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Aug 16, 2023

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Recent articles

A first look at the Medicaid unwind: August 2023

by | Aug 16, 2023

Community Insight, COVID-19, Health, Resources

Katie Wallat, CCLP’s Senior Attorney, provided testimony at the August 11, 2023, meeting of the Medical Services Board. 

 

Good morning Mr. President and members of the board, 

My name is Katie Wallat and I’m an attorney at the Colorado Center on Law and Policy, a statewide anti-poverty nonprofit organization. I wanted to take a quick moment this morning to provide additional perspective on how the Medicaid unwind process is going. 

The Department has shared data on the first two months of the unwind process in public meetings, online, and to this board. This point-in-time data is often presented in comparison with what happened before the pandemic. However, while the pre-pandemic data provides a baseline, the state’s processing problems before 2020 were such that this is not a goal we think the department should be shooting for. The reported average rate of disenrollments for 2018-2019 was 40%, which is very high. We know that our Medicaid rolls did not dwindle by 40% each year before the pandemic, so many of these people must have been re-enrolled. This means that a large portion may have been terminated inappropriately or could not navigate the process of remaining enrolled. We know that we all have a shared goal of making sure this happens as little as possible.  

I’d like to revisit the data for the past two months of renewals—by the end of June, a staggering 112,792 people have been disenrolled from Medicaid, which represents 45.7% of all of the people who were up for renewal. We know from our conversations in the community that this number includes not just those in the income-based categories, but many people with disabilities who rely on daily services to remain at home and in the community. 

Unfortunately, Colorado is not doing very well relative to other states so far. A nonpartisan, independent source of health policy research called KFF, formerly the Kaiser Family Foundation, has been tracking each state’s reported data and providing comparisons. Colorado has the 15th highest rate of disenrollments in the nation. So, 35 other states, plus the District of Columbia, have had a lower rate of disenrollments during these first two months of the unwind.  

 

Another important data point is the rate of what are called procedural disenrollments, which are distinct from disenrollments for an eligibility reason, where the state has sufficient information to determine that the person is ineligible. Procedural disenrollments, on the other hand, are those where the state terminates enrollment because it lacks sufficient information—either because they didn’t get a renewal packet back or information was missing—or because the county was unable to process the information received by the deadline. We have heard that many counties are currently overwhelmed with a backlog of applications and renewal packets. 

In May alone, 50,253 people were disenrolled from Medicaid. The data from the Department show that 62% of them, or 31,000, were disenrolled for procedural reasons. In June, nearly half of the people who were up for renewal, or 62,539 people, were disenrolled. Of these, nearly 44,000, or 70% of them, were disenrolled for procedural reasons. We’re not drawing conclusions about trends from just two months of data, but we are frankly distressed about what this means for the 75,000 Coloradans with procedural denials over just the first two months of the unwind process. The Centers for Medicare and Medicaid Services has also expressed concerns about that rate in a letter to the state that was publicly posted yesterday. 

 

CCLP is among the community organizations that have been contacted on a near-daily basis by families who have been disenrolled.  I want to paint a picture of some of these individuals that the data are describing.   

Thanks to the outreach that the department and case management agencies have undertaken to spread the word about the unwind, one family we’re in contact with was aware of the upcoming need to fill out the renewal paperwork for their disabled child, but report that they never received a renewal packet in the mail. Instead, the family went to the county office in person, to fill out their packet before their renewal deadline. Despite their vigilance, the paperwork was not processed in time by the county and the child’s Medicaid was terminated. As a result, the family was unable to get the G-tube supplies needed and had to pause therapy appointments until the child was reinstated. According to the data, this person would have been considered one of the people who were procedurally disenrolled because of a failure to complete the renewal packet.   

Another child has been on Medicaid for 8 years. The parents also reported not receiving a renewal packet, but they did receive a letter asking for additional information. She submitted that information before the deadline and confirmed by phone with the county that it had been received. But because the information was not processed in time, her child was disenrolled from Medicaid, for the procedural reason of “failing to provide verification.” A major surgery had to be put on hold because of this.  

More terminations are pending, and advocates are scrambling to prevent them from taking place. One parent has learned that her infant, born prematurely and dependent on oxygen, will lose Medicaid at the end of the month. She has been told that the county will be unable to process his application before the renewal deadline—meaning that he, too, will be counted among those who “failed to complete the renewal process” when data is tabulated, unless advocates can help her stop that from happening. 

