Redeterminations are among the many significant changes and challenges that State Medicaid agencies are facing.
"Existential threat." Those are the words the National Association of Medicaid Directors (NAMD) has used to describe the workforce challenges faced by State Medicaid agencies.
While employees in other economic sectors face mass layoffs, State Medicaid programs are struggling. And they will need help now more than ever as they engage in the Medicaid redeterminations that could cause millions to lose the coverage they gained or retained during the pandemic.
These are just a few of the challenges Medicaid programs face as the NAMD names new leadership and the association responds to new proposed rules and recommendations at the federal level.
Medicaid workforce challenges
Workforce shortages and vacancies may create significant barriers for Medicaid agencies as they work on redeterminations. Turnover is common in the Medicaid workforce, including for State Medicaid Directors who often serve just a few years. In a March blog on the topic, NAMD noted the challenges workforce shortages represent and what states are doing about them, including:
- The State Medicaid agency vacancy rate is between 17–40%.
- Skilled workers are required to conduct the "detail-oriented, pressure-filled, and time-sensitive" work that redeterminations represent.
- State workforce strategies range from who can fill the needed roles (temporary or borrowed staff, contractors, and former employees) to how the work is supported (funding, training, complex case triage, tech tools and remote work).
The NAMD blog concludes: "State workforce shortages are another reason for states to 'strike a balance' on the speed with which they do the unwinding" (e.g., an approach that prevents unintended administrative costs/burdens downstream while adopting timelines that reflect unique State challenges).
NAMD response to CMS rules and MACPAC concerns
The NAMD recently weighed in on CMS's proposed rule, Advancing Interoperability and Improving Prior Authorization. The rule would require Medicaid agencies to "expand the Patient Access API, implement three additional APIs, and meet new timeframe requirements for prior authorization decisions." NAMD supports the proposed rules but recommends longer implementation deadlines.
NAMD also weighed in MACPAC's annual March report to Congress. MACPAC—the Medicaid and CHIP Payment and Access Commission—is a "non-partisan legislative branch agency" that makes policy and data analysis recommendations to Congress, HHS, and State Medicaid programs. NAMD supports MACPAC's recommendation for a national coverage determination that aligns select Medicaid coverage with the Medicare program to help protect those that are dually eligible for both programs. MACPAC also recommends that new questions on race and ethnicity be added to the Medicaid model streamlined application.
Changes in NAMD executive leadership
In the midst of multiple Medicaid program challenges, the NAMD named a new executive director, Kate McEvoy, in October 2022. In her monthly public message, McEvoy—who assumed her role in January 2023—addressed the "active, iterative process" that Medicaid redeterminations represent and announced upcoming technical assistance for long-term services and supports as those programs are impacted by the end of the public health emergency (PHE).
McEvoy also made note of the current federal budget impasse, its impact on Medicaid, and separate proposals made by the Biden administration in its March proposed FY 2024 budget. The proposal includes "sizeable investments in behavioral health services, the health care workforce, long-term care, and maternal health" and a plan to offer "Medicaid-like coverage" in non-expansion states.
Nearly a year ago, NAMD also welcomed a new Board president, Allison Taylor. She continues to serve as Indiana's State Medicaid Director, a role she assumed in 2017. As part of Taylor's work in the Hoosier state, her agency has shared reimbursement and managed care innovations with other programs in an attempt to align the actions of multiple state human service agencies as well as insurers.
State-level leadership changes
In addition to executive-level shifts, two states have new Medicaid directors: Janet Mann in Arkansas, who was previously with Mississippi Medicaid, and Jay Ludlam, the new Deputy Secretary for North Carolina Medicaid, who was promoted from within. A complete listing of State Medicaid directors is available here.
Medicaid's "new normal"
In the middle of multiple changes, Medicaid agencies must also make annual projections. In another blog on the topic, the NAMD notes "the key factors states are taking into account" as they face a possible 20-million-member reduction in their programs. These factors include:
- Historical "churn" in Medicaid and its relationship to overall economic health, including unemployment rates and the incomes of those who are typically eligible for the program.
- How cost and utilization will be affected by both standard churn and the redeterminations, particularly among older adults and those who are disabled.
- The NAMD notes that these populations represent the "highest and most costly users of Medicaid services" but "typically make up only 10 percent to 15 percent of the overall population of members."
- While these members are not as subject to Medicaid churn, children are—due to the eligibility changes of their families.
This is particularly important given the NAMD's note that "some people who do in fact remain eligible for Medicaid may lose coverage due to lack of awareness or administrative error. Individuals may not realize they have lost Medicaid coverage until they need to use the health care system."
Laura Beerman is a contributing writer for HealthLeaders.
The end of the COVID-19 public health emergency initiates a massive Medicaid redetermination process for tens of millions of program enrollees.
Redeterminations, also referred to as the Medicaid "unwinding," is occurring in the midst of new national Medicaid leadership and annual program projections.
The following summarizes these and other updates from the National Association of Medicaid Directors.