Blog & News
Explore Physician Acceptance of New Medicaid Patients through Two New Measures on SHADAC’s State Health Compare and in a New MACPAC Factsheet
August 5, 2021:Authors: Robert Hest and Julia Ngep
In order for the more than 80 million Medicaid beneficiaries to access needed care in a timely manner, there must be a sufficient number of health care providers to serve these patients. There has long been concern that providers are less likely to accept Medicaid patients than patients with other types of health insurance coverage. Because Medicaid policies—and providers’ responses to those policies—differ substantially across states, state-level data is critical for monitoring the providers’ decisions to accept Medicaid patients and for understanding the factors that influence those decisions.
Using data from the 2011-2017 National Electronic Health Records Survey (NEHRS),1 SHADAC performed an analysis to examine and compare physician acceptance of new Medicaid patients at the state level and by physician and practice characteristics. This analysis was performed under contract with the Medicaid and CHIP Payment and Access Commission (MACPAC) and is presented in two new measures on SHADAC’s State Health Compare web tool as well as in a new MACPAC factsheet.
State Health Compare Measures
Physicians who accept new patients
Physicians who accept new patients measures the percent of physicians who accept new patients by type of coverage: private, Medicare, and Medicaid. Data years were pooled where single-year estimates were not possible and are available for 2011-2013 and 2014-2017.
In 2014-2017, state-level physician acceptance of Medicaid patients ranged from 42.2 percent in New Jersey to 99.4 percent in North Dakota, acceptance of Medicare patients ranged from 77.1 percent in Georgia to 98.3 percent in North Dakota, and acceptance of private patients ranged from 80.3 percent in the District of Columbia (D.C.) to 100.0 percent in Nebraska.
Physicians who accept new Medicaid patients
Physicians who accept new Medicaid patients measures the percent of physicians who accept new Medicaid patients by the following physician/practice characteristics:
- Setting (private solo/group versus total) available for pooled data years 2011-2012 and 2014-2017;
- The share of Medicaid existing patients (above versus below national average) available for pooled data years 2011 & 2013 and 2014-2017;
- And the ratio of mid-level providers (above versus below national average) available for pooled data years 2014-2017.
At the national level in the most recent time period: physicians in private solo/group practices were less likely to accept new Medicaid patients compared to all physicians (70.4% versus 74.0%); physicians with an above-average share of existing Medicaid patients were more likely to accept new Medicaid patients compared to all physicians (87.4% versus 63.8%); and physicians with an above-average ratio of mid-level providers were more likely to accept new Medicaid patients compared with all physicians (80.5% versus 73.7%).
New MACPAC Factsheet
Physician Acceptance of New Medicaid Patients: Findings from the National Electronic Health Records Survey
This new MACPAC factsheet analyzes physician acceptance of new Medicaid patients at the national and state levels. As Medicaid programs vary by each state and there is little information on physician participation in Medicaid at the state level, this analysis provides an important update of previous MACPAC work analyzing physician acceptance at the national level and prior literature analyzing state-level physician acceptance, last updated for data year 2013.
The analysis found significant differences in rates of physician acceptance of new patients by coverage type, with physicians being more likely to accept private and Medicare patients compared with Medicaid patients. Acceptance of Medicaid patients varied significantly by state and by various patient, physician, and practice characteristics. These include source of patient coverage (Medicaid, Medicare, and private), physician specialty, practice setting, existing Medicaid caseload, and presence of mid-level providers. The analysis found that nationally, rates of physician acceptance were stable over time and increased significantly in a handful of states, with no states experiencing significant decreases in rates of acceptance.
1 Data for 2016 was not released by National Center for Health Statistics (NCHS), which conducts the NEHRS. Data were unavailable by setting in data year 2013; data were unavailable by share of existing Medicaid patients for data year 2012; and data were unavailable by ratio of mid-level providers for data years 2011-2013.
Blog & News
Minnesota Medicaid Enrollment Grew More than the U.S. Average during COVID-19
July 21, 2021:The Minnesota Medicaid program has served as an important safety net program during the COVID-19 crisis. As a countercyclical program, Medicaid enrollment/spending increases when the economy is in decline (such as during a pandemic or a recession), as employer-sponsored insurance decreases and the low-income population increases.1
The additional enrollment of 166,364 individuals in Minnesota from February 2020 to January 2021 provided important and needed coverage during this unprecedented time.2 The COVID-19 public health emergency declaration has supported this growth with the moratorium on disenrollment and extended open enrollment sessions.