 

I could share a dozen more stories, and other community members could as well. Our goal in sharing these stories is to give a more nuanced perspective of what these categories can and do mean for real families. We recognize how hard the Department is working to conduct what can only be described as a herculean task, which is complicated by having to work with eligibility staff in 64 different counties. 

HCPF has been responsive to resolve individual cases that we and others bring to them. But for every case we hear of, we know there are many times as many people terminated in the last three months who don’t know who to call. We have had promising conversations with the Department about working together to fix some of these problems but want to emphasize that fixing these issues may call for fundamental changes to how eligibility applications are processed. We know that good communication channels, hands-on assistance with renewal packets, and timely processing can help keep procedural disenrollments to a minimum. We thank the Department for their ongoing partnership and will continue to share information with this board, as the unwind continues. Thank you for your time and attention.

 

Sincerely,

Katherine Wallat

Senior Attorney

Colorado Center on Law and Policy

 

Click here to learn more about the Public Health Emergency (PHE) Unwind, including a Medicaid survey, guides, webinar, and more.

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HEALTH:
HEALTH FIRST COLORADO (MEDICAID)

Health First Colorado is the name given to Colorado’s Medicaid program. Medicaid provides public, low-cost health insurance to qualifying adults and children. It is an entitlement program funded by the federal, state, and county governments and is administered by counties in Colorado. Those who are required to pay must pay a small co-pay when receiving certain health care services.

State Department: Department of Health Care Policy and Financing

Eligibility: Most adults 18 to 64 are eligible for Medicaid in Colorado if their household income is at or below 133% of the federal poverty limit (FPL). Pregnant women are eligible with incomes of up to 195% FPL, while children under 18 may be eligible if the live in a household with income at or below 142% FPL. Some adults over 65 may also be eligible for Medicaid.

Program Benefits: Through Medicaid, low-income Coloradans are eligible for a range of health care services at little to not cost. Services provided include doctors visits, prescription drugs, mental health services, and dental care. Co-pays for certain individuals may be needed for certain services.

Program Funding and Access: Colorado funds our Medicaid program through state and federal dollars. Medicaid is an entitlement program, which means that all who are eligible for Medicaid can access the program, regardless of the funding level in a given year. This does not mean that it is always easy to access Medicaid, even when eligible. And since the program is administered by counties, funding levels for county staff and other administrative roles can make it easier or harder for Coloradans to access the program. On top of this, not all medical providers accept Medicaid which limits the ability of Coloradans to seek health services even if enrolled, such as if the nearest provider is a 2+ hour drive away.

Note: This data is from before the pandemic and does not reflect changes in enrollment rules during the COVID-19 pandemic and public health emergency.

Statewide Program Access 2015-19: Over the study period of this report, an average of 89.0% of the population at or below 133% of FPL (i.e., the population who is likely to be eligible for Medicaid) were enrolled in Medicaid in Colorado.

FOOD SECURITY:
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

The Supplemental Nutrition Assistance Program or SNAP helps low-income Coloradans purchase food by providing individuals and families with a monthly cash benefit that can be used to buy certain foods. SNAP is an entitlement program that is funded by the federal and state governments and administered by counties in Colorado.

State Department: Department of Human Services

Eligibility: Currently, Coloradans qualify for SNAP if they have incomes below 200% FPL, are unemployed or work part-time or receive other forms of assistance such as TANF, among other eligibility criteria. Income eligibility for SNAP was different during the study period of this report than today—it was 130% FPL back in 2019 for example. The US Department of Agriculture uses the population at or below 125% FPL when calculating the Program Access Index (or PAI) for SNAP. We follow this practice in our analysis despite Colorado currently having a higher income eligibility threshold.

Program Benefits: SNAP participants receive a monthly SNAP benefit that is determined by the number of people in their household and their income. Benefit amounts decrease as income increases, helping households avoid a sudden loss of SNAP when their incomes increase, even by a minor amount. Benefits are provided to an Electronic Benefit Transfer (EBT) card that can be used to purchase eligible food items, such as fruits and vegetables; meat, poultry, and fish; dairy products; and breads and cereals. Other items, such as foods that are hot at their point of sale, are not allowable purchases under current SNAP rules.

