By Clarissa Donnelly-DeRoven
When the pandemic hit, Rachel got sick with COVID-19. Like millions of others across the country, the rural eastern North Carolina resident lost her job. Though it was a blow to her income, it meant she was eligible for something she hadn’t been before: Medicaid, the federal and state-funded insurance program for low-income people.
Rachel’s two sons are autistic and already received coverage through the program, so she was somewhat familiar with the process. She’d also had Medicaid when she was pregnant. And as a person with bipolar disorder, she’d experienced how helpful reliable insurance coverage could be in keeping her condition under control.
(NC Health News chose not to identify Rachel with her full name due to the ongoing stigma of mental illness.)
Eventually, as some of the economic impacts of the pandemic began to wane, Rachel got a new job at a small nonprofit. The only issue was that the position didn’t offer health insurance. Under normal circumstances, that probably would’ve been a big deal — maybe even a deal breaker.
However, when the federal government declared COVID-19 a public health emergency in 2020, part of that declaration included a requirement that prohibited states from terminating nearly anyone’s Medicaid coverage, regardless of changes to their income.
That federal policy change meant Rachel could keep receiving coverage even though she now made too much money to qualify for the program under normal circumstances. In North Carolina, which is one of 12 states that hasn’t expanded Medicaid eligibility, Rachel would lose her coverage if her annual household income exceeded $30,630, the upper limit for a family of three. It’s the equivalent of one person working full time at an hourly wage of $14.73.
The requirement of the public health emergency that everyone’s coverage continue led Medicaid enrollment numbers to swell nationwide. In North Carolina, the number of people enrolled in Medicaid grew from 2.1 million in February 2020 to 2.8 million in July 2022 — an increase of nearly 30 percent.
But once the federal public health emergency ends, scheduled now for October, the coverage requirement will also end. That’ll mean thousands of people will, once again, find themselves without health insurance. It also means that the county Medicaid employees, who are responsible for enrolling and terminating people from the program, will find themselves with massively inflated workloads.
Still reviewing, not terminating
Per federal law, county or state Medicaid workers (depending on how the program is administered at the state level) receive and review income documents on a yearly basis from everybody on the state’s Medicaid program. The workers determine if each person has a low enough income that they’re still eligible for coverage, or if they make too much and need to be removed from the rolls.
Those in the field call this process — interchangeably — a case review, renewal, recertification or redetermination. Throughout the pandemic, county Medicaid workers in North Carolina kept doing case reviews each month, but they did not end people’s coverage even if they were found to no longer be eligible.
While the state saw an overall increase in Medicaid enrollment of about 30 percent, county by county enrollment varied significantly, according to an NC Health News analysis of state Medicaid enrollment data.
Coastal Currituck County, for example, saw its Medicaid enrollment increase by 43 percent between February 2020 and April 2022 — the highest increase in the state.
There are 16 employees at the county social service department who can do case reviews, according to Samantha Hurd, the director of Currituck’s DSS office. Depending on how complicated the case is, doing a case review can take a few minutes or a few hours.
Regardless of whether Medicaid is expanded or not, state and county officials have tips for how people with Medicaid can best navigate the case review process.
- Make sure your address and phone number are updated with the county and with the insurance company — Healthy Blue, WellCare, AmeriHealth Caritas, UnitedHealthcare, Carolina Complete — that manages your plan if you have managed care.
- When it’s time for your yearly case review, don’t panic! You should receive a letter from your county DSS office explaining what they need from you. If you’re on a managed care plan you’ll receive information from that organization as well.
- If the public health emergency ends in October, the county will begin reviewing cases in November. That means if you were first enrolled in Medicaid in October, for example, you’d still be covered by the program for a year and you can continue to use your coverage during this period.
- If you’re found to be ineligible, you have a right to appeal that decision. Friends, family or advocates from legal aid organizations can help you navigate the process.
- If you’re found to be ineligible and you think that decision is correct, there are other options available to you for coverage. At healthcare.gov you can look for plans that fit your needs and see if you qualify for federal subsidies (here’s a calculator) through the Affordable Care Act. These can help make private insurance coverage more affordable.]
“Every client is going to be on a different review cycle, depending upon when they applied for Medicaid and when that Medicaid was approved,” Hurd explained.
During an interview in July, Hurd, and many other county DSS directors, expressed concern that the state may require all the pandemic-era Medicaid cases to be reviewed within a specific timeframe, such as 90 days, rather than on their usual yearly cycle.
But Dave Richard, the deputy director of NC Medicaid at the state health department, explained that county workers can continue to review cases on their normal yearlong cycle thanks to a provision — which can be found under section 9D.5. — in the 2022 state budget bill. Gov. Roy Cooper signed the budget into law on July 11.
