Tag: Medicaid

Feds Move to Rein In Prior Authorization, a System That Harms and Frustrates Patients

When Paula Chestnut needed hip replacement surgery last year, a pre-operative X-ray found irregularities in her chest.

As a smoker for 40 years, Chestnut was at high risk for lung cancer. A specialist in Los Angeles recommended the 67-year-old undergo an MRI, a high-resolution image that could help spot the disease.

But her MRI appointment kept getting canceled, Chestnut’s son, Jaron Roux, told KHN. First, it was scheduled at the wrong hospital. Next, the provider wasn’t available. The ultimate roadblock she faced, Roux said, arrived when Chestnut’s health insurer deemed the MRI medically unnecessary and would not authorize the visit.

“On at least four or five occasions, she called me up, hysterical,” Roux said.

Months later, Chestnut, struggling to breathe, was rushed to the emergency room. A tumor in her chest had become so large that it was pressing against her windpipe. Doctors started a regimen of chemotherapy, but it was too late. Despite treatment, she died in the hospital within six weeks of being admitted.

Though Roux doesn’t fully blame the health insurer for his mother’s death, “it was a contributing factor,” he said. “It limited her options.”

Few things about the American health care system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years.

Prior authorization, or pre-certification, was designed decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or needed, with the aim of delivering cost-effective care.

Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. In a 2021 survey conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization.

So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say.

“The prior authorization system should be completely done away with in physicians’ offices,” said Dr. Shikha Jain, a Chicago hematologist-oncologist. “It’s really devastating, these unnecessary delays.”

In December, the federal government proposed several changes that would force health plans, including Medicaid, Medicare Advantage, and federal Affordable Care Act marketplace plans, to speed up prior authorization decisions and provide more information about the reasons for denials. Starting in 2026, it would require plans to respond to a standard prior authorization request within seven days, typically, instead of the current 14, and within 72 hours for urgent requests. The proposed rule was scheduled to be open for public comment through March 13.

Read the full article from KHN.

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What You Can Do to Help Kids Stay on Medicaid in 2023

One of the few silver linings of our bleak public health reality throughout the COVID-19 pandemic is that child health insurance coverage under Medicaid and the Children’s Health Insurance Program (CHIP) is at an all-time high. Due to temporary protections against Medicaid disenrollment, about 41 million children are insured through Medicaid or CHIP as of August 2022–greater than the population of California.  

The long-term benefits of Medicaid enrollment on the health and wellbeing of children–particularly young children between the ages of 0 and 3–are well documented. Medicaid covers half of all babies born in the United States, which is 40 percent of all children. Study after study has shown that childhood Medicaid coverage is associated with long-lasting benefits to overall health, educational attainment, and financial stability.  

However, temporary continuous coverage protections originally implemented as part of the COVID-19 pandemic response will end on March 31, 2023. This means that states will resume normal Medicaid renewal processes for all enrollees. Specifically, states will disenroll people who don’t complete the process or are newly ineligible for coverage. Policy advocates estimate that more than 6.7 million children are at risk of losing coverage if there is not a collective effort to ensure that all eligible children remain enrolled in Medicaid. State administrators, service providers, advocates, and parents/caregivers must all take proactive steps to ensure that children are not improperly disenrolled from Medicaid when states begin the massive administrative undertaking of restarting the re-enrollment process in the coming months. 

Read the full article from the Center for Law and Social Policy.

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Open Enrollment Period for Health Insurance

Open enrollment for most medical plans, including Medicaid and Medicare, starts November 1st and goes through early to mid-December. This is the time to sign up, renew, or change coverage to best suit your family’s situation. If you wish to estimate how much how health insurance will cost your family without giving any information to a government entity, you can visit the KFF Health Insurance Marketplace Calculator, which provides estimates for health care premiums through marketplaces, aka health insurance exchanges.

For individuals who are on, or expect to be on Medicare, the open enrollment for 2023 is open now through January 15th. If enrolled by December 15, coverage will start January 1, 2023. Medicare is generally for those 65 years or older, but certain younger individuals with disabilities, End-Stage Renal Disease, or ALS can be eligible. For step-by-step instructions on how to sign up for Medicaid or change plans in Medicaid, visit the medicaid.gov or healthcare.gov websites.

For more information on health insurance available through the health insurance exchanges, visit either healthcare.gov or wahealthplanfinder.gov. Medicaid, also known as Apple Health in Washington state, is available through the Washington Health Plan Finder. Many uninsured children, aged 18 and under, who are a part of a low-to-medium income family, are likely to be eligible for free health insurance through Apple Health. A full breakdown of the program and income requirements is available.

Help is available for those who are having a difficult time navigating the health insurance landscape.  Washington Health Plan Finder has step-by-step instructions for applying and navigators to help apply.

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More Than Half a Million People in the U.S. Are On Waiting Lists for Medicaid Home- and Community-Based Services

Other Findings From Our 50-State Survey of Medicaid HCBS Programs Focus on How States Are Responding to Chronic Workforce Shortages That Were Exacerbated by the Pandemic

About 656,000 people across the country were on state waiting lists for home and community-based services financed through Medicaid waivers in 2021, finds a new KFF analysis. But such waiting lists are an incomplete and often inaccurate measure that can both overstate and understate unmet need.