Program Funding and Access: SNAP, like Medicaid, is a federal entitlement program. This means that Colorado must serve any Coloradan who is eligible for the program. As such, funding should not be a limit to how many Coloradans can be served by the program. However, funding for administration of SNAP at the state and county level can limit the ability of county human service departments to enroll those who are eligible. Other program rules and administrative barriers can make it difficult for Coloradans to receive the benefits they are legally entitled to receive.

Statewide Program Access 2015-19: Over the study period of this report, an average of 61.1% of the population at or below 125% of FPL (i.e., the population who is likely to be eligible for SNAP) were enrolled.

FOOD SECURITY:
SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC)

The Special Supplemental Nutrition Program for Women, Infants, and Children, also know as WIC, provides healthcare and nutritional support to low-income Coloradans who are pregnant, recently pregnant, breastfeeding, and to children under 5 who are nutritionally at risk based on a nutrition assessment.

State Department: Department of Public Health and Environment

Eligibility: To participate in WIC you must be pregnant, pregnant in the last six months, breastfeeding a baby under 1 year of age, or a child under the age of 5. Coloradans do not need to be U.S. citizens to be eligible for WIC. In terms of income, households cannot have incomes that exceed 185% FPL. Families who are enrolled in SNAP, TANF, Food Distribution Program on Indian Reservations (FDPIR), or Medicaid are automatically eligible for WIC. Regardless of gender, any parents, foster parents, or caregivers are able to apply for and use WIC services for eligible children.

Program Benefits: WIC provides a range of services to young children and their parents. These include funds to purchase healthy, fresh foods; breastfeeding support; personalized nutrition education and shopping tips; and referrals to health care and other services participants may be eligible for.

Program Funding and Access: WIC is funded by the US Department of Agriculture. The state uses these federal funds to contract with local providers, known as WIC Clinics. In most cases, these are county public health agencies, but that is not the case in all Colorado counties. Some WIC Clinics cover multiple counties, while others are served by multiple clinics. Private non-profit providers are also eligible to be selected as a WIC Clinic.

Statewide Program Access 2015-17: Between 2015 and 2017, an average of 52.2% of the population eligible for WIC were enrolled in the program in Colorado.

Financial Security:
Colorado Works

Colorado Works is the name given to Colorado’s program for Temporary Assistance to Needy Families or TANF. It is an employment program that supports families with dependent children on their path to self-sufficiency. Participants can receive cash assistance, schooling, workforce development and skills training depending on the services available in their county.

State Department: Department of Human Services

Eligibility: In general, Coloradans are eligible to enroll in TANF if they are a resident of Colorado, have one or more children under the age of 18 or pregnant, and have very low or no income. For example, to be eligible to receive a basic cash assistance grant through TANF, a single-parent of one child could not earn more than $331 per month, with some exclusions—and would only receive $440 per month (as of 2022). That said, there are other services provided by counties through TANF that those with incomes as high as $75,000 may be eligible for. In addition to these, participants in TANF are required to work or be pursuing an eligible “work activity” or work-related activity. Any eligible individual can only receive assistance if they have not previously been enrolled in TANF for a cumulative amount of time of more than 60 months—this is a lifetime limit that does not reset. Counties may have additional requirements and offer benefits that are not available in other counties in Colorado.

Program Benefits:  While the exact benefits that one is eligible for under TANF can vary, all qualified participants are eligible to receive a monthly cash payment, call basic cash assistance. Other than cash assistance, counties are have a lot of choice in how to use their TANF funding; generally a use of TANF funds is appropriate so long as it advances one or more of the four purposes of the program: (1) provide assistance to needy families so that children can be cared for in their own homes or in the homes of their relatives; (2) end the dependence of needy families on government benefits by promoting job preparation, work, and marriage; (3) prevent and reduce the incidence of out-of-wedlock pregnancies; and (4) encourage the formation and maintenance of two-parent families.

It is important to note that those eligible for TANF are also eligible for many of the other programs we’ve included in this report, such as SNAP, Medicaid, and CCCAP.

Program Funding and Access: Colorado funds its TANF program through funds received from the federal government through the Temporary Assistance for Needy Families block grant. Most of the federal funds are allocated by the state to counties, which are required to provide a 20% match of state funding. Federal and state rules allow the state and counties to retain a portion of unspent funds in a TANF reserve.

