Nearly half of people who lost their government coverage signed back up weeks or months later — suggesting they should never have been dropped in the first place.

This article was published on Friday, April 12, in KFF Health News.

By Phil Galewitz

Nearly a quarter of adults disenrolled from Medicaid in the past year say they are now uninsured, according to a survey released Friday that details how tens of millions of Americans struggled to retain coverage in the government insurance program for low-income people after pandemic-era protections began expiring last spring.

The first national survey of adults whose Medicaid eligibility was reviewed during the unwinding found nearly half of people who lost their government coverage signed back up weeks or months later — suggesting they should never have been dropped in the first place.

While 23% reported being uninsured, an additional 28% found other coverage — through an employer, Medicare, the Affordable Care Act's insurance marketplace, or health care for members of the military, the survey by KFF found.

"Twenty-three percent is a striking number especially when you think about the number of people who lost Medicaid coverage," said Chima Ndumele, an associate professor of health policy at the Yale University School of Public Health.

Going without insurance even for a short period of time can lead people to delay seeking care and leave them at financial risk when they do.

Seven in 10 adults who were disenrolled during the unwinding process say they became uninsured at least temporarily when they lost their Medicaid coverage.

Adrienne Hamar, 49, of Plymouth Meeting, Pennsylvania, said she struggled to enroll in an Affordable Care Act marketplace plan this winter after the state informed her that she and her two children no longer qualified for Medicaid. They had been enrolled since 2020. She said phone lines were busy at the state's marketplace and she couldn't complete the process online.

Hamar, who works as a home health aide, and her children were uninsured in March. But since April 1, they've been enrolled in a marketplace plan that, with the help of government subsidies, costs $50 a month for the family.

"I was very relieved," she said. Unsure of their insurance status, Hamar said, her 23-year-old daughter delayed getting a dental checkup.

Hamar's struggles were common, the survey found.

Of adults enrolled in Medicaid before the unwinding, about 35% who tried to renew their coverage described the process as difficult, and about 48% said it was at least somewhat stressful.

About 56% of those disenrolled say they skipped or delayed care or prescriptions while attempting to renew their Medicaid coverage.

"People's current insurance status is likely to be very much in flux, and we would expect at least some of the people who say they are currently uninsured to reenroll in Medicaid — many say they are still trying — or enroll in other coverage within a short period of time," said Jennifer Tolbert, a co-author of the KFF report and the director of KFF's State Health Reform and Data Program.

The survey didn't include children, and the KFF researchers said their findings therefore couldn't be extrapolated to determine how the Medicaid unwinding has affected the overall U.S. uninsured rate, which hit a record low of 7.7% in early 2023. Nearly half of enrollees in Medicaid and the related Children's Health Insurance Program are children.

The unwinding, in which states are reassessing eligibility for Medicaid among millions of Americans who enrolled before or during the pandemic and dropping those who no longer qualify or did not complete the renewal process, won't be completed until later this year. Enrollment in Medicaid and CHIP grew to a record of nearly 94.5 million in April of last year, three years after the federal government prohibited states from cutting people from their rolls during the covid-19 public health emergency.

Nationally, states have disenrolled about 20 million people from Medicaid in the past year, most of them for procedural reasons such as failure to submit required paperwork. That number is expected to grow, as states have a few more months to redetermine enrollees' eligibility.

Among adults who had Medicaid prior to the start of the unwinding, 83% retained their coverage or reenrolled, while 8% found other insurance and 8% were uninsured. The share left uninsured was larger in states that have not expanded Medicaid under the ACA (17%) than in states that have (6%). Forty states have expanded Medicaid to cover everyone with an income under 138% of the federal poverty rate, or $31,200 for a family of four this year.

The KFF survey found that nearly 1 in 3 disenrolled adults discovered only when they sought health care — such as going to a doctor or a pharmacy — that they had been dropped from Medicaid.

