More than 32,000 Missourians – half of them children – lost Medicaid coverage in June during Missouri’s first round of eligibility checks after the COVID public health emergency.

According to a Department of Social Services announcement Thursday, out of the roughly 116,000 Medicaid recipients who had their eligibility checked in June, around 43% retained coverage, 28% lost coverage and 29% have their determinations pending. 

June was the first month of eligibility reviews as the state works through all of the roughly 1.5 million Medicaid enrollees on its books. About one-quarter of the state’s population is enrolled in Medicaid, the government health insurance program for low-income residents, called MO HealthNet in Missouri.

As part of the federal government’s COVID relief measures, states were barred from removing Medicaid participants from their rolls in most cases from March 2020 to May 2023, regardless of whether they no longer qualified due to income or other eligibility limits. 

The public health emergency ended in May and states have begun the process of “unwinding” the continuous coverage rule. In Missouri, the process will play out over 12 months, and then regular annual renewals will resume. 

The majority of those who lost coverage in June — around 72%, or 23,000 Missourians — were not directly found ineligible but were instead disenrolled because of what are called “procedural reasons,” meaning the state was unable to determine whether they were eligible or not.

Procedural reasons could refer to a participant’s failure to return a form, to submit additional information, or their inability to be reached by the department.

Children accounted for half of all Medicaid terminations, and nearly half of all procedural terminations. 

Two-thirds of children denied coverage lost it because of procedural issues. There were 16,262 kids removed from the rolls, 10,747 for procedural reasons.

Rep. Sarah Unsicker, D-Shrewsbury, said she was “concerned” that the state could be “cutting kids off Medicaid who really through no fault of their own or even of their parents, and they really should still be on Medicaid.”

“It’s, unfortunately, kind of what I was afraid was going to be happening and it’s not good with that many terminations and so many still not processed,” she said.

A significant portion of renewals initiated in June were not finalized — nearly 30% are pending, meaning they were ‘held open due to a potential determination issue found before the end of June 2023,” according to the state’s website.

Casey Hanson, director of outreach and engagement at the child advocacy nonprofit Kids Win Missouri, said the high pending number is what first jumped out to her.

“It’s not great to have that many [cases] that we just don’t actually know the outcome on,” Hanson said. Pending applications could pile up, she said, and not knowing the final numbers makes it harder to place the preliminary data in context.

Hanson said 10,700 kids kicked off for procedural reasons is “not encouraging,” in part because kids can be eligible even when their parents are not because of Medicaid income limits.

“It’s a really big number and if that trend continues, that’s when we begin to worry about access,” Hanson said, adding that outreach to families, so they know their children may still be eligible even if adults lose coverage, will continue to be important going forward. 

“Hopefully we can get that message out there so that we don’t see these higher numbers continue to trend forward,” Hanson said. 

Asked about the children disenrolled, Department of Social Services spokeswoman Caitlin Whaley said children make up a large portion of overall Medicaid participants: “Children account for over 48% of all MO HealthNet enrollees and over 48% of renewals due in June were for children.”

Whaley said the high pending count is a result of a number of factors: The participant could have “returned their paperwork on the very last day,” delaying the determination or the department could be waiting on an additional request for verification, for example.

In the majority of pending cases, Whaley said, the issue was households where one person may be eligible but others are not.

“There was not a way for those to automatically process in the system, so those are being done by workers individually,” Whaley said, adding that the department hopes that that “system work” will be resolved in the next few months, in time for August renewals.

“On those particular cases where there’s a combination of eligibility factors in a household, the system hasn’t been updated to process those in an automated fashion,” Whaley said.

According to the national nonpartisan think tank Center on Budget and Policy Priorities, many states have a high number of renewals pending — either because of operational issues getting through all of them, or out of caution to avoid initiating procedural disenrollments before all avenues are exhausted. Whaley said in Missouri it is a combination of factors.

Automatic renewal improvements

Missouri initiated eligibility reviews later than many other states, and elsewhere the number of people kicked off the rolls have ranged widely. Nationally, over three million Medicaid participants have been disenrolled, according to health policy nonprofit KFF, and millions more will likely lose coverage, either because they are no longer eligible or because they are still eligible but fall through the cracks due to administrative issues.

Before the pandemic, during regular renewals, recipients cycling on and off Medicaid due to administrative issues was common nationally.

In 2019, Missouri came under scrutiny for significant enrollment declines. Missouri Budget Project, a progressive public policy think tank, determined that families often lost Medicaid despite being eligible for coverage because of challenges with the annual renewal process. Issues included not receiving the proper paperwork or documents  submitted to the state being lost or not processed. 

States are required to attempt to renew participants’ eligibility using existing data before contacting enrollees to complete forms or documentation themselves — a process called ex-parte renewals that Missouri historically used at a low rate.

In January 2020, Missouri was one of seven states that processed fewer than 25% of renewals on an ex-parte basis. The rate of the state’s use of the streamlined renewal process was, pre-COVID, only “about 10%,” said Kim Evans, director of Family Support Division, in a May MO Healthnet Oversight meeting.

In the June renewals, 32% of all cases were renewed using the streamlined process. Around three-quarters of cases that were successfully renewed were processed through ex-parte.

Whaley said the agency “continues to explore and implement additional technology to increase the number of ex parte renewals .”

Next renewal batch due July 31

The state has not provided a definitive estimate of the number of enrollees expected to lose coverage. At a budget presentation earlier this year, officials estimated 200,000 Missourians could eventually lose coverage.

The health policy nonprofit KFF estimated that if 18% are disenrolled, around 254,000 Missourians will lose Medicaid coverage. If the rate is 28%, then 373,800 could lose coverage.

The social services department has said it is  working to avoid disruptions in coverage or for eligible participants to lose coverage. The department upgraded its renewal process and expanded outreach, producing a website, outreach materials and posting its plan publicly. 

For those no longer eligible, due to income change or other circumstance, the state will work to connect them to other health insurance, Director Robert Knodell said at a March news conference, including through the Affordable Care Act. 

Participants’ renewal date are generally the anniversary month of when they originally enrolled. 

The earliest group was the June renewal group. In April, the state attempted to review eligibility  for those individuals using existing data. Then in May, the department mailed decision letters, either rendering a decision or requesting more information. 

The next batch of renewals, the July annual renewal group, needs to return any forms by July 31. 

After a case is closed, the participant has 90 days to reopen their case, after which they would need to reapply.

The agency encourages participants to keep their contact information up to date, check their mail regularly and verify their renewal date through the Family Support Division Benefit Portal.

This story was updated to provide additional comments from the Department of Social Services.