Medicaid in Minnesota
Minnesota was an early Medicaid expansion state through the options provided by the Affordable Care Act. Minnesota extended eligibility for Medicaid (called Medical Assistance in the state) to childless adults at or below 75% of the Federal Poverty Guideline (FPG) in 2011 and adopted the full expansion to 138% FPG in 2014.3,4 In 2019, Medical Assistance in Minnesota provided health insurance coverage to approximately 13.1% of the state’s population.5
Minnesota’s Medicaid expansion was a crucial resource during the COVID-19 pandemic for those who lost their jobs and/or their employer-sponsored health insurance coverage. It is estimated that approximately 29,500 Minnesotans lost their private health insurance coverage between April 2020-July 2020.6 Despite these changes, data from the 2019 Minnesota Health Access Survey and the state’s 2020 Health Insurance Enrollment Survey show that Minnesota’s uninsured population has stayed relatively stable during COVID-19, with increases in Medicaid enrollment making up for some of the losses experienced in the private insurance market.6
Minnesota in Context
SHADAC analyzed a recently released 50-state review of Medicaid growth during COVID-19 from Manatt Health to explore how Medicaid enrollment in Minnesota during COVID-19 compares to the rest of the United States.1 Manatt Health utilized state-specific sources to gather data from February 2020 through January 2021. These data show that Minnesota’s Medicaid program has not only stabilized the state’s coverage landscape but has also grown at a faster pace than many other state Medicaid programs. A total of 21 states have reported data from February 2020 to January 2021, and they are included in this analysis.
Key Findings1
From February 2020 to January 2021, enrollment in Medical Assistance grew by 19.7 percent in Minnesota, from 844,467 to 1,010,831. This increase was higher than the national median growth rate of 14.5 percent in expansion states and 15.7 percent in non-expansion states.
Only 3 of the 21 states that provided Medicaid enrollment data for this time period experienced larger growth: Florida, Indiana, and Missouri. The highest percentage growth among states was 22.6% in Missouri, and the lowest growth was 8.2% in Tennessee.
When comparing Medicaid expansion adults with non-expansion adults, Minnesota saw a growth in enrollment of 33.4% vs 28.7%, respectively. Minnesota’s enrollment growth was above the median for reporting states for expansion adults (31.0%) but below the 37.1% median for non-expansion adults (Exhibits 1 and 2).1
Conclusion
While Minnesota’s Medicaid growth during COVID-19 has helped to offset private health insurance coverage losses and the state’s program has done well with respect to coverage relative to many other states, the eventual end of the federal public health emergency will bring with it an end to special emergency Medicaid rules such as the moratorium on disenrollment. The public health emergency’s mandate of continuous eligibility was vital in the growth of Medicaid as a safety net. As the economy continues to recover and the federal public health emergency concludes as soon as the end of the year, we should see an increase in employer-sponsored insurance and a decrease in Medicaid enrollment due to the countercyclical nature of the program. It will be important to track Medicaid enrollment as these emergency rules are phased out to evaluate the impact of returning to standard enrollment and retention practices.
Further Reading
Pandemic’s Impact on Health Insurance Coverage in Minnesota was Modest by Summer 2020. (Minnesota Department of Health, May 2021)
Tracking Medicaid Enrollment Growth during COVID-19. (State Health and Value Strategies, February 2021)
1 MACPAC. (June 2020) Considerations for countercyclical financing adjustments in Medicaid. https://www.macpac.gov/wp-content/uploads/2020/06/Considerations-for-Countercyclical-Financing-Adjustments-in-Medicaid.pdf.
