Idaho might have broken rules in Medicaid unwinding, federal regulators warn

Originally published Aug. 18 on IdahoCapitalSun.com.Idaho officials say that a letter from federal regulators that says Idaho may have broken federal rules in how the state removed people from Medicaid this spring doesn't paint a full picture.

Idaho's 51% procedural disenrollment rate was the second highest in the country, just behind Texas, at 52%. That's according to the Idaho Capital Sun's review of letters the Centers for Medicaid and Medicare Services, or CMS, sent to all 50 states and Washington, D.C.

"We urge caution in making comparisons across states' data at this time. CMS has made note of cautioning any comparison data as all states have an independently approved unwinding plan that significantly impacts the information being reported," Idaho Department of Health and Welfare spokesman Greg Stahl told the Idaho Capital Sun in an email on Wednesday.

Idaho's call centers were backlogged by half an hour longer than most states, with an average call wait time of 34 minutes — which was the seventh highest in the nation in May.

About 51% of people Idaho removed from Medicaid that month were disenrolled for procedural reasons, which means they didn't reply to the state's requests for information. The national median rate for procedural disenrollments was 10% that month.

The letter to state officials, sent Aug. 9, doesn't capture how Idaho began Medicaid unwinding earlier and the state's process is more targeted than many other states, Stahl said. And Idaho is already working to improve metrics that the federal regulators flagged, including increasing staffing in the call center and the use of a call-back feature that connects enrollees with a customer service representative as soon as one is available, Stahl said.

Only four states started removing people from Medicaid by April and 21 prioritized at least some renewals for people who were likely ineligible, according to separate data from CMS.

"Few states are as far into unwinding as we are," Stahl wrote, pointing out that 18 states hadn't removed people procedurally by May, only 3 states had removed people in April and only 6 states removed people in May. "… Our being so far ahead likely skews the data for states who are just beginning: it is not helpful to compare states as the volume and strategy of who is included in each month vary drastically as that part was left up to each state to decide in their CMS approved unwinding plan."

Idahoans who call the call centers for Medicaid renewal also don't actually "wait" on the phone, Stahl said. They wait for a call back.

"While 34 minutes to receive a call back is longer than we would like, it is comparable to call back times during other peak times of (the) year, such as during Open Enrollment," Stahl said, noting that people can also renew online at any time.

HOW IDAHO APPROACHED MEDICAID UNWINDING: EARLY AND TARGETED

Idaho started Medicaid unwinding in April, which was earlier than most states, and it had a head start. Officials had already flagged 153,000 Idahoans as likely to be removed from Medicaid, and Idaho kept processing Medicaid applications during the pandemic, but federal law prevented Idaho and other states from removing people from Medicaid until early this year.

"Many states, for example, had not started processing procedural closures by May" and "have chosen to pause procedural closures, and are not prioritizing populations who may no longer be eligible," Stahl said. Idaho estimates a total of just nine states had started procedural disenrollments by May, Stahl said.

So far, many people being removed from Medicaid in Idaho have been removed because of "procedural reasons," meaning they didn't fill out paperwork telling the state their income. Most applications the state has reviewed so far have resulted in people being removed from Medicaid.

But the rate of people removed for not responding to the state's requests for information is likely to decline soon. The state is wrapping up disenrolling people from the Medicaid Protected population, which includes 153,000 flagged as likely to be removed from Medicaid, and shifts to reviewing the eligibility of everybody on Medicaid.

"While we would expect the termination rate and procedural termination rate to be higher in a state that is prioritizing ineligibles, Idaho's rates are significantly higher than other states taking a similar approach," said Jennifer Wagner in an email to the Idaho Capital Sun. Wagner is the director of Medicaid eligibility and enrollment at Center on Budget and Policy Priorities and a Medicaid expert who has worked on state policy for 13 years.

