More Louisianans than ever are enrolled in Medicaid. The federal-state health program has been a vital part of the state’s response to the Covid-19 pandemic, allowing people with disabilities or low incomes to have secure, stable health coverage that provides them access to medical care when they need it. Temporary changes to federal rules in response to Covid-19 have allowed Medicaid enrollees to keep their coverage until after the federal government declares an end to the Public Health Emergency (PHE).
When the PHE ends, state Medicaid programs will transition back to pre-pandemic rules that cause people to lose coverage if their earnings rise above the program’s limits ($1,482 per month for a single person) or if they fail to meet other eligibility criteria. In many cases, states will rely on a paper-based renewal process that puts many people eligible for Medicaid at serious risk of losing their coverage due to paperwork problems. But there are several steps Louisiana can take to reduce harm to eligible recipients as the state transitions back to the pre-pandemic rules.
The Public Health Emergency and Covid-19 Flexibilities
In March 2020, with Covid-19 causing immense strains on our health system and forcing millions of people out of work, Congress included an important two-pronged provision related to Medicaid in the Families First Coronavirus Relief Act (Families First). That provision temporarily increased the federal share of states’ Medicaid costs by 6.2 percentage points, which helped to stabilize state budgets and to offset the costs to states of responding to the pandemic. In return for the higher match, Congress required states to keep people enrolled in Medicaid throughout the duration of the federal PHE. We don’t yet know when the PHE will end. But when it does, the enhanced federal funding will end and Louisiana will resume administering renewals and re-assessing eligibility for the 40% of our state’s residents who are enrolled in Medicaid. The federal government has issued new guidance for states to return to normal Medicaid eligibility determinations once the PHE and its continuous coverage provision end.
Because Medicaid is means-tested, people naturally cycle on and off the program as their financial circumstances change. The loss of a job may make someone newly eligible for Medicaid coverage, while a pay raise could make them newly ineligible. In normal times, a large portion of Medicaid disenrollments each month are the result of procedural reasons – for example, when mail sent to clients is not returned. Coverage loss and “churn” as a result of procedural barriers is costly and often preventable, and results in thousands of families and individuals each year being cut off from health coverage. Churn also costs Louisiana’s Medicaid agency additional time and resources to re-enroll eligible people when they reapply. The continuous coverage provision in the Families First Act eliminated the usual churn of Medicaid recipients by requiring that states keep all Medicaid recipients covered throughout the Public Health Emergency.
Millions will be affected by how the state returns to normal operations
Even before the pandemic, Medicaid was a critical part of Louisiana’s health infrastructure: One in 3 Louisianans received coverage through the program before the pandemic began. During Covid-19, Medicaid enrollment grew even further, with the program now covering 40% of all people in Louisiana as of September 2021—a total of 1.9 million people.
There are several factors that explain this growth. Some of the increase is due to higher levels of need due to the pandemic, when hundreds of thousands of Louisianans lost their jobs and their employer-provided health coverage. Some other proportion of the increase is due to the continuous coverage provision of the Families First Act, which had two effects that increased the state’s Medicaid rolls:
When the PHE ends, the state will return to normal Medicaid operations by resuming eligibility checks and renewals. Communicating clearly about what people will need to do to keep their coverage will be essential to ensure people do not lose their access to health care by misinterpreting a notice or forgetting to respond to a piece of mail. Multiple studies have found that confusion about the terms of continuity of Medicaid coverage leads enrolled participants to forgo or delay medical care.
It is important that Louisiana accurately redetermine eligibility for Medicaid coverage once the PHE ends. This means not only that the Louisiana Department of Health must screen out ineligible people, but also that the department must avoid screening out people who are eligible for Medicaid coverage. To avoid jeopardizing access to medical care for people with limited financial resources, Louisiana must act now to put policies and processes in place that will reduce the risk that eligible people will lose coverage.
Federal guidance on the transition to post-Covid-19 Medicaid operations
Federal Medicaid rules provide the framework for state Medicaid programs, but within that framework, states have flexibility to make their own rules and decisions. Guidance issued in December 2020 by the federal Center for Medicare and Medicaid Services (CMS) gave states only six months after the PHE ended to catch up on renewals and eligibility redeterminations and return to normal operations. In order to make that timeline feasible, states were given the option to start assessing enrollees’ eligibility six months before the end of the PHE.
In practice, this guidance proved difficult for states to administer for two reasons:
1) The public health emergency is ongoing, with no announced end date. While the Biden Administration later told states that the PHE would continue at least through the end of 2021, the original guidance still left state Medicaid agencies guessing about when they would have to return to normal operations; and
2) The six-month window before the end of the PHE allowed states to make eligibility determinations based on data about employment and wages that could be up to a year out of date.
New guidance published in August by CMS extended the timeframe to return to normal operation from six months to a full year after the PHE expires, and eliminated the option of closing Medicaid cases based on outdated information. Because of this extension, states will have time to check eligibility for all enrollees using more current data. The new guidance also requires states to redetermine eligibility for all enrollees after the PHE ends. This means that anyone who was determined ineligible during the PHE must have another redetermination based on more accurate data that will reflect their current situation.
This new guidance gives states a critical window to make important changes to their eligibility procedures and to communicate with clients. But that window won’t stay open forever. Louisiana must act now to ensure that eligible people don’t lose their health coverage after the PHE ends.
What Louisiana can do to protect eligible Medicaid enrollees
Louisiana can take several proactive steps to reduce harm to eligible Medicaid recipients while using state resources efficiently as it transitions back to normal operations post-Covid-19:
Many options for the transition to normal Medicaid rules not only protect Louisianans who get health coverage through Medicaid, but also help the Department of Health use state resources efficiently and balance out what could otherwise be an overwhelming agency workload.
Medicaid coverage lets children see the doctor for regular check ups, and lets adults stay current on their prescriptions. For Louisianans with chronic illnesses and for those who can’t afford an emergency trip to the hospital, Medicaid is a critical lifeline. Medicaid has been a pillar of Louisiana’s response to the pandemic. When the public health emergency ends, no one should have to lose their health coverage because of bureaucratic problems. As the state plans for life after Covid-19, Louisiana should take steps now to ensure eligible people keep their coverage, and that others successfully transition to other affordable forms of coverage.
– by Courtney Foster