Because the county workers in Currituck have continued conducting their reviews as normal, Hurd said she’s not worried about the work piling up, or how they’ll manage.
Workforce and technology issues
Not all county workers feel the same. Some are concerned about the emotional toll terminating people’s Medicaid benefits will have on county workers.
“First and foremost, these are not just case numbers. These are families. These are the grandmother out there who’s taken on her grandchildren, the mom and dad who are both working and just trying to make ends meet and still need assistance,” said Renee Smith, who works with Medicaid and other public benefits at the Johnston County Department of Social Services, which saw about a 34 percent increase in Medicaid enrollment.
“It’s gonna be a process and we’re just gonna have to take that one day at a time,” Smith said. “We need to do what’s in the best interest of the client while taking care of our employees and keeping them from burning out. That’s very important because if we don’t have the employees here to do the job, then the clients aren’t gonna get taken care of.”
County workers will also need a refresher course on the policies and rules, as terminating people from Medicaid hasn’t been part of their workflow for more than two years, Smith explained.
Staff turnover has also proven to be a real challenge for many county DSS offices, especially over the last few years during what’s come to be known as the “great resignation.”
Karen Calhoun, the director of human services at Cabarrus County’s DSS office, said the office has seen massive turnover in staff since the start of the pandemic, so much so that many people in the office have never actually done a termination. “We have hired staff over the last two years that don’t know what that normal culture of seeing people in person is,” she said.
Cabarrus also experienced about a 34 percent increase in Medicaid enrollment over the course of the pandemic.
“Even if there was a significant amount of new money that came in from counties or states to hire additional people to do this work,” said Richard, from the state health department, “The workers just aren’t there — and this is complicated work.”
“We’re very worried about the workforce issues, primarily, when this changes. We’re doing everything we can to try to enhance some of the technology aspects to make it easier for folks to get through it, but the truth is, it’s just going to be an increased workload,” he said.
Some of those technological improvements include updates to the NCFAST system, which counties, providers and the state use for many different social service administrative processes.
The state health department is working on updates to the system that would allow it to do case reviews electronically.
“NCFAST will run all of its electronic matches for income, etc. on a case, and if it is able to make an eligibility determination based on those matches, it will process that redetermination automatically without the county DSS having to touch the case,” Richard said. “Right now, the county DSS has to touch the case up to three times to review and start the next steps.”
The state has implemented this aspect of the NCFAST system in a couple of counties and has found that up to 40 percent of case reviews can be completed this way. The goal is to have the software rolled out statewide by Dec. 1.
The role of expansion
While updates to NCFAST and more training seminars could help counties balance this work, many argue there’s one clear way to avoid disruptions to both county workers and patients.
“Frankly, one of the most important things we could do actually to ease the burden on counties would be to pass Medicaid expansion,” Richard said. “There’s such a significant number of people that are currently on the roles that would wind up not having to be disenrolled because they would be eligible for expansion.”
While expansion would mean that more people would be on Medicaid, it would also mean the state would get more money from the federal government to pay for those additional costs. Additionally, the state could pass some of those funds along to the counties to deal with their added workload.
The way the current Medicaid system works is the federal government pays about 68 percent of the cost of Medicaid, while North Carolina pays for the rest. But for those newly covered through expansion, the federal government will pay 90 percent. To cover its 10 percent of the tab, some experts have proposed that North Carolina increase assessment costs on hospitals, which would bring in more money to the state.
“We would use a portion of those dollars to support counties because we knew there would be additional workload,” Richard said. “The question that people ask is, could the program handle these additional people on the program? Well, we have.
“We can handle it,” he said. “If we’re going to expand, expanding sooner rather than later makes sense because you avoid having to go to people saying, ‘Oh, you don’t have insurance,’ but then three months later, go back to that same group of people saying, ‘Oh, well you now have it because we’ve expanded.’”
For Rachel, the eastern North Carolina resident who received Medicaid benefits under the public health emergency, it’s impossible to overstate how helpful it’s been. In addition to getting proper care for her bipolar disorder, it’s also meant she’s been able to see doctors to manage her fibromyalgia and that she could attend several follow-up appointments after a hysterectomy that she received to treat endometriosis.
For years, she’d figured out how to manage these chronic conditions without insurance, but “not in very healthy ways,” she said. She took a lot of Motrin. She spent hours on the phone calling pharmacies to see which one offered the cheapest out-of-pocket price for her medications. She asked her doctor to forgo some of the really expensive blood work that they wanted to run on her, and so on.
With Medicaid, she goes to see her specialists when she needs them, and they can run the full gamut of tests. Now Rachel worries what will happen in October.
“Last month I was back to feeling the same way I felt in 2019 when I was in the coverage gap and didn’t have insurance,” she said. “It was back to those sleepless nights, those crying nights.”