Thirteen states, including North Carolina, have received letters from federal officials about their Medicaid application backlogs. The move has state and local officials frustrated at federal policymakers.
By Rose Hoban
North Carolina Medicaid head Robin Cummings received word last week that federal officials from the Centers for Medicare and Medicaid Services want to review the backlog of Medicaid applications in North Carolina.
Currently, close to 70,000 people have applications pending for Medicaid, the combined federally and state-financed program that covers health care for low-income children, their parents, poor seniors and people with disabilities. Overall, about 1.6 million North Carolinians qualify for the program.
“While our federal standards are flexible in allowing state agencies to establish their own time standards, applications are to be processed and enrollment effectuated without undue delays,” reads the letter from Cindy Mann, deputy administrator of CMS and director of the Center for Medicaid and CHIP Services, dated July 9.
Mann gave North Carolina officials 30 days to gather information on what they’re doing to address the backlog of applications.
Thirteen states have received similar letters from federal officials since June 27.
But officials here and in other states say they’re frustrated by the letters because they say much of the problem lies on the federal side.
Computer woes at all levels
Part of the reason for the application backlog is ongoing troubles with the NC FAST benefits registration system that was rolled out last July 1. Glitches in the system were responsible for a backlog in processing applications for the Supplemental Nutritional Assistance Program (commonly known as food stamps), or SNAP, this past winter.
But the other reason for the problem is outgoing communication from the software controlling the federally run health insurance exchanges that people used to sign up for insurance under the Affordable Care Act.
“DHHS was ready to receive applications on October 1; however, we were notified that the Federally Facilitated Marketplace (FFM) was not prepared to begin transmitting,” wrote Department of Health and Human Services spokesman Aaron Mullins in response to an inquiry by N.C. Health News. “It was not until January 16, 2014 that the FFM was able to sporadically transfer cases to North Carolina.”
Federal programmers didn’t anticipate how much preparation the interface would need, said John Eller, director of Catawba County’s Department of Social Services.
“So the way the cases came down from CMS was not timely,” he said. “We’re getting thousands of cases at one time that were stuck. And by the time the applications get to counties, they’re already overdue.”
Eller said that some of the applications he’s gotten recently date back to as far as October, when the federal exchanges were still having lots of problems. He also said that many of the backlogged applications are duplicates, because a lot of people who were waiting for their online Medicaid applications to be approved walked into county offices and applied again in person.
Eller, who is also president of the North Carolina Association of County Social Service Directors, said he’s heard from other county directors that they’re getting data dumps of thousands – sometimes more than 10,000 – of applications at one time from the federal system.
“You can’t dig your way out of something like that even when you have staff; you can’t do that and keep up,” he said. “This isn’t the state’s fault.”
Eller complained that even as federal officials are dumping cases on counties, “the feds want to make sure… they’re working them.”
Mullins said North Carolina was notified by federal officials that 97,370 Healthcare.gov applications might be eligible. But an initial review of close to 54,000 of those applications found that only 4,148 of them were eligible and approved for Medicaid.
These sorts of data problems have been contributing to the inability of the state legislature to plan for next year’s Medicaid program.
Missing data
North Carolina is not the only state frustrated by receiving these letters, said Mark Salo, head of the National Association of Medicaid Directors.
“Most are saying, ‘We know about these issues, we’re working on them,’” he said, noting that the tone of some of the letters borders on threatening. “Some are frustrated because some of the details that are being pointed out in those letters are inaccurate.”
Salo said part of the frustration comes from the fact that much of the data being sent to states is riddled with errors.
“For example, income data isn’t there or immigration status is not there or the zip code is wrong, and you can’t just push it through the system,” he said. “You have to have people who pick up the phone and call applicants to see what’s going on.”
And the initial data download to North Carolina had almost 100,000 cases.
“When you get that dump of applications, you can’t just magically whisk them away,” Salo said.
Eller confirmed that at least a third of the applications Catawba County received from the feds were duplicates.
But Salo noted, in defense of the federal system, that creating Healthcare.gov was much more complicated than creating a website like Travelocity, which President Barack Obama has repeatedly used as a comparison for the federal marketplace.
“You need multiple federal agencies – HHS, IRS, Department of Homeland Security, the Treasury – all interfacing seamlessly in real time using shared data sets that never existed before. And that’s just the federal hub,” Salo said. “At the same time, each state had to completely overhaul their Medicaid eligibility systems, and at the end of that those had to communicate with each other.”
He added that the political fight over the Affordable Care Act delayed federal programmers from getting started and meeting a timeline that was already tight.
“You can’t pull this off in a couple years,” Salo said. “It takes a long time.”
Costly fixes
In the letters sent to some states, including California and Tennessee, CMS’ Cindy Mann referenced “continued delays,” said the states are “not meeting any of these critical success factors” and issued deadlines that are as short as ten days to respond.
