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The Obamacare Glitch That Undermines Medicaid Enrollment

The federal government is offering a temporary fix for a problem that prevents consumers from signing up for Medicaid through the online insurance marketplace.

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The federal government is proposing a temporary fix to an ongoing technological problem that prevents people from signing up for Medicaid directly through the online marketplace serving 36 states. But the original vision of seamless Medicaid enrollment for all consumers will remain elusive indefinitely because of varying levels of readiness among states and the continued inability of the feds to transfer accounts directly to individual Medicaid agencies.  

Instead of transferring accounts directly, the Centers for Medicare and Medicaid Services (CMS)—the federal agency operating the insurance exchange in addition to managing the two publicly financed health programs—has been sending state Medicaid agencies digital files containing basic information about visitors to the health exchange who may qualify for the program. That’s required additional outreach from individual agencies to connect with those people, and identifying information has been spotty.

The online marketplace evaluates consumers according to income, sending them to a private plan if they earn too much for Medicaid. The federal government was expecting far more states to create their own exchanges, but so far only 14 and the District of Columbia have created their own systems. The federal health exchange marketplace was supposed to electronically transfer people who qualify for Medicaid to their individual agencies for immediate enrollment. At the same time, people are supposed to be able to visit their Medicaid agencies to sign up electronically and, if they’re found ineligible, be transferred electronically to the federal exchange, where they may qualify for subsidies to defray the cost of private insurance. 

The federal government first delayed Medicaid account transfers by a month after the Oct. 1 rollout of the health law before issuing another delay, this one indefinite. Faced with changes to eligibility systems and the technological demands of connecting with the federal exchange, not all state Medicaid agencies can handle seamless electronic enrollment. 

The Kaiser Family Foundation surveyed Medicaid directors earlier this year and found most planned to have their eligibility systems updated by the Oct. 1 launch, but 11 states said they wouldn’t be ready until Jan. 1 and four others didn’t respond, according to Eileen Ellis, a consultant with Health Management Associates, which helped conduct Kaiser’s research. Others that said they’d be ready Oct. 1 don’t appear to be ready, she added. Another eight states said they wouldn’t be ready to connect with the federal exchange by Oct. 1 but would by Jan. 1. Three others didn’t respond, and another said it wouldn’t be ready until after January. 

CMS is now offering to send more complete files (with information such as Social Security numbers and dates of birth) that can be sent through enrollment systems for immediate processing.  Exactly when CMS will do that and how agencies will be able to process the information hasn’t been made clear, said Matt Salo, executive director of the National Association of Medicaid Directors. Also of concern, Salo added, is the accuracy of the information coming in, especially considering wide-ranging differences in eligibility among the states. “What happens if we come back in three months and it turns out a whole bunch of these people weren’t qualified?” he said. “Will we be penalized? It’s not too much of a stretch to imagine that possibility.” 

The hundreds of thousands of people floating through the system without closure on their Medicaid status worries agency directors, who want to get them enrolled before Jan. 1, when people are required to have medical insurance under the Affordable Care Act. Some may show up to a medical facility mistakenly thinking they’re covered. 

“It starts becoming a problem the closer you get to January,” said Darin Gordon, Tennessee’s Medicaid director, at a conference last month in Washington, D.C. “When you start getting to December, everybody needs to start thinking about what kind of implications that might cause.”  

Regardless of whether a state is expanding Medicaid to childless adults under the new health law, each agency has to update its income eligibility system to a uniform model that more closely resembles what’s listed on a tax return. They also have to provide online enrollment and have the ability to communicate with the federal exchange. Those tasks are necessary for seamless Medicaid enrollment. 

Deborah Bachrach, a partner at Manatt Health Solutions and a former New York Medicaid director, noted that states are ramping up staffing and call centers to get people signed up who couldn’t do so electronically. And when people come to an agency and don’t qualify for Medicaid, they’re simply telling them to go to the federal exchange. “Each state’s in a different place, but I wouldn’t say I’m worried,” she said. “There’s a heavy burden on both, on the state’s side to bring the eligibility system up to standard and interface with the federal government, but for the federal government it’s a bigger, more complicated undertaking because it has to accommodate so many state models.”

Although some state-run marketplaces have serious technical problems, state-based exchanges have had far more success with seamless Medicaid enrollment because they don’t need the federal government, Bachrach said.

Chris covers health care for GOVERNING. An Ohio native with an interest in education, he set out for New Orleans with Teach For America after finishing a degree at Ohio University’s E.W. Scripps School of Journalism. He later covered government and politics at the Savannah Morning News and its South Carolina paper. He most recently covered North Carolina’s 2013 legislative session for the Associated Press.
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