Federal officials last month approved a plan to help Missouri deal with “ongoing and persistent” delays in processing Medicaid applications that have left the state out of compliance with federal standards for nearly a year.

Longtime observers of the state’s Medicaid program say the decision by Centers for Medicare and Medicaid Services to intervene is unusual and demonstrates how severe the application delays have become.

The most recent publicly-available data, from the end of June, shows Medicaid applicants waiting an average of 115 days for the state to process their paperwork. That is up from 106 days a month earlier, and more than double what federal regulations allow.

Before Medicaid eligibility was finally expanded to include low-income adults last year, the average processing time in June was eight days. 

Last month, the federal agency Centers for Medicare & Medicaid Services published a summary of Missouri’s shortcomings and signed off on strategies proposed by the state to help it come back into compliance with federal standards. The state’s Medicaid program, which is called MO HealthNet and administered by the Department of Social Services, has committed to those strategies.

The plan includes measures some advocates say they’ve been pushing for months. One measure, for applications received through the federal marketplace, allows the state to accept the federal information and put those eligible onto a fast track for coverage.

The mitigation plan set a deadline for Missouri to meet the federal standards: Sept. 30.

The wait times have been on a steady uptick since late last year. And the backlog, though decreasing, still sat at nearly 50,000 applications at the end of June.

Advocates and researchers are largely excited to see their suggestions implemented, although many remain skeptical that the state can meet its goal by the deadline.

“I’m happy the plan is in place and [the Department of Social Services] is moving forward with it,” said Sheldon Weisgrau, vice president of health policy at Missouri Foundation for Health.

“But given their performance,” Weisgrau added, “it’s hard to really feel confident that they’re going to get the problems all under control, certainly by Sept. 30.”

‘A problem state’

Centers for Medicare & Medicaid Services, or CMS, works in tandem with state agencies to fund Medicaid, and states administer the program under broad federal guidelines. 

But CMS rarely steps in when states limit access to services or coverage, said Joel Ferber, director of advocacy at Legal Services of Eastern Missouri, who has been studying Medicaid since the late 1980s.

“CMS doesn’t usually intervene to deal with problems on the ground on client access issues,” Ferber said.

Paul Shafer, co-director of the Boston University Medicaid Policy Lab and assistant professor at the BU School of Public Health, agreed with Ferber that CMS’s decision to intervene in Missouri was an unusual one, to match unusual circumstances. 

“I don’t think any states have had the widespread and bad enough problem with the pure processing elements of this, that [Missouri] rose to national prominence,” Shafer said.

DSS did not respond to questions about the process leading up to the mitigation plan.

In general, when CMS works with states on mitigation plans, it is after months of dialogue have failed to resolve compliance issues, said Tricia Brooks, research professor at Georgetown University’s Center for Children and Families. 

“When they go to a mitigation plan,” Brooks said, “it’s often at the point when CMS is not seeing any progress on the more informal dialogue that’s going on.” 

CMS tries to put the plans in writing to hold the state accountable, Brooks said.

Ferber said it was a “big deal that they’re engaged at this level,” adding that because CMS sees Missouri as potentially a “problem state,” they’re more likely to keep an eye on the program moving forward.

Caitlin Whaley, spokesperson for DSS said in an email to The Independent that the department has been “working closely with solution-driven stakeholders, policymakers, and partners” for months while navigating “unprecedented challenges,” and will continue to “work diligently to deliver services and benefits to some of Missouri’s most vulnerable citizens.”

Slow progress

DSS has consistently pointed to staffing shortages as among the most significant causes of the delays, holding hiring fairs and offering overtime to try to fill the gaps. 

In March, MO HealthNet Director Todd Richardson told lawmakers he expected to see “momentum” on bringing the processing times back within 45 days “in the coming weeks.”

By early June, CMS was working with the state to develop the compliance plan, Evans said at the June 1 oversight meeting. 

At that meeting, Evans predicted their personnel efforts would pay off, saying: “We’ll get to a place where we should be processing in under 45 days by the end of July.” 

By August, they’d be working towards 30 days, she said.

But so far that optimism has not been borne out, and by July, CMS approved the plan for how the state would get wait times and application backlogs down. 