2 State Health and Value Strategies. (2021, February 25). Tracking Medicaid enrollment growth during COVID-19 databook. https://www.shvs.org/wp-content/uploads/2020/10/Tracking-Medicaid-Enrollment-Growth-During-COVID-19-Databook_03.2021.xlsx
3 Minnesota Department of Human Services. (2018). Medicaid Matters: The impact of Minnesota’s Medicaid Program [DHS-7659-ENG 2-18]. https://www.leg.mn.gov/docs/2018/other/180391.pdf
4 Office of Rural Health and Primary Care. (April 2017). Public and individual health insurance trends in rural Minnesota: enrollment during implementation of the Affordable Care Act. Minnesota Department of Health. https://www.health.state.mn.us/facilities/ruralhealth/pubs/docs/2017enroll.pdf
5 State Health Compare. (2021). Health Insurance Coverage Type. State Health Access Data Assistance Center (SHADAC). http://statehealthcompare.shadac.org/map/11/health-insurance-coverage-type-by-total#8/27/21
6 Minnesota Department of Health. (May 2021). Pandemic’s impact on health insurance coverage in Minnesota was modest by summer 2020. https://www.health.state.mn.us/data/economics/docs/inscoverage2020.pdf
Blog & News
New State Health Compare Measure: Medicaid Expenses as a Percent of State Budgets
March 24, 2021:Medicaid provides public health coverage to millions of low-income individuals and families and serves as an important safety net program for those in need. Medicaid also serves an important role for low-income elderly and the disabled by covering services not included in Medicare, such as long-term care and other support services for persons with mental or physical disabilities.i The program is jointly financed by the federal and state governments along with the Children’s Health Insurance Program (CHIP).ii
This brief reviews the federal and state shares of Medicaid spending and highlights a new measure on State Health Access Data Assistance Center’s (SHADAC) web-based data tool – State Health Compare. Our measure presents total Medicaid spending as a percent of state budgets, including trends over time and variation in spending by state. We acknowledge both state and federal contributions to this total measure, highlighting the significant role of federal financing in the Medicaid program.
Click the image to read more about this new State Health Compare measure - Medicaid expenses as a percent of state budgets.
i Medicaid and CHIP Payment and Access Commission (MACPAC). (2011, March). Overview of Medicaid. https://www.macpac.gov/publication/ch-2-overview-of-medicaid/
ii Medicaid.gov. (n.d.). September 2020 Medicaid & CHIP Enrollment Data Highlights. https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html
Blog & News
Addressing Persistent Medicaid Enrollment and Renewal Challenges as Rolls Increase
September 2, 2020:Growth in Medicaid enrollment is expected to accelerate as a result of both the COVID-19 pandemic and the associated economic downturn. An analysis by the Kaiser Family Foundation (KFF), for example, shows that by January 2021, nearly 17 million people could be newly eligible for Medicaid.i In June, the Georgetown Center for Children and Families reported that Medicaid enrollment in 15 states had increased 5.8 percent over the past three months.ii The additional expected increase could mirror the surge seen during the first Patient Protection and Affordable Care Act (ACA) Open Enrollment Period (OEP1) in 2013, during which there was an influx of first-time applicants who were unfamiliar with Medicaid enrollment and renewal processes.
Although significant progress has been made in streamlining and simplifying these processes and systems for beneficiaries whose income eligibility is determined based on modified adjusted gross income (MAGI), states vary widely in their priorities and approaches.iii There are still many points along the enrollment and renewal paths where eligible individuals might remain uninsured or lose Medicaid coverage, and these challenges may be exacerbated by a surge in newly eligible individuals. Recently, some states have taken advantage of the flexibility in enrollment and eligibility determination offered by the COVID-19 Public Health Emergency (PHE) declared by Health and Human Services Secretary Alex Azar in order to streamline Medicaid enrollment processingiv v vi vii viii ix; however, this flexibility may be rolled back at the end of the PHE while widespread enrollment and renewal challenges will continue to persist.
Drawing on work done for the Medicaid and CHIP Payment and Access Commission (MACPAC), this blog provides a summary of documented, effective mitigation strategies states can use to address enrollment and renewal challenges in Medicaid and highlights strategies currently being used in four states: California, Idaho, Rhode Island, and Washington. Although this analysis pre-dates the coronavirus outbreak, these findings may offer helpful ideas about how states can address long-standing challenges in enrolling and renewing individuals in Medicaid as during current nationwide enrollment increases nationwide due to COVID-19 as well as in anticipation of returning to regular operations once the PHE expires. The findings, statements, and views expressed here are those of the authors and do not necessarily represent those of MACPAC.
Overview: Challenges and Mitigation Strategies
Trends in state Medicaid and CHIP eligibility, enrollment, and renewal policies over the past four years indicate that an increasing number of states are complying with ACA provisions designed to streamline program administration at enrollment and renewal.x States are also moving toward providing more application supports, which can make the process faster and more user-friendly, as shown in Table 1.