By comparison, the tone of North Carolina’s letter sounds mild.
“The primary purpose of the review will be to gather additional information to determine the reasons for the backlog of applications, at a level of detail that would allow CMS to discern what numbers of people are being impacted, for what length of time, and by what operational or technical challenges or gaps,” Mann wrote.
“Over the last number of months, state and county officials have worked aggressively to identify and implement strategies to eliminate the Medicaid application backlog in North Carolina,” Cummings said in the DHHS press release.
“The N.C. Department of Health and Human Services looks forward to sharing our analysis and the counties continued progress with the Center for Medicare and Medicaid Services (CMS) in the coming weeks.”
Salo said states are throwing people at the problem, paying for overtime and temporary workers, and the federal government has been sending money to states to pay for the extra work.
But Eller said that money’s been slow to come and can get tied up in local politics.
“The way county budgets work, commissioners have to approve positions, and sometimes they’ll take that money as additional revenue,” said Eller, who told of moving his workers around to cover the work.
He said his county commissioners have given his department the flexibility to respond, but other county social service directors are not as fortunate.
“Align those factors together,” Eller said, “it’s a perfect storm for many of them.”
| COUNTY | Total Untimely Medicaid Applications as of July 2nd |
| Alamance | 1,236 |
| Alexander | 77 |
| Alleghany | 13 |
| Anson | 17 |
| Ashe | 154 |
| Avery | 34 |
| Beaufort | 83 |
| Bertie | 22 |
| Bladen | 127 |
| Brunswick | 842 |
| Buncombe | 449 |
| Burke | 109 |
| Cabarrus | 1,125 |
| Caldwell | 297 |
| Camden | 15 |
| Carteret | 125 |
| Caswell | 10 |
| Catawba | 476 |
| Chatham | 168 |
| Cherokee | 32 |
| Chowan | 19 |
| Clay | 4 |
| Cleveland | 70 |
| Columbus | 633 |
| Craven | 192 |
| Cumberland | 5,500 |
| Currituck | 30 |
| Dare | 83 |
| Davidson | 419 |
| Davie | 318 |
| Duplin | 58 |
| Durham | 1,846 |
| Edgecombe | 442 |
| Forsyth | 4,686 |
| Franklin | 86 |
| Gaston | 1,599 |
| Gates | 22 |
| Graham | 95 |
| Granville | 157 |
| Greene | 49 |
| Guilford | 3,270 |
| Halifax | 86 |
| Harnett | 417 |
| Haywood | 22 |
| Henderson | 202 |
| Hertford | 77 |
| Hoke | 471 |
| Hyde | 30 |
| Iredell | 878 |
| Jackson | 218 |
| Johnston | 1,078 |
| Jones | 107 |
| Lee | 97 |
| Lenoir | 127 |
| Lincoln | 156 |
| Macon | 11 |
| Madison | 65 |
| Martin | 79 |
| McDowell | 53 |
| Mecklenburg | 13,376 |
| Mitchell | 27 |
| Montgomery | 24 |
| Moore | 224 |
| Nash | 148 |
| New Hanover | 218 |
| Northampton | 24 |
| Onslow | 845 |
| Orange | 484 |
| Pamlico | 124 |
| Pasquotank | 90 |
| Pender | 228 |
| Perquimans | 16 |
| Person | 64 |
| Pitt | 1,899 |
| Polk | 31 |
| Randolph | 902 |
| Richmond | 266 |
| Robeson | 1,966 |
| Rockingham | 353 |
| Rowan | 745 |
| Rutherford | 61 |
| Sampson | 454 |
| Scotland | 182 |
| Stanly | 36 |
| Stokes | 68 |
| Surry | 248 |
| Swain | 87 |
| Transylvania | 25 |
| Tyrrell | 1 |
| Union | 1,351 |
| Vance | 283 |
| Wake | 14,491 |
| Warren | 23 |
| Washington | 42 |
| Watauga | 372 |
| Wayne | 136 |
| Wilkes | 141 |
| Wilson | 121 |
| Yadkin | 150 |
| Yancey | 49 |
| County Total | 69,538 |
| NC DHHS State Queue | 561 |
| Total | 70,099 |
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If NC would have taken the initial Medicaid incentives offered to every state as a supplement to the increased program costs instead of refusing to acknowledge the existence of the ACA thanks to our wonderful GOP leadership, this process would have been streamlined and successful yet we continue to burn up my tax money trying to fight the law, rescind the medical help that our state needs and feed the GOP corporate lawyers coffers. Who you vote for in this next election will really make the difference in how we will stratify our population. It’s OK to be conservative but THINK about what the consequences will be outside the revenue box. Our system is all about money now and I don’t see that changing any time soon as long as our elected officials only concern is where their next kickback lobby check is coming from.