Federal health officials are urging states like Florida to make it easier for people to renew their Medicaid coverage as a mass unwinding following the COVID-19 public health emergency continues.
Thousands of Floridians have been disenrolled from Medicaid since the state began redetermining eligibility in May, after a federal directive that states suspend such efforts during the pandemic was lifted. Florida began its process earlier than some others, but committed to spreading out renewals over the course of a year.
Health care advocates have been raising the alarm about large numbers of people in Florida and nationally who are losing coverage not because they no longer qualify but because of procedural issues, such as failing to respond to renewal notices or submitting information incorrectly. They say it suggests states are not doing enough to communicate with families about the renewal process and help them navigate it.
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Advocates and health officials say they are especially concerned about children, who are more likely to remain eligible for Medicaid than adults. Kids make up the majority of Florida’s Medicaid population, so coverage losses due to red tape could threaten their access to care.
The feds are offering help. Florida hasn't taken it yet
The Centers for Medicare and Medicaid Services set minimum standards for states to follow to reduce the risk of people wrongfully losing coverage, but has also offered states some flexibilities to assist in the unwinding, including a series of policy waivers that Health and Human Services Secretary Xavier Becerra outlined in aJune 12 letter to governors. But Florida is one of two states that has so far declined to take advantage, along with Montana.
“We really are at a moment here where we have the potential for millions of people to lose health care coverage,” CMS deputy administrator Dan Tsai said during a virtual meeting with reporters this week. “We need everybody, and that includes our state partners, to go far above and beyond the minimums and to do everything in their power to keep eligible people covered.”
The waivers allow states to do things such as automatically renew people who appear to have no or very little income, partner with Medicaid managed care plans to assist people with completing renewal forms, or delay administrative terminations for one month while the state conducts additional outreach.
This gives families more time to understand what steps they need to take to renew coverage, and also reduces the amount of resources states have to spend tracking down enrollees who are likely still eligible for coverage.
CMS has so far approved nearly 250 waivers for the remaining states and territories, and officials want to see Florida participate as well.
Some of the waivers allow for processes that Florida has already included in its state plan, according to Department of Children and Families spokesperson Tori Cuddy.
For example, some waivers let states use information about residents receiving benefits through the Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) to determine Medicaid eligibility. Florida is already able to do this, Cuddy noted.
The state of Florida's Medicaid unwinding
Medicaid enrollment reached record highs in Florida during the public health emergency, at more than 5 million people, but the state projected roughly 1 million were no longer eligible.
So far, the state has only been able to verify about 35% of the 303,000 Medicaid enrollees it’s estimated to have disenrolled during the process were ineligible, according to a Kaiser Family Foundation analysis of state unwinding dashboards and monthly reports submitted to CMS. The remaining 65% are due to procedural reasons.
That marks an improvement from the procedural termination rate during the first four weeks of redeterminations in Florida, which was closer to 80%. It is also lower than the current national average, which KFF lists as 71%, though the organization notes not all states have made data publicly available.
Calls for Florida to pause redeterminations
Still, the fact that the state has not been able to confirm ineligibility for a majority of enrollees that have lost coverage so far has CMS officials and other health care advocates concerned.
A coalition of 52 organizations sent a letter to Gov. Ron DeSantis and state health officials in late May asking them to pause the redetermination process, which in its first month resulted in a quarter-million Floridians losing Medicaid coverage.
In addition to the high rate of procedural terminations, advocates also cited long waits at state call centers as well as anecdotal reports of children with complex medical conditions, who were supposed to go last in Florida’s redetermination plan, experiencing disruptions in coverage as reasons to slow the process.
“As organizations that represent and advocate for the well-being of Florida’s families, we are deeply concerned about those with serious, acute and chronic conditions who will continue to lose access to their lifesaving treatments during this time, along with people who risk substantial medical debt, or even bankruptcy, as a result of coverage loss,” the groups, which include the Florida Policy Institute and Florida Health Justice Project, among others, wrote in the letter.
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CMS has asked some states to pause procedural terminations, Tsai said during Wednesday’s briefing, though he did not name which ones, nor did a CMS spokesperson upon follow-up inquiry.
“We are finishing discussions with states and will have more information to follow up with soon,” the CMS spokesperson said in an email.
There has been a “constant stream” of concerns that health providers and advocates have brought to CMS’ attention when it comes to challenges with renewals in Florida and other states, Tsai said. Staff are investigating individual cases and monitoring data.
But to take action against a state, CMS must find a “clear regulatory violation” occurred, which Tsai said is not always easy.
“Federal Medicaid regulations do not get very specific on some of the things including how understandable, say, a [renewal] notice is. That is an issue that we need to remedy, to be clear, but that is also why, in instances, we may not find a clear violation of a regulatory standard,” Tsai said.
The state touts its response
DCF officials tell Health News Florida that the state has implemented a variety of communication strategies to reduce the number of procedural terminations.
"The Department has implemented an extensive public outreach campaign, well exceeding federal requirements, including mail, email, texts, and call outs to Medicaid beneficiaries to encourage engagement in renewal," said Cuddy.
More than 80% of recipients have responded to their redetermination requests compared to fewer than 50% pre-pandemic, she added. Recipients who don't respond have 90 days to submit a late application and can get their coverage restored retroactively if determined eligible.
The department also notes thousands of residents who have been determined ineligible for Medicaid have been referred to other health insurance options, including Florida Healthy Kids, a program for children in families with low incomes, and plans available through the Affordable Care Act marketplace.
