenter society.

Amy Osborne for Tradeoffs

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Amy Osborne for Tradeoffs

Lee Reed spent his first night after getting out of a state prison sleeping in the stairwell of a parking garage in downtown San Francisco.

Just a few days shy of his 62nd birthday, Reed had nowhere else to go. During his two decades in prison, his mom and wife had died, and he’d lost touch with most of his family.

“I had nothing. I had nobody,” Reed said.

But he wasn’t alone on that first night. He had the same companion he’d had for years: agonizing back pain.

“Imagine somebody standing on your foot, and you can’t stop that pain,” Reed said. “It’s going to be there when you wake up. It’s going to be there when you go to sleep. Half the time I never even got out of bed while I was in prison because I couldn’t stand up, it was so painful.”

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Reed’s doctors in prison told him he needed back surgery, but because he was so close to his release date, they said he’d have to get it done on the outside. Reed saw that surgery as his ticket to being able to get a job and effectively reenter society.

But without health insurance or a support network, being able to do any kind of work seemed impossible as he laid down in the concrete stairwell, his prison-issued walker his only blanket.

“I was tired, and I was literally ready to give up,” Reed said.

Medicaid can be a bridge to a healthy life outside

Around 600,000 people leave prison in the U.S. every year, and another 10 million are released from county jails. Like Reed, many of them suffer from chronic physical, mental and substance use conditions. Research shows they are also at an extremely high risk of hospitalization and death; one study from Washington state found that recently incarcerated people were 12 times more likely to die in their first two weeks after release from prison than the general population.

That’s why in January, federal health officials for the first time signed off on having Medicaid pay for services for some people in state or local jails, prisons or juvenile facilities. The goal is to use the time before someone leaves a corrections facility to connect them with medical providers in the community and limit any disruption in their care as they transition out of incarceration.

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Most people who are incarcerated are eligible for Medicaid based on their low income, but a provision known as the “inmate exclusion policy” prohibits federal Medicaid dollars from being spent on a person’s care while incarcerated. (The only exception is for an overnight hospital stay.) Many counties and states try to connect people to Medicaid as soon as they’re released, but it can be a bureaucratic nightmare, and even if it works, people often have other priorities like finding a job, food and a place to live.

Some states like Arizona require private Medicaid plans to connect with incarcerated people before they are released, which state officials say helps individuals get care more quickly when they get out. And small pilot programs in California and New Mexico showed offering care coordination before release led to more primary care visits, less recidivism and fewer ER trips. But the inmate exclusion policy remains a significant barrier.

In 2018, Congress directed federal health officials to help states figure out a better transition plan for people leaving incarceration. Since then, 15 states from across the political spectrum have asked the Centers for Medicare and Medicaid Services to let them test what would happen if they turned Medicaid on before people leave jail, prison and juvenile facilities. In January, California became the first state to get the green light.

“We hope that what we are approving today is an exciting model for what we are able to partner [on] with states across the country,” said Dan Tsai, deputy administrator and director of the Center for Medicaid and CHIP Services at CMS.

States are taking differing approaches

All of the proposals pending before CMS share a common goal: bridging care between incarceration and the community for the more than 10 million people who leave incarceration each year. Many policymakers also see this as a way to improve health equity — people of color are disproportionately incarcerated in the U.S.

In theory, getting people connected to care sooner and keeping them on their medications should improve health outcomes and, over time, help state Medicaid programs save money, because fewer people will end up needing expensive hospital and ER visits. But with limited previous experience to guide them, states are having to guess at the best way to use finite Medicaid dollars when it comes to who should receive these new benefits, what benefits they should receive and when those benefits should start.

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“If you are providing and paying for the Medicaid services, you want to ensure that you are focused on those that truly need it,” said California Medicaid Director Jacey Cooper.

Most states, including California, would limit eligibility to incarcerated people with documented health needs, such as chronic physical and mental health conditions or substance use disorder. Cooper estimates around 70{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of people incarcerated in California meet this criteria.

In West Virginia and Kentucky, only people with a substance use disorder would be eligible, as part of those states’ broader efforts to address addiction. Research shows drug overdose is one of the most common ways people die after leaving prison, with studies suggesting returning prisoners are 40 to 129 times more likely to fatally overdose in their first two weeks after release.

Rhode Island, Vermont, Washington and Oregon would offer pre-release services to everyone in jail and prison who is eligible for Medicaid.

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“The odds are so high that people in that situation are going to need the support that it didn’t seem to make sense to us to be trying to distinguish who did and who did not meet some threshold or have a particular condition,” said Amy Katzen, the director of policy and strategy for Rhode Island’s Medicaid program.

Rhode Island is one of four states — along with Massachusetts, Utah and Vermont — that would offer people soon to leave jails and state prisons the same Medicaid benefits as anyone else in the community.

“This is going to be so complicated to implement,” said Mike Levine, director of MassHealth, Massachusetts’ Medicaid program. “When we finally do, there’s something to be said for just if you are a MassHealth member, you’re getting the MassHealth benefit.”

