Just when Alexis Smith thought it couldn’t get any worse, she was diagnosed with cervical cancer.
The 30-year-old mom of four had been recently widowed and lost her job of five years after missing work to care for her dying husband.
Her grief, though, was soon replaced by the more imminent stress of a long and arduous Medicaid application process that left her wondering how she would pay for the hysterectomy and chemotherapy she needed.
“Every time I was calling to check the status, no one could tell me anything,” she said.
At first, agency officials told her over the phone it would take 90 days to approve her application. Then, that became 120 days, Smith said. Her worries grew.
“I was getting worried, stressed out, I already had depression and anxiety,” she said. “In my head I’m like, ‘I’m sick, I can barely get up to cook for my children, I need to have this surgery, I have no money, and they won’t even approve my Medicaid?’ Medicaid was really my only hope.”
Smith’s first application, filed on Aug. 7, was approved 93 days later on Nov. 8., the day before her surgery – only after Mississippi Today reached out to the Mississippi Health Advocacy Program and its consumer advocates got involved.
Smith’s story likely sounds familiar to the thousands of Mississippians who have experienced increased Medicaid application processing times in the second half of 2023.
Experts say the increased application times are due in large part to “unwinding,” a process in which state Medicaid divisions across the country have been reviewing their rolls for the first time in three years after the end of COVID-19 restrictions that prevented them from unenrolling beneficiaries.
It’s a massive undertaking for state Medicaid agencies, and in states such as Mississippi, the diversion of resources has made an already-lengthy application process even more prolonged.
Medicaid spokesperson Matt Westerfield confirmed that “unwinding is the main reason for the shift in eligibility application processing times.”
Westerfield said that most of the applications taking more than 45 days end up being deemed ineligible. But in the last six months in Mississippi, ineligibility only accounted for 23% of those kicked off Medicaid. The other 77% of cases fell under the “procedural disenrollment” category – most of them a result of issues with paperwork.
Mississippi has the 10th lowest rate of ex-parte renewals – automatic renewals that cut down on processing times during unwinding.
Some of the people who are disenrolled for procedural errors end up reapplying, adding more stress to the system, explained Joan Alker, executive director of Georgetown University’s Center for Children and Families.
“On the slowdowns getting worse, we do think that is likely due to unwinding and the pressure on the system of families being inappropriately terminated and then reapplying — this is one example of why the state should slow down or pause procedural terminations, especially for children,” Alker said.
Children have been disproportionately affected by unwinding. So far, most of the people who have lost coverage in Mississippi have likely been kids — 54,918 children have lost Medicaid coverage since unwinding began in June. A total of 98,766 people have been dropped in Mississippi thus far, but the agency won’t say exactly how many of the people kicked off due to unwinding are children.
There’s not a simple solution. In the short-term, it would obviously be helpful to hire more staff, but the agency is already struggling with its vacancy rate.
Mississippi Medicaid’s staff vacancy rate was 12% around the time unwinding began. That percentage has since inched up to 15%. Though that’s in line with other Medicaid agencies, Westerfield acknowledged that the department is working “aggressively to recruit and retain employees.”
The agency is adding 70 contractors this month to aid the workforce in eligibility determinations and redeterminations, he said.
If Mississippi already had Medicaid expansion, unwinding likely would not be this bad, Alker said, since more people would fall under the income limit and would be automatically enrolled. The short-term effects of expansion could mean a much larger application volume, but in the long-term, expansion would provide for a more streamlined process.
A majority of Mississippians support the policy, and most other states have expanded Medicaid. But Republican state leaders, such as Gov. Tate Reeves, have remained staunchly against it.
“What [Smith’s case] is demonstrating is that a simple income determination is a lot easier to make than a disability determination,” said Alker. “If you just have an income standard, as you would under Medicaid expansion, everyone under 138% of poverty is eligible. Period. You don’t have to prove other things.”
Right now, not only is the application process time-consuming — it’s confusing.
When Smith first filed her regular Medicaid application on Aug. 7, nobody told her that cancer is considered a disability and she would need to apply for Aged, Blind and Disabled Medicaid. When she was told a week later and filed her new application, not only did the clock start all over again for her application’s processing time, but it was longer.
States are required by law to approve or deny a regular Medicaid application within 45 days. For disability determination, that number is 90 days.
“Medicaid is complicated,” Alker said. “It’s very confusing and there are a lot of changes happening … The workforce is overloaded and they’re understaffed at most places. Unquestionably, unfortunately, there are mistakes made.”
Though Westerfield said, in the short term, “finishing the unwinding is going to be the best thing we can do to decrease application processing times,” Medicaid’s latest unwinding numbers show the biggest backlog yet in December.
The vast majority of the reviews due in December — 42,531 of 57,616 — went uncompleted last month.
The agency’s growing backlog appeared to be shrinking some in recent months — until December. The latest numbers increased the agency’s total number of incomplete reviews by 72%, bringing the grand total to 81,358.
“Having pending renewals is not uncommon, and it’s neither good nor bad news,” Westerfield said. “We’ve been committed to a balanced approach aimed at protecting beneficiaries by ensuring accurate redeterminations and at protecting taxpayers by promptly removing ineligible individuals from the rolls.”
For the first time during unwinding, the majority of Mississippians dropped last month were disenrolled because they were found to be ineligible. Still, the majority of people kicked off the rolls so far during unwinding in Mississippi have been dropped for procedural reasons, instead of being found ineligible for Medicaid.
Short-term relief isn’t coming anytime soon — unwinding is set to continue for months. And while patients are waiting for Medicaid approval, they have to pay out of pocket for doctor’s visits and treatments.
As a single, unemployed mother of four, Smith began a number of ventures – cooking and selling plates of lunch to workers, braiding hair, cleaning houses and party decorating – to cover basic needs. But she wonders if she had been able to pay for regular doctor’s visits if a pap smear could have detected the precancerous condition, which is nearly 100% treatable.
“I still wonder, since I was not going to those frequent doctor visits like I was supposed to, maybe they could have caught it before it turned cancerous,” Smith mused.
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