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Previously I’ve spotlighted the Medicaid member “churn” phenomena and have advocated for improvements to keep people who are eligible for Medicaid from getting bounced on and off coverage. The churn issue is important because it results in fragmented care, and burdens safety-net health care providers and medical homes, MMCOs, and the state with the time and effort to re-enroll these members.
As Commonwealth Care moves beyond its freshman year and into a maturing program, the same eligibility redetermination process is now being applied to its members — with disquieting results.
The redetermination process kicked off in December. At Network Health, we have subsequently seen 12,000 Commonwealth Care members involuntarily disenrolled in February and March, nearly three times the previous disenrollment rate.
To put a human face on these numbers, I can offer an unfortunately “spectacular” story of one of our Commonwealth Care members who has lost his Commonwealth Care coverage not once, but twice since his enrollment last spring.
This man was asked for citizenship documentation, which he provided three times by fax and mail. While continuing to pay his premium, he inexplicably lost coverage, leaving him to pay a steep $400 monthly prescription bill, in addition to other medical bills. He also missed medical appointments due to his lack of coverage as he didn’t feel it was appropriate to present for care without health insurance. He was finally re-enrolled in Commonwealth Care a few months later, only to be again disenrolled after a month of coverage, this time with his wife, for allegedly having access to employer-sponsored insurance (ESI). Unfortunately (but predictably), this was erroneous information, as they did not have access to ESI; their small employer apparently had once offered coverage to employees, but no longer does. They are both currently uninsured, trying to re-enroll.
We would be delighted to hear that the majority, if not all, of our involuntarily disenrolled Commonwealth Care members had gained access to employer-sponsored insurance or other public-sector insurance, or had increased their income to move into the Commonwealth Choice market. However, this one example echoes consistent trends of members being disenrolled for returned mail, failure to complete paperwork on time (often out of confusion or belief that they have previously answered the questions), or miscommunication about the presence of employer-sponsored insurance.
Sweeping administrative disenrollments result in gaps in coverage that disrupt continuity of care for people who still meet eligibility requirements — people for whom the program was intended. They are also detrimental to the providers serving as “medical homes” who are working to organize care and services for these members and their communities. We continue to have data that support that a large number of individuals involuntarily kicked off publicly funded health insurance programs are eligible for the programs at the time they are terminated. I’m a supporter of the saying, “Always make new mistakes,” but why do we choose to make the same ones over and over? Doesn’t this data support that the process lacks legitimacy when we know that the largest affected cohort is incorrectly classified as ineligible? I’m all for having a strict process — one that is tough on fraud and abuse, and one that uses a thoughtful and diligent process to manage beneficiary eligibility. However, the current process, which is based on a guilty-until-proven-innocent premise, does not serve to protect the interests of state beneficiaries at large.
Christina Severin is executive director of Network Health, a health plan with more than 160,000 MassHealth and Commonwealth Care members across Massachusetts.
This program aired on March 31, 2008. The audio for this program is not available.
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