Indira Navas of Miami found out that her 6-year-old son, Andres, had been disenrolled from Florida's Medicaid program when she took him to a doctor appointment in March. She had scheduled Andres' appointment months in advance and is frustrated that he remains uninsured and his therapy for anxiety and hyperactivity has been disrupted.

Navas said the state could not explain why her 12-year-old daughter, Camila, remained covered by Medicaid even though the children live in the same household with their parents.

"It doesn't make sense that they would cover one of my children and not the other," she said.

Kate McEvoy, executive director of the National Association of Medicaid Directors, said the sheer volume of millions of people being redetermined for eligibility has overwhelmed some state call centers trying to support enrollees.

She said states have tried many ways to communicate with enrollees, including through public outreach campaigns, text, email, and apps. "Until the moment your coverage is at stake, it's hard to penetrate people's busy lives," she said.

The KFF survey, of 1,227 adults who had Medicaid coverage in early 2023 prior to the start of the unwinding on April 1, 2023, was conducted between Feb. 15, 2024, and March 11, 2024. The margin of sampling error was plus or minus 4 percentage points.

KFF Health News correspondent Daniel Chang contributed to this article.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Returns are getting rejected by the IRS and some people will have to pay more in taxes.

This article was published on Monday, April 15, 2024 in KFF Health News.

By Julie Appleby

Tax season is never fun. But some tax filers this year face an added complication: Their returns are being rejected because they failed to provide information about Affordable Care Act coverage they didn't even know they had.

While the concern about unscrupulous brokers enrolling unsuspecting people in ACA coverage has simmered for years, complaints have risen in recent months as consumers discover their health insurance coverage isn't what they thought it was.

Now such unauthorized enrollments are also causing tax headaches. Returns are getting rejected by the IRS and some people will have to pay more in taxes.

"It's definitely gotten worse over the past year. We've helped three to four dozen people this year already," said Erin Kinard, director of systems and intake for the Health and Economic Opportunity Program at Pisgah Legal Services in North Carolina, which helps low-income families enroll in ACA plans and get tax help.

Neither the IRS nor the Centers for Medicare & Medicaid Services, which oversees the federal Obamacare marketplace, responded to questions about the problem.

The IRS did, however, issue an FAQ in February instructing consumers on what to do if their electronically filed returns are rejected because of ACA issues.

Unauthorized sign-ups can happen in several ways, Kinard and others said. Some rogue agents troll online enrollment portals that are accessible only to brokers but are integrated with the healthcare.gov website. When those agents open a new policy or switch an already enrolled policyholder to a different plan, they garner the associated monthly commissions. Other consumers unwittingly sign up when they respond to advertisements touting gift cards or government subsidies then are transferred to agents who enroll them in health coverage. It's happening even after new rules were put in place requiring agents to get written or recorded consent from clients before making changes.

CMS has not released details on how many consumers have been affected or how many agents have been sanctioned for participating in such schemes.

There's also no public tally of how many taxpayers are facing problems as a result. And the tax consequences can come as a surprise.

"Many people are finding out when they go to e-file their taxes and it bounces back and the IRS says it can't accept your return," said Christine Speidel, an associate professor and the director of the Federal Tax Clinic at Villanova University's Charles Widger School of Law.

Returns are rejected if the IRS has information indicating the taxpayer has ACA coverage but the returns don't include forms that help determine whether premium tax credits paid on the policyholder's behalf to insurers were correct. If their income was misstated by the rogue broker who enrolled them, for example, they might not have qualified for the full amount paid. Or, if they had affordable employer coverage, they would not have been eligible for ACA subsidies at all.

Ashley Zukoski, an ultrasound technologist in Charlotte, North Carolina, had employer coverage but now faces a tax bill for an ACA plan she said she never signed up for. She reached out to KFF Health News after it reported on such unauthorized plan enrollments.

Unbeknownst to her, she said, a broker in Florida enrolled her family in an ACA plan in late February 2023, even though Zukoski had coverage starting that January through her job. The broker listed an income that qualified the household for a full subsidy, so Zukoski never received a premium bill.

