Unwinding issues show that Medicaid eligibility systems need better oversight to ensure coverage
The upcoming election in November will have a significant effect on health care across the country. Candidates at the federal and states levels may propose policy proposals that could have a profound impact on health law and policies in 2025. In this new blog, NHeLP experts will analyze and discuss the impact of various policies on access to care for low-income people and people with disabilities. They will also examine the impact of policies on people who are Black, Indigenous and people of colour, LGBTQI+ people, pregnant women, and those living at the intersections of these identities. Follow along with NHeLP through Election Day as we explore opportunities and threats to health care in the United States.
Artificial Intelligence and automated decision-making systems are a bipartisan concern and will likely be a focal point for the next administration. Project 2025 emphasizes Medicaid system upgrades to prevent fraud (pg. 467). Medicaid eligibility systems often deny coverage to those who are eligible, causing irreversible damage to those denied. These issues are not always identified by audits or federal oversight. They are only discovered when people who have lost coverage start to appeal denials, ask questions, and seek help from advocates. The cost of fixing system problems can be in the millions, and often cause harm for months. Although eligibility system issues have occurred for years, the Medicaid unwinding revealed system errors.
The Medicaid unwinding highlighted the need for improved system performance and increased oversight.
The volume of redeterminations during the unwinding is unprecedented and has highlighted many issues that should shape policy change. The current eligibility technology automates policies that do not align with federal requirements, and encodes system mistakes. These are not harmless tech glitches. These glitches result in people not being able to access care. A system issue in Florida, for example, kicked postpartum women off Medicaid. Instead of receiving 12 month’s postpartum coverage they only received 2. Florida Medicaid enrollees also complained that their notices were not sufficient to challenge the loss of coverage. Chianne D., a Floridian who was sick, had to go without care because of this glitch. Her child, who had cystic fibrosis, developed worsening symptoms, and the family was left with a $2800 bill. In Tennessee, eligibility issues have led to incorrect coverage denials over the past few years. The system was implemented in 2019, with a variety of issues identified in AMC v. Smith, which was decided to plaintiffs’ benefit in August 2024. Below is a list of non-exhaustive examples of recent technology problems contributing to terminations and people not being able to access care:
Online portal issues:
In some states, online Medicaid portals have file size, file upload, and file transmission issues that cause people to lose coverage, even though they believe they have provided all the documentation needed Colorado had several online portal issues. Arkansas had a system issue that disproportionately affected individuals with disabilities. The online portal showed that renewal documents and forms were uploaded correctly, but they received notices from the agency that it had not received the necessary documents. Even though a phone call to the state agency resulted in assurance that the problem was solved, people later found out they had lost coverage through home and community-based services (HCBS) providers.
Terminations for “Missing” Paperwork Submitted But Not Processed:
Several state systems caused automatic coverage termination when redeterminations became backlogged. The information and paperwork were submitted on time but the information was not processed by the scheduled redetermination deadline. When the system lacked a decision input, it automatically terminated coverage.
- Incorrect Household Counting: Widespread issues occurred with states improperly applying federal requirements on household “counting”, resulting in children erroneously losing coverage. The eligibility systems of states incorrectly performed automatic redeterminations on the household level, instead of at the individual level. Many people who were eligible for Medicaid lost their coverage. This was especially true for children who were eligible at higher income levels and whose parents or caregivers couldn’t renew their coverage automatically. Children who were eligible for coverage lost it when other household members could not renew their coverage and did not respond when asked for information. The problem existed before the unwinding but it was only the sheer volume of people affected that brought the issue to the Center for Medicare & Medicaid Services’ (CMS) attention. This prompted action from CMS to raise the issue with state directors and call for pauses in procedural terminations.
- Improper Renewals for Individuals Who Formerly Received SSI: In Kentucky, the state system failed to check for all categories of Medicaid eligibility in violation of federal regulations. Those who previously received Supplemental Security Income benefits (SSI) were deemed ineligible once they no longer qualified to receive SSI-related coverage. They lost Medicaid coverage despite being eligible under a different category. The same issue occurred in Arkansas until CMS worked with state officials to revise processes to correct the problem.
- Eligibility systems issues across the country cause people to lose access to necessary health care. The volume of redeterminations made during the unwinding has brought to light many of these issues. These issues will not disappear on their own. CMS must provide more oversight to states, while states need to have stronger oversight over contractors to identify, prevent, and mitigate these harms. The next administration should focus on upgrading the eligibility system to improve access to Medicaid, rather than preventing fraud and abuse.