FEDERAL REGULATORS TOLD 16 STATES THEY MAY HAVE BROKEN RULES OVER CALL TIMES

A handful of Western states— such as Montana, Utah, Alaska, Oregon and Nevada — also had longer wait times, high rates of call abandonments or high rates of procedural disenrollments and their health departments were warned they may have broken federal rules.

CMS told 16 states they may have violated federal law due to call wait times, Wagner said. But the CMS letters included several other measurements for how Medicaid unwinding is going.

Idaho's rate of call abandonment was below the national median, at 7%.

Montana had the second longest call wait time in the country, the Daily Montanan reported.

"It's hard to say what numbers are 'good' or 'bad," Wagner said. "But when we compare Idaho to other states — even similarly situated states — the numbers are very concerning."

Medicaid unwinding is new, Wagner said. States typically annually renew the eligibility of Medicaid recipients without a three-year wait time, brought on during federal law during the pandemic. Metrics like this haven't been published before, Wagner said.

So far, Idaho has removed 103,000 people from Medicaid out of a group of 153,000 the state flagged as likely to be removed from Medicaid, Shane Leach administrator of the Division of Welfare in the Department of Health and Welfare, told the agency's board Thursday. More than half of those people — 62% — were removed for procedural reasons, or because they didn't reply to the state's requests for eligibility information. Another 42,000 were removed because they were determined to be ineligible for Medicaid, Leach said.

He said it's unclear where people who are being removed from Medicaid are getting insurance. It could be that they're getting insurance through their job, the state based insurance marketplace, or they could've moved out of state or died.

"Where are these individuals? That is kind of the million dollar question," Leach told the board.

WHAT CMS TOLD IDAHO ON DISENROLLMENT PROCESS

Idaho's high rate of procedural disenrollments, the letter said, "raises concerns that eligible individuals, including children, may be losing coverage." About 23,000 Idaho children have been removed for Medicaid for not replying to paperwork, according to data from April to July that the Idaho Capital Sun previously reported.

Idaho expected May to be a "high month of closures" because the people up for removal that month hadn't responded to re-evaluation requests for two years during the pandemic, Stahl said.

"The closure that occurred for these people means that we could not determine what their income is, and can therefore not determine if they are eligible or what level of Medicaid coverage they'd be eligible for," Stahl said. "Even children are subject to an income limit test, and if their income cannot be verified, then we cannot determine that child's eligibility."

In its letter, CMS listed several areas Idaho may have been non-compliant in.

Idaho suggested not all of CMS's recommendations apply to them, Stahl said.

"CMS is looking at unwinding at the nationwide level to ensure that the maximum amount of people on Medicaid who remain eligible stay on Medicaid. As a result, this letter includes language that is being suggested to many states, that includes direction that is not specific to them," Stahl said. "This is evident in the language that points to areas that may be looked at, and suggestions that should be considered that have already been intimately discussed with CMS here in Idaho and long standing strategies we use."

Federal regulators told Idaho they were concerned about Idaho's high rate of removing people for not responding to the state.

"While CMS expects procedural terminations, a high rate of terminations may indicate that beneficiaries may not be receiving notices, are unable to understand them, or are unable to submit their renewal through the required modalities," the letter said.

IDAHO SAYS PROCEDURAL REMOVALS WILL DECLINE; NO-ACTION RENEWALS WILL RISE

CMS, in the letter, asked Idaho to increase the rate of ex parte renewals — which is when the state renewed someone's Medicaid without the person having to update their information.

"It is important to note that this is what Idaho does: we attempt to complete an ex parte renewal first, and only when we cannot do we ask the household to complete the process by going online or by calling us," Stahl said.

Ex parte renewals will increase in Idaho over the coming months as the state switches from removing people from Medicaid who are likely ineligible to evaluating the eligibility of everyone on Medicaid, Stahl said. Leach previously told the Idaho Capital Sun that the number of people removed from Medicaid for not replying to the state would likely decline.

Stahl also said Idaho is continually looking at options for its Medicaid program, including automation changes that could benefit all Idahoans on Medicaid.

The federal agency wrote that it would follow up with Idaho on the changes the state is making.