An illustration showing confusion around the Medicaid reenrollment process.
Pennsylvania is struggling with faulty technology, persistent staffing shortages, and flawed procedures as it reassesses health care coverage for hundreds of thousands of adults and children.
All states were required to begin reevaluating who qualifies for Medicaid and the Children's Health Insurance Program, or CHIP, in April as part of the "unwinding” of pandemic-era rules that allowed for continuous coverage.
Since then, tens of thousands of people in Pennsylvania are believed to have wrongly lost their benefits, at least temporarily.
Determining the exact impact is difficult. For instance, the Shapiro administration doesn’t know how many people lost benefits because of paperwork issues but were actually eligible.
Broadly, it’s clear that Pennsylvanians are dealing with a frustrating bureaucratic maze when they try to reenroll or correct coverage errors through the commonwealth’s Department of Human Services.
Kathryn Ah Wong is one of those people.
In April, the Clearfield County mother of two was told her younger son had been kicked off of his CHIP benefits because he had outside insurance. It was an error, Ah Wong said, but it led her on a monthslong odyssey.
It’s possible Ah Wong’s issues were related to yet another big change Pennsylvania was undertaking earlier this year: an ambitious IT overhaul of its CHIP system, switching the responsibility for reenrolling children in that program from participating insurers to DHS.
That move transferred new responsibilities to county caseworkers, who were already dealing with heavy workloads because of the record number of people enrolled in Medicaid.
This isn’t the only issue Ah Wong has faced since the unwinding began. All the while, she said workers have been "pretty blatant” in telling her that they didn’t know how to help her.
"[They were] just explaining, ‘I got a four-minute training. This all got thrown on us. I [also] have to do SNAP benefits,’” Ah Wong said. "Every person I've talked to has been super apologetic, which is great, and just forthcoming with the fact that they don't know what they're doing.”
Ex Parte Problems
Under non-pandemic conditions, Medicaid and CHIP recipients have to reenroll in their benefits every year. Now that this process has restarted, there are a couple of ways it’s happening.
People on benefits should begin receiving notices in the mail about 90 days before their appointed reenrollment date; they’ll also get emails and texts if DHS has contact information on file. They can either mail back the necessary forms, submit them online, or they can visit a county assistance office for in-person help.
In a small minority of cases, the state can conduct what’s known as an ex parte renewal, in which county workers use publicly available information to automatically reenroll a person.
The federal government has been pushing states to use this method, which is considered to be more efficient for administrators and easier for benefit recipients, who end up with a lower chance of losing coverage over bungled paperwork.
But Pennsylvania has among the lowest rates of ex parte renewals for Medicaid in the nation. Since the unwinding began, just 4% of Medicaid renewals have been done through the ex parte process, higher than only Texas and Wyoming.
In a conversation with Spotlight PA, top DHS officials, including Secretary Val Arkoosh, conceded that it’s something they’re working on.
Hoa Pham, a deputy DHS secretary who heads the Office of Income Maintenance, said "a number of really specific technical challenges” with the state's systems serve as a barrier to expanding ex parte. Plus, she said, DHS has policies that require certain "guideposts" for a case to be completely renewed using the ex parte process.
Officials said one of the big limitations is that the ex parte system was only designed for people who aren’t on multiple benefit programs — like SNAP along with Medicaid — and who don’t have significant assets that need to be accounted for. People with these more complicated cases are excluded from ex parte renewals.
"We really do want to see the rates of ex parte renewals increase over time,” Pham said. "We've got a number of plans over the next year to make some substantial progress in that regard.”
Officials added in a statement that there is a reason they aren’t moving more quickly to boost ex parte numbers.
"Accuracy has, and will continue to be, our primary goal for the 12-month unwinding process — which the federal government has made clear it supports,” a spokesperson for the department wrote in an email. "Rushing through processes could lead to wrongful terminations, as we've seen in other states.”
Patrick Keenan — policy director at the Pennsylvania Health Access Network, which advocates for people in the benefits system — said these problems aren’t new, and he’s optimistic that the current administration is trying to solve them.
The system, he said, "has underperformed for a very long time now.”
Another issue with Pennsylvania’s ex parte process was spotlighted in late August when federal officials sent letters to state Medicaid directors flagging that "multiple states” were conducting automatic reassessments in a way that "may be resulting in eligible individuals being improperly disenrolled.”
They asked states to assess the damage and in September, released data showing that Pennsylvania was among the states using a faulty process and was one of just two that may have wrongly disenrolled more than 100,000 people as a result.
The problem involved states conducting what are often called household-level reassessments.
Essentially, if one member of the household was suspected of being ineligible, Pennsylvania asked all members to fill out reenrollment paperwork. If any household member failed to return that paperwork, the state took away their health insurance.
If all members of a household had the same income limits, this approach was unlikely to cause harm. But in cases in which some members of the household had higher limits than others — for instance, if they were children on CHIP — then they could be kicked off the rolls inappropriately.
Pennsylvania Department of Human Services Secretary Val Arkoosh in Lancaster discussing changes to Medicaid and CHIP. (Credit: Commonwealth Media Services)
Arkoosh said the Centers for Medicare and Medicaid Services was aware Pennsylvania was using a household-based approach to reenrollements.
She also said Pennsylvania’s estimate of more than 100,000 people losing access to benefits is likely too high. The commonwealth is still figuring out exactly how many people were affected, but the initial figure it submitted to the feds was "the maximum, highest possible universe of households that could be impacted.”
