{"subscriber":false,"subscribedOffers":{}} How States Are Facilitating Medicaid Enrollment During COVID-19—And How They Can Do Even More | Health Affairs
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How States Are Facilitating Medicaid Enrollment During COVID-19—And How They Can Do Even More

As the number of individuals who find themselves unemployed due to COVID-19 continues to increase, reports have come out documenting that the majority of those filing unemployment claims are facing significant delays in confirming eligibility and receiving benefits. This led us to wonder if similar issues exist for individuals who are applying for Medicaid coverage after becoming newly eligible.

As a result of the COVID-19 pandemic, the number of people unemployed has skyrocketed to more than 40 million individuals, with April 2020 having the greatest net change in unemployment in the past decade. The exact number of newly unemployed (or reduced work hour/incomes) individuals who are now eligible for Medicaid is unknown, but some are estimating a significant increase in people eligible for Medicaid, especially in Medicaid expansion states

With more than 70 million people currently enrolled, representing more than 20 percent of the US population, Medicaid provides coverage for essential services such as primary and preventive care, treatment for chronic illnesses, and behavioral health care to individuals with low income or disabilities. During the pandemic, the Medicaid program, similarly to unemployment benefits, has the potential to offer a vital safety net.

Between April 13, 2020, and May 8, 2020, we conducted a content analysis of strategies taken by states during COVID-19 and policies enacted prior to the pandemic that may facilitate Medicaid enrollment for individuals who are newly eligible due to the pandemic. Policies enacted by states prior to and not in response to the pandemic were included if they supported the enrollment of individuals during COVID-19. In some cases, states amplified and made this information and other COVID-19 specific resources more accessible for enrollees. Since a number of those applying for Medicaid during the pandemic are first-time applicants navigating the process, we identified which states had these strategies in place to facilitate and streamline enrollment.

We searched state Medicaid agency and department of health websites, press releases, announcements, public service documents, approved Medicaid waivers, federal websites, and various media outlets (for example, archived videos of local evening news and digital newspaper articles). For information that was not available online or was ambiguous, the project team reached out to state Medicaid agency and Medicaid health plan staff to obtain the information needed. Thirty-eight data points including 23 strategies specific to enrolling the newly eligible were retrieved. An overview of the data points, methods, and additional findings can be found here.  

Common Strategies

As of May 8, 2020, all but four states reported a statewide stay-at-home or shelter-in-place order with state Medicaid offices either closed with phone access or opened with a modified appointment schedule. All states allowed individuals to apply for Medicaid online or by phone, and all had a dedicated phone line to provide enrollment assistance (exhibit 1). However, it is worth noting that both strategies are federal requirements that were implemented prior to the COVID-19 pandemic. Most states (92 percent) additionally have provided a phone number on the state Medicaid website that can be called for assistance and are not requiring an in-person or phone interview (82 percent). However, the majority (55 percent) of states did not provide updated enrollment information on their website on how to apply for Medicaid benefits during the COVID-19 emergency. Ninety-two percent of states offered real-time eligibility determinations within 24 hours. 

Automating the application process to support eligibility determinations on the same day and reviewing qualifications that are required to be processed in real time can facilitate Medicaid enrollment and ultimately allow for more timely provision of health care services. All states, except Idaho, maintained documentation requirements (for example, proof of a social security number) of applicants during the pandemic to apply for Medicaid. However, the federal field offices to obtain these documents (for example, social security office) were closed during this time with limited phone capacity. There were other strategies that were less commonly deployed by states such as accepting self-attestation of information for criteria besides citizenship/immigration (29 percent) and adopting a simplified application with less items on the form (6 percent). Additionally, of note, some state-level strategies may have been enacted prior to the COVID-19 pandemic. For example, 48 percent of states already allowed presumptive eligibility determinations by hospitals.

Exhibit 1: Strategies deployed by states to support Medicaid enrollment during COVID-19, 2020

Strategy

Total

N=51*

Medicaid Expansion States**

N=36

Non-Expansion States

N=15

Dedicated phone for enrollment assistance.^

100%

100%

100%

Ability to enroll online or over-the-phone.^

100%

100%

100%

Phone number for assistance on state Medicaid website.

92%

97%

80%

Real-time eligibility determinations (<24 hours).

92%

97%

81%

Interview not required (in-person or telephone).

82%

81%

87%

Requirements waived for timely processing of applications and/or expanded immigration status verification period.

60%a

66%a

47%

Additional entities allowed to determine presumptive eligibility.

55%b

59%b

47%

Information on state department of health’s website on Medicaid enrollment during COVID-19.

45%

64%

0%

State has a hospital presumptive eligibility program.

48%c

55%c

33%

Medicaid agency allowed to determine presumptive eligibility; excluding pregnancy.

44%d

46%d

40%

State accepts self-attestation of information for criteria besides citizenship/immigration.

29%e

35%e

13%

State adopted a simplified application form.

6%

8%

0%

Source: Institute for Medicaid Innovation. Medicaid enrollment during COVID-19: content analysis of state actions to mitigate barriers. Washington, DC; 2020. Notes: *Includes District of Columbia. **Includes District of Columbia; excludes Nebraska. ^States were required to implement these strategies prior to COVID-19. aUnable to verify information for Delaware; excluded from denominator. bUnable to verify information for Alaska and Arizona; excluded from denominator. cUnable to verify information for Alaska, Arizona, Colorado, Massachusetts, and West Virginia; excluded from denominator. dUnable to verify information for Arizona; excluded from denominator. eUnable to verify information for Minnesota and Michigan; excluded from denominator.

