Cleaning up Medicaid eligibility

Over the past week, the Medicaid eligibility and enrollment process has been in the news. While the Oregon Health Authority (OHA) appreciates the Secretary of State’s shared commitment to ensuring that the right Oregonians get the health care and benefits for which they are eligible, we are concerned by the assertions contained in last week’s “Auditor Alert,” which referenced preliminary information and did not provide important Medicaid context for the Oregon Health Plan’s renewal and eligibility process.  On Tuesday OHA leadership testified to the Oregon Ways and Means Subcommittee on Human Services to provide this context and correct misinformation.

The transition from the Cover Oregon failure to the new ONE eligibility system has taken three years and is still underway. We are in the final stages of this transition and the subsequent anticipated clean-up of individual cases. As part of this final clean-up, OHA has identified a number of individuals for whom further analysis is need to determine what action, if any, is necessary. We are on track to complete this analysis by May 31, and we have an action plan in place to complete all renewals by August 31. It is important to emphasizethat all of these individuals were deemed eligible for at least a 12-month period, and just because a renewal is not complete does not indicate that the individual is ineligible for Medicaid.

So that no OHP members would lose access to health coverage during the transition to a new eligibility system, Oregon asked the Centers for Medicare & Medicaid Services (CMS) for a waiver to pause Medicaid eligibility renewals. This waiver and four subsequent waivers were approved by CMS and the state until June 2016. OHA resumed the renewal process using the state’s new system for eligibility in March 2016. Since then, OHA has completed 90 percent of this work. As of May 1, more than 733,695 eligible individuals were entered into the new ONE system.

Due to poor data quality from OHA’s older legacy data systems, OHA had to contact each OHP member to have them complete a paper application. The paper application was then manually entered into the ONE system. This process took more than two years to complete. What now remains are the final renewal cases that are more complex in nature due to reasons that include multiple eligibility criteria and other household circumstances such as:

  • Individuals who have a protected eligibility such as pregnant women or children under the age of 1 year.
  • An individual has not responded to the renewal paperwork but is connected to an eligible case. For example, a child hasn’t responded but the parent is eligible, so we have not terminated the child because we know that the child is actually eligible if their parent is.
  • An individual has presumptive eligibility through categories like the breast and cervical cancer program, extended medical or hospital presumption.
  • The individual is eligible but their case file is stuck in an old legacy system.
  • Application was started in the ONE system but not finished due to procedural and system issues.

OHA anticipated that significant clean-up would be required once we reached the end of the transition into the ONE system. OHA has reported on this process on multiple occasions to the Governor, the Legislature and CMS throughout the last three years.

OHA has added capacity through outside contractors to assist and support in completing the final renewals, and ensuring the system is audited for fraud and abuse. We are continuing to work with the Governor, the Legislature and Secretary of State’s office to answer questions about this process.

OHA will be providing a monthly dashboard to demonstrate the progress related to member services. This dashboard will show the OHP call center monthly averages and total OHP enrollment. This will provide greater transparency and up-to-date information for the Governor, Legislature and stakeholders.

SOS audit shows eligibility processed appropriately

While we still have work to do to complete this transition, the good news is that we know the system works. In fact on Wednesday the Secretary of State issued a final audit of the MMIS and ONE systems that highlighted that 99.7 percent of the time, the systems accurately determine eligibility, properly enroll individuals in coordinated care organizations (CCOs), provide appropriate payments to CCOs and have a reconciliation process in place to identify potential enrollment errors.

Oregon has made tremendous progress on reducing the uninsured rate and transforming our health system. We are in the last stages of finalizing the transition to the new eligibility system, which will provide an improved process for all Oregon Health Plan members.