Impacts of Medicaid Unwinding Continue in the Flathead

The impacts of Medicaid unwinding continue to ripple through the Flathead Valley as Montana’s redetermination process continues in the new year with thousands fewer children and adults receiving coverage since the state began reviewing its Medicaid rolls last year.  

Medicaid is a joint state and federal program which provides health coverage for tens of millions of Americans, and those who are eligible can include children, pregnant women, parents, seniors, people with disabilities, and low-income families. A pandemic-era federal policy preventing states from kicking people off Medicaid was ended by Congress in 2022, meaning states have had to undertake a review of Medicaid eligibility for the first time in years, which has become a massive undertaking. People have lost coverage for a number of reasons, including because they were determined to be ineligible, or they were unaware they might need to re-enroll in some cases because they did not receive redetermination paperwork to re-enroll.

The Montana Department of Public Health and Human Services tracks Medicaid enrollment in an online dashboard which updates on a 90-day lag to account for the delay in processing applications and retroactive enrollments, meaning the most recent data available is from October 2023. That snapshot shows that in Flathead County, the number of people enrolled in Medicaid programs went from 28,468 in 2022 down to 22,701 in 2023.  

People who have had their Medicaid coverage ended and need to re-enroll, have 90 days from the termination of coverage date to submit redetermination paperwork. Otherwise, people are able to apply again for Medicaid coverage at any time, although that process takes more time. In cases where DPHHS receives the redetermination paperwork within the 90 day window, and a person is eligible for Medicaid coverage, DPHHS can provide up to three months of retroactive coverage.

“I just want to continue to drive that that point home, and stress that point,” DPHHS Director Charlie Brereton said at a Jan. 18 meeting of the Children, Families, Health and Human Services interim legislative committee. “For anybody out there, any Montanan, any of your constituents who believe that they are in fact eligible for Medicaid, but had their coverage closed, likely because the department didn’t have the information and the data sources, the data sets, to determine their eligibility, and verify their eligibility. Please get that redetermination packet submitted to us. If you’re outside of the 90 day window, I would strongly encourage those individuals to stop by their local office of public assistance or to use our self service portal, or SSP Online, to reapply for Medicaid coverage.”

In terms of DPHHS operations involved in redetermining Medicaid status, Brereton told the committee he expects those operations to be affected likely through the fall of 2024. As of December 2023, DPHHS was taking about 30 days to process applications, and 21 days to process redetermination applications.

January was the final month of the state’s 10-month period where it redetermined Medicaid coverage, but because of the way the process works, a more clear picture of how many people have had their coverage affected is still months away.

Gene Hermanson, the DPHHS chief financial officer for Medicaid, told the Children, Families, Health and Human Services interim legislative committee during a Jan. 18 meeting that the data going back to October showed about 6% fewer people were enrolled in Medicaid than his agency had originally anticipated, and that the Medicaid Expansion program had about 12% fewer people enrolled than anticipated.

“At this point we consider it is too early to know if what we’re currently seeing will hold throughout the fiscal year,” Hermanson said. Describing some of the unknowns and potential factors, he said it’s possible that they see a drastic reduction in disenrollments as they move forward, and that it’s unclear how many of those people that may have not sent in the necessary paperwork yet end up doing so. Hermanson said they’ll have a better idea on where Medicaid enrollment stands by the spring, and that they won’t have a true picture until later this summer.

In November, KFF News was reporting people in Montana were struggling to connect to state offices that were seeing a high volume of requests for assistance. Mandie Fleming, the manager of the Flathead City-County Health Department’s Family Planning Clinic, said that, anecdotally, she has heard those issues have persisted for some people, including some who have had to spend hours waiting on the phone.

The health department’s family planning clinic offers a range of services, including STI screenings and treatment, access to birth control, pregnancy testing, and cancer screenings. Fleming said that some of the people who come to the clinic aren’t aware they’ve lost their Medicaid coverage until they’ve arrived at the clinic for treatment.

The clinic provides services to people regardless of their insurance coverage or lack thereof, meaning that people who find themselves without health insurance pay on a sliding scale. Depending on where they fall on the Federal Poverty Level, that means they could end up receiving treatment for free, or at a reduced cost. But with more people having lost Medicaid coverage or stuck navigating the process of reapplying, the clinic has seen a marked increase in people who are paying on the sliding scale, which has led to a loss in revenue that otherwise would be coming from payments made through Medicaid.

“When we talk about Medicaid, we have a very delicate algorithm that we would need to see with a payer mix to keep us financially sustainable. So having a good mix of folks who have private insurance, and public insurance, like Medicaid, helps us be able to bill for insurance, get revenue in, to help subsidize visits for people who utilize our sliding scale,” Fleming said.

Fleming said that in October, November and December of 2023, the clinic saw a 15% decline in people with Medicaid coverage, and a 15% increase in people using the sliding scale payments, compared to the same period a year earlier. There was some anticipation that this could happen as a result of the unwinding, but the amount of people impacted has exceeded Fleming’s expectations, and she doesn’t have a firm sense of when the situation could improve or be resolved.

At the family planning clinic, Fleming said the revenue impact hasn’t yet reached the point at which it’s necessary to have discussions about making major cuts to services. Right now the focus is more on exhausting other options, which could include trying things like marketing efforts aimed at promoting the clinic’s services to a broader demographic of people, or possibly fundraising campaigns.

Cover Montana, a nonprofit operating under the Montana Primary Care Association, which helps people understand their health insurance options and enroll, has been tracking the Medicaid unwinding closely. Cover Montana works in communities throughout Montana, including in the Flathead. Olivia Riutta, who oversees Cover Montana, said it has been “exceptionally busy.”

“We have spent a lot of time helping people understand the unwinding process, helping people complete redeterminations, referring folks back in to the OPA (office of public assistance) if there is an issue with their case and it needs to be resolved. We’re not Medicaid case workers, so we can fill out applications, but we can’t kind of go in and fix, if you will, if something’s going on with the case. We can’t work those cases. We have done a lot of work with folks who have lost Medicaid or Healthy Montana Kids, kind of at some point since the unwinding process began in April.”

As Riutta noted, more than 100,000 people in the state have had their Medicaid redetermination cases closed so far. A DPHHS dashboard tracking redetermination cases shows 64% of those people having failed to provide requested information, meaning they weren’t determined ineligible but were disenrolled because they didn’t return information requested.

Because of an extended deadline for people who may have lost Medicaid or Healthy Montana Kids coverage in April to enroll in the federal Health Insurance Marketplace, Riutta said she’s expecting that Cover Montana is focused on trying to help people get enrolled in coverage for the next six months. The end of open enrollment, a process Cover Montana also offers assistance for, has offered a minor reprieve.

“It has been exceptionally busy since April,” Riutta said. “And I think only now are we starting to see it get slightly less busy.”