The other 11 states would offer a more limited set of services for people in the weeks or months before they leave incarceration, focused on transitioning someone back into the community. Services would include connecting them to new doctors, making sure they can get their prescriptions filled and helping them find housing.

In most of these states’ proposals, services like addiction treatment and daily medications would continue to be provided and paid for by the jail or prison. However, Rahul Gupta, the director of the White House Office of National Drug Control Policy, said on Tuesday that states would be required at a minimum to provide mental health and drug treatment services in this pre-release period. CMS would not confirm Gupta’s statement and said the agency plans to release further guidance for states soon.

Some advocates believe Medicaid should take a larger role in health care during incarceration, pointing to numerous reports of inadequate and negligent health care behind bars.

“I’ve seen people wither away — literally, people who were 280 pounds solid, healthy-looking individuals, wither all the way down to skin and bones. And that was because something that they had was diagnosed late or was misdiagnosed in the beginning,” said Khalil Cumberbatch, who served 6½ years in a New York prison before becoming the director of strategic partnerships at the Council on Criminal Justice.

For now, states are unwilling to go that far. Most are asking for Medicaid to start paying for services 30 days before someone is released, but a few have asked for more, including California, which has been approved to start coverage 90 days pre-release. Medicaid Director Cooper said that’s a more realistic window to build a trusting clinical relationship with someone, get all their appointments set up and make sure they have everything they need before they’re released.

Medicaid experts suggested the quickest way for the other 14 states to win CMS approval may be to follow California’s lead on these questions, but they believe federal health officials might want to let states make different choices so they can gather more evidence about what works best.

Implementation challenges await

In California, the first incarcerated people won’t receive Medicaid services until April 2024, Cooper said, with full implementation expected to take until 2026. That’s in part due to the daunting task of integrating the health care and criminal justice systems. The state asked for and received $561 million from the federal government to help providers and correctional facilities build up the infrastructure to do things like share data and bill appropriately.

Massachusetts’ Mike Levine said his team has been working closely with law enforcement and corrections officials for years. “You can’t wait to engage correctional partners when it’s time to implement,” Levine said. “They have to be involved in the policy design because this is going to require so much change within their workflows and their daily business that they have to be at the table.”

Advocates insist that people who are incarcerated or formerly incarcerated need to be included in these conversations too. “If we want people to use that Medicaid card to engage in services in the community, we need to ask them, what is it you need? How can we support you best in coming home?” said Shira Shavit, a professor of family and community medicine at the University of California San Francisco and executive director of the Transitions Clinic Network, which specializes in caring for people post-incarceration.

Including those perspectives, Shavit said, could prevent unintended consequences, like people becoming less likely to engage with Medicaid because they see it as a part of a criminal justice system they don’t trust.

Help came late, but Reed has hope for the future

This entire conversation is coming too late for Lee Reed. No one reached out to him before he got out of prison. He spent two days sleeping in that parking garage stairwell before a security guard pointed him toward a nearby homeless shelter.

A few weeks later, a doctor at the shelter restarted Reed’s medications for diabetes and high blood pressure, and referred him to a specialist who scheduled his back surgery for early 2023 — more than six months after Reed had been released from prison.

Six months after he was released, Reed finally got his back surgery. He’s in less pain now, but he’s still homeless, jobless and struggling to find purpose in his life.

Amy Osborne for Tradeoffs

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Amy Osborne for Tradeoffs

Six months after he was released, Reed finally got his back surgery. He’s in less pain now, but he’s still homeless, jobless and struggling to find purpose in his life.

Amy Osborne for Tradeoffs

But his pain continued to get worse. The constant agony and Reed’s inability to support himself took a toll on his mental health, occasionally making him wonder if his life was worth living.

“Who would want to live this? This is horrible, man,” he said. “I can’t do anything to protect myself. I can’t do anything to feed myself. How the hell am I a man?”

The doctor at the shelter referred Reed to Shira Shavit’s Transitions program at the Southeast Family Health Center, a community clinic run by the San Francisco Department of Public Health. Shavit prescribed a medication patch for Reed’s back and scheduled follow-up appointments for his diabetes. The program also gave him a bag of groceries, a bus card and ordered him a winter coat.

“When people come out of prison, they have so many needs,” Shavit said. “[We’re] just trying to bring people to the starting line to kind of get them to where they need to be to then even start to be able to become successful in the community.”

Reed finally got his surgery at the end of January, the day after CMS approved California’s request to bring Medicaid behind bars. He’s in less pain now and dreams of moving back to Arkansas to spend time with his grandchildren.

But his challenges are far from over. He’s still living at the homeless shelter without a job and struggling to find purpose. He said if someone had reached out to him before he left prison and helped him get his surgery sooner, there’s a better chance he’d be supporting himself by now.

“I’m trying to keep a positive attitude on everything because my whole world feels like it’s falling apart,” he said a week after his surgery. “I have no control over my own life right now. I’m just like a child. I’m just helpless.”

This story comes from the health policy podcast Tradeoffs. Dan Gorenstein is Tradeoffs’ executive editor, and Ryan Levi is a reporter/producer for the show, where a version of this story first appeared.