It is important to note that the Affordable Care Act (ACA) provided states the option to extend presumptive eligibility (PE) to other populations in addition to children and pregnant women as well as allow hospitals to determine PE even in states without established programs. During the pandemic, states may submit a disaster-relief state plan amendment to allow other entities to determine PE, such as the state agency, or to extend PE to additional populations. Furthermore, the ACA also streamlined Medicaid enrollment processes by requiring a single application for Medicaid, the Children’s Health Insurance Program, and Marketplace coverage, supporting simplified online applications, eliminating in-person application requirements, and providing for real-time eligibility determinations.

Differences Between Medicaid Expansion Status

With anticipated differences in the magnitude of increase in newly eligible Medicaid enrollment in Medicaid expansion states, we compared state-level strategies based on expansion status. Regardless of status, expansion or non-expansion, both deployed the same top five most common strategies including 1) having a dedicated phone line for enrollment assistance (expansion 100 percent, non-expansion 100 percent); 2) having the ability to apply online or over the phone (expansion 100 percent, non-expansion 100 percent); 3) providing a phone number for assistance posted on the state Medicaid website (expansion 97 percent, non-expansion 80 percent); 4) establishing a process for real-time eligibility determinations within less than 24 hours (expansion 97 percent, non-expansion 81 percent); and 5) no longer requiring in-person or telephone interviews (expansion 81 percent, non-expansion 87 percent). However, rates declined sharply for non-expansion states compared to expansion states for strategies such as having information on the state department of health’s website on Medicaid enrollment during COVID-19 and the state accepting self-attestation of criteria besides citizenship/immigration. Adopting a more simplified application with fewer items on the form was the least common strategy for all states.  

Opportunities To Continue Or Enhance Support For Medicaid Enrollment

The strategies identified in our content analysis represent important findings that can be used to inform ongoing policies specific to the COVID-19 pandemic at the state and federal levels. Although our work did not seek to identify specific barriers with technology, it is assumed that states without robust technological infrastructure may have more difficulty in streamlining the application process and processing a higher volume of applications. Furthermore, it is expected that technological factors will impact the degree to which barriers will exist for states and Medicaid applicants. Implementing strategies to help facilitate Medicaid enrollment, including those identified above as well as those that help to address potential underlying technology barriers, has the potential to strengthen the safety net for those who need it during this unprecedented crisis. Finally, as states consider additional strategies to support Medicaid enrollment, we believe they should consider the following opportunities:

Increase The Number Of PE Entities

More than half of states had a hospital PE program either in place prior to COVID-19 or newly authorized during the pandemic. Presumptive eligibility allows states to grant authority for certain qualified entities (for example, hospitals) to screen for Medicaid eligibility and immediately enroll individuals on a temporary basis until full eligibility determination can be made. States can choose the entities that are able to presumptively enroll individuals. Details on the requirements and options for states regarding PE can be found here. Increasing the number of hospitals, clinics, and other entities to conduct an initial screening for Medicaid eligibility and temporarily enroll individuals who appear to be eligible allows for more timely treatment at the time care is needed, as well as provides some level of assistance for individuals to begin the process of Medicaid enrollment. While PE is a helpful strategy to obtain temporary coverage, it is important to remember that a full application is still required to remain eligible, and any barriers involved in completing that full process may still be a factor for applicants.

Extend The Type Of Qualified PE Entities To Determine PE

Extending the type of qualified entities to include schools, community-based providers, and state agencies such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) offices may offer additional opportunities to facilitate enrollment into the Medicaid program. Reasons for not adopting have been discussed here. Similar to the potential benefits of PE through hospitals, additional PE entities increase the probability of an individual contacting an entity that can start them along the pathway of enrollment prior to the time care is provided. Despite these benefits, fewer than half of states have adopted this strategy. The relative infrequent adoption of this strategy may be a result of the administrative burden of establishing the PE programs, such as the need to complete required applications for the waiver as well as the need to create and maintain training materials for the additional entities.

Use The Federally Facilitated Marketplace Enrollment Determinations, Data, Or Both

Of the states that rely on the federally facilitated Marketplace (FFM), only nine states accept the FFM’s eligibility findings and enroll all the applicants deemed eligible. The other 29 states use the FFM information but conduct a full eligibility determination at the state level before enrolling the individual into Medicaid. The requirement to conduct a full eligibility determination delays potential coverage and access to health care services. Following the model adopted by the nine states to accept the FFM eligibility findings is an efficient approach to support enrollment. The approach a state takes is both a policy choice and a potential technical challenge. The policy choice is usually related to relying on federal data sources rather than information that a given state controls. The technical issues arise given the challenges that may be associated with the information technology infrastructures required for data exchange. 

Minimize Documentation Requirements For Eligibility

Minimizing requirements for submitting paper documentation for verification may be accomplished by increasing use of electronic data systems to verify eligibility at the state and federal levels. This strategy could also include providing an extension of the reasonable opportunity period (that is, the amount of time, generally 90 days, that an individual must provide all required application documentation). It is unknown why more states have not adopted this strategy or the obstacles that they may be facing such as administrative burden in considering this option.

Implications

States are facing higher rates of Medicaid enrollment and costs than anticipated for 2020 due to the pandemic and its related impacts on employment. From February to April of this year, Medicaid enrollment has increased by 2.8 percent with four states soaring above a 5.0 percent increase. As the pandemic continues to impact rates of unemployment, many will rely on Medicaid as a critical source of health coverage and access to care. Given the large number of potential applicants, states have an opportunity to adopt strategies to make the application and enrollment processes easier and more efficient for potential applicants. These strategies, individually and collectively, have the potential to support the health and well-being of a nation facing the challenges of the pandemic. 

Authors’ Note

Co-author Jennifer E. Moore, PhD, is the wife of Health Affairs editor-in-chief, Alan Weil, who had no editorial role in the decision to accept and publish this post.

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