Medicaid Redetermination: Impact on LTC Pharmacy

Not long ago, Medicaid redetermination was something that happened in the background. Not many people paid attention to it, and it didn’t affect the daily life of the pharmacy. Then came COVID. The COVID-19 pandemic gave birth to the Families First Coronavirus Response Act (FFCRA) which, among many other provisions, slammed the brakes on the routine process of examining the status of Medicaid enrollees to redetermine whether they remain eligible for Medicaid benefits. Under normal circumstances this process takes place every 12 months for each enrollee.

FFCRA gave states a 6.5% boost in federal matching funds in Medicaid. One of the requirements was that states could not perform redeterminations during the period in which the federal emergency remained in effect. This became known as the continuous enrollment provision.

Near the end of 2022, Congress passed the Consolidated Appropriations Act (CAA), which required states to re-start Medicaid redeterminations beginning April 1, 2023. The extra 6.5% matching funds for states expire at the end of the year.

How Could Medicaid Redetermination Affect Long-Term Care?

Imagine a nursing home resident enrolled in Medicaid during the pandemic. While the emergency was in effect, the state was unable to determine whether they remained eligible for Medicaid. Now that the process has re-started, if residents are determined to no longer qualify for Medicaid, their continued healthcare coverage becomes an issue.

Estimates of how many Medicaid recipients will be disenrolled reach as high as 15 million. At this point, about 3.6 million in 37 states have lost coverage. There are no official estimates of how many nursing home residents are at risk of losing coverage.

What Happens to People Who Lose Medicaid?

CMS has created a special enrollment opportunity in the Affordable Care Act healthcare exchange program for people who lose Medicaid coverage. The coverage includes low-income subsidies for people who qualify. People who may have initially qualified for Medicaid – but no longer qualify under redetermination – may have to spend down assets to qualify again for Medicaid coverage.

Nursing home residents who find themselves in the unusual situation of no longer qualifying for Medicaid coverage, and who are not enrolled in Medicare, may, depending on the state in which they reside, be discharged from the facility if they are unable to pay or have no other means of coverage. Since Medicare does not offer a custodial nursing home benefit, these people may be at risk.

How Does Medicaid Redetermination Affect Drug Coverage for Seniors?

Nursing home residents who are dually eligible for Medicare and Medicaid will continue to receive drug coverage under the Medicare Part D benefit or, if enrolled, under the Medicare Advantage plan to which they have been enrolled. Drug coverage is also available under the Affordable Care Act plans.

The Biden Administration Responds

Unlike Medicare, which is a federal program, Medicaid is a state-federal partnership which places most enrollment and disenrollment authority in the states. As a result, there are relatively few options open to the Administration to slow down or alter the path of disenrollments resulting from redeterminations.

When one million Medicaid enrollees nationwide had lost eligibility in June, the White House noted that many of the disenrollments were the result of administrative errors rather than actual failure to qualify. These errors may have involved not providing documents to state Medicaid programs quickly enough, missing information in documents that were filed, and failure to submit documentation because of problems with contact information. As a result, the Administration asked states to slow down on Medicaid redetermination efforts in order to give enrollees time to be contacted and respond.

The Administration has gone further, encouraging Medicaid managed care plans to help enrollees requalify, allowing states authority to delay determinations for 30 days, and asking pharmacies to facilitate Medicaid reinstatement.

Meanwhile, the clock continues to tick and the additional Medicaid money to states will be gone at the end of the year.

X Factors for Medicaid Redeterminations

• Stay in touch with your state pharmacy association and state Medicaid authorities to determine how the process works in your state.
• Speak frequently with your nursing facilities to determine how the process affects their residents.
• Know what resources you can access to help enrollees you serve to maintain coverage.