The data about waiting lists are among the latest findings from the 20th KFF survey of state officials administering Medicaid HCBS programs in all 50 states and Washington DC.

Waiting lists can sometimes overstate the need for services because not all states screen for Medicaid eligibility before adding people to their lists, which inflates the numbers with people who may never be eligible for services. In all years since 2016, over half of people on HCBS waiting lists lived in states that did not screen people on waiting lists for eligibility, the new analysis found. This also is a key reason that waiting lists are not comparable across states.

Waiting lists can also understate need. They reflect the populations a state chooses to serve, as well as the resources it commits. In many cases, people may need additional services, but because the state doesn’t offer them—or doesn’t offer them to specific populations, such as people ages 65 and older—they would not appear on a waiting list.

HCBS waiting lists remain a source of concern to policymakers and proposals to eliminate them have been put forth by both Republicans and Democrats.

Many of the other findings from the 50-state survey focus on chronic workforce shortages that were exacerbated by the COVID-19 pandemic and are the biggest challenges facing state Medicaid HCBS programs. Key takeaways from that analysis include:

  • Amid the pandemic, HCBS workforce shortages have contributed to provider closures. Most states (44) reported a permanent closure of at least one Medicaid HCBS provider during the pandemic, up from 30 states in 2021.
  • Almost all states (48) responded to the workforce crisis by increasing HCBS provider payment rates. States also increased self-directed and family caregiving opportunities for HCBS beneficiaries. All states offer at least one HCBS program with the option for enrollees to self-direct their services. Forty-eight states allow legally responsible relatives to be paid caregivers, up from 36 states in 2020.
  • When asked how they used temporary funding from the American Rescue Plan Act of 2021, over two-thirds of states (35) reported initiatives with high start-up costs that were generally time-limited to avoid higher ongoing costs after the enhanced federal funding ended. Some of the most common initiatives included offering providers bonuses or incentive payments to stay on, developing or expanding worker training or certification programs, and upgrading IT systems.

The full analyses of the survey findings are available here:

For more data and analyses about Medicaid HCBS, visit kff.org.

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Care Coordinators: MCOs’ Best Kept Secret

For families who have children with complex health care needs, coordinating all the appointments, medications, and therapies can be difficult. When an individual has several doctors and specialists that they regularly see, the help of a care coordinator can be invaluable. A care coordinator, or patient care coordinator, is a health professional employed by an MCO, or managed care organization, to oversee complex care cases. They can help with getting needed appointments, acquiring resources outside of prescriptions, ensuring that medications are easily available and do not have any interactions, and help families have better peace of mind that all of their medical practitioners are on the same page.

Care coordinators are available to many patients, but they are rarely given as an option to overtaxed patients or patients’ parents. Primary care physicians sometimes recommend a care coordinator to help a patient or family, but as they are not familiar with every aspect of a patient’s life and health care, they will often assume that a family does not need a care coordinator when they would be greatly aided by having one. For those with a strong connection to a primary provider, asking them to request a care coordinator for their healthcare can be an efficient way to start the process. While a primary care physician is often the one to initiate the assistance of a care coordinator, is possible for a patient or their family to request care coordination on their own.

The process for requesting a care coordinator is different through different health care systems. The majority of individuals on Medicaid, also known as Apple Health, have their healthcare covered by an MCO. Calling the MCO’s customer service line is often the first step in getting a care coordinator.  The phone numbers of the five MCO’s that oversee apple health in Washington state are as follows: Amerigroup at 1-800-600-4441, Community Health Plan of Washington at 1-800-440-1561, Coordinated Care of Washington at 1-877-644-4613, Molina Healthcare of Washington at 1-800-869-7165, and UnitedHealthcare Community Plan at 1-877-542-8997.  If you are unsure which MCO is in charge of your healthcare, view our video on Who is in Charge of Your Apple Health Healthcare? If there are problems in getting through to your MCO, you can call the Health Care Authority, that oversees all Washington Medicaid MCOs, at 1-800-562-3022.

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Who is in Charge of Your Apple Health Healthcare?

For individuals enrolled In Washington State Medicaid, also known as Apple Health, understanding who manages their medical care is not always easy.  In almost all cases, the management of care for people with Apple Health is delegated to an MCO, or Managed Care Organization. These are large for-profit organizations that often have a large infrastructure, making it confusing and difficult to find information or direction.

There are five MCO’s under Apple Health in Washington.  They are Amerigroup Washington, Community Health Plan of Washington, Coordinated Care of Washington, Molina Healthcare of Washington, and UnitedHealthcare Community Plan.  All of these MCOs are available statewide, except UnitedHealthcare Community Plan, with is only available in the western half of the State.  For anyone in the foster care system, they are automatically enrolled in Coordinated Care of Washington and this coverage will follow them until they are 21. Health Care Authority has a Service Area Matrix to view what MCOs are available in each county.

