After a summer pause to expand outreach efforts to SoonerCare members, the Oklahoma Health Care Authority has resumed an unwinding process to pare an estimated 270,000 low-income Oklahomans who kept Medicaid coverage during the COVID-19 pandemic.

A federal public health emergency stopped states from dropping people from the joint federal-state Medicaid program even if they no longer met eligibility requirements under routine renewals. That emergency designation ended March 31. Oklahoma was among four states that began disenrolling ineligible people from Medicaid in April.

Oklahoma took a phased approach based on perceived health-care needs, with the first group having incomes above the eligibility limits, no children under 5 on SoonerCare and other coverage. The next group was similar but had no recent SoonerCare claims history.

State officials paused the disenrollment process in June after early indications that thousands who remained eligible were being kicked off for failing to return the proper paperwork, a bureaucratic category called procedural denial.

The Centers for Medicare and Medicaid Services said it was concerned states were acting too hastily as they unwound Medicaid rolls after the expiration of the public health emergency.

“CMS has learned of additional systems and operational issues affecting multiple states, which may be resulting in eligible individuals being improperly disenrolled,” said an Aug. 30 letter to state Medicaid officials. “These actions violate federal renewal requirements and must be addressed immediately.”

Oklahoma mailed a series of four letters to SoonerCare members starting in February to let them know of the eligibility renewal process. But many people in and around the edges of SoonerCare coverage limits also experience access barriers like a lack of reliable transportation, internet connectivity and higher rates of changing mailing addresses.

Almost 75% of the 160,000 Oklahomans who have been dropped from Medicaid since May 1 have been procedural denials. That compares to a national procedural denial rate of 72%, according to KFF, a health policy research organization.

An estimated 12,400 Oklahomans retained their coverage as a direct result of the state’s 30-day pause in SoonerCare disenrollments, according to the Oklahoma Health Care Authority. Monthly procedural termination rates fell to 34% in July, down from 41% in April. The latest snapshot shows October’s procedural termination rate at 34%. 

Traylor Rains, state Medicaid director, said many of the people in the early months were over the income limits and had not used any medical services during the pandemic. Oklahoma’s unwinding pause was self-directed and not mandated by the Centers for Medicare and Medicaid Services, he said.

“We expected that group of folks to not really watch their mail or update their account because they probably went out and got or had third-party liability commercial coverage,” Rains said. “So the high rate didn’t alarm us as much as it alarmed CMS. We know as we go along, we’re seeing that rate go down because now we’re getting to the population that has used it, does rely on it and has kids under the age of 5.”

Before the pandemic, SoonerCare had a typical monthly churn rate of about 25,000 people, Rains said.

“SoonerCare is sometimes a temporary solution,” Rains said. “They might lose their job and need SoonerCare for a few months. Then they might retain employment and not need it anymore.”

Through September, 58% of those who were disenrolled from SoonerCare earned more than 228% of the federal poverty level. That’s an annual income of up to $33,240 for an individual or $68,400 for a family of four.

Since voters approved Medicaid expansion in June 2020 under State Question 802, qualifying for SoonerCare is up to 138% of the federal poverty limit. Currently, that would be individual income of $20,000 or less. The state’s per-capita income is about $31,000 a year, according to the U.S. Census Bureau.

Planning for the unwinding process began more than a year ago as the federal government signaled the end of the public health emergency. Those federal designations must be renewed every 90 days. The Biden administration renewed the COVID-19 emergencies several times in 2022 before issuing the final one in February.

That uncertainty could have contributed to SoonerCare members ignoring letters or thinking the emergency would be extended, said Jeanean Yanish Jones, executive director of the Health Alliance for the Uninsured. Her organization helps Oklahomans without health insurance find care at a network of free clinics across the state.

“We each need to be an advocate for our health, and we need to make sure that we’re getting the treatment we need,” she said. “Delaying or prolonging access to health care is just going to result in more serious issues.”

Most people experience a period without any health insurance, between nine and 12 months, after disenrollment from a publicly funded program like Medicaid, Yanish Jones said. That can lead to skipped medications, a lack of routine screenings and canceled mental health appointments. Several organizations, including Legal Aid of Oklahoma and Unite Oklahoma, can help people find alternatives and help them work through the paperwork.

“It's really challenging for them just to manage all the other things going on in their lives,” Yanish Jones said. “They're trying to work, they're trying to take care of families. They have transportation issues. They have food insecurity. There's a lot of things going on. And so it's not like they have this dedicated amount of time to sit on a computer and kind of go through this process.”

Options for Oklahomans who no longer meet eligibility requirements for SoonerCare range from coverage from an employer or the federal insurance marketplace, which offers tax credit subsidies for various health insurance plans. Others may qualify for coverage under Medicare, through a Native American tribe, the Veterans Administration or be able to afford co-pays at federally qualified health centers.

“If all those options are coming back negative, we help them find a free clinic match at the 92 free clinics in our state,” Yanish Jones said. “Each clinic is different. Sometimes there’s language barriers or other resources they need like transportation or bus passes to get to appointments.”

Nationally, more than 643,000 people who previously had Medicaid coverage under the Public Health Emergency qualified for federal marketplace health insurance plans, according to the latest CMS data. That included more than 23,200 people from Oklahoma. 

The Health Care Authority recently got federal approval to transition from a fee-for-service payment system to managed care run by private insurers. Rains, the state Medicaid director, said the agency will retain the SoonerCare eligibility and enrollment function under managed care, which the state has branded SoonerSelect.

Editor's Note: This story has been updated to reflect a new methodology used by the Oklahoma Health Care Authority on monthly procedural denial rates that better aligns with reporting by other states to the federal Centers for Medicare and Medicaid Services.

Paul Monies has been a reporter with Epic Text Books since 2017 and covers state agencies and public health. Contact him at (571) 319-3289 or Follow him on Twitter @pmonies. 

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