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Missouri advocates decry Medicaid application delays and coverage losses

An illustration of a stethescope.
Susannah Lohr
St. Louis Public Radio
Interviews with advocates, applicants, participants and experts reveal that increased pressure on the social service agency’s capacity has intensified bureaucratic hurdles for low-income and low-resource Missourians trying to access government health insurance.

Hannah Kaplanis applied to Missouri’s Medicaid program nearly two months ago, but hasn’t received any response from the state.

Just shy of 18 weeks pregnant, she’s in need of prenatal care and growing increasingly hopeless. Aside from a free ultrasound in November, she hasn’t been able to access any care. She called Missouri’s Medicaid helpline earlier this month but had to hang up after waiting on hold for 45 minutes, and she is unable to apply for other insurance until she is out of Medicaid limbo.

“It feels like I’m doing motherhood wrong already, but it’s out of my hands,” she said. “I’m at a loss. It’s just a waiting game and that gives me anxiety.”

Jim Torres, program manager for health insurance services at Samuel Rodgers Health Center in Kansas City, helped Kaplanis submit her application and has been checking its status. He said that he hasn’t seen “any movement on her most recent application that was submitted on Dec. 4.”

Kaplanis’ struggles are not isolated.

Missourians trying to enroll in or retain Medicaid — the government-run health insurance program for low-income Americans — report running headlong into the state’s increasingly-strained system. Interviews with advocates, applicants, participants and experts reveal increased pressure on the state’s capacity has intensified bureaucratic hurdles to accessing Medicaid, which include lost and missing paperwork, indecipherable state notices and marathon call center wait times.

“I’ve been doing this with my organization for 10 years now,” said Saralyn Erwin, a marketplace and Medicaid coordinator at Northeast Missouri Health Council who assists with applications and renewals, “and this is the worst that I have seen it.”

“I know Medicaid is doing the best that they can,” Erwin said. “It’s just overwhelming.”

Missouri, like all states, is in the midst of the massive undertaking: evaluating the eligibility of every participant on its caseload for the first time in three years.

After the COVID-era federal pause on annual renewals expired last year, the state in June began to review the eligibility of all 1.5 million Missourians on its Medicaid rolls, also called MO HealthNet in Missouri — which is around one-quarter of the state’s population. Now, just over halfway through the process, Medicaid enrollment hasdropped by over 106,000 individuals, with half of them being kids.

As the state evaluates hundreds of thousands of current Medicaid recipients each month and processes their updated information, it continues to receive new applications.

From November to mid-January, during open enrollment season for the federal insurance marketplace, the state generally sees an uptick in Medicaid applications — a situation Erwin called, coupled with the resumed eligibility checks, a “double whammy” compounding the state’s capacity issues.

The backlog of applications under review swelled to over 45,000last month — a “pretty alarming number,” said Tim McBride, a health policy analyst, professor at Washington University in St. Louis and former chair of the MO HealthNet Oversight Committee. The average processing time has ticked up in the last few months and is now 36 days for low-income Medicaid applicants — approaching the federal maximum of 45 days.

Joel Ferber, director of advocacy at the nonprofit Legal Services of Eastern Missouri — one of the state’s legal aid programs which provides free legal assistance to low-income and disadvantaged Missourians — called the situation the “perfect storm of problems.” The result: Eligible Missourians can slip through the cracks of a complex bureaucracy and be denied health care they’re entitled to and in desperate need of.

“There are all these different breakdowns in the system,” he said, “and that causes people to lose coverage who are eligible.”

Routine changes turn painstaking

Christa Swillum holds a letter from the Missouri Department of Social Services. It has taken her months to receive benefits (Annelise Hanshaw/Missouri Independent).
Annelise Hanshaw
Missouri Independent
Advocates said some notices from the state are confusing and unclear, leaving participants unsure whether or why they are losing coverage.

Brittani Rusu, of Washington, spent a month and a half last fall trying to inform the state of her pregnancy so she could be switched from the adult Medicaid coverage category to Medicaid for Pregnant Women — a process that was “way too stressful…when it should have been super easy.”

“I couldn’t go to doctor’s appointments, I couldn’t do anything until Medicaid was switched to pregnant women,” Rusu said, citing potential billing and coverage issues.

But she says she couldn’t seem to get her information through to the state.

“I updated changes within the system online and went and dropped off physical copies at the local office here in Washington,” Rusu, a mother of six said, “and nothing changed.”

She tried several times to contact the state’s call center to update her information but faced hours-long wait times and queues of dozens of people ahead of her, even when she would strategically time her calls for right as the center opened.

When she went to her local social services office for help, she said she was directed to a phone in the back of the room, where she faced the same call center wait she was trying to escape.

“In order to have things changed, you will have to wait on the phone in the office,” she said she was told. “And I waited there for two hours one day.”

Torres said routine changes like switching coverage for pregnant women or getting coverage for newborns used to be a “pretty quick and painless process.”

“The easiest things,” he said, “are becoming very difficult right now.”

The Department of Social Services, which oversees Medicaid, didn’t respond to a list of questions sent last week but in August told The Independent the agency was working to improve wait times and would “continue to explore additional strategies and implement enhanced technology options to assist participants in connecting with our services.”

