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OHA: Determining Medicaid eligibility complicated

Oregon Health Authority says the process for determining eligibility has been hampered by old, disparate tracking systems and the failure of Cover Oregon.

By Claire Withycombe

Published on May 18, 2017 5:18PM


Capital Bureau

SALEM — More than three years after Oregon opted to expand healthcare coverage under Medicaid, the government’s healthcare plan, it’s still not clear how much the state may have spent on people who don’t qualify.

In response to an audit memo released by the Oregon Secretary of State this week, the Oregon Health Authority said that the process for determining eligibility for the program has been hampered by old, disparate systems for keeping track of Medicaid recipients and the failure of Cover Oregon, the state’s expensive attempt at a health insurance marketplace.

Oregon decided to expand Medicaid in 2013 under the federal Affordable Care Act, and dramatically widened the pool of Oregonians who could receive government health coverage.

State auditors’ preliminary findings, first reported by The Oregonian on Tuesday evening, brought more visibility to what has been another wrinkle in a litany of problems with the state’s implementation of the Medicaid expansion, including the Cover Oregon failure, which cost state and federal taxpayers about $300 million.

Richardson’s memo said that at a cost of $430 per patient per month, the state could have spent millions of dollars providing coverage for approximately 86,000 people whose qualifications for the program are still in question.

The health authority and several Democratic legislators on healthcare committees maintained this week that the Legislature, Oregon Gov. Kate Brown and the Centers for Medicare and Medicaid Services were already aware of problems with enrollment and eligibility, which are in the process of being resolved.

As of May 1, there were 1,028,509 Oregonians on the Oregon Health Plan, representing about a quarter of the state’s population.

Most people receiving Medicaid coverage in the state — nearly 734,000 recipients — have been determined eligible and have been enrolled in a new eligibility system called ONE. Another 180,000 people are receiving benefits through programs for foster children, the elderly and people with disabilities administered by the Oregon Department of Human Services.

That leaves about 115,000 people who were previously determined eligible for Medicaid benefits, but whose current qualifications for the program have not been confirmed.

Of that 115,000:

• 14,000 are in the process of having their benefits terminated because they haven’t responded to the health authority’s inquiry.

• 17,000 have responded and are undergoing analysis to determine whether they are eligible for Medicaid, a process OHA expects to complete Friday.

• 84,000 people are still being analyzed to find out what the agency needs to do next about them, as they have previously been eligible for Medicaid benefits, but have not been “redetermined” eligible.

“Just because redetermination is not complete, does not indicate that they are ineligible for Medicaid,” an agency spokeswoman said in an email.

Eligibility is an official term that denotes whether or not someone has met the government’s criteria for health coverage. Eligibility determination is a formal process that is supposed to take place annually; the state got several passes on performing those annual determinations from the federal government until mid-2016.

According to the Oregon Health Authority, federal law says that once someone has been determined eligible for Medicaid coverage, eligibility cannot be revoked until the case has been reviewed, and he or she has been notified and given a chance to respond.

Someone would no longer meet the criteria if he or she started earning more than the maximum income, for example, but official eligibility isn’t up until the formal determination and revocation processes are complete.

According to OHA, “poor data quality” in Cover Oregon and the state’s older data systems meant that the agency had to contact each person receiving benefits to complete a paper application.

It took more than two years to finish that process on fairly straightforward cases. What’s left, the agency said, are cases “more complex in nature.” The health authority says it will know what to do next with the group of about 84,000 people by the end of the month.

“At that time we will be able to clearly understand the number of Oregonians that still need to go through the redetermination process to ensure they remain eligible for Medicaid benefits,” OHA said in a statement Wednesday.



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