‘Real Heartache’: Medicaid Redetermination Post-PHE Causing Nursing Homes Serious Cash Flow Problems, Anxiety

Flaws with the Medicaid redetermination process are leading to an increasing number of existing nursing home residents being found ineligible for Medicaid coverage — creating headaches for nursing homes.

This view is held by officials at several state health care associations, who spoke to Skilled Nursing News.

Montana, for one, has Medicaid redetermination information being sent to family members, or to addresses that are no longer correct, according to Rose Hughes, executive director for the Montana Health Care Association. Often the information is sent to those that don’t understand its significance. All this in the end leads to patients being found ineligible for Medicaid due to missing paperwork, she said.


There are larger ramifications for nursing homes arising out of this seemingly minor issue, however. It is causing major financial stress and “serious cash flow problems,” said Hughes because facilities are having to go for months without Medicaid payment for a notable number of residents.

Fabiola Bundy, business office manager for EmpRes by Evergreen in Missoula, said the facility is owed more than $457,000 from Medicaid since renewals have begun. Bundy spoke about Medicaid redetermination at an interim legislative meeting in January.

Forty-eight of Evergreen’s 51 residents rely on Medicaid coverage – eight had to renew but shortly after were denied for Medicaid, forcing them to fill out new applications. Of those eight, only one has received approval since renewals began in April 2023, Bundy said. It took that resident six months to get approved.


Another operator in the state with five facilities, currently has 77 patients that are “Medicaid pending” due to having to file a new application as a result of redetermination or reapplication paperwork not getting back to government officials in time. In other words, they missed the window for redetermination and have to apply for Medicaid as if it was the first time.

The Montana operator who preferred to remain anonymous, Hughes said, is spending $500,000 a month as a result of pending Medicaid coverage.

Another operator on the assisted living side had to take out an $80,000 loan after waiting on Medicaid reimbursement as redeterminations are being processed, she said.

The state of Montana gave Medicaid residents requiring redetermination paperwork 90 days to complete it. Once that timeframe was up, the resident and facilities were getting notified that a resident wasn’t on Medicaid anymore, leading in other cases to canceled appointments for residents.

Such circumstances caused residents and their families anxiety and some “real heartache” over potential evictions, Hughes said.

“Providers are having a really difficult time with this process,” said Hughes. “The department developed a process where they sent out packets to whatever address they had. We did suggest that they find a different process for nursing homes and assisted living facilities because these people typically don’t handle their own affairs.”

And yet, older residents are likely the ones getting the Medicaid redetermination documents in the mail, she said. Moreover, they may not have someone appointed to handle such documentation.

“You send mail to a nursing home resident, there’s absolutely no guarantee that anything’s going to happen,” she added. Even in sending such information to a family member, they may not understand the redetermination process, or not think it’s that important to do – that is if they get the paperwork at all. Hughes said contact information was also likely three years old, since the redetermination process wasn’t done during the pandemic.

States decide Medicaid redetermination time frame

The core issue, Hughes said, stems from a moratorium of sorts being put on Medicaid redeterminations during the pandemic. Congress enacted the Families First Coronavirus Response Act which required that Medicaid programs keep people continuously enrolled through the end of the public health emergency (PHE).

The Consolidated Appropriations Act effective in March of last year delinked continuous enrollment to the PHE. States were able to choose how long Medicaid beneficiaries had to complete the redetermination process as part of an “unwinding period,” according to a report from KFF.

Hughes said the state should have given special consideration to nursing home and assisted living Medicaid beneficiaries, and also the state should have worked more closely with providers when determining the Medicaid redetermination plan post-pandemic.

“For the most part, you can assume that in 99% of the cases or more, people in a nursing home or an assisted living facility are going to continue to be [Medicaid] eligible. Their finances don’t change very much once they’re living in a facility,” she said. “It wouldn’t be a high risk to make some assumptions about this population.”

The chances of nursing home residents having new income, for example, is highly unlikely, she said.

As for Montana, the state decided to give providers and beneficiaries 10 months to redetermine Medicaid coverage, which still isn’t adequate time to file the paperwork, Hughes said. The process is usually similar across the nation, she said.

“It probably could have been avoided with a little more thought process on the part of the state in terms of how to do this in a more reasonable fashion,” said Hughes.

Residents do have the option to sign paperwork that then allows the provider to help with Medicaid redetermination, although many prefer to handle it on their own or with family.

Still, even if providers, patients and families comply with the redetermination process, they have to contend with a shortage of government workers to process paperwork on an overly ambitious timeline, she said.

A shortage of state Medicaid workers means a backup of applications and redeterminations – operators have told Hughes that the Medicaid coverage process has taken a significant administrative toll as well.

“[SNF operators] talk about being unable to get an appointment with [Medicaid offices,] they talk about sitting on the phone for hours. They are saying that, even if they’ve sat for four hours, once they get somebody on the line, the phone call is limited in some fashion,” said Hughes.

A facility might have a list of 10 people that they’re trying to get Medicaid coverage for, but officials only have the capacity to do two at a time. Or, officials limit the phone call to 15 minutes and operators try to get as many Medicaid cases addressed in that time as possible.

States vary on communication strategies

In Florida, the number of patients receiving Medicaid increased “dramatically” during the PHE, from 3.8 million in March 2020 to 5.5 million in November 2022, according to the Florida Department of Children and Families, which handles Medicaid redetermination in the state.

“Many Floridians’ circumstances have improved since the pause of redeterminations and with an unemployment rate of 3%, it should be expected that families in a stronger financial situation would no longer be eligible,” the department said in a statement.

In terms of communication strategy in the state, the response rate to Medicaid redetermination paperwork was 87%, a significant increase from 49% pre-pandemic.

The state made efforts to streamline the renewal process, utilizing addresses from the department’s electronic benefits transfer (EBT) vendor and Medicaid managed care providers to facilitate client reporting of address changes.

“The state without violating anybody’s privacy or anything could have provided more of a heads up for providers about who was being redetermined and that kind of thing, so that [the nursing homes] could have provided some help,” said Hughes of the Montana process.

Florida also offers an online chatbot to change addresses, identification of notices returned in the mail, and text calls and emails to make sure patients and their families know that renewal is due.

From the perspective of some state officials, and outlined in an op-ed for the Tampa Bay Times, the faster Medicaid redetermination can happen post-pandemic the better, touching back on the 50% increase in Medicaid recipients costing taxpayers “billions” each month.

Florida Agency for Health Care Administration Jason Weida and Florida Department of Children and Families Secretary Shevaun Harris, who penned the op-ed, consider a tight Medicaid turnaround to be a rightsizing of the Medicaid program.

“When someone is disenrolled for procedural reasons, it is because they failed to respond to our initial request for information or our follow-up requests for supporting documentation … we make up to 13 contact attempts to get the information we need,” said Weida and Harris.

This was in response to criticism much like what was mentioned in Montana, that individuals were being disenrolled due to procedural reasons, and that the disenrollment was a result of bureaucratic red tape.

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