Under some circumstances a person on Apple Health will not be put into an MCO. If an individual is American Indian/Alaska Native they can view their options on the Health Care Authority’s American Indians and Alaska Natives page. Other non-MCO Apple Health patients will have a distinct services card that looks the card shown:

For those patients, review the Health Care Authority’s Handbook on Coverage Without a Managed Care Plan for information about how to receive services.  It is also possible to call them at 1-800-562-3022.

For those who do not remember which MCO they or their children are signed up with, it might have been done automatically for them when the initial roll out happened in 2014 or when they first became eligible for Apple Health under the ACA.  The switch to managed care was fully implemented in 2020.  Here are three ways in which to find out which MCO is overseeing an individual’s care:

  1. Review your Provider One Card to see which MCO is listed. Individuals who are on MCO-managed Apple Health will have the name and/or logo of the MCO on the Provider One card, like the example

In this case, UnitedHealthcare is the MCO.  The PCP listed is the Primary Care Physician, or a patient’s main doctor, and the PCP phone number listed can be called to schedule visits and ask medical-related questions.

  1. If the provider card is missing, call: 1-800-562-3022 and choose option 1 for self-service, then option 1 for services card. They can help replace the provider card and help enrollees get the services they require.
  2. Call the Health Care Authority Customer Service Line at 1-800-562-3022.

It is important to note that everyone enrolled in Apple Health within one household must be on the same managed care plan. Provider One cards are usually sent out once a year to enrollees and there is a number on the card to call for customer service. Below is the Apple Health managed care plan contact information:

Amerigroup (AMG)1-800-600-4441
Community Health Plan of Washington (CHPW)1-800-440-1561
Coordinated Care of Washington (CCW)1-877-644-4613
Molina Healthcare of Washington, Inc. (MHW)1-800-869-7165
UnitedHealthcare Community Plan (UHC)1-877-542-8997

All Apple Health enrollees have the right to change their MCO at any time, with no fee and with no gap in coverage. The shift usually occurs by the 15 of the following month, but the Provider One portal can help if there are challenges. There are several ways to switch plans:

If considering changing to a different MCO, visiting other MCOs websites or calling their information line with some questions can be useful. It is helpful to see what hospitals, urgent care facilities, specialists, and therapists are covered. Not all physicians or medical facilities that take Apple Health are contracted with all MCOs.

View our video on Who is in Charge of Your Apple Health Healthcare?

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Patients’ Perilous Months-Long Waiting for Medicaid Coverage Is a Sign of What’s to Come

Korra Elliott has tried to avoid seeing a doctor while waiting to get on Medicaid. She worries she can’t afford more bills without any insurance coverage. But in early March — five months, she said, after applying and with still no decision about her application — a suspected case of the flu sent her blood pressure soaring and landed her in the emergency room.

The 28-year-old mother of four from Salem, Missouri, is among the tens of thousands of uninsured Missourians stuck waiting as the state slogs through a flood of applications for the state-federal health insurance program. Missouri expanded the program last year after a lengthy legal and political battle, and it now covers adults who earn up to 138% of the federal poverty level — about $18,800 annually for an individual.

Missouri had nearly 72,000 pending Medicaid applications at the end of February and was averaging 119 days to process one, more than twice the maximum turnaround time of 45 days allowed by federal rules. Adding people to Medicaid is labor-intensive, and the jobs require training and expertise. The program covers many populations — children, people with disabilities, seniors, adults who are pregnant or have children, and some without children. Different rules dictate who qualifies.

Read the full article from KHN.

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Why Millions on Medicaid Are at Risk of Losing Coverage in the Months Ahead

The Biden administration and state officials are bracing for a great unwinding: millions of people losing their Medicaid benefits when the pandemic health emergency ends. Some might sign up for different insurance. Many others are bound to get lost in the transition.

State Medicaid agencies for months have been preparing for the end of a federal mandate that anyone enrolled in Medicaid cannot lose coverage during the pandemic.

Before the public health crisis, states regularly reviewed whether people still qualified for the safety-net program, based on their income or perhaps their age or disability status. While those routines have been suspended for the past two years, enrollment climbed to record highs. As of July, 76.7 million people, or nearly 1 in 4 Americans, were enrolled, according to the Centers for Medicare & Medicaid Services.

When the public health emergency ends, state Medicaid officials face a huge job of reevaluating each person’s eligibility and connecting with people whose jobs, income, and housing might have been upended in the pandemic. People could lose their coverage if they earn too much or don’t provide the information their state needs to verify their income or residency.

Medicaid provides coverage to a vast population, including seniors, the disabled, pregnant women, children, and adults who are not disabled. However, income limits vary by state and eligibility group. For example, in 2021 a single adult without children in Virginia, a state that expanded Medicaid under the Affordable Care Act, had to earn less than $1,482 a month to qualify. In Texas, which has not expanded its program, adults without children don’t qualify for Medicaid.

State Medicaid agencies often send renewal documents by mail, and in the best of times letters go unreturned or end up at the wrong address. As this tsunami of work approaches, many state and local offices are short-staffed.

Read the full article from KHN.

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