Kim Evans, director of the Family Support Division, which oversees Medicaid eligibility within the Department of Social Services, previously attributed the long call center wait times to individuals selecting the wrong phone line.

There is one phone line devoted to renewals and one for other Medicaid questions, which are run by two separate companies. When The Independent called last week and selected the non-renewal Medicaid line, the wait time was one hour before the call dropped, and after calling back, it was 1 hour 54 minutes before being connected to a representative.

Thirty seconds of the same piano loop plays on repeat during the wait, punctuated by a 10-second automated voice message: “Your call is very important to us,” it begins.

‘Chronic’ administrative issues

At each stage, advocates say, the system’s flaws can prevent people from keeping or getting coverage.

The state’s computer system produces sometimes-confusing notices, Erwin said, which can leave participants unsure whether they are losing coverage or not.

One Legal Services client’s renewal form listed nine different reasons for the termination of benefits, eight of which weren’t applicable or relevant, Ferber and a group of attorneys wrote in a letter to the federal Medicaid agency late last year.

“People should not have to guess why their coverage is changing; they need a clear reason for the change,” they wrote.

One participant told The Independent they didn’t receive a denial letter until after the date by which they were allowed to appeal.

The state’s online portal for document submission, which launched last year to allow people to scan and upload their documents virtually, has also been a source of concern. Ed Kolkebeck, public benefits attorney at Legal Services of Mid Missouri, said online document submission issues have been, “I think, the biggest problems that I’ve seen amongst my clients.”

Kolkebeck said he’s helped several people who were certain they’ve uploaded documents, who were then notified the state had no record of them ever turning anything in.

After clients receive notice that the state never got their documents, they must go in person, complete the renewal by phone, or submit documents by mail. The process “kind of defeats the purpose of having a document upload portal in the first place,” Kolkebeck said.

Once the state does manage to receive information, Erwin said, it often seems to “be sitting there” without being processed.

Torres said he’s seen documents being lost, the state requesting pay stubs they’d already received and documents languishing without being worked on by staff.

“Me, everybody on my team, I’ve been in meetings with people from health centers across the state, everybody’s really frustrated,” Torres said. “And it’s not just one off. It is chronic and almost across the board.”

He added: “This is the worst we’ve seen in a long time.”

Steve Foelsch, who lives in St. Louis, has utilized a Medicaid program for over a decade designed to help people with disabilities be able to work.

But he’s spent the last six months under the threat of losing it.

Foelsch is a quadriplegic and the program, called Ticket to Work, helps pay for his personal care attendants. His yearly renewal for the program resumed last summer, after the three year pause.

He had issues pre-COVID with the annual renewal. But this year it’s gotten worse, he said, with a variety of issues including the state initially finding his income too high to qualify, then later in the year, failing to collect his premium and providing conflicting information about his status in the program.

He had to take a day off work last summer to take the bus to go to his local resource center, in downtown St. Louis, and said he waited for around four hours before being helped.

Disability Resource Association, a local nonprofit, had to step in to cover the cost of his payments to his personal care attendants at the end of last year after he was incorrectly determined to be inactive. The issues weren’t resolved until earlier this month, he said.

Looking ahead

Some advocates think the state could be doing more to reduce the number of eligible recipients removed from the rolls.

Around three-quarters of all denied renewals are due to what are called procedural reasons, meaning generally that the participant failed to return paperwork or the state didn’t receive it. Missouri’s rate is around the national average.

“There are other states that are doing better on this,” said McBride, the health policy analyst at Washington University in St. Louis, “and we think the state could probably improve these numbers.”

Missouri could rely on more existing data to assess renewals, McBride said, without needing to get back information from the participant, erring more on the side of keeping people covered with other data than insisting they provide verification. Those are called ex parte renewals.

Children are eligible at higher income levels but have made up half of those removed from the state’s rolls. That portion of kids disenrolled is currently fourth highest in the countryamong the 21 states reporting age breakouts, according to the health policy nonprofit KFF.

There were 53,673 fewer kids on Medicaid in December as there were in June. The state has, in prior months, stressed that it is focused on the issue and working to ensure kids remain covered if they are eligible, even if other members of their household are not. They have also pointed to the fact that kids make up roughly one half of the state’s overall caseload.

After kids, the next two Medicaid groups with the highest rates of net loss were low-income adults (18% decline) and persons with disabilities (15% decline).

Centers for Medicare and Medicaid Services, the federal agency overseeing state Medicaid programs, has released guidance and options to increase the rate of renewals using data the state already has. They’ve expressed particular concern about the coverage loss for children.

Ferber has been urging the state to take up more of those optional strategies, which include renewing those at or below 100% of the federal poverty when no data is returned.

He said he wishes the state could fix the portal, act on documents in a timely manner and staff adequately. In the meantime, though, “It just seems like any way they could ease the burden on families and their staff like the ones CMS is offering is worth trying,” Ferber said.

“That’d be a starting point.”

This story was originally published by the Missouri Independent, part of the States Newsroom.

Clara Bates covers social services and poverty for The Missouri Independent.