Table 1. Application Supports Aimed at Streamlining Enrollment | ||||
Indicator from Kaiser/Georgetown Survey | # of States as of | |||
January 2017 | January 2018 | January 2019 | January 2020 | |
Online application submission using mobile device | 28 | 31 | 38 | 44 |
Online application has mobile-friendly design | 7 | 9 | 18 | 20 |
Online beneficiary account supports uploading of verification documentation | 29 | 31 | 32 | 33 |
Online secure portal for application assister | 26 | 27 | 27 | 30 |
Through document review and key informant interviews, we identified 30 ongoing Medicaid enrollment and renewal challenges, many of which are longstanding issues that predate state streamlining efforts and the COVID-19 outbreak. Exhibit 1 shows the different challenges states and beneficiaries may face at each point of the Medicaid application, income verification, and renewal processes, as well as the points between enrollment and renewal.
Exhibit 1. Remaining MAGI Medicaid Enrollment and Renewal Challenges
Source: State Health Access Data Assistance Center (SHADAC) document review and select key informant discussions 2020.
We also reviewed the robust body of literature on effective strategies for increasing MAGI Medicaid enrollment, and we compiled and organized some of the most effective strategies that states can implement at each point of the Medicaid enrollment and renewal processes (Exhibit 2).
Exhibit 2. Summary of Effective Strategies for Mitigating Enrollment and Renewal Risks |
Stage: Application |
|
Stage: Verification and processing, including changes between enrollment and renewal |
|
Stage: Renewal |
|
During our analysis we identified two persistent risk points that are especially relevant during the COVID-19 pandemic: verifying self-employment income and making eligibility determinations for complicated cases. Below we highlight effective mitigation strategies that California, Idaho, Rhode Island, and Washington have implemented to address these challenges.
Challenge: Verifying Self-Employment Income.
Income verification remains one of the biggest challenges states face when determining an individual’s financial eligibility for Medicaid.xi This is especially true for those with unstable incomes, such as individuals who are self-employed, seasonally employed, or frequently change jobs. In these cases, income may not be able to be confirmed with electronic income data sources due to data lags or other limitations. When electronic sources cannot be used, alternative documentation is required (e.g., pay stubs). Further, individuals reporting self-employment income often have to submit additional financial information, compared to those who are not self-employed, in order to verify their income. This information may include recent tax filings or profit and loss statements (i.e., summaries of revenues, costs, and expenses that were incurred during a specific period). Collecting and reporting this information can be confusing and difficult, especially for new Medicaid enrollees.
Mitigation Strategy: Offer multiple options for reporting and verifying self-employment income.
- Allow multiple forms of documentation (e.g., bank statements or self-created profit and loss statements, or self-attestation) to report self-employment income. California and Idaho both allow self-employed individuals to verify income by submitting their own self-generated profit and loss statement or a summary of their expected income generated by a certified public accountant. Both states have also created alternative forms that mirror the income and expense categories typical for self-employed individuals and can be used to help self-employed applicants or beneficiaries report their net income.
- Provide flexible tools that help self-employed individuals accurately calculate their income. Washington’s online Medicaid application includes a built-in income calculator, which assists individuals with accurately reporting their income in a variety of increments (e.g., hourly, monthly, quarterly, or annually) and then prompts individuals with additional questions in order to determine financial eligibility.
Mitigation Strategy: Clearly explain what individuals need to report and how to report it.
- Provide explicit direction about what counts as income for MAGI purposes. California has worked collaboratively with community stakeholders to create a “What Income Counts” documentxii that explains what income to report and how to report it. Similarly, Washington has a dedicated webpagexiii with guidance for self-employed individuals to calculate income and provides helpful examples of business expenses to deduct from this calculation.
- Provide education and referrals to help applicants collect needed documentation. Respondents indicated that in-person assistance from navigators and enrollment assistors remains a critical tool for individuals to successfully report their income upon initial application and at times of renewal. For example, in Idaho, navigators report success in scheduling pre-appointments with applicants to review what documents are needed for the application. Similarly, navigators in Washington indicate that tax accountants (e.g., United Way free tax preparers) have become an important referral for individuals who need help calculating profit and loss statements.
Challenge: Making Swift and Accurate Eligibility Determinations for Complex Cases.
