About 119,000 Alabamians were removed from Medicaid in the first three months after federal restrictions on disenrollment expired earlier this year, according to data published by the Centers for Medicare and Medicaid Services.
The numbers, while in line with national trends, are higher than estimates earlier this year, though experts suggested they could also mirror similar challenges other states face.
“Based on the data that we’re seeing — when we focus exclusively on disenrollment, so the number of people who have been disenrolled — that total is likely going to exceed our estimates from last year,” said Jennifer Tolbert, director of state health reform at KFF, a San Francisco-based nonprofit that studies and reports on health policy.
About 87% of these terminations, or just over 100,000, were due to procedural or administrative reasons, such as not turning in required paperwork on time, according to the Centers for Medicare and Medicaid Services.
Melanie Cleveland, a spokesperson for the Alabama Medicaid Agency, pointed in an email to the percentage of procedural terminations as a percentage of overall determinations, which is much lower — a third — compared to the number of determinations. Cleveland did not return a request for further comment.
Cleveland also previously said there are many reasons that contribute to people not turning renewal forms back in, such as dying or moving out of state.
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Some of the Medicaid recipients who signed on to the program during high unemployment rates amid the pandemic may have since gotten health insurance through new jobs as unemployment dropped back to pre-pandemic lows, while other disenrolled Alabamians may be signing up for Affordable Care Act marketplace plans.
It’s fairly early to draw conclusions, Tolbert said, since Alabama lags behind most states in reporting data to the Centers for Medicare and Medicaid Services.
A COVID-era program
As part of the response to the pandemic in 2020, the federal government banned states from removing anyone from Medicaid rolls. During that time, Alabama’s Medicaid enrollment went from just over 1 million people before the pandemic to 1.37 million in May 2023.
The Alabama Medicaid Agency began evaluating Medicaid recipients’ eligibility for coverage in June. The agency completed six months of redeterminations, but only June, July and August determinations have been published by the Centers for Medicare and Medicaid Services.
KFF initially estimated that about 170,000 Alabamians could lose Medicaid coverage at the end of the 12-month unwinding period. But at current rates, the state may end up terminating over 400,000 people by next June.
The organization’s estimates for overall terminations were based on a middle-ground estimate of 18% disenrollment, with a low range of 8% and a high range of 28%.
But Alabama exceeded the high-end estimates, terminating about 33% of recipients from its Medicaid rolls. That is slightly below the national average of 34%, according to Tolbert, but there is still uncertainty as to why.
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KFF did not consider net change in Medicaid enrollment when looking at overall termination rates, which contributed to the high rates of terminations seen in Alabama and other states.
Alabama’s net enrollment for Medicaid and the Children’s Health Insurance Program decreased by about 5.7% from 1.38 million in June to 1.3 million in September, a significant difference from the 33% disenrollment. The eligibility for Medicaid alone in the state decreased about 7.4% since June, slightly higher likely because more children became eligible for the Children’s Health Insurance Program.
Because the pandemic public health emergency prevented states from terminating people from its Medicaid rolls, children who would have otherwise qualified for the the Children’s Health Insurance Program stayed on Alabama Medicaid rolls, and the number of children eligible for Medicaid coverage, who would have otherwise been eligible for the the Children’s Health Insurance Program, increased.
Children who qualified for the Children’s Health Insurance Program were automatically enrolled during the unwinding period.
Net enrollment
Alabama has taken advantage of several flexibility waivers provided by the federal government. These waivers are meant to help states manage the volume of the redetermination caseload, but also to avoid terminating coverage for those who may still be eligible.
Alabama has received five waivers to help with the process, including coordinating renewals for recipients enrolled in Temporary Aid to Needy Families, and automatically renewing recipients with no income, which Tolbert said reduces the number of procedural terminations.
“So again, disenrollments are currently higher than our estimates, but an important — very important piece of the picture — is this looking at the net enrollment decline,” Tolbert said. That decline, she said, is relatively low compared to other states, from 88% renewals in June to 69% in September.
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Medicaid in Alabama mainly covers children, older adults and the disabled. Childless, able-bodied adults almost never qualify. Adults with qualifying children must make no more than 18% of the poverty line ($2,673 a year for an individual; $4,475 for a family of three) to receive Medicaid.
Cleveland said in August the agency was about three months behind publishing unwinding data because officials wanted to validate all numbers before reporting them to the Centers for Medicare and Medicaid Services.
Since those who lost coverage have 90 days to reinstate coverage, agency officials want to avoid amending numbers if they report them too early.
Tolbert said across states, new applications are increasing because people with terminated coverage are also completing new applications instead of renewal forms. This could be contributing to the high termination rates, but that “disentangling” this data across states may be nearly impossible.
“There are good reasons to pay attention to that procedural disenrollment rate,” Tolbert said, “but it’s also important to look at that rate in the context of how many people are actually being renewed,” an average of 70% since June.
Read more at AlabamaReflector.com.