In addition to allowing the state to fast track applications received through the federal marketplace, the mitigation plan also includes strategies such as enrolling the parents of children enrolled on Medicaid. Prior to expansion, low-income adults were not eligible for Medicaid, but their children were.

Tim McBride, a health policy analyst, professor at the Brown School at Washington University in St. Louis and former chair of the MO HealthNet Oversight Committee, said he will applaud DSS if the agency can meet the new Sept. 30 goal. 

“But it’s a big mountain to climb,” he said. On average, the state processes 2,000 to 3,000 applications per week, although this past week they saw a jump, processing 5,000 applications. 

‘I need Medicaid for the appointment’

Over 200,000 newly-eligible Missourians have enrolled in Medicaid since expansion went into effect last year. But the state is still receiving a steady influx of new applications atop the large backlog.

“The fact that you have [over] 200,000 people enrolled in Medicaid expansion and you still have this many more that are waiting in a queue really speaks to the need,” Weisgrau said. 

For applicants, waiting months is often untenable. Long wait times deprive patients of their necessary medications, cause them to delay needed care and forgo preventative care altogether, said Brooks, the Georgetown University professor.

Katezar Be, a 25 year old from Kansas City who works as a home health aide for the elderly, applied for Medicaid on April 26.

 Over four months later, she’s still waiting. 

 Be has an appointment for a cancer screening early next month. 

“I need Medicaid for the appointment,” she said. She will have to cancel it if she doesn’t get enrolled on time. She also needs to go to the dentist for a filling, but can’t afford it. 

“I don’t know why it’s taking so long,” she said. “We’ve been applying since April.”

Be has heard nothing from the state about her application.  

She submitted her application with the help of Jim Torres, who enrolled her at the community health center Samuel Rodgers Health Center. Be was there for a discounted dentist appointment and Torres was doing outreach to help low-income patients apply for Medicaid.

Torres, who is the program manager for health insurance services at Sam Rodgers, said when he searches Be’s name in the system to view the status of her application, which federally qualified health centers can access, “it looks like nothing is in there,” as of Aug. 5.

“They need to find this application and start working on it,” said Torres. 

Torres told Be not to submit another application; he knows that the state has dealt with duplicate application problems. When patients don’t hear back, they fear their application hasn’t gone through and resubmit, which worsens the backlog, and the cycle repeats. 

The mitigation plan states at one point Missouri identified at least 10,000 duplicate applications, and as of the mid-July mitigation plan, had just under 3,000.

Torres said this is just one of many cases he’s worked on with severe delays. One applicant he helped apply in December wasn’t approved until June. 

“And not everybody’s got access to a navigator,” he said.

‘Another wave is coming’

Overcoming the compliance issues is of great urgency, some say, because more administrative hurdles lie on the horizon. 

In November, the federal marketplace enrollment season will open, which typically brings in a stream of new applications to Medicaid, because the marketplace automatically transfers the applications of those with too low an income to qualify for the federal healthcare.

Longer-term, possibly early next year, the end of the federal public health emergency looms, which paused recertifications for Medicaid. The state cannot currently remove anyone from its Medicaid rolls. 

Once the public health emergency ends, the state must complete eligibility renewals for all Medicaid recipients — a process some worry could overwhelm the department, erroneously strip qualified patients of coverage, and strain the state’s processing of new applications.

“If they don’t dig themselves out of this hole, they’ll be facing a significant uphill battle in terms of processing renewals for the hundreds of thousands of people enrolled come the end of the (public health emergency)” Brooks said. 

“It is really important,” she added, “the state get a handle on this and get caught up as quickly as possible because another wave is coming.”

Tracy McCreery, a state representative who sits on the MO HealthNet Oversight Committee, said that the state is still working on applications from February. The backlog was nearly 50,000 in June; McBride said the ideal count is closer to 10,000 or under.

“That’s very concerning to me,” McCreery said, later adding: “It makes me uncomfortable that we as the state government are doing things that are adding worry and concern to families rather than helping alleviate things.”

When administrative challenges mount, “it’s always the enrollees who fall through the cracks,” said Shafer, from Boston University. “Or they have to deal with the headache of pestering the state agency about it.”