Her first inkling that something was amiss came early in 2024 when she received a special form, called a 1095-A, which showed she had an ACA plan. After reporting the problem to the federal marketplace, she sought to get the 1095-A voided so she would not be liable for the plan's premium subsidies paid by the government to the insurer.

But, because Zukoski's pharmacy had billed the ACA plan instead of her job-based coverage, her request was denied. She plans to appeal.

In the meantime, the family has filed an extension on their taxes.

"Instead of getting a $4,100 refund, we now owe almost $700 in taxes based on the 1095-A and premium tax credit applied," Zukoski said.

With the April 15 federal tax filing deadline upon us, there are some important steps for affected consumers to take, tax and insurance experts said.

First, because it could take weeks to get corrected forms, experts recommend filing for an extension to buy more time. When consumers file for that extension, they should also pay any taxes owed to avoid penalties and interest.

In general, consumers who at any point in the year think they are victims of an unauthorized enrollment or plan switch should report it immediately to the relevant federal or state ACA marketplace and request a corrected Form 1095-A. But move fast. Appeals to cancel coverage retroactively must be made within 60 days of discovering the fraudulent enrollment, Speidel said.

Consumers can ask for help filing a complaint with federal or state regulators by contacting their own insurance agents or seeking help from assisters or "navigator" programs, which are government-funded nonprofit groups that help people enroll or deal with insurance problems.

Navigators and assisters are fielding many such cases this year and can submit what are called "complex case forms," which help federal officials investigate such complaints, said Lynn Cowles, program manager for Prosper Health Coverage, a navigator program in Texas.

Julie Appleby: jappleby@kff.org, @Julie_appleby

Safety-nets are integrating oral health into medical checkups for children, pregnant women, and others who cannot afford or do not have easy access to dentists.

This article was published on Wednesday, April 10, 2024 in KFF Health News.

By Kate Ruder

DENVER — Pediatrician Patricia Braun and her team saw roughly 100 children at a community health clinic on a recent Monday. They gave flu shots and treatments for illnesses like ear infections. But Braun also did something most primary care doctors don't. She peered inside mouths searching for cavities or she brushed fluoride varnish on their teeth.

"We're seeing more oral disease than the general population. There is a bigger need," Braun said of the patients she treats at Bernard F. Gipson Eastside Family Health Center, which is part of Denver Health, the largest safety-net hospital in Colorado, serving low-income, uninsured, and underinsured residents.

Braun is part of a trend across the United States to integrate oral health into medical checkups for children, pregnant women, and others who cannot afford or do not have easy access to dentists. With federal and private funding, these programs have expanded in the past 10 years, but they face socioeconomic barriers, workforce shortages, and the challenge of dealing with the needs of new immigrants.

With a five-year, $6 million federal grant, Braun and her colleagues have helped train 250 primary care providers in oral health in Colorado, Montana, Wyoming, and Arizona. Similar projects are wrapping up in Illinois, Michigan, Virginia, and New York, funded by the federal Health Resources and Services Administration's Maternal and Child Health Bureau. Beyond assessment, education, and preventive care, primary care providers refer patients to on- or off-site dentists, or work with embedded dental hygienists as part of their practice.

"Federally qualified health centers have a long history of co-locating dental services within their systems," Braun said. "We're taking that next step where care is not just co-located, meaning, say, we're upstairs and dental is downstairs, but we're integrated so that it becomes part of the same visit for the patient."

Having doctors, nurses, and physician assistants who assess oral health, make referrals, and apply fluoride at community health centers is critical for the many children who lack access to dental care, said Tara Callaghan, director of operations for the Montana Primary Care Association, which represents 14 federally qualified health centers and five Urban Indian organizations.

"Providing these services during medical visits increases the frequency of fluoride application," Callaghan said, and "improves parents' knowledge of caring for their child's teeth." But obstacles remain.

