'Removing Duplicate Enrollees From Medicaid, ACA Plans Is Not as Easy as You'd Think'

 The Trump administration's plan to identify

opens in a new tab or window and disenroll people who are enrolled in more than one federal or state-sponsored health plan is leaving several unanswered questions for policy experts.

In its announcement last month, HHS said a recent analysis of 2024 enrollment data found that there were approximately 2.8 million people "either enrolled in Medicaid or the Children's Health Insurance Program (CHIP) in multiple states or simultaneously enrolled in both Medicaid/CHIP and a subsidized Affordable Care Act (ACA) exchange plan."

CMS "is taking action to ensure individuals are only enrolled in one program and to stop the federal government from paying multiple times for these individuals to receive health coverage," the press release said. It also quoted HHS Secretary Robert F. Kennedy Jr., who said that "Under the Trump administration, we will no longer tolerate waste, fraud, and abuse at the expense of our most vulnerable citizens."

Some experts are skeptical, however. "The press release doesn't provide much in the way of information," Edwin Park, JD, research professor at Georgetown University's Center for Children and Families, in Washington, D.C., said in an email. For one thing, he said, many states were still completing the "unwinding" -- or disenrollment -- of Medicaid beneficiaries who were required to be kept on the Medicaid rolls during the COVID-19 public health emergency.

In addition, "we don't know how long a single individual was enrolled in multiple plans -- since it takes time for a state to disenroll an individual and to enroll an individual (and that's especially the case for [ACA] marketplace plans where individuals don't get enrolled until the first of the next month), there may be nothing inappropriate," he said. "There needs to be a lot more granular data."

Multiple Enrollments in Medicaid, CHIP, and ACA Plans

Getting rid of these duplicate enrollments would save the federal government an estimated $14 billion annually, HHS said. The agency outlined several strategies for finding these duplicate enrollees, including:

• Providing states with a list of people who are enrolled in Medicaid or CHIP in two or more states and asking states to recheck their Medicaid or CHIP eligibility.
• Notifying people who are enrolled in both Medicaid or CHIP and a federally run ACA insurance exchange plan with a subsidy. CMS has already notified these enrollees, who have been asked to disenroll from Medicaid or CHIP if they're no longer eligible, end their subsidy (as well as their coverage if they would like), or tell the exchange that the information is not correct and provide documentation that they are not enrolled in two plans. After 30 days, the exchange will end the subsidy for those who seem to be enrolled in more than one plan.
• Identifying people enrolled in both Medicaid or CHIP and a state-run ACA exchange plan. CMS will give the state exchanges a list of those potentially enrolled in the two types of plans and "ask [the exchanges] to determine whether these individuals are dually enrolled," according to the release.

"CMS will work with states to prevent individuals from losing coverage inappropriately," the release said.

Several Possible Causes

Duplicate enrollment can occur for various reasons, America's Health Insurance Plans (AHIP), a trade group for health insurers, said in a March blog postopens in a new tab or window. "Complex individual circumstances can result in multiple residence changes for some beneficiaries," the post said. "For example, people experiencing chronic homelessness or in unstable housing situations, seasonal employees, people with frequent job changes, and/or people suffering from illnesses may relocate more often, resulting in lags to updated data."

In addition, "from 2019 to 2021, COVID-19 created a higher-than-average level of movement among beneficiaries, both across states lines as well as between and among coverage markets, straining states' administrative resources. Pauses on routine eligibility redeterminations further contributed to temporary instances of concurrent enrollments," the post said. Experts in this area also have noted that, for a time, there was a lack of regular data connectivity between the ACA marketplaces and state Medicaid systems, although that has since been resolved.

Is the government's estimate of 2.8 million potential dual enrollees reasonable? Clay Farris, MHS, founder of the consulting firm Mostly Medicaid, in Birmingham, Alabama, thinks it probably is. "I absolutely can verify this has been going on a long time," he said in a phone interview. "I'm in no way surprised to see numbers like 2.8 million," based on the numbers he has seen in the states he has worked with on the issue.

'Nobody Wants to Be the Bad Guy'

The biggest problem, said Farris -- who has consulted for state Medicaid agencies -- is that "nobody wants to be the bad guy." If someone is enrolled in several states' Medicaid plans, "none of them want to do the work to kick them off, because then you've got to go through various notification processes and what if [the person] appeals, and all this other kind of stuff," he said. Some years back, in one state Farris worked with, "we would give them several tens of thousands every quarter" of potential duplicate enrollees, "and they didn't want to do anything." There is also little interest on the part of Medicaid managed care plans, which get paid a per-capita amount for each enrollee regardless of how much -- or how little -- care they use, he said.

There are, however, other actions states are more interested in, he added. For example, if the state found out that someone was enrolled in both a managed care plan and was in the Department of Veterans Affairs (VA) health system, "we actually ended up sending letters to some of the members who had VA coverage, saying, 'Hey, look, you might not know it, but you've actually got better drug coverage through your Veterans Affairs benefit ... so stop using your Medicaid [coverage] for drugs.'"

States may be loathe to look into the duplicate enrollment problem for other reasons too, Joe Antos, PhD, senior fellow emeritus at the American Enterprise Institute in Washington, D.C., said in an email. "Since the states use state-directed payments and various tax schemes to increase the federal share [of money they receive], they have little incentive to correct their records or disenroll people who already have coverage elsewhere," he said. "Moreover, sorting this out would be difficult -- even with duplicate enrollments identified by CMS, the state would have to track people down and verify their residence, eligibility for programs, etc. States would also have to cooperate with each other to determine whether multiple enrollment in state Medicaid programs is real or an accounting error."

Because of this, even if it's true that there are 2.8 million duplicate enrollees, "getting $14 billion out of the system is extremely optimistic," Antos added. "There would also be a considerable lag between identifying potential multiple enrollees and actually reducing federal subsidy payments that are incorrect."

That being said, however, "multiple enrollment is a real problem," he concluded. "Going from data analysis to solving the problem is a big leap that would take years of effort and require better management by both states and the federal government on an ongoing basis. It's unclear that either side would be fully committed to this effort over the long term."

https://www.medpagetoday.com/publichealthpolicy/medicaid/117029