One-year-olds and 18-year-olds are still wrongly losing Medicaid coverage because of administrative glitches and confusing notices, despite pledges from Department of Social Services officials to address the issues, according to the researchers who identified the problems.
"[W]e want to bring to your attention the fact that the fixes agreed upon have not been implemented," Mary Alice Lee and Sharon Langer wrote to DSS Commissioner Roderick L. Bremby. In particular, they cited confusing notices that are still being sent to the families of babies turning 1.
Lee and Langer, who are senior fellows at Connecticut Voices for Children, reported this month that babies turning 1 and teens turning 18 were in 2010 twice as likely as other children to lose coverage in HUSKY, the Medicaid program that covers poor children and their parents. They initially reported on the problems involving 1-year-olds last year, and 18-year-olds the year before.
In response, Bremby wrote that the department had significantly improved the percentage of 18-year-olds who maintain coverage, but that the progress had not been sustained since then. The department is working to address the eligibility process for both age groups, recently got approval to hire additional eligibility staff and will change the notices sent to families as part of information technology changes slated to be complete by October, he wrote.
"We're here to acknowledge that we do have a problem," Peter Palermino, program manager for DSS' bureau of assistance programs, said during a meeting of the council that oversees Medicaid Friday. Bremby has charged Palermino with monitoring progress on the issue. "There are babies and there are 18-year-olds who are losing coverage."
Among the ways the department is trying to address the problems is by trying to identify early on who could lose coverage and trying to prevent it, he said.
But Palermino noted that the department has lost staff to retirements and is dealing with antiquated technology, and said addressing the coverage of the 1-year-olds and 18-year-olds has had to compete with other pressing issues facing DSS. Those include improving the food stamp program as the department faces potential federal sanctions because of poor performance; increasing the speed of processing Medicaid applications, the subject of legal action; and administering a disaster relief program last fall that produced allegations of fraud.
"We're trying to refocus on this particular population group," Palermino said of the babies and 18-year-olds at risk of losing coverage.
Administrative glitches, lost coverage
HUSKY is available to anyone under 19 whose family qualifies. DSS categorizes those in the program into one of many coverage groups, which are used to meet federal requirements, but have no bearing on the types of benefits a child or family gets. A person could be ineligible for one coverage group -- for example, one that only covers infants up to age 1 -- but remain eligible for the program. To maintain coverage, though, they must be moved by a DSS worker into another category.
That's the root of the problems Lee and Langer identified.
One coverage group, for babies under 1, is intended to keep infants from losing coverage. Federal law entitles any baby born to a woman who qualifies for Medicaid to one year of coverage, even if the mother loses eligibility during the year. But babies in that group must be moved into another category once they turn 1, or they'll lose coverage, even if their families still qualify.
More than 40 percent of infants in that coverage group lost their health insurance in the month after turning 1 between January 2008 and September 2009, Lee and Langer found.
To move those infants to another category, DSS needs to know that their families still qualify for coverage. Families of children turning 1 are sent notices that the babies' coverage is being discontinued because "YOU ARE NOT THE RIGHT AGE TO BE ELIGIBLE FOR THIS PROGRAM."
But that's not really the case, Langer and Lee pointed out; the infants' age only disqualifies them from one coverage category. The real issue is whether the family still meets HUSKY's income requirements. DSS later sends families a notice telling them the baby has been disenrolled, and a blank eight-page form used to apply for Medicaid and other public assistance programs, which asks for information not typically required for HUSKY. By contrast, when gathering information to retain other children in HUSKY, DSS sends a four-page prefilled HUSKY renewal form.
Bremby wrote that the notice will be changed by October -- "the soonest timeframe possible" -- as part of the department's technology improvement efforts. In addition, the eligibility management system will be programmed to send families the four-page prefilled renewal forms, not the blank eight-page ones, he wrote.
In some cases, DSS staff can maintain a 1-year-old's coverage even if the family hasn't returned a form if the family is receiving another type of assistance and the department has current information that shows they qualify for HUSKY.
The problems 18-year-olds face also stem from trouble moving them from one coverage group to another. Lee and Langer reported in 2010 that nearly one in six teens lose coverage after turning 18. As with the newborns, some teens are in coverage groups that have an age limit, requiring them to be manually moved to another group when they turn 18.
Bremby wrote that the department had improved the retention rate among 18-year-olds, reducing the percentage who lose coverage from 40 percent to 5 percent, but said that "our previous success...has steadily increased in the opposite direction."
United Way's 2-1-1 infoline continues to receive calls about 18-year-olds losing coverage, Lee and Langer wrote to Bremby. When they reported on the problem in 2010, they described cases including one in which an 18-year-old with HIV wrongly lost coverage, leaving her mother to pay out of pocket for antiretroviral drugs. In other cases, they said, teens have been referred to buy coverage, even though they could get HUSKY at no cost.
ER visits, a lost application and a collection agency
Their letter to Bremby cited what Lee called a "particularly egregious case," involving a 1-year-old who lost HUSKY coverage after turning 1 in March 2011. The child's mother continued to take her to the pediatrician and began getting billed. The mother later began taking the child to the emergency room for medical needs such as colds, fevers and ear infections, incurring emergency room bills. She later sought help from a community-based organization, which helped her apply for HUSKY in December, but DSS lost the application.
Staff from the community organization and the mother went to DSS and saw a caseworker, who told the mother she should have been reported to the Department of Children and Families, Lee and Langer wrote.
The worker told the mother to set up an appointment with the pediatrician to get her daughter's immunizations, and to tell the doctor's office that the child would be placed back on HUSKY. But the mother still got billed for the shots because the HUSKY coverage wasn't reinstated, Lee and Langer wrote.
After the child received the vaccines, the pediatrician told the mother that he couldn't continue seeing her until she paid her outstanding bills. When she tried to find another pediatrician, the mother was told her daughter wouldn't be seen because of the outstanding balance with her previous pediatrician.
When the child's HUSKY coverage was finally restored, the mother was left with a $110 balance that wasn't covered, and got a notice that it was being forwarded to a collections agency. Ultimately, the child's grandmother paid the bill.
Beth Cheney, a nurse practitioner at Windham Hospital's prenatal clinic, said during the meeting Friday that she frequently sees similar problems.
"I often can't refer a patient back to, say, an ob-gyn provider in the community because she has an outstanding balance, and that's a huge problem," she said. "And this is unnecessary."
Kathy Yacavone, CEO of Southwest Community Health Center in Bridgeport, said she asked her staff about the problem after reading Lee and Langer's report.
"It is a pressing problem, particularly the 1-year-olds," she said. "Our Medicaid outreach workers and our other outreach workers deal with this on a daily basis. It absolutely affects care."
When children lose coverage, families often incur costs, as do health care providers who treat them without getting reimbursed by HUSKY, Lee said. Research in other states also suggests that there's a cost to the government, too, when children go off and on Medicaid -- administrative costs and additional medical costs because of care missed during the gap in coverage, she said.
Lee said it's been helpful to alert community-based social service groups and health care providers about the problems so they know that certain families will need extra help maintaining coverage for their children.