Bethany Pray currently serves as CCLP's Interim Executive Director. Her areas of expertise include regulatory analysis and advocacy for Medicaid and commercial coverage, access to behavioral health benefits, Medicaid eligibility and much more.Staff page ›

Oct 28, 2020

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Give Medicaid clients the process they are due

by | Oct 28, 2020

Health First Colorado, the state’s Medicaid program, is critical to the health and well-being of the over 1.4 million Coloradans who qualify based on income or disability. Unfortunately, getting enrolled and staying enrolled in the program can be very challenging.

According to a recent audit of 100 Colorado Medicaid notices related to eligibility, two-thirds of notices sampled were found to have errors, omissions or other problems. Such notices are intended to inform applicants about their eligibility, to explain their appeal rights and to let them know what additional information might be needed for them to get or stay enrolled. Inaccurate notices can be a life-or-death issue for some, but for all enrollees, they complicate access to health care and economic security and cause anxiety and frustration.

The Colorado Department of Health Care Policy and Finance (HCPF) has described steps they’ve taken to address these ongoing concerns, but there is clearly much room for improvement. Moreover, the state’s failure to provide accurate, clear notices may in some circumstances violate Coloradans’ constitutional rights.

Giving ‘due process’ its due
Though it’s not a household concept, “due process” is a matter we at Colorado Center on Law and Policy take seriously in the context of public programs. Your property rights – your right to a license, to some types of civil service jobs, and to certain public benefits, are protected under the 14th Amendment of the U.S. Constitution and under our state constitution. Because of those constitutional protections, an individual is entitled to notice and a hearing before that property can be taken away. For example, you can’t be deprived of either your Medicaid benefits or your license to provide physical therapy unless the state gives you adequate notice and an opportunity to be heard.

We understand that the state’s job is not an easy one. Medicaid eligibility is extremely complicated due to federal requirements, despite changes in the ACA that streamlined rules and processes. Eligibility depends on who resides in your household, monthly income, residence and citizenship or immigration status. It can also hinge on a disability determination, what assets you have, whether you qualify for Medicare and pregnancy.  Federal rules and requirements change frequently. Unlike most commercial coverage and Medicare coverage, your Medicaid eligibility in Colorado can change month to month unless you are a child; this means the state must track changes throughout the year and not just annually.

Other problems
Accuracy of notices also depends on a functioning computer system and well-trained workers. Roughly half of the errors identified in the audit were attributed to human error. Providing training on federal and state requirements to all 64 counties is a challenging task for Colorado’s very low-overhead state agency. If, for example, the state learns that workers have filled in the blanks of a Spanish-language notice with English, or have failed to update case information, the next step for the state may be training or clarified guidance. County autonomy, however, means that there is no guarantee that all workers will complete the new training or that internal processes will change immediately.

Most of the remaining errors involved the state’s computer systems. The complex set of data points described above – income, residence, household, assets, and more – is maintained by  the Colorado Benefits Management System (CBMS), a system that was technologically out of date when we bought it in 2004. System errors included plugging in out-of-date financial information and plugging in the wrong due date for a response. When mistakes are made, the state is subject to pressure and potentially disastrous financial penalties from the federal government.

Enrollees who have variable income or household changes must live with the related uncertainty. Inaccurate notices add significantly to members’ stress and frustration and can undermine their trust in government — even if they are able to sort through the problem and keep coverage. Notice problems also contribute to a false narrative about the competence of government, with that narrative failing to take into account administrative complexity and a history of inadequate funding for infrastructure.

Hope for the near future?
Despite these daunting challenges, there’s still hope for improving notices and reducing the administrative burdens on Coloradans who are eligible for the Medicaid program. HCPF is about to launch a new program that will improve their ability to oversee and assist counties with eligibility processing. That approach should allow the state to have a better view of where help is needed. That might include developing a process to make sure that Spanish-speakers don’t receive form notices in Spanish that contain crucial language in English, a problem identified in the audit; or training for staff on lesser-known income rules that govern self-employed workers.

The program is a start but not enough to address the many changes needed to ensure that Coloradans can get critical access to health care. While working to improve county processes, the state must ensure that people get the due process to which they’re entitled. If errors are identified, the state should quickly restore coverage until proper notice can be issued. The next audit of Medicaid correspondence, scheduled for 2023, should include other state programs, like Supplemental Nutrition Assistance Program (SNAP) and Colorado Works, because those programs rely on the same IT system and county staff when communicating with enrollees.

We believe that the state needs to look hard at our funding for the system infrastructure that close to a quarter of our state’s residents rely on to achieve better health, that helps fund our clinics and hospitals, that brings in federal dollars that keep our economy running even in hard times like these. If we can make a successful system a priority, more Coloradans will be able to access the health care they need when they need it, and to see the state as a partner in their ability to achieve better health.

– By Bethany Pray

Recent articles

May Letter from Bethany Pray, Interim Executive Director

The anti-poverty movement involves hundreds of organizations that, like CCLP, take the fight to the state. Operating at the state level is an absolute necessity because many of the core laws and policies that affect access to health, housing, income, and food are...