Because of Montana's large geographic area and small population, recruiting dental professionals is difficult, Callaghan said. Fifty of the state's 56 counties are designated dental shortage areas and some counties don't have a single dentist who takes Medicaid, she added. Montana ranks near the bottom for residents having access to fluoridated water, which can prevent cavities and strengthen teeth.

Pediatric dental specialists, in particular, are scarce in rural areas, with families sometimes driving hours to neighboring counties for care, she said.

Embedding dental hygienists with medical doctors is one way to reach patients in a single medical visit.

Valerie Cuzella, a registered dental hygienist, works closely with Braun and others at Denver Health, which serves nearly half of the city's children and has embedded hygienists in five of its clinics that see children.

State regulations vary on which services hygienists can provide without supervision from a dentist. In Colorado, Cuzella can, among other things, independently perform X-rays and apply silver diamine fluoride, a tool to harden teeth and slow decay. She does all this in a cozy corner office.

Braun and Cuzella work so closely that they often finish each other's sentences. Throughout the day they text each other, taking advantage of brief lulls when Cuzella can pop into an exam room to check for gum disease or demonstrate good brushing habits. Braun herself takes similar opportunities to assess oral health during her exams, and both focus on educating parents.

Medical and dental care have traditionally been siloed. "Schools are getting better at interprofessional collaboration and education, but by and large we train separately, we practice separately," said Katy Battani, a registered dental hygienist and assistant professor at Georgetown University.

Battani is trying to bridge the divide by helping community health centers in nine states — including California, Texas, and Maryland — integrate dental care into prenatal visits for pregnant women. Pregnancy creates opportunities to improve oral health because some women gain dental coverage with Medicaid and see providers at least once a month, Battani said.

In Denver, housing instability, language barriers, lack of transportation, and the "astronomical cost" of dentistry without insurance make dental care inaccessible for many children, the migrant community, and seniors, said Sung Cho, a dentist who oversees the dental program at STRIDE Community Health Center, serving the Denver metro area.

STRIDE tries to overcome these barriers by offering interpretation services and a sliding pay scale for those without insurance. That includes people like Celinda Ochoa, 35, of Wheat Ridge, who waited at STRIDE Community Health Center while her 15-year-old son, Alexander, had his teeth cleaned. He was flagged for dental care during a past medical checkup and now he and his three siblings regularly see a dentist and hygienist at STRIDE.

One of Ochoa's children has Medicaid dental coverage, but her three others are uninsured, and they couldn't otherwise afford dental care, said Ochoa. STRIDE offers an exam, X-rays, and cleaning for $60 for the uninsured.

In the past year, Cho has seen an influx of migrants and refugees who have never seen a dentist before and need extensive care. Medical exams for refugees at STRIDE increased to 1,700 in 2023 from 1,300 in 2022, said Ryn Moravec, STRIDE's director of development. She estimates the program has seen 800 to 1,000 new immigrants in 2024.

Even with growing needs, Cho said the Medicaid "unwinding" — the process underway to reexamine post-pandemic eligibility for the government program that provides health coverage for people with low incomes and disabilities — has created financial uncertainty. He said he worries about meeting the upfront costs of new staff and of replacing aging dental equipment.

At STRIDE's Wheat Ridge clinic, two hygienists float between dental and pediatrics as part of the medical-dental integration. Yet Cho said he needs more hygienists at other locations to keep up with demand. The pandemic created bottlenecks of need that are only now being slowly cleared, particularly because few dentists take Medicaid. If they do accept it, they often limit the number of Medicaid patients they'll take, said Moravec. Ideally, STRIDE could hire two hygienists and three dental assistants, Moravec said.

In 2022, Colorado enacted a law to alleviate workforce shortages by allowing dental therapists — midlevel providers who do preventive and restorative care — to practice. But Colorado does not have any schools to train or accredit them.