Statewide Program Access 2015-19: Over the study period of this report, an average of 50.7% of the population at or below 100% of FPL (i.e., the population who is likely to be eligible for TANF) were enrolled in TANF in Colorado.

EARLY LEARNING:
COLORADO CHILD CARE ASSISTANCE PROGRAM (CCCAP)

The Colorado Child Care Assistance Program provides child care assistance to low-income families and caregivers living in Colorado in the form of reduced payments for child care. It is a program funded by the federal, state, and county governments and is administered by counties in Colorado. The share owed by parents/caregivers is determined on a sliding scale based on the family’s income.

State Department: Department of Early Childhood Education

Eligibility: Counties set eligibility for families separately, but must serve families with incomes at or below 185% of the Federal Poverty Limit. Families accepted to the program are no longer eligible once their income exceeds 85% of the state median income. Parents or caregivers must be employed, searching for work, or engaged in another approved activity to be eligible for CCCAP. Parents and caregivers enrolled in Colorado Works (Temporary Assistance to Needy Families or TANF) or in the child welfare system are also eligible to participate in CCCAP. Generally, CCCAP serves families with children under 13, although children as old as 19 may be eligible under certain circumstances.

Program Benefits: If a family is eligible for CCCAP and has income, they may likely have to pay a portion of their child’s or children’s child care costs each month. The amount that families owe is based on their gross income, number of household members, and the number of children in child care in the household. As such, households tend not to experience a benefit cliff with CCCAP when they see their incomes increase

Program Funding and Access: Colorado funds the CCCAP program using federal dollars it receives from the Child Care and Development Block Grant program. The state allocates federal and state funds to counties using a formula that takes into account factors like current caseloads and the number of eligible residents. Assistance is available until the county’s funds are spent, so the number of families that can be served is often a function of how much funding is available and the income and composition of the household that applies. It is not uncommon for counties to overspend or underspend their allocations of funds. The state reallocates unspent funds from counties who underspent to those who overspent. While underspending could indicate a problem with the way a county administers its CCCAP program, it could just as likely be a sign that there are few providers in the county who participate in CCCAP—or a lack of providers generally.

Statewide Program Access 2015-19: Over the study period of this report, an average of 10.8% of the population at or below 165% of FPL and younger than age 13 (i.e., the population who is likely to be eligible for CCCAP) were enrolled in CCCAP.

Housing:
HUD rental assistance programs

The US Department of Housing and Urban Development (HUD) has three housing assistance programs that we look at together: Housing Choice Vouchers (Section 8), Project-based Section 8, and Public Housing. In Colorado, these programs provided assistance to over 90% of the households who received federal housing assistance from all HUD programs. Through federally funded, local or regional public housing agencies (PHAs) are the agencies that administer these programs, through not all are available in all counties. These are not the only programs available in Colorado that assist households afford the cost of housing, such as units funded through federal and state tax credit programs.

State Department: Department of Local Affairs

Eligibility: Generally, households with incomes under 50% of the area median income (AMI) of the county they live in are eligible for these rental assistance programs, although PHAs have discretion to select households with incomes at higher percentages of AMI. That said, HUD requires that 75% of new vouchers issued through the Housing Choice Voucher/Section 8 program in a given year are targeted to households with incomes at or below 30% of AMI. PHAs are also able to create criteria that give priority to certain types of households who are on waiting lists for these programs.

Program Benefits: These rental assistance programs help households afford the cost of housing by reducing their housing costs to around 30% of their household income. In the case of the Housing Choice Voucher program, the PHA pays the voucher holder’s landlord the remaining portion of the rent.

Program Funding and Access: Funding and access are both challenges for these rental assistance programs. In addition to limitations on the number of public housing units or housing vouchers a PHA can manage or issue, lack of funding compared to the need constrains the ability of PHAs to assist low-income households. In 2020, Coloradans were on waitlists for Housing Choice Vouchers for an average of 17 months. Waitlists also exist for the other rental assistance programs.

Statewide Program Access 2015-19: Over the study period of this report, an average of 21.1% of renter households with incomes at or below 50% AMI (i.e., the population who is likely to be eligible for HUD rental assistance programs) were living in subsidized housing.