by Jill Nolin, Georgia Recorder [This article first appeared in the Georgia Recorder, republished with permission]

May 2, 2023

Some people know what Alysia Cutting is talking about when she brings up Medicaid unwinding as she moves from one community event to the next in southwest Georgia.

But for most of them, word of the renewal process starting up again – and the potential they could lose Medicaid coverage – is news to them.

Medicaid renewals are back after a three-year hiatus during the pandemic, when states were barred from kicking people off the public insurance program during the COVID-19 crisis.

And the yearlong process of determining the eligibility of all 2.7 million adults and children covered by Medicaid started last month could end with more than a half million Georgians losing coverage because they no longer qualify.

When she catches someone unaware, Cutting quickly fills them in on what’s happening, directs them to the state’s staycovered.ga.gov site and tries to convey a sense of urgency as she sends them on their way with a flier in English and Spanish.

“Please make sure you do this. It’s super, super important. It’s really urgent. Make sure you get this done,” Cutting, who is the rural health equity director with SOWEGA Rising, said of her message.

On a recent Saturday, Cutting was spreading the word at a health fair held at a public housing community in Albany, where a financial incentive was being offered for anyone who received their first COVID-19 vaccine or booster.

Most Sundays, you will find Cutting visiting places of worship in the area as she tries to work information about Medicaid redetermination into announcements to the congregation and into church bulletins. Another key strategy to reaching people in her corner of the state: Getting the information posted at barbershops, salons and other small businesses.

She attempts to amplify the message state agencies have been pushing for several months: Make sure your contact information is up to date in your Georgia Gateway account.

“People have moved. People have relocated. Situations have changed,” Cutting said. “It’s a lot. I just would not want for someone’s mailbox to have a little letter in there, and they’ve moved and now they’re sleeping at their grandmother’s house because they lost the apartment or lost the house.”

‘Knowing about it is one thing, and navigating the process is another thing’

The 2.7 million renewals are being handled as about a dozen batches, with the first group of people mailed notices in mid-April. This work will be underway through next May.  

The state sent out nearly 7,500 renewal notices last month, but most of the groupings will be about 250,000 each, according to the state Department of Human Services. Medicaid enrollees can see their scheduled renewal date in their Gateway account.

This massive multi-agency undertaking will mostly fall to an army of caseworkers with the Division of Family and Children Services within DHS. About $8.4 million was added to this year’s budget and another $11 million was pumped into next year’s budget to increase staffing and purchase technology to support the workload.

But low public awareness has also presented a challenge nationally. In December, more than six in 10 adults in Medicaid-enrolled families said they were not aware that the regular renewal process was restarting, according to a survey from the Urban Institute.

A major focus for the state has been to put the looming renewal on the radar of those covered by Medicaid while directing them to update their contact information in their Georgia Gateway account so they will receive important notices when it is their turn to go through the process.

The department contracted with Atlanta-based Jackson Spalding last June to lead Georgia’s statewide public information campaign, including a series of ads featuring an animated “spokespeach” named George A. Peach.

The contract with the firm allows it to spend up to $5 million on this work in the first year, according to its contract with the state.

The statewide marketing campaign has so far included social media, TV, radio and digital ads, billboards, direct mail outreach, printed materials, and text message outreach. The state’s unwinding website includes resources available in Spanish, Burmese, Korean and other languages.

The state is also working with the three care management organizations that provide Medicaid benefits, notifying them which of their members are up for redetermination.

Jason Bearden, president of CareSource Georgia, says his organization is attempting to reach out to those members – or talk to them when they initiate communication – to discuss the process and their coverage options. CareSource, which provides Medicaid benefits for about a half million Georgians, offers private insurance plans through the federal marketplace.

CareSource’s community educators are also setting up at local events and on major hospital campuses like Grady Health and Northeast Georgia Health System to catch enrollees as they use their benefits.

Bearden says public awareness about important health care events is always a concern. He lauded the state for putting money into a public relations and marketing campaign to try to boost awareness. 

“Us policy wonks, we get it. But we have got to do a really good job of getting the word out there,” Bearden said.

“Is it perfect? No. Can we always do more? Yes. But it is a big concern to all of us around awareness and what do I need to do, because it’s complex – why is eligibility anchored to all these different variables? Income, job status, family size – it’s confusing.”

The state has provided an online toolkit and other information for groups like SOWEGA Rising to use as they assist their communities.

But other states have gone further. For example, Arkansas has offered small grants to community organizations to reach more people and help them through what many advocates describe as a thorny process.

“Knowing about it is one thing, and navigating the process is another thing,” said Callan Wells, senior health policy manager with the Georgia Early Education Alliance for Ready Students.

Kylie Winton, communications director with DHS, said other plans are in the works to partner with local organizations that can often act as a trusted messenger in their community, as seen during the pandemic.

“The campaign will continue to focus on providing critical information while helping members navigate the Medicaid redetermination process,” Winton said in a statement, referring to the statewide information campaign.

“Our goal is to ensure that all members have access to the information they need to stay in charge of their coverage.”

Winton said last year’s one-time cash assistance program has also indirectly helped freshen up account information. The $1 billion program included all Medicaid enrollees, who were asked to update their information to receive the $350 payment. There was a less than 3% non-response rate among them, Winton said.

How much of all this can be automated?

Behind the scenes, state officials say there is work underway to renew coverage when possible without all the tedious back-and-forth exchange of paperwork.

Caseworkers will attempt to determine a Medicaid enrollee’s status with the data already on file, although it remains to be seen how many people’s eligibility can be redetermined this way. 

