SAN JOSE, Calif. – César Chávez Elementary school stands quietly on a Saturday morning in October. A metal gate hangs open at the entrance, leading to a brightly painted school building. There’s a tiny path tucked behind the building that leads to an innocuous classroom where a team of county enrollment workers sits, awaiting people who want help re-enrolling in Medi-Cal.
It’s the first community Medi-Cal re-enrollment event of the year and turnout is scarce. The campus is silent save for the occasional laughter of the enrollment workers passing the time.
The lack of attendance at community events such as this one reflects a broader disconnect between county outreach efforts and Medi-Cal recipients.
More than 890,000 Californians have been kicked off of Medi-Cal since the statewide process to redetermine the eligibility status of everyone on Medi-Cal began in April 2023.
Less than 10% of these discontinuations are due to legitimate ineligibility, such as having excess income or moving out of the state. The majority–more than 800,000 people–lost coverage due to procedural reasons, such as failing to return their forms in time or returning forms with incomplete or inaccurate information, according to state data.
This indicates that the majority of people losing their coverage still qualify for Medi-Cal but are being dropped for administrative reasons.
Medi-Cal is California’s Medicaid healthcare program that provides medical services for children and adults with limited income and resources. At the start of the year, more than 15.5 million people–more than a third of California’s population–were enrolled in Medi-Cal.
“Medi-Cal has become the cornerstone of health insurance in the state,” said Shannon McConville, a researcher and health policy expert at the Public Policy Institute of California.
If the current rate of discontinuations continues, more than three million Californians will lose Medi-Cal coverage by May 2024.
The state began redetermining eligibility for Medi-Cal enrollees on April 1 after the COVID-19 public health emergency ended.
The redeterminations are processed in a staggered manner. Every month, between April 2023 and May 2024, the California Department of Healthcare Services (DHCS) reviews the eligibility of a little over a million Medi-Cal enrollees.
County officials are able to automatically renew the eligibility of about a third of the people up for redetermination each month by retrieving the necessary information from other government agencies, such as the IRS. The other two-thirds are sent a yellow renewal packet in the mail that they have to fill out and return to their county Medi-Cal office by a certain date.
It sounds simple, but for many, this mail-based system results in procedural issues that make up more than 90% of all discontinuations.
One challenge is when people move but do not update their address in the county system. These recipients never receive the renewal packet or subsequent notices at their new address and are therefore discontinued for procedural reasons without ever being aware of it.
Vulnerable populations, such as the unhoused, senior citizens, and people who don’t speak English as their primary language, are particularly susceptible to missing notices by mail or making procedural mistakes that could result in loss of Medi-Cal coverage.
At Hope’s Corner in Mountain View, almost all of the community members in line for a free meal and warm shower said they were on Medi-Cal but could not recall the last time that they renewed their coverage. For many of these community members, the lack of a stable mailing address was the biggest challenge to corresponding with county welfare programs.
“The people most in need have the most barriers,” said Yuka Michitaka, an unhoused Mountain View community member currently going through the Medi-Cal renewal process.
Michitaka is disabled and recently lost her housing. She said applying to get Medi-Cal in the first place was a difficult process that took many months even though she had a knowledgeable case manager working with her. Now, having to renew it again annually is a terrible ordeal that adds burdens to her already tenuous situation.
“Do I invest this energy that I have in my future and renew my healthcare, or do I just make it to the next day,” she said. “My life has been chaos…I am just focused on survival.”
Since Michitaka became unhoused, the challenges to successfully renewing her coverage have become startlingly apparent. She no longer has a stable mailing address where she can receive her renewal packet and other correspondences from the county. She lost her phone service, so resolving any of these matters by phone is impossible. She also is in a wheelchair, which makes it difficult for her to physically get to county offices.
“I’m one of many victims of a system that doesn’t work too well,” she said.
The procedural difficulties that are responsible for over 90% of Medi-Cal discontinuations are not a new problem. Prior to the pandemic, Medi-Cal redetermination was an annual process that resulted in what policy experts call “churn,” the on-again, off-again pattern of people being disenrolled and then re-enrolled in Medi-Cal repeatedly. In 2018, 72% of discontinuations were procedural. In 2019, the number was 67%.
“The idea of churning is absolutely a feature of our safety net programs,” McConville said. “We do see a pretty big fall off at the one year mark [when redeterminations are due]…it suggests that there is this administrative piece that is a longstanding issue in several of these programs.”
The COVID-19 pandemic provided an unexpected opportunity to witness what happens when the churn stops for three years. In response to the COVID-19 public health emergency in March 2020, a continuous coverage requirement for Medi-Cal recipients was enacted. This requirement prevented people from losing health coverage by pausing re-enrollments and automatically renewing Medi-Cal status, unless specific exceptions were met. These exceptions included instances where the individual requested coverage be discontinued, passed away, or moved out of the state.
This continuous coverage mandate kept people on Medi-Cal and reduced churn to zero, increasing the total number of Medi-Cal enrollees significantly. In early 2020, there were about 12.5 million Medi-Cal enrollees. By the start of 2023, that number had increased to almost 16 million.
For policy experts, the restart of Medi-Cal redeterminations presents a unique opportunity to evaluate churn and the administrative burden of the entire process.
“This is the longest time that [redeterminations were] paused…there’s a lot of focus on trying to understand how it’s working,” McConville said.
For those who enrolled during the pandemic, this will be their first time going through the renewal process. For those who had Medi-Cal before the pandemic, it will have been several years since they have had to re-apply. In both cases, recipients are navigating a complex administrative process to ensure they are able to maintain their Medi-Cal coverage.
Outreach is critical for Medi-Cal recipients up for redetermination. Earlier in the year, the state launched the largest outreach campaign in Medi-Cal history, hoping to reach enrollees through avenues such as text, email, radio and social media. In addition, many counties are partnering with local community groups and healthcare entities to ensure people are aware that the renewal process is underway.
This process is not unique to California, states across the US restarted eligibility redeterminations for all their Medicaid recipients in April. According to the KFF unwinding tracker, California ranks 39th for disenrollment rate, which means that the state is discontinuing a smaller percentage of people than other states. However, it ranks 4th in terms of the share of disenrollments that are procedural, meaning that a greater percentage of discontinuations are due to procedural reasons rather than ineligibility compared to other states.
Not all people who lose Medi-Cal become completely uninsured. Some transition to other plans, such as employer-based insurance or Covered California plans.
In the case where an individual fails to renew their coverage by the deadline and is discontinued, there is a 90-day grace period. During this time, those who missed the first deadline can still submit their renewal application and reinstate their Medi-Cal coverage retroactively.
However, once the 90-day period passes, the individual is kicked off of Medi-Cal and must start a new application entirely to get their health insurance back.
For more information about what to do if you lose Medi-Cal coverage: https://calmatters.org/health/2023/09/what-to-do-if-you-lose-medi-cal-health-insurance/