More than 52,000 Missouri children have been kicked off of Medicaid in the first four months of renewed eligibility checks, though the state isn’t sure how many of those kids have managed to re-enroll.

At Tuesday’s quarterly meeting of the board that oversees Missouri’s Medicaid program, the MO HealthNet oversight committee, concerns about the number of children losing coverage were raised. According to research by the health policy nonprofit KFF, the proportion of children disenrolled in Missouri is higher than all but two of the 20 states that publicly report data. 

Sen. Tracy McCreery, a Democrat Olivette who serves on the committee, asked Tuesday why “so many kids are losing coverage during the unwinding process.”

“My concern is that there are kids out there that are dependent on adults to get the forms filled out properly,” McCreery said, “and in the meantime it’s a kid that’s losing coverage.”

Federal spending bill ensures one year continuous coverage for Missouri kids in Medicaid, CHIP

Kim Evans, director of the state’s Family Support Division, told the committee that one culprit is that Missouri has a “high rate of self employment,” specifically mentioning professions like beauticians, Uber drivers and landscapers.

She said that can make it hard for the state to get renewal paperwork back from those individuals, and “unfortunately, sometimes, you know, the children are in the household. They’re some of our largest groups, and when it’s that self-employment, then we have trouble getting that information.”

The income limit for kids to be eligible for Medicaid is higher than adults — meaning even if parents lose coverage, kids may still qualify but sometimes fall through the cracks. Children make up roughly half of the overall Medicaid caseload in the state.

Due to a federal policy change, children will soon have one full year of coverage once they’re approved or renewed for the program — unlike adults, who can lose coverage in the months between yearly checks if, for instance, their income changes. But that policy change has little bearing on the current renewal issues which stem from the required, one-a-year eligibility check.

Paperwork issues are the main reason most in Missouri lose coverage — not lack of eligibility. 

Over the first four months, 79% of those who lost coverage in Missouri lost it for procedural reasons, which is slightly higher than the national average of 71%, according to KFF.

September, the most recent month for which data is available, was the fourth month of the state reassessing the eligibility of every Medicaid participant after a three year COVID-era pause on the practice. The process will take place over a year. 

Around one-quarter of the state’s population, or over 1.5 million people, were enrolled in Medicaid in June when the process began. On Sept. 30, there were 1,459,399 people on the program — it’s not yet clear the breakdown of new applicants to Medicaid versus those who lost coverage and then cycled back onto the program.  

Over the first four months of eligibility checks, one-quarter of those reviewed lost coverage. Over half remained eligible and 22% of renewals were still pending.

‘Distressing cases’

As is the case nationally, Missouri has, so far, had a high rate of terminations due to paperwork issues. Procedural disenrollments refer to a variety of paperwork-related issues that prevent the state from determining a participant’s eligibility — including that the state never received the completed paperwork or the participant never received the form. 

Enrollees have 90 days after termination to submit required paperwork for reconsideration and to be reinstated if eligible. After 90 days, they need to fill out a new application to be enrolled.

The state has not yet broken down the sources of procedural issues.

Elizabeth Larsen, attorney and program director of advocates for family health at Legal Services of Eastern Missouri, said she and colleagues are seeing a variety of issues.

Some of the common causes of procedural denials, she said, include people who did not receive the renewal form; received it but are confused and so don’t complete it; and people who submitted it on time and submitted more information as requested, but are nonetheless denied because their information isn’t processed in time by the state. 

In the latter case, Larsen said the denial could be because the state’s document processing can sometimes take “days and we’ve even seen a week” — so the state’s computer system closes out the case and automatically denies coverage while the documents are still waiting to be processed. 

“To me, those are the most distressing cases,” Larsen said, “because there is literally nothing else the person could have done. They did everything that was requested of them and they’re still losing coverage.”

The Department of Social Services, which oversees the Medicaid program, didn’t immediately respond to a request for comment and the specific causes of procedural denials didn’t come up in the Tuesday meeting.

Missouri last year came under scrutiny for its long processing times for new Medicaid applications. The average processing times have been ticking upward since the renewals began and the workload for staff has expanded.

For the Medicaid group which includes the majority of participants, the average time to process a new application went from 15 days in July to 24 days in September. Federal rules say the wait should be no longer than 45 days.

As of the September report, there was a backlog of 12,205 of these applications awaiting determination, up from 4,266 in July and 8,686 in August. 

Many other states make these determinations near-instantaneously, automatically verifying through electronic data sources.

For the aged, blind and disabled Medicaid group, the average wait, up to 87 days in September from 54 in July, is just under what federal rules allow. The federal rule is a maximum of 90 days.

As of September there was a backlog of 9,588 of these applications pending determinations, compared to 8,906 in July and 10,210 in August. 

There has been a rise in new applications, which Evans attributed to  open enrollment, the period when the federal marketplace is open to new applicants, which began Nov. 1 and lasts until Jan. 16. She said some of the increase can also be attributed to new residents in Missouri. 

There have been reports of high wait times for those calling for assistance with their renewal, too, but Evans attributed the issue to individuals selecting the wrong phone line.

“One thing that we’re hearing from some of our stakeholders…is that participants are having trouble getting through the phone,” Evans said. “What we found is that the individuals are not going to the Medicaid call center so they’re not taking that option to get themselves to the call centers.”

Evans said callers are mistakenly going through the general questions line and urged those at the meeting to educate participants: “They’re not choosing that option to take them to Medicaid.”

On a “really positive note,” Evans said the division’s longstanding staffing issues have ebbed. During job fairs, the family support division has had “more applicants than we have positions” in several places in Missouri. 

“That’s really going to help us,” she said, “as we talk to some of these numbers and all the work that we have in front of us right now.”