Federal officials have instructed states to start automatically reenrolling people on the individual level, instead of as a full household. Pennsylvania isn’t equipped to do that, said Pham. Instead, with CMS’ support, caseworkers are now manually checking publicly available income data and other financial factors to assess eligibility.
This slower, lower-tech approach takes "more time,” Pham said. "While it's not our ideal that it's not automated, we are conducting the type of review needed to ensure that the folks who are eligible maintain eligibility.”
Pennsylvania has also lagged in figuring out exactly who was wrongfully terminated under the old ex parte system. Nevada, the other state with more than an estimated 100,000 people incorrectly disenrolled, told the New York Times last month it has already restored benefits to about 114,000 people.
At publication time, Pennsylvania DHS officials didn’t have a final number of people affected and hadn’t restored coverage to anyone.
Federal officials have given states a deadline of the end of November to accomplish the fix, DHS leaders said.
An Overwhelmed System?
These tech issues are compounded by short staffing in the offices that process benefit cases, advocates for health care access argue.
DHS is 91% staffed statewide, according to department leaders, who said that’s not bad overall. But big counties are struggling more, they said.
Allegheny County is 85% staffed, and Philadelphia is about 83% staffed. Certain categories of jobs have been especially hard to fill.
Joanna Rosenhein, a consumer engagement manager with PHAN, said Philadelphia’s office only has about 71% of the necessary clerical workers, whose responsibilities include digitizing important paper documents.
"Across the board, the department is not immune to staffing challenges that other private employers have been encountering,” Arkoosh, the DHS secretary, said. But, she argued, the department has dealt with the challenges well, by shifting workloads to counties with less staffing.
And overall, Arkoosh said, the state’s reenrollment numbers have been fine.
DHS only provided complete data for April and May, the first two months of the unwinding. In both of those months, about 71% of enrollees kept their coverage and a little less than 13% were found ineligible. Another 15 to 16% were terminated for "procedural” reasons, which means it’s unclear if they were eligible, but paperwork issues precluded their renewal.
Advocates maintain that they see other signs that the system is bogged down.
In its August report to the federal government, for instance, Pennsylvania reported that of the roughly 322,000 people due for renewal during that reporting period, more than 40% didn’t have their renewals done when the period ended.
That large volume of pending renewals could show that people are waiting for their applications to be processed, which means some may have to put off care while they’re in limbo.
Keenan, the PHAN policy director, said it’s a problem. "Timely and accurate eligibility decisions help new applicants get the medical care they need,” he said.
Arkoosh argued that this is an uncharitable interpretation of these numbers.
While reenrollments are only supposed to last 30 days and the department often takes longer than that, it’s for the good of Medicaid users, Arkoosh said.
"That's really what we're always focused on, is keeping people covered,” she said.
Advocates from PHAN and Community Legal Services of Philadelphia, which also helps people navigate the benefits system, said that anecdotally, they’ve seen a notable rise in people who are reporting interminable wait times — another sign, they say, that points to an overloaded system.
"They wait on hold for hours just to talk to anybody,” said Maripat Pileggi, a supervising attorney at CLS Philly. "It can be very difficult.”
PHAN’s Rosenhein said that she thinks the CHIP IT transition is also playing a role in slowing things down.
The CHIP enrollment process includes verifying that a child doesn’t have outside health insurance. PHAN, Rosenhein said, has "seen delays in this verification process throughout the unwinding period, leaving some children who are transitioning from [Medicaid] to CHIP without coverage for over a month.”
Many of these factors have been in play for Bethany, a 27-year-old mom of two who lives outside Allegheny County and whose children, as of mid-October, had no medical coverage. Bethany preferred not to use her last name while publicly discussing her benefits.
She said over the summer, she played hours of "phone tag” with DHS to resolve Medicaid issues after she returned to work following the birth of her younger daughter.
A new issue popped up this month. After she switched jobs and filed new pay stubs to keep her daughters’ benefits, she got two separate, conflicting notices from DHS. One said she hadn’t submitted the information she said she had, and the other, scarier one said nobody in her family qualified for either Medicaid or CHIP.
At least part of the error was likely due to "staffing issues,” according to Keenan, who learned about Bethany’s case after she turned to PHAN for help.
Keenan said the children qualify for CHIP and is hopeful the issue will be resolved quickly. But in the meantime, Bethany is in a tough spot. It’s too expensive to add her daughters to her work insurance — "we're talking a $5,000 deductible,” she said — and for now, her daughters are uninsured.
"What really stresses me out is like, kids get sick,” she said. "It's October. It's flu season. COVID exists. My kids get sick, I have to wonder, can I take them to the doctor?”
Ah Wong, the Clearfield County mom who spent the spring and summer trying to get her younger son back on CHIP, is in a similar situation.
After months spent battling with DHS, she said the initial issue was resolved. But when it came time to reenroll both of her boys in the program in August, she said she got a notice, without warning, that their coverage had been terminated.
She filed an appeal and was told she was missing income information. She resubmitted the information and said she was told everything should be resolved. But this month, when she tried to schedule doctor’s appointments for her sons, she was once again told they didn’t have coverage.
Last week, one of her sons spiked a fever. When she spoke to Spotlight PA, she was trying to figure out if his coverage had been restored so she could take him to the doctor. It was unclear.
"I feel like I'm a fairly competent person. I have appointments scheduled, I keep up with things, my bills are paid,” she said. "And I have spent hours and hours and hours having to follow up with people and try to do their job and try to problem solve on my own. Because of just complete and total incompetence.”
"There's not even a person to call,” she added. "I don't know what to do.”