Before age 3, children are scheduled to see a pediatrician for 12 well visits, a metric that medical and dental integration capitalizes on, particularly for at-risk children. As part of Braun's program in the Rocky Mountain region, providers have applied more than 17,000 fluoride varnishes and increased the percentage of children 3 and younger who received preventive oral health care to 78% from 33% in its first 2½ years.

Callaghan, at the Montana Primary Care Association, witnesses that on the ground at community health centers in Montana. "It's about leveraging the fact that kids see their medical provider for a well-child visit much more often and before they see their dental provider — if they have one."

Kate Ruder: @KateRuderWriter

The access to policyholders' personal information was one of the problems cited by KFF Health News.

This article was published on Tuesday, April 9, 2023 in KFF Health News.

By Julie Appleby

Until last week, the system that is used to enroll people in federal Affordable Care Act insurance plans inadvertently allowed access by insurance brokers to consumers' full Social Security numbers, information brokers don't need.

That raised concerns about the potential for misuse.

The access to policyholders' personal information was one of the problems cited in a KFF Health News article describing growing complaints about rogue agents enrolling people in ACA coverage, also known as Obamacare, or switching consumers' plans without their permission in order to garner the commissions. The consumers are often unaware of the changes until they go to use their plan and find their doctors are not in the new plan's network or their drugs are not covered.

Agent Joshua Brooker told KFF Health News it was relatively easy for agents to access full Social Security numbers through the federal insurance marketplace's enrollment platforms, warning that "bad eggs now have access to all this private information about an individual."

On April 1, the morning the article was posted on NPR's website, Brooker said, he got a call from the Centers for Medicare & Medicaid Services questioning the accuracy of his comments.

A CMS representative told him he was wrong and that the numbers were hidden, Brooker said April 7. "I illustrated that they were not," he said.

After he showed how the information could be accessed, "the immediate response was a scramble to patch what was acknowledged as 'problematic,'" Brooker posted to social media late last week.

Brooker has followed the issue closely as chair of a marketplace committee for the National Association of Benefits and Insurance Professionals, a trade group.

After some phone calls with CMS and other technical experts, Brooker said, the federal site and direct enrollment partner platforms now mask the first six digits of the SSNs.

"It was fixed Wednesday evening," Brooker told KFF Health News. "This is great news for consumers."

An April 8 written statement from CMS said the agency places the highest priority on protecting consumer privacy.

"Upon learning of this system vulnerability, CMS took immediate action to reach out to the direct enrollment platform where vulnerability was identified to make sure it was addressed," wrote Jeff Wu, acting director of the Center for Consumer Information & Insurance Oversight at CMS.

He added that the Social Security numbers were not accessible through routine use of the platform but were in a portion of the site called developer tools. "This issue does not impact healthcare.gov," Wu wrote.

Brooker's concern about Social Security numbers centered on access by licensed agents to existing policyholder information though the federal marketplace, not including the parts of healthcare.gov used by consumers, who cannot access anything but their own accounts.

While consumers can enroll on their own, many turn to agents for assistance. There are about 70,000 licensed agents nationwide certified to use the healthcare.gov site or its partner enrollment platforms. They must meet certain training and licensing requirements to do so. Brooker has been quick to say it is a minority of agents who are causing the problem.

But agents increasingly are frustrated by what they describe as a sharp increase during the second half of 2023 and into 2024 of unscrupulous rivals switching people from one plan to another, or at least switching the "agent of record" on the accounts, which directs the commission to the new agent. Wu's statements have so far not included requested information on the number of complaints about unauthorized switching, or the number of agents who have been sanctioned as a result.

The changes shielding the Social Security numbers are helpful, Brooker said, but won't necessarily slow unauthorized switching of plans. Rogue agents can still switch an enrollee's plan with simply their name, date of birth, and state of residence, despite rules that require agents to collect written or recorded consent from consumers before making any changes.

Julie Appleby: jappleby@kff.org, @Julie_appleby