Katheryn Houghton | KFF Health News (TNS)
In September, Jason George noticed that Medicaid payments had stopped for some residents of the assisted living facility he manages.
Guardian Group Montana, which owns three small facilities in rural Montana, relies on Medicaid to cover care for low-income residents. George said residents’ Medicaid delays have ranged from a few weeks to over six months, with a total amounting to about $150,000 at one point.
George said the company couldn't pay its employees due to the lack of funds. When he reached out to state health and public assistance officials for help, they mentioned being overwhelmed with processing Medicaid cases and advised patience.
He questioned if they would have to evict residents if payment delays continued for several months.
Ultimately, the company resorted to taking out bank loans at 8% interest, according to George.
By January, Montana officials completed their initial review of Medicaid eligibility after the federal government lifted a freeze on disenrollments during the pandemic. Over 127,200 people in Montana lost Medicaid, with many cases still being processed as of mid-February.
Healthcare providers accepting Medicaid have reported disrupted state payments, leading to financial struggles and, in some cases, accruing debt. This has affected small long-term care facilities, substance use disorder clinics, and federally funded health centers that rely on Medicaid to provide need-based treatment.
State health officials have defended their Medicaid redetermination process and stated efforts to address public assistance backlogs.
Financial hardships were anticipated as individuals who no longer qualify were removed from coverage. However, businesses have cited challenges arising from an overburdened state workforce. Some individuals have faced lengthy delays in reapplying for Medicaid or obtaining coverage for the first time, attributed to extended wait times when contacting the state's call center and limited in-person assistance.
The problem persists: George reported that two Guardian residents were removed from Medicaid in mid-March due to a lack of information cited by the state.
He claimed, “I have evidence of submitting the required information weeks ago.”
Providers have also encountered cases of inconsistent Medicaid payments for individuals who have not lost coverage. Understanding why payments suddenly cease can be challenging. Both patients and providers are navigating the same overstretched system. Jon Forte, head of the Yellowstone County health department in Billings, oversees health centers offering care regardless of patients' ability to pay. He noted that some of the clinics' regular Medicaid claims went unpaid for up to six months at one point. As a result, their doctors are finding it difficult to refer patients for specialist care, especially as some providers reduce their clientele..
"Some have had to stop seeing Medicaid patients to meet their needs and keep the lights on," Forte said. "It is just making the access crisis worse."
Clinics that base fees on patient income are especially affected by payment shortfalls.
David Mark, a doctor and the CEO of One Health, which has rural clinics in eastern Montana and Wyoming, said the company expected to make about $500,000 in profit through its budget year so far. Instead, it’s $1.5 million in the red.
In Yellowstone County, Forte said the health department, known as RiverStone Health, is down $2.2 million from its expected Medicaid revenue. Forte said while state officials have nearly caught up on RiverStone Health’s direct Medicaid payments, smaller providers still experience delays, which causes problems referring patients for care.
Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services, said Medicaid can retroactively pay for services for people who have lost coverage but are then found eligible within 90 days. He said the state’s average redetermination processing time is 34 days, the average processing time for applications is 48 days, and, when processing times are longer, it’s often due to ongoing communication with a client.
Ebelt didn’t acknowledge broader Medicaid payment delays, but instead said a provider may be submitting claims for Medicaid enrollees who aren’t eligible. He rejected the idea that individual examples of disruptions amount to a systemic problem.
"We would caution you against using broad brush strokes to paint a picture of our overall eligibility system and processes based on a handful of anecdotal stories," Ebelt said in an emailed response to a KFF Health News query.
Ebelt didn’t directly answer questions about continued long waits for people seeking help but instead said continued coverage depends on individual beneficiaries submitting information on time.
Federal data shows
Montana’s average call center wait time is 30 minutes — putting it among states with the highest average wait times. Mike White, co-owner of Caslen Living Centers, which has six small assisted living facilities across central and southwestern Montana, said some family members allowed the company to manage residents’ Medicaid accounts to help avoid missing deadlines or paperwork. Even so, he said, the company is waiting for about $30,000 in Medicaid payments, and it’s hard to reach the state when problems arise. When they do get through to the state’s call center, the person on the other end can’t always resolve their issue or will answer questions for only one case at a time.
"You don’t know how long it’s going to take — it could be two months, it could be six months — and there’s nobody to talk to," White said.
Ebelt said long-term care facilities were
provided information on how to prepare for the unwinding process. He said new Medicaid cases for long-term care facilities are complicated and can take time. Stan Klaumann lives in Ennis and has power of attorney for his 94-year-old mom, who resides in one of Guardian’s assisted living homes. Klaumann said that while she never lost coverage, the state didn’t make Medicaid payments toward her long-term care for more than four months and he still doesn’t know why.
He mentioned that the state has not consistently sent him the regular paperwork he needs to complete in order to continue receiving Medicaid payments since last fall. He tried calling the state's call center, but each time he waited for over two hours. He also made four two-hour round trips to the nearest public assistance office to seek answers.
At times, the workers told him there was a mistake by the state, while other times they said that he was missing paperwork that he had already turned in, like the details of the money from selling his mom's car.
Klaumann said that every time he visited, he received a different explanation for why his mother's bills were not being paid.
Throughout the country, individuals have reported
problems with the system and outdated contact details that caused states to remove eligible individuals. At least 28 states halted the process of removing individuals to increase outreach to eligible people, and according to federal data. Montana adhered to its original schedule and has a higher rate of removing individuals than most other states, according to KFFStephen Ferguson, the executive director of Crosswinds Recovery in Missoula, mentioned that the program for substance use disorder does not have a full-time employee dedicated to billing and sometimes does not realize that clients have lost Medicaid coverage until the state rejects thousands of dollars in services submitted by Crosswinds for reimbursement. After that, it can take months for clients to either be reenrolled or find out that they no longer qualify. Ferguson stated that he is seeking grant funding to continue treating people even if they cannot pay..
“We’re improvising right now,” he said. “We are uncertain about what the next month or the next quarter will look like.”
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