The federal government is pushing states to lean on this method.

Caylee Noggle, commissioner of state Department of Community Health, which administers the state’s Medicaid program, told the agency’s advisory board in April that the state agencies will first try to use this method – known as an ex parte renewal.

“I don’t know exactly what we’ll hit. We’re trying to increase our ability to be really effective at that. But we’re going to shoot for as high as we can get,” Noggle said.

There’s room for improvement, advocates say. In 2019, Georgia was one of 22 states where less than half of renewals were done using available data sources, according to a KFF survey.

Maximizing this strategy benefits both enrollees and DFCS employees, who are toiling in roles in state government with historically high turnover, says Leah Chan, senior health analyst with the Georgia Budget and Policy Institute.

“This process – that is already fraught even in the best of circumstances – relies on this workforce that I don’t think is getting all of the support it needs in our state budget, and so, that’s one of the reasons this ex parte is so critical,” Chan said.

“If we can take a little bit of the pressure off that frontline DFCS workforce, it could reduce the risk for human error being made.”

The renewal process can be arduous, requiring multiple steps and supporting documentation in a short 45-day period. If an enrollee believes they have been denied coverage in error, they can appeal the decision.

But Wells with the Georgia Early Education Alliance for Ready Students said she worries about even short breaks in coverage for young children due to “bureaucratic errors.” A lapse in care, for example, could mean missing health screenings designed to catch a developmental delay early.

Nearly 40% of Georgia children are covered by Medicaid, according to Georgetown’s Center for Children and Families.

“Even if they can reapply and get back on Medicaid, we could see gaps in coverage during this really critical time,” Wells said.

Wells said the state can minimize the number of people removed in error by utilizing those alternative data sources for renewals when possible. But in the long term, she advocates for allowing continuous Medicaid eligibility for the youngest Georgians – through age six – to avoid unnecessary coverage gaps.

“This is going to continue to be an issue beyond unwinding,” she said.

In Georgia, 6.6% of children have no insurance, which is higher than the national average, and there is concern that number could increase because of the redetermination process, Wells said.

“I am worried about the number of families who are going to lose (coverage) because of the bureaucratic barriers, and I think that that’s missing from the conversation,” she said.

Winton with DHS said the agency expects about three-fourths of renewals for children and adults to be able to go the automated route. Some, though, will require a manual review.

She also said the state will try at least two other methods to find someone if their renewal notice cannot be delivered to the address on file, using all available databases to find up-to-date contact information.

Medicaid enrollees also have a chance following the renewal process to submit any missing documents or information. 

“If a case is closed because a member’s whereabouts are unknown or there are procedural issues with their renewal, the member has 90 days to provide additional information to verify their eligibility,” Winton said. 

‘We will see very large coverage losses‘

The earliest anyone is likely to lose Medicaid coverage under the state’s timeline for the unwinding is June 1.

That’s when Cynthia Gibson says she expects the phones at Georgia Legal Services Program to start lighting up.

Georgia Legal Services Program, which provides free assistance to those outside of metro Atlanta, will help someone submit an appeal if they believe their coverage was denied in error. The organization also runs a federally funded program called Georgia Enroll that can help people who are no longer eligible for Medicaid find coverage.

“Our expectation is that we’re going to get a lot of calls once the terminations start,” said Gibson, who is a managing attorney and a health law specialist with the program. 

“And we expect there’s going to be people who never get the notices, and so they’re not going to know about their termination until they try to use their insurance and then they’re going to find out they don’t have it.”  

Gibson said the organization anticipates a “large need” to represent those affected by the redetermination process, whether it’s filing an appeal or signing up for an insurance plan on the marketplace because they no longer qualify for Medicaid.

Adding to the confusion is the question of whether Georgia’s new Medicaid plan – Georgia Pathways to Coverage – will launch as planned this July.

Gov. Brian Kemp’s narrower alternative to traditional Medicaid expansion has been delayed by legal challenges and pushback from the Biden administration, which did not appeal a federal judge’s opinion that sided with the state.

When Kemp’s plan was first unveiled, about 50,000 people were estimated to gain coverage. The agency now projects about 345,000 people may be eligible, according to Fiona Roberts, press secretary for DCH.

“Georgia Pathways is expected to launch on July 1, 2023. DCH continues to work with (the Centers for Medicare and Medicaid Services) and its partners to be ready to implement on the go-live date,” Roberts said in a statement.

Low-income adults can qualify for coverage through the new Medicaid program if they complete 80 hours of a qualifying activity, such as working, attending school, or volunteering every month – a controversial condition known as a work requirement.

But patient and health care advocates warn that the risk of significant numbers of people becoming uninsured is greater in states like Georgia, which is now one of 10 states that have not fully expanded Medicaid under the Affordable Care Act.

North Carolina lawmakers voted to change course this year, becoming the first neighboring Southern state to expand Medicaid.

“There will be far fewer uninsured folks as a result of this Medicaid renewal process in states with Medicaid expansion. Georgia is not one of those, so we will see very large coverage losses,” Laura Colbert, executive director of Georgians for a Health Future, which is a nonpartisan patient advocacy group, said during a recent Protect Our Care program.

Colbert said the state agencies have made “really good faith efforts to plan as best they can,” but noted that it falls to the governor and lawmakers to ensure they have the resources they need.

But even with additional funding this year, attracting and training enough workers for this complex task that is already underway will be a challenge in the current labor environment, she said.

That hiring is ongoing. Winton with DHS said the agency just onboarded 276 new employees, with more people in the pipeline, and said there are early signs the agency’s turnover rate for the role of economic support specialist is trending lower. 

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