Thousands in Wyoming could soon lose their health insurance

Between 10,000 and 15,000 people in Wyoming may lose their Medicaid insurance coverage in the next year, according to the Wyoming Department of Health.

Part of the reason is that two federal COVID-19 emergency declarations will end in May, prompting an end to extendeded Medicaid coverage and other options for many across the state.

The declarations, made by the Trump administration in 2020, provided agencies, states and health care organizations with a host of new resources and permissions. They were reauthorized several times before Jan. 30 when the Biden administration announced the emergency declarations would end May 11.

"While the response to COVID-19 is not over … we are in a position where we can effectively start to lift the Public Health Emergency (PHE) and the National Emergency related authorities," a spokesperson for the Centers for Medicare & Medicaid Services stated in an email.

Some of the new resources and programmatic flexibilities will dry up with the end of the declared emergency, creating a potential cliff for Medicaid patients.

History

During the pandemic, the federal government gave states additional money for Medicaid with the requirement that no one could lose that coverage. That meant if someone had a life change that would normally disqualify them from the program — increased income, becoming an adult, etc. — they could still keep that insurance, at least until the emergency declarations ended.

In December, though, Congress passed legislation to allow states to start phasing patients off of Medicaid who no longer qualify, starting in April.

"We're going to start sending renewal notices in March to clients," Kim Deti, Wyoming Department of Health spokesperson, said via email. "It won't be everyone at once. We'll send a certain percentage of renewal notices each month over the next 12 months."

A lot more Wyoming residents used Medicaid during the pandemic — about 85,000 in fiscal 2023 compared to 57,000 in FY 2020 — according to Deti. As the Health Department starts re-analyzing Medicaid eligibility, it expects thousands will lose coverage.

"It's been estimated by our Medicaid program that perhaps 10,000 to 15,000 individuals will no longer be eligible to receive Wyoming Medicaid benefits," Deti stated. "Common reasons this can happen include reaching adulthood so no longer eligible for coverage as a child or a change in personal and family income."

The department will help people transition off Medicaid and potentially to other insurance options, Deti said.

The purge could mean increased need at free clinics like the Downtown Clinic in Laramie, which only serves those without insurance and who make less than 200% the federal poverty level.

"We expect there to be more applicants for our services," said Pete Gosar, executive director of the largely volunteer-run Downtown Clinic. "And it's difficult because we're only able to keep our doors open three days a week."

The disenrollment will coincide with the end of emergency rental assistance programs, "and so you could easily find people without health care and without housing here by the end of June," he said.

Gosar is also concerned more residents will wait till health challenges are acute before reaching out for help. That already happens at his clinic, he said, and it can ultimately lead to unpaid emergency room bills and people facing serious health complications or death.

"Is that really a way we want to address each other as Wyoming citizens? Or is that really a smart plan for our workforce and a health care system that's already strained?" he asked.

Efforts to expand Medicaid in Wyoming for those who earn too much to qualify for the coverage — but often too little to afford private insurance — have failed at the legislature several times. The state estimates Medicaid expansion would insure about 19,000 people over two years.

A bill that would help extend Medicaid coverage for new mothers passed the House and is now up for consideration on the Senate floor.

Telehealth access

Emergency declarations enabled providers to offer a wide range of new services via telehealth that once required in person visits or other types of care. Congress extended many of those flexibilities late last year.

"[T]hanks to the Consolidated Appropriations Act, 2023, many of the telehealth flexibilities that people with Medicare have relied on during the [Public Health Emergency] will remain available through December 31, 2024," a CMS spokesperson wrote.

That specifically included a waiver to provide Medicare recipients with acute care from home via telehealth.

The extension of services was significant, but left out a few key provisions, according to Kyle Zebley, the senior vice president of public policy for the American Telemedicine Association.

The ability to prescribe controlled substances over a screen didn't make the cut and is set to end with the public health emergency.

"So that could end and that in-person requirement could come back into effect as soon as May 11," Zebley said.

That includes substances like psychiatric medications and treatments for attention-deficit/hyperactivity disorder. Zebley fears that could leave some to seek substances illegally, risking their lives. People will still be able to get buprenorphine as treatment for opioid use disorder via telehealth.

Reimbursement for telehealth services may also change, Zebley said. In 2021, there were requirements put in place for telehealth appointments to be reimbursed at the same rate as in-person ones.

Now, that decision will likely be handled like other reimbursement calculations: via the annual physician fee schedule.

"Might not be the way we want it handled, but I think that we will get a clearer answer through regular regulatory rulemaking," he said.

If rates drop, that could discourage health care providers from offering the option.

Those reimbursement levels would only last a year, though, which Zebley said leaves room for uncertainty no matter what they end up being. Even the two-year extension for other telehealth policies isn't much time for the medical community to establish new telehealth systems.

"This is no way to run a healthcare system," he said. "It's a giant system that moves slowly and requires predictability in order to make the investments necessary to deliver the highest level of care that's in the best interest of [the] patient population."

States also have substantial influence on telehealth practices and mandates, Zebley said, including standards of care, regulations and what state Medicaid will cover.

Wyoming lawmakers recently embraced new forms of telehealth by signing onto multi-state compacts where counselors and psychologists in other areas could help treat patients over a screen. Both compacts passed the Legislature, and the counselor compact has been signed into law.

Odds and ends

The policies above just scratch the surface of what the ending federal emergency declarations will mean for patients, providers, hospital systems and insurance companies.

Certain reporting requirements may lapse, for example, making it harder to know the rate of COVID-19 infections in the U.S. Access to free COVID-19 tests will also become limited to what the government has already purchased and to certain groups.

Federal officials are also still in conversations about what will end and what might be preserved through new agency policies or law.

With all that flux, individuals with concerns about access to tests or treatment are encouraged to reach out to their insurance or health care providers.

The CMS have also been posting information on CMS.gov, the webpage cms.gov/coronavirus-waivers and on Medicaid.gov.