Robust business rules engines (software systems that automate Medicaid rules as well as electronic access to data sources to verify various factors of eligibility) have been critical tools to support successful and real-time Medicaid eligibility determinations. This is especially true for simple cases, such as a single adult with relatively stable employment. Some states, however, continue to struggle with business rules engines making correct determinations in more complex enrollment situations, such as families with mixed health insurance coverage or individuals missing information on key eligibility factors.
Mitigation Strategy: Deploy a specifically trained workforce and formalize escalation procedures to resolve issues in the eligibility system.
- Create a category of navigators authorized to move more complex cases through the application or renewal process. Washington provides additional training to “enhanced” navigators who offer technical assistance to regular navigators in order to troubleshoot problems that arise when processing complex cases. Enhanced navigators attend additional training throughout the year to receive updates on processes and policies, and they have a higher level of access to the eligibility system.
- Provide a mechanism to escalate cases. Rhode Island provides navigators with the ability to escalate cases that appear to have received incorrect eligibility determinations, especially in situations where there is a quick-turnaround time needed—e.g., medical emergencies. Escalation teams within the state’s human services agency are designated to respond to navigators in a timely manner with a determination review.
Mitigation Strategy: Utilize community feedback mechanisms to identify enrollment challenges with complex cases and identify mitigation solutions.
- Interviewees in all four states (California, Idaho, Washington, and Rhode Island) highlighted the importance of community feedback mechanisms in providing a venue for navigators to bring developing challenges and areas of concern to the attention of the state and to suggest solutions. Specifically, stakeholders in California and Washington spoke positively about the increasing number of opportunities—such as formal consumer-focused stakeholder workgroup meetings or informal communication channels—for navigators, eligibility workers, and community organizations to collaborate regularly with state agency staff to discuss complex cases and consider ways to better address these situations.
Conclusion
Our analysis focused on identifying effective and innovative strategies for addressing Medicaid enrollment and renewal challenges and exploring specific strategies used by four states—California, Idaho, Washington, and Rhode Island. Since this study, the spread of the COVID-19 virus has simultaneously increased the need for medical coverage to cover fees associated with COVID treatment and triggered an economic downturn, and both of these issues are expected to increase enrollment in Medicaid programs nationwide.xiv While the administrative flexibilities mentioned earlier aim to facilitate the influx of new Medicaid enrollments for the time being, the main risk points of Medicaid enrollment and renewal can be expected to continue in some form and will no doubt return when the Public Health Emergency ends.xv The need to continue to explore and implement innovative enrollment and renewal approaches remains, and the findings from this analysis can offer a reminder to states of ongoing efforts to improve Medicaid enrollment and renewal processes.
Publication
2018 State-level Estimates of Medical Out-of-Pocket Spending for Individuals with Employer-sponsored Insurance Coverage
U.S. health care spending continues to grow, reaching $3.6 trillion and 17.7% of the GDP in 2018.[i] Unfortunately, a significant share of these costs are increasingly born by Americans in the form of increased deductibles, copayment, and coinsurance—commonly referred to as patient “out-of-pocket” (OOP) costs. Even for the 52% of Americans who have private health insurance through their own or their spouse’s employer, affordability of health care is a pressing issue. Nationally, the average deductible for families in 2018 was $3,392, and almost half (49.1%) of all Americans were enrolled in high-deductible health plans with a deductible of at least $2,700 for family coverage.[ii],[iii]
The State Health Access Data Assistance Center (SHADAC) at the University of Minnesota continues to monitor trends in coverage, access, and affordability. This brief highlights the affordability of coverage for those with employer-sponsored health insurance (ESI). Using data from the Annual Social and Economic Supplement (ASEC) of the 2019 Current Population Survey (CPS; data year 2018), we estimated family out-of-pocket costs for people with employer coverage across all 50 states and the District of Columbia (D.C.). For individuals with ESI, we looked at: (1) the family median out-of-pocket costs by state, and (2) an estimate of the high medical cost burden where family out-of-pocket spending is greater than 10% of household income. For additional estimates, please visit SHADAC’s State Health Compare web tool.
[i] Centers for Medicare & Medicaid Services (CMS). (2019, December 5). NHE Fact Sheet. Retrieved from https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet/
[ii] State Health Access Data Assistance Center analysis of the 2018 American Community Survey microdata.
[iii] State Health Access Data Assistance Center, State-level Trends in Employer-Sponsored Health Insurance, 2014-2018. Available at: https://www.shadac.org/ESIReport2019