Image courtesy Seiichi Kusunoki, flickr creative commons


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.

cindy mann headshot
Cindy Mann, deputy administrator of CMS and director of the Center for Medicaid and CHIP Services. Photo courtesy: CMS

“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.”

The system was not sending Medicaid applications to states for months following the beginning of the enrollment period in Oct. 2013.
The system was not sending Medicaid applications to states for months following the beginning of the enrollment period in Oct. 2013.

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 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 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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One reply on “Feds, State and County Officials Argue Over Medicaid Application Backlog”

  1. 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.

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