How Many Iowans Lost Medicaid Coverage During the ‘Settlement Period’?

On By Vaseline

More than 200,000 Iowans removed from Medicaid during the state’s eligibility review lost coverage due to improperly completing paperwork, not responding to the state or other procedural reasons.

In some cases, those Iowans didn’t realize they had to re-enroll for coverage under the state insurance program.

As a result, local health officials at Broadlawns Medical Center say they often encounter patients who do not realize they have lost their coverage until they were admitted for a hospital stay or attempted to refill a prescription.

“Unfortunately, most patients don’t know they’ve been dropped from Medicaid until they’re not feeling well,” said Tira Mays, government programs coordinator at Broadlawns.

Over the past year, state officials have revised health care coverage for thousands of Iowans under the safety net insurance program following the end of the national public health emergency, which guaranteed no one would lose Medicaid coverage during the pandemic.

As of April 1, 2023, state officials reviewed the qualifications of more than 890,000 Iowans enrolled in state programs, including traditional Medicaid and CHIP (the Children’s Health Insurance Program).

Those who are still eligible have the option to re-enroll for coverage. Those who are no longer eligible will be terminated.

Since the state began this “resolution process,” nearly 550,000 Iowans have re-enrolled in Medicaid coverage, according to the most recent data available from the Iowa Department of Health and Human Services. Fifty-one percent of these renewals were done automatically based on information the state has about the enrollee, through a process called “ex parte renewals.”

But more than 282,000 Iowans have been kicked out of Medicaid coverage.

Of those, about 74% – or more than 209,000 – were deregistered for ‘procedural reasons’, such as failure to correctly complete and return government paperwork.

The remaining 26%, approximately 73,500 individuals, were ineligible.

“The COVID-19 pandemic presented unprecedented circumstances, without any point of reference for what to expect if the constant reporting subsided,” said Alex Murphy, communications director for Iowa HHS.

Murphy said “disenrollments” were initially proportionately high, but “Iowa anticipated the standard churn that occurs in Medicaid enrollments based on annual renewal cycles.”

Still, that coverage gap raises concerns about disrupted patient health care for physicians like Dr. Jason Kruse, an internist and interim CEO of Broadlawns.

It is a particular concern for patients with chronic medical conditions such as heart failure and diabetes, especially if doctors are unaware that they cannot afford their medications due to insurance issues.

“People feel like the rug is being pulled out from under them if they don’t understand what’s happening, and there can be a sense of shame for people who suddenly have to acknowledge that they don’t have coverage,” Kruse says. “It’s a barrier to get past that and connect them carefully.”

How has the unwinding of Medicaid affected Iowa’s overall enrollment?

By early 2023, state officials projected that about 17% of Iowa’s total enrollees would be disenrolled from coverage during the Medicaid redetermination process, or more than 150,000 individuals.

According to HHS, Iowa currently has a net disenrollment rate of 18-19%.

Iowa offers a 90-day grace period for members whose Medicaid coverage has been terminated for procedural reasons to ensure coverage does not lapse.

Currently, government officials are seeing a 25-30% re-enrollment among these individuals within that three-month period, Murphy said.

Iowa’s procedural disenrollment rate is on par with the national average, according to Louise Norris, health policy analyst for healthinsurance.org. To date, approximately 69% of all deregistrations across the country have been procedural.

The pace of these deregistrations also changed over the course of the settlement period, Norris said. As of April 2023, there were approximately 30,000 procedural disenrollments in Iowa. By December this had fallen to 4,800.

That adjustment came after the U.S. Centers for Medicare and Medicaid Services sent a letter to Iowa and other states warning them that a problem with their renewal process could improperly cover eligible individuals.

Overall, total Medicaid enrollment in Iowa has fallen by about 19%, which Norris said puts Iowa among the highest declines in net enrollment nationwide. Only 11 other states have a higher overall percentage decline in Medicaid enrollment, she said.

As of March, Iowa had more than 725,000 members enrolled in a state Medicaid program, according to HHS.

Why are procedural deregistrations a concern?

Norris said procedural disenrollments can be intentional, where the individual chooses not to participate in Medicaid renewal because they no longer need that coverage.

However, that doesn’t apply to everyone, Norris said. Some people are too busy and miss a deadline to complete their re-enlistment paperwork, she said.

Others may be homeless and may not have received a renewal package from the state.

It’s unclear whether Iowans affected by the settlement process will return to some form of health insurance, Norris said.

“We’ve thrown a lot of people off Medicaid, and I think there’s reason to be concerned about how their health care needs are being met,” said Anne Discher, executive director of Common Good Iowa, which advocates for children and families. .

State officials say that among adult Iowans disenrolled for procedural reasons, about 3% have a Medicare plan and another 35% have some form of major medical coverage. Of the children, 28% have extensive medical coverage.

More than 28,000 Iowans who previously had Medicaid had enrolled in a plan through the Affordable Care Act Marketplace as of December 2023, according to the most recent data available, according to healthinsurance.org.

However, about 62% of adults and 72% of children in Iowa who are disenrolled for procedural reasons have no other known health care coverage, HHS officials say.

That’s raising concerns among some advocates that Iowans may be left without insurance. A study by KFF, the national health policy research organization, found that about 23% of American adults who were excluded from Medicaid during the phase-out period are now uninsured.

The thresholds for children are much higher than those for adults, but there is no clear data on how many children find their way into CHIP or Hawki, a health care plan for low-income children in Iowa.

That worries advocates like Discher, who said children could miss developmental screenings and other important doctor appointments if they lose health care coverage.

“Those are things that you would really expect to be on the sidelines if there’s no insurance,” she said.

What’s the next step for relaxing Medicaid?

March 2024 was the last renewal month to end Iowa’s continued coverage, but Murphy said processing “may continue for several more months.”

Because of delays in federal data, Norris said it could be months before analysts have a full picture of how the settlement played out in Iowa and across the country. That includes information about how many individuals may have been left uninsured because of the lawsuit.

The post-pandemic Medicaid redetermination process has drawn attention to how complex insurance can be for everyday Iowans to navigate, said Mays, one of the financial advisors at Broadlawns who help with the health insurance enrollment process.

If these bureaucratic aspects can’t be simplified, Kruse says insurance companies and healthcare organizations will need to better staff their service departments to help patients navigate that process.

If individuals have been disenrolled from Medicaid coverage or otherwise need assistance obtaining insurance, Mays encouraged patients to contact their health care provider for financial assistance.

Michaela Ramm covers health care for the Des Moines Register. She can be reached at [email protected], at (319) 339-7354 or on Twitter at @Michaela_Ramm.