How Medicaid Unwinding Could Impact Radiology Practices

pexels-karen-laårk-boshoff-7489676 (1) During the COVID-19 Public Health Emergency, states were required to maintain enrollment of nearly all Medicaid enrollees as a condition of receiving a temporary 6.2 percentage point Federal Medical Assistance Percentage (FMAP) increase under the Families First Coronavirus Response Act (FFCRA). There was significant growth of national Medicaid enrollment figures due to this continuous Medicaid enrollment requirement, coupled with additional incentives for states to implement Medicaid expansion. The Kaiser Family Foundation estimates that the combination of Medicaid and CHIP (Children’s Health Insurance Program) enrollment has increased by over 23 million people between February 2020 and March 2023. However, when that continuous enrollment condition ended on March 31, 2023, Medicaid enrollment numbers started to decline. States had to resume normal operations, including restarting full Medicaid eligibility renewals and terminations of coverage for individuals who are no longer eligible. The full process could take up to a year, with the earliest removals from coverage having begun in April 2023.

Widespread Loss of Medicaid Coverage

Once the unwinding began, it became clear to the Centers for Medicare and Medicaid Services (CMS) that some states were improperly denying coverage to some individuals. By July 19, at least 3 million people had been disenrolled from Medicaid, 74% of which were due to procedural errors rather than being determined ineligible for the program.

According to Inside Health Policy on July 21, 2023, these nine states had agreed to pause procedural terminations in response to the CMS directive: Delaware, Idaho, Iowa, Maine, Minnesota, Mississippi, New York, West Virginia, and Wyoming. Mitigation plans had been approved for 35 states as of the report date. Among the steps included in the mitigation plans are simplified renewal forms, clearer instructions, and pre-populated forms, along with the option to use a variety of reporting modalities such as phone, mail, in-person or online. Additionally, part of the corrective action includes confirming Medicaid eligibility ex parte, which is an auto-renewal method used to renew eligibility based on data already available through CMS so that in many cases Medicaid coverage can be renewed without any new documentation.

CMS issued guidance on August 30 to all states, warning them of the problems they had observed and requiring states to take action to:

Immediately pause procedural terminations for those individuals whose coverage may have been terminated inappropriately.
Reinstate coverage for all affected individuals who were procedurally disenrolled due to a failure to account for the individual’s eligibility status. This commonly occurred where the state looked only at a family’s eligibility rather than at the eligibility of each individual in the family.
Fix the state’s systems and process to ensure that redeterminations are conducted appropriately.
Implement one or more mitigation strategies, as outlined in the CMS document.

The Boston Globe reported on September 21 that “30 states, including Massachusetts, are altering the process they use to remove ineligible people from Medicaid enrollment and pausing the removal of others after identifying a ‘glitch’ that had accidentally removed half a million people across the country from state-sponsored insurance.”

Implications for Radiology Practices

Termination of Medicaid coverage for so many people will pose a challenge for radiology practices. Individuals who have lost their Medicaid coverage could become uninsured, in which case reimbursement for radiology services will virtually disappear, or they could undergo a change in coverage. In either case, the practice has to be aware of each patient’s current situation without relying on past coverage as a guide.

Imaging centers will have to be more diligent about confirming every patient’s coverage at the time appointments are made. In some cases, Medicaid beneficiaries will transition to Marketplace plans under the Affordable Care Act, but practices will have to know this in order to file claims in the right place. Other Medicaid beneficiaries will become uninsured, in which case the practice will have to decide whether or not to provide services.

Hospital-based practices do not have the opportunity to deny service, regardless of insurance coverage. Radiology groups that have no control over hospital patient registration could see a decline in reimbursement due to uninsured patients, or because the hospital’s registrars did not capture a change of coverage.

The Future of Medicaid & Your Practice

A majority of states are adopting Medicaid expansion that will, over time, alleviate some of the Medicaid disenrollment problems. For example, North Carolina recently passed legislation making it the 41^st state to expand Medicaid beginning on December 1, 2023.

Healthcare Administrative Partners wants you to know about all the forces that could affect your reimbursement, so we will continue to monitor and report on Medicaid and other programs without restricting access for patients or other gating techniques. Subscribe to this blog for the latest information.

Sandy Coffta is the Vice President of Client Services at Healthcare Administrative Partners.

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