Missouri’s delays in processing Medicaid applications — among the worst in the nation — have the attention of federal regulators, who will conduct a “focused review” of the problem, according to a letter obtained by The Independent.

The federal Centers for Medicare and Medicaid Services in a letter sent to the state May 22 and obtained Friday afternoon under Missouri’s Sunshine Law, said it is concerned the state is not doing enough to “achieve and sustain” compliance with federal rules on Medicaid and the Children’s Health Insurance Program. Because of these concerns, the agency will intervene to help Missouri identify strategies to come back into compliance. 

Medicaid applications for low-income Americans are required to be reviewed within 45 days. 

In Missouri, the most recent federal data from February shows 72% of applications took more than 45 days to process — the worst in the country that month. That’s up from 58% in January. 

Nationwide, most applications were processed within 24 hours last year.

The Missouri Department of Social Services, which oversees the state’s Medicaid program, is required to submit specified data to the feds this month to work on strategies for coming back into compliance. If it doesn’t improve, Missouri could be subject to formal compliance actions, including an official corrective action plan, and would be at risk of losing federal funding.

A similar letter was sent to Texas, according to the business publication Modern Healthcare. A CMS spokesperson didn’t immediately answer a question about which other states were included. 

Long processing times can cause low-income patients and those with disabilities to forego medical care and prescriptions. Patients have told The Independent they are delaying medical care during pregnancy because they can’t get enrolled in Medicaid.

The federal government said in the May letter it is concerned “particularly given the prolonged period of the state’s noncompliance.” 

 In December, more than half of Missouri’s applications took longer than 45 days to process. 

As of February, Missouri’s 72% noncompliance rate stands far above other states. The next highest were New Mexico (58%), Alaska (53%) and Texas (46%). 

Tim McBride, a health policy analyst, professor at Washington University in St. Louis and former chair of the board that oversees Missouri’s Medicaid program, said it is “very concerning” just how much Missouri’s issues stand out.

“If we compare the state’s processing time to other states, we appear to really be an outlier,” he said, and “in not such a good way.”

It’s not clear why Missouri can’t meet the 45 day requirement, McBride said. 

“We have heard the problem is understaffing, antiquated computer systems and a problematic call center,” he said. “But more could be done to rectify this.”

In summer 2022, the federal government initiated a formal mitigation plan with the state to get the processing time down.

It worked, but wait times started creeping back up in October, according to the letter. In October, 34% of determinations exceeded 45 days. 

“Although we understand that the state continues to employ the strategies outlined in its July 2022 mitigation plan,” the letter states, “due to the persistent nature of the current backlog, we believe it is critical for the state to review its current processes and adopt additional alternative strategies that will mitigate the harm being caused to applicants.”

Missouri’s social services agency is committed to cooperating with the federal probe and improving the wait times, spokesperson Baylee Watts said, and will submit the data by the deadline.

“The Department of Social Services is actively working to furnish the information needed for CMS’s review process,” Watts said.

“Our goal is always to strive towards continuous improvement when serving Missourians, and we will continue to work with our federal partners to achieve that.”

The letter states that CMS engaged with Missouri staff in January to try to understand and fix the backlog, and that the state attributed the problem to an increase in applications at the time.

From November to mid-January, during open enrollment season for the federal insurance marketplace, the state generally sees an uptick in Medicaid applications.

McBride said that influx in applications “should have been anticipated” around open enrollment.

And the increase in applications hasn’t leveled off as much this year as was expected, officials previously said. McBride said some of the continual increase in applications could be due to people losing coverage and reapplying. 

The state around a year ago began re-checking every Medicaid participant’s eligibility, after a federal COVID-era suspension on annual renewals expired.

‘Perfect storm’: Missouri advocates decry Medicaid application delays, coverage losses

Around 356,000 people have lost coverage in the renewal process, preliminary state data analyzed by the Center for Advancing Health Services Policy and Economics Research at Washington University in St. Louis, shows. Around half of them were children.

Net enrollment, which includes the number of people who got on the program as others were getting removed, fell by 212,203 people. Medicaid participation sits at 1.3 million as of May, down from 1.5 million in June of last year. 

Joel Ferber, director of advocacy at the nonprofit Legal Services of Eastern Missouri, said he’s glad the feds are “finally taking action” to require Missouri to explore more strategies for compliance. 

Legal Services of Eastern Missouri is one of the state’s legal aid programs that provides free legal assistance to low-income and disadvantaged Missourians, including on Medicaid application issues. Advocates for months have noted the intensifying bureaucratic hurdles for Missourians to access and retain coverage, including issues with the state’s online portal to upload eligibility documents.

Ferber has been urging Missouri to pause its disenrollments while it makes improvements.

“Too many are falling through the cracks under the current system,” Ferber said.

Another issue the state identified, according to the letter, was that it “faced shortages in eligibility staff due to the needs of other human services programs, which compete with the state’s Medicaid and [Children’s Health Insurance Program] agency for resources.”

One of those programs competing for the Department of Social Services’ resources is food stamps: A federal court last month ruled Missourians were being illegally denied food aid by the state, in part due to hours-long call center wait times. 

The call center wait time issues seem to cut across all of DSS’ programs  — Medicaid’s average call wait time was the longest in the nation in Missouri as of February, according to federal data, though it’s not the focus of this probe. It was 56 minutes in February.