As Missouri struggles to catch its footing amid Medicaid expansion, officials are already looking ahead to what could be the next big problem in administering health care coverage for Missourians who are lower-income or disabled. 

A federal public health emergency declared during the pandemic is about to expire. And that would require the state to redetermine the eligibility status of  hundreds of thousands of Medicaid participants. 

As of Wednesday, nearly 60,000 Missourians are awaiting news on the status of their Medicaid enrollment applications, said Kim Evans, director of the Family Support Division of the Department of Social Services, which manages the program. 

But with a federal emergency declaration set to expire at any point, the state is scrambling to process those applications before new work begins. 

How long does it take the state to process applications?

April data shows that it took the state on average 101 days to process its most recent applications, well above the federally mandated 45 days the state should be abiding by. Evans said the department’s goal is for processing times to drop to 30 days before August as new hires begin tackling the backlog. 

The federal government’s “public health emergency,” or PHE, has eliminated loads of work for those administering Medicaid by allowing for continuous enrollment in the program, meaning redeterminations of a patient’s eligibility have not been required since January 2020. Once the PHE expires, most of Missouri’s 1.2 million Medicaid recipients will have to go through the redetermination process.  

It could expire at any point, but states will have 60 days notice before the change is made. Officials expect to hear about whether the PHE will be extended by mid-August. If it is, the extension will likely last another quarter, they said Wednesday. 

Sheldon Weisgrau, vice president of health policy at the Missouri Foundation for Health, said he is worried as the state prepares to pick up eligibility checks and workloads that haven’t been necessary for months. 

“I think all of us that work in Medicaid policy are very concerned about how that’s going to happen, given what we’re seeing currently with enrollment, how the state is going to continue to try to enroll people into Medicaid, and at the same time redetermine eligibility for everybody that is currently in the program,” Weisgrau said. “I think we’re all really worried about how that’s going to work out.” 

The state will be tasked with reaching out to all Missouri Medicaid recipients to let them know of the redetermination. In some cases, the state will have all the data it needs to decide if a person is still eligible. If it does not, workers would need to collect that information from the recipients, something that can be difficult when relying on mail services for communication. 

“That’s a process that is going to be problematic, because this is a population that tends to be fairly mobile, people move around a lot, and so the state may not have their latest address,” Weisgrau said. 

Missouri’s main focus surrounding the PHE at this time, according to DSS communications director Heather Dolce, is ensuring that recipients have their mailing addresses updated for redetermination. Participants can update their addresses online. 

Weisgrau added that he fears plenty of Missourians who are eligible to receive coverage will be taken off the program because they didn’t update information.

“You’re clearly going to have several hundred thousand people dropping off the Medicaid program, and a lot of them are going to be people who are no longer eligible for Medicaid. But a lot of them are probably still eligible for Medicaid, and for one reason or another are going to be dropped from enrollment. And that’s going to create problems,” he said. 

Progress on Medicaid application backlog expected

Voters in Missouri approved a plan to expand Medicaid coverage to low-income residents in 2020. Under the expansion, people who earn up to 138% of the federal poverty level, or about $18,000 a year, qualify for coverage. For a family of four, the threshold is about $38,000.

Since then, the state has consistently fumbled with the rollout of the program, with wait times for processing applications far outpacing other states with newly expanded programs. Recipients often cite long waiting times when trying to place phone calls to the division, and health care advocacy groups have had to step in to help get applications processed. 

Wil Franklin, the CEO of KC Care Health Center, a federally qualified health center in Kansas City, said that while the backlog doesn’t prevent his organization from providing care, it does affect his reimbursements for providing care to those who would otherwise be on Medicaid. 

“The challenge is that the less reimbursement there is for a coverage option like Medicaid, the more that costs us to provide the care. So, the longer that occurs, that means there is less we can reinvest into the care delivery for patients,” Franklin said. 

“If this type of backlog continues, ultimately you’ll see resources constrained at the community provider level, and that’s going to impact mostly organizations like us,” he added. 

The backlogs are just the latest obstacle in the quest to expand Medicaid eligibility in Missouri, which will be mostly funded by federal money made available through the Affordable Care Act.

After the legislature refused for years to expand eligibility, advocates placed an initiative on the statewide ballot. After it passed in August 2020, the legislature refused to fund the expansion, and Gov. Mike Parson announced in May 2021 that Missouri would “withdraw” the plan. A judge later ordered the state to begin accepting applications, but the state did not start processing them until Oct. 1. 

Critics point to Oklahoma, which passed expansion around the same time as Missouri. In the initial year following voter approval of those programs, Oklahoma had enrolled more than 210,000 people, while Missouri had enrolled fewer than 20,000.  Although that number has risen to 178,237 enrolled in the expansion, Evans said Wednesday during a MO HealthNet Oversight Committee meeting, critics say the state hasn’t done enough to educate the public on the expansion. 

Even during the 2022 legislative session, bills were introduced to roll back some of the voter-approved expansion. One bill would have asked voters to give the legislature the power to decide whether they would fund the expansion year after year. Another would have implemented a work requirement for Medicaid recipients. Neither of those measures passed.

“Really the onus has been put on providers in the community to educate people about Medicaid expansion and their eligibility,” Franklin said. “The burden is really on providers like us to continue to get the word out.” 

Part of the issue, according to Evans, has been staffing. The department has struggled to recruit staff. In April 2022, the Family Services Division had an average of seven applicants per job posting, down from 47 in March 2021.

With newly passed state employee raises on the horizon, the department has been able to make some hires. 

“​​We have been doing job fairs, we’ve been doing interviews onsite and offering employment at those job fairs. And we are now filling our current vacancies. So while it takes us three to four months to really get someone where they can start the process, we do have that large number of vacancies down,” Evans said. 

The 2023 budget, which is awaiting a signature from Parson, sets aside nearly $3 billion in new funding for the program. That includes funding for adding 75.5 additional staff positions to handle the expected increase in administrative work once the federal health emergency expires and funding for the call center to reduce hold times. 

The department is also looking toward technology upgrades that will help reduce the administrative burden workers are facing. 

Still, Evans acknowledged that the department has a long way to go in getting caught up for a post-pandemic system. 

“I told somebody the other day, if I get all this in place by the end of the year, it’s going to scare me [because of] how high-tech we’re going to be,” Evans said. “But it just adds to the efficiency, and we want to be able to use electronic verification as much as we can, so that that participant doesn’t have a barrier to completing an annual renewal.”