Revelations cast doubt on Missouri’s claim that ‘improved economy’ shrunk Medicaid rolls

April 25-- Apr. 25--JEFFERSON CITY -- Gov. Mike Parson's administration has said an improving economy was the key reason behind an abrupt drop in the number of Missourians receiving Medicaid last year, but newly found processing errors by the state cast doubt on those claims.

Advocates for Medicaid recipients say the renewal system adopted last spring by the Department of Social Services automatically renews only a low rate of recipients and operates with several data access issues. That's at least one reason why an estimated 70,000 people dropped off the state's Medicaid rolls last year, they say.

One glitch in the system, the advocates say, is in violation of federal law.

Federal regulations require states to determine recipients' Medicaid eligibility by first checking a variety of sources for patient income information, including data from its Supplemental Nutrition Assistance Program, known as SNAP. Missouri's renewal system has never checked SNAP data since its implementation last spring.

Joel Ferber, director of advocacy for the Legal Services of Eastern Missouri, said this meant someone could report their income information to SNAP one week, then find out they have to go through the process again for Medicaid.

In a worst-case scenario, he said, recipients never receive the Medicaid application and then find out they've been dropped despite already self-reporting their income to the state.

"Every child that has needed our help has been eligible for Medicaid or CHIP," Ferber said. "They only lost coverage because their parents were unable to get over the unnecessary bureaucratic hurdles. We have had children unable to get their asthma medication, unable to be treated for ringworm and kept out of school, unable to receive their psychiatric medication, unable to receive physical therapy."

St. Louis University law professor Sidney Watson said the ultimate repercussion for violating federal Medicaid regulations would be cutting off funding, but that has never happened. Instead, if an infringement was found, Watson said, the Center for Medicare and Medicaid Services (CMS) more likely would send a corrective action letter instructing the state to fix the problem by a certain time.

"The intent behind those regulations was to assure that when information was available to the state, and it is available to the state, they just have to make the computer system work," Watson said. "There are federal matching funds to create those computer systems to keep them up-to-date. It's a matter of will."

Missouri's renewal program also funnels patients with no income through the manual renewal process, even though they clearly qualify for Medicaid.

Another error: For several months after its implementation, the renewal system did not have access to recipients' federal tax income information. For the state to access this database, individuals have to provide consent, but the system was not programmed to include this field.

Pat Luebbering, director of the Family Support Division of the Department of Social Services, told the MoHealthNet oversight committee last week that the system still faced other issues in accessing federal income information when the state had mismatching personal identification information with what the federal system required.

Because of the glitches, MoHealthNet has fewer ways to access patient income information and, thus, less ability to automatically renew patients.

Ferber said he and other Legal Services members had confirmed each of the renewal system errors with Department of Social Services officials over the past few months. The department did not directly answer the Post-Dispatch's questions regarding the issues after department spokeswoman Rebecca Woelfel said "we respectfully decline" an interview with administrators to address the concerns.

In a later statement, the department acknowledged it planned to build a new tracking system that integrates SNAP with Medicaid eligibility.

It is unclear if the agency tracked exactly how many Missourians should have been automatically renewed who instead had to self-report their income information or how many of those qualified recipients were eventually dropped from the Medicaid rolls.

But MoHealthNet does keep track of how of many patients were renewed automatically: about 11 percent on average in recent months, according to the Department of Social Services.

Missouri is among the bottom 10 states that automatically renew less than a quarter of Medicaid recipients, according to a nationwide report conducted by the Henry J. Kaiser Family Foundation. On the other end of the spectrum, 10 states are able to automatically renew over 75 percent of recipients.

Luebbering pointed out last week that only about 100,000 cases went through the renewal process last year. The large majority of recipients' eligibility was updated when they came in contact with the department sometime during the year.

The Department of Social Services statement sent to the Post-Dispatch says the department is working with the federal government to explore ways the state can automatically renew Medicaid determination reliably through federal data.

Though the state's economy has improved, Missouri's coverage of children has dropped dramatically compared with other states'.

Children accounted for about 56,700 of the former Medicaid recipients in the 2018 drop, amounting to a 9.1 percent decline in coverage -- five times the national decline in children's coverage, according to federal Medicaid data.

Tim McBride, chairman of the oversight committee, has remained stuck on the number of children who fell out of eligibility. He said that even if a parent's income increased and they subsequently dropped off the rolls, their children should still remain eligible for Medicaid.

"I'm frustrated with the view that I think they still attribute a lot of this change to the improving economy, which I believe is part of the story, but a pretty small part of it," McBride said. "Whenever I push, that's the answer we get, and that's sort of the public answer."

Going through the manual renewal process rather than being automatically renewed does not necessarily mean a recipient will be dropped from the rolls, but both sides agreed self-reporting comes with challenges.

The department found that of the Missourians dropped from Medicaid last year, 43,200 failed to return renewal forms for various reasons and 20,000 were dropped because the department was unable to locate them, according to letters the Department of Social Services sent to House Minority Leader Crystal Quade, D-Springfield, and Sen. Scott Sifton, D-south St. Louis County.

During the February oversight committee meeting, Luebbering said it was difficult to reach some Medicaid recipients. The agency began mailing out a series of alerts, tweeting warnings and sending robocall reminders in November after tens of thousands had already been removed from the rolls.

Committee members brought up a list of hoops Medicaid recipients must jump through when renewing membership themselves, including extended call center wait times, lack of access to online resources and applications that arrive only in English.

Ferber said some of his clients were even turned away when visiting Family Service offices in person and were told to instead call the toll-free number.

While the Department of Social Services continues to study what caused the decline, rolls continue to drop. In the first three months of 2019 alone, the department's data show more than 12,000 more people, including 9,500 additional children, no longer have Medicaid coverage.

"This is clearly a red flag that needs to be investigated," Watson said. "Children need health insurance, and they need health coverage. We should be concerned and ask questions when we see thousands of kids losing coverage."

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