Despite ACA mandates for states to streamline renewal, many beneficiaries still need assistance to retain Medicaid coverage

Enrollment in Medicaid has been shown to enhance access to health care for our nation’s most vulnerable citizens. Yet despite these benefits, a substantial number of beneficiaries lose coverage at the time of renewal. An article by Xu Ji and colleagues, published in this month’s issue of Medical Care, demonstrates how critical maintaining continuous Medicaid coverage is for beneficiaries with mental health conditions.

Ji and colleagues found that adults with major depression who lost Medicaid coverage for a period of months and then re-enrolled were more likely to visit the emergency department and use inpatient hospital services than those who remained continuously enrolled. These increases in utilization translated into higher monthly acute care costs for state Medicaid programs.

In the Spring of 2017, we conducted a series of telephone interviews with state Medicaid officials, providers, and consumer advocates in 5 states implementing the Medicaid expansion (Michigan, Rhode Island, Oregon, New Mexico, and West Virginia).  During interviews, we discussed states’ progress implementing the Affordable Care Act’s (ACA’s) streamlined renewal policies and their initial impact on beneficiaries.  We found that ACA policies that simplified renewal processes helped keep Medicaid beneficiaries enrolled, but challenges remain – especially for people with mental illness and other vulnerable populations who often need one-on-one assistance to maintain coverage.

ACA mandates to enhance retention in Medicaid

The ACA includes several provisions to simplify the renewal process for Medicaid beneficiaries:

  • First, states are required to review data from other human service programs to confirm eligibility prior to requesting documentation from the beneficiary.
    • If a beneficiary is found eligible after reviewing state data sources, the recipient does not need to take any additional action to remain enrolled.
  • When passive renewal is not possible, states must send beneficiaries a pre-populated renewal form with a clear request for any additional documentation.
  • The law also required that states implement 12-month renewal cycles and allow individuals 90 days to re-enroll without completing a new application if they miss the renewal deadline.
  • Finally, in keeping with the ACA’s goal of encouraging states to modernize their IT systems, the law requires Medicaid agencies to provide the option to enroll and renew coverage online.

Our discussions with stakeholders revealed that these reforms have helped keep people enrolled, but barriers to retaining continuous Medicaid coverage remain, and they are especially likely to affect those with mental health and other behavioral health conditions.

Barriers to renewal for individuals with mental illness

Although passive renewal substantially reduces the likelihood of losing Medicaid coverage at renewal, it is not always possible. In some of our case study states, large percentages of beneficiaries were not passively renewed. When passive renewal is not possible, the state must be able to contact a beneficiary to verify eligibility. This poses challenges for state Medicaid agencies, which have traditionally relied on paper mailings to inform beneficiaries that they need to renew coverage. Unfortunately, many individuals with a mental health disorder experience bouts of homelessness throughout their lifetime. Some experts estimate that about one-third of the homeless population has an untreated mental illness [PDF]. Because homeless individuals lack a permanent address, they are more likely to lose coverage at renewal. Many of these individuals often re-enroll when they visit a community health center or social service organization, but they typically must reapply for coverage because they have missed the 90-day window for reinstatement.

Understanding renewal notices poses another considerable barrier for individuals with mental disorders. Pre-populated renewal forms are intended to make it easier for enrollees to update and verify information, but notices can be multiple pages long and often contain technical language that is not easily understood. Although states are working to simplify these forms, many Medicaid recipients need individual assistance interpreting and responding to renewal notices. People with mental illness are especially likely to need this help.

States have made substantial progress in developing web-based application and enrollment systems. In many states, Medicaid beneficiaries now have the option to both apply for and renew coverage on-line. For beneficiaries with access to the internet and some level of technological savvy, this is a definite improvement. But for enrollees with mental illness, navigating the internet and technology, which requires keeping track of user IDs and passwords, can be challenging. Enrollment assisters and application counselors play an active role in helping many individuals both understand and complete on-line renewal forms.

One-one-one assistance still important for maintaining coverage

The Ji, et al. study demonstrates that maintaining continuous Medicaid coverage can prevent hospitalizations and unnecessary emergency department visits for individuals with mental illness. To improve coverage continuity in Medicaid and facilitate access to care, the authors call attention to the importance of streamlined re-enrollment policies. The ACA simplification requirements are a step in the right direction. However, even with streamlined renewal processes in place it’s clear that certain populations, many who have serious mental health conditions, will continue to need individual assistance to maintain Medicaid coverage.

Holly Stockdale

Holly Stockdale

Holly Stockdale, MPH,MPP is a research associate in the Division for Health Services and Social Policy at RTI International, an independent, non-profit research organization. At RTI, she has contributed to the design and implementation of evaluations related to state health care transformation, health care organization and delivery, and Medicaid.
Holly Stockdale
Holly Stockdale

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Susan Haber

Susan Haber

Director, Health Coverage for Low-income and Uninsured Populations at RTI International
Susan Haber, ScD, is a senior economist at RTI International, where she leads RTI's program on Health Coverage for Low-Income and Uninsured Populations. Dr. Haber has more than 25 years of experience studying Medicaid programs in many states, including evaluations of waiver programs and the impact of Medicaid policies on access to care. She has conducted extensive research on the population dually eligible for Medicare and Medicaid and is an expert in the analysis of merged Medicare and Medicaid data. She directed the study conducted for the Medicaid and CHIP Payment and Access Commission on the effect of the gap between Medicare cost sharing amounts and Medicaid payments on use of primary care services among Medicare-Medicaid dually eligible beneficiaries. Her current research includes evaluations of the implementation of the Medicaid eligibility expansion under the Affordable Care Act in five states; Maryland's all-payer hospital payment system in which hospitals operate under fixed global budgets; and a multi-state patient-centered medical home initiative, the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration.
Susan Haber

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