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Procedural barriers complicate Medicaid enrollment for the unhoused

On a cold February morning at the Flathead Warming Center in Kalispell, shelter guests got ready for the day, eating breakfast, or figuring out if the bus was running on time.

Tashya Evans was in the parking lot smoking a cigarette while she waited for help with her Medicaid application.

Evans is one of about 120,000 Montanans who lost Medicaid as the state re-evaluated everyone’s eligibility. That number is still growing as the state releases more data.

About two-thirds of those who were kicked off state Medicaid rolls lost it for technical reasons like incorrectly filling out paperwork. That’s one of the highest procedural disenrollment rates nationwide, according to a KFF analysis.

Even unsheltered people like Evans, who still qualify, are losing their health insurance. That’s despite the state saying publicly it would use datasets like social security and disability to automatically renew people who likely still qualify for Medicaid.

Evans said she lost coverage in September because she didn’t receive paperwork as she moved from Great Falls.

That’s forcing her to forgo her blood pressure medication and pause dental work. She thinks her blood pressure has been ok, but waiting for the dentist has been hard.

“The teeth broke off. My gums hurt. There’s sometimes where I’m not feeling good and I don’t want to eat,” she said.

She sat down in a spare shelter office with an application counselor from Greater Valley Health Clinic, which serves much of the homeless population in the Flathead Valley.

Evans recounted all the struggles she’s had.

She tried asking for help at the local state public assistance office. She said staff there don’t have time to answer all her questions about which forms she needs to fill out or walk through the paperwork with her. She tried the state help line, but she couldn’t get through.

“You just get to the point where you’re like, ‘I’m frustrated right now. I have other things that are more important, so let’s not deal with it,’” she said.

Evans said she needs to spend her time looking for a job, finding her next meal and a place to sleep. Sitting on the phone most of the day isn’t feasible.

There’s no public data on how many unhoused people in Montana, or nationwide, have lost Medicaid, but homeless service providers and experts say it’s a big problem.

Montana health officials said they provided training to prepare homeless service providers.

State health department Director Charlie Brereton also resisted calls from Democratic state lawmakers to pause the redetermination process.

“I’m confident in our redetermination process,” Brereton told lawmakers. “I do believe that many of the Medicaid members who’ve been disenrolled were disenrolled correctly.”

The head of Montana’s health department has no plans to temporarily stop checking patients' Medicaid eligibility. About one in 10 Montanans have lost coverage through that process this year.

Redetermination went on as planned, ending in January, four months ahead of the federal deadline.

Those helping unsheltered people who have lost coverage said they have spent much of their time trying to help people get in touch with the state Medicaid office to provide them with the correct information.

Sorting through paperwork mistakes has also been a headache, said Crystal Baker, a case manager at HRDC, the homeless shelter in Bozeman.

“We’re getting mail that’s like, ‘Oh, this needs to be turned in by this date,’ and that’s already two weeks past. So, now we have to start the process all over again. Now, they have to wait two to three months without insurance,” she said.

Federal health officials warned Montana and other conservative states that have been unenrolling high rates of people for technicalities. The agency also warned states for having unreasonable barriers to accessing assistance, such as long hold times on help lines. CMS said that it could force states to halt their process, but so far hasn’t done so.

However, experts said blue states are also kicking homeless people off their rolls and that the redetermination has been chaotic everywhere. Because of the barriers unsheltered people face, it’s easy for them to fall through the cracks.

“It doesn’t seem like such a big deal to fill out paperwork,” said Dr. Margot Kushel, a primary care provider and a homeless researcher at the University of California, San Francisco. Put yourself in the position of an elder who’s experiencing homelessness and has lost their vision, who has no access to [a] computer, no access to [a] car, doesn’t have [a] cell phone.”

People can typically get retroactive coverage if they get back on Medicaid after they are kicked off.

Kushel said being without Medicaid for any period can be dangerous for the homeless community, which has high rates of chronic health conditions.

“Being out of your asthma medicine for three days can be life threatening. If you have high blood pressure and you suddenly stop your medicine, your blood pressure shoots up, and your risk of having a heart attack goes way up,” she said.

When people don’t understand why they’re losing coverage or how to get it back, that erodes their trust in the medical system, said Kushel.

Evans, who was able to get help with her application, is likely to regain coverage.

Providers on the ground said it could take years to get everyone who lost coverage back on Medicaid. They worry that those who go without coverage will resort to using the emergency room rather than managing their health conditions proactively.

Baker, the case manager at the Bozeman shelter, set up several call-backs from the state for one client. The state needed to interview him to make sure he still qualified, but the state never called back.

“He waited all-day long. It was so stressful for him that he just gave up,” she said.

That client ended up leaving the Bozeman area before she could convince him it was worth trying to regain Medicaid.

Baker worries his health will catch up with him before he decides to reapply to Medicaid.

Aaron graduated from the University of Minnesota School of Journalism in 2015 after interning at Minnesota Public Radio. He landed his first reporting gig in Wrangell, Alaska where he enjoyed the remote Alaskan lifestyle and eventually moved back to the road system as the KBBI News Director in Homer, Alaska. He joined the MTPR team in 2019. Aaron now reports on all things in northwest Montana and statewide health care.
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