Oklahoma’s Medicaid agency should withdraw plan to terminate health coverage over returned mail

For many low-income Oklahomans, having a place to call home isn’t something you can take for granted. Many families struggle with high rent, frequent evictions, unstable family environments, and more. Now, the state Medicaid agency, the Oklahoma Health Care Authority (OHCA), has proposed a new policy to terminate coverage for families who move and don’t update their address quickly enough in agency records. This proposal rests on bad assumptions, isn’t required by any legislation, and won’t generate promised savings – but it will disrupt needed medical care and create unnecessary bureaucratic hurdles for low-income families.

The rule to implement this policy was slated to be voted on by the Health Care Authority’s Board this Thursday, February 14th, but it has been put on hold pending discussions with CMS, the state’s federal Medicaid partner. While this delay is welcome, the agency should opt to withdraw the proposed rule entirely. Here’s why.  

OHCA says this is required by legislation. That’s not true.

OHCA’s proposal would result in SoonerCare coverage being terminated for enrollees whose mail is returned and marked undeliverable. OHCA says this is a way of establishing residency — that is, whether or not an enrollee still lives in Oklahoma. In circulation documents, the state Medicaid agency has said that the rule was prompted by HB 1270, which passed last spring. That bill did indeed direct OHCA to implement more rigorous and frequent eligibility verification checks on SoonerCare members. However, the bill only said that OHCA has to verify residency — it didn’t say how. The agency has a range of options to see if enrollees still live in the state, from reviewing employment data, which shows where household members are employed, to claims data, which shows if enrollees have seen a doctor or filled a prescription recently. Furthermore, the bill specifically says OHCA must contract with a third party to handle much of the enhanced scrutiny the bill requires. OHCA has said that they plan to release a Request for Proposals for that contract later this spring, so why duplicate efforts by moving forward with the returned mail policy?

There’s no evidence that this will save OHCA any money, although OHCA claims it will. If a SoonerCare enrollee does move out of state, they’re not able to use their SoonerCare to see a doctor or fill a prescription in their new home state. While providers do receive a small care coordination fee for some enrollees, it maxes out at about $8 per month for the most complex patients. SoonerCare members are already required to update their addresses during yearly redeterminations, so at most, a provider could net 12 months of improper case management payments, topping out at less than $100. There’s no evidence that this happens at a rate anywhere near what would warrant this proposal. Given the new bureaucratic hurdles this will create, it’s possible that the cost of this policy could actually outweigh any savings. 

Finally, HB 1270 explicitly excludes certain SoonerCare members who receive care through some programs for people with significant disabilities (TEFRA and Home and Community Based Services waivers). OHCA’s circulation document doesn’t mention those exclusions, suggesting that the new policy could apply to individuals far outside of what HB 1270’s authors intended. 

This policy rests on flawed assumptions.

With this proposed policy, OHCA is assuming that mail is a reliable proxy for residency: when mail is returned, the agency will assume that the individual has left the state and is thus no longer eligible for SoonerCare.

There’s a lot of evidence to show that this assumption is false and no reason to believe that this is true. As housing costs have outpaced wage growth, low-income families are increasingly housing-insecure. This means that they may have to pay an untenable share of income on rent (45.5 percent of Oklahoma renters spent more than one-third of their income on housing expenses in 2017), face frequent evictions (1 in 20 rental households were evicted in Oklahoma in 2016, including 1 in 14 in Tulsa and 1 in 16 in Oklahoma City), move their families and belongings between friends’ and relatives’ homes, and experience outright homelessness (between 4,700 and 5,900 people were homeless in Oklahoma City alone in 2018).

SoonerCare is by definition limited to low-income families, meaning that SoonerCare enrollees are likely to move more often than the general population. In that turmoil, families may not be able to prioritize updating their address in OHCA’s online portal. Furthermore, members at recent Member Advisory Task Force meetings have pointed out that OHCA’s member portal is difficult to navigate. In short, returned mail doesn’t mean that the members have left the state, and the agency shouldn’t assume that it does. 

SoonerCare-eligible families will be uninsured 

When people are wrongfully cut from programs they should qualify for, many of those who lose needed help don’t realize that they can re-enroll. That’s one reason why this proposed returned mail rule is so dangerous. It’s not just that low-income families may be wrongfully removed from coverage. It’s also that many won’t re-enroll and will instead join the already swollen ranks of Oklahoma’s uninsured. Oklahoma has the second-highest uninsured rate in the US. Pushing more people out of needed health coverage moves us in the wrong direction. 

For too many SoonerCare enrollees, losing care will be devastating. Two in three SoonerCare members are children, and about 1 in 6 are adults who are elderly, blind, or have a disability. About 1 in 10 are very low-income parents. For children, disruptions in access to care may affect their ability to fully participate in school. For adults who are elderly or who have disabilities, going without just one prescription can throw complex health issues into disarray. And for parents, losing access to needed care can harm their ability to work and raise children effectively.

OHCA should withdraw this proposal

OHCA has tried to assure advocates that the agency will do outreach to members ahead of implementing the new rule and will try to contact at least some individuals whose mail is returned before terminating their coverage. Both actions will likely soften at least some of the impact – but without the plan to cut coverage for members whose mail is returned, neither would be necessary in the first place. In January, the OHCA Medical Advisory Committee rejected this proposal and the agency has since decided to delay submitting the rule to its Board. While this delay is welcome, OHCA should instead withdraw this cruel and unnecessary proposal entirely.

ABOUT THE AUTHOR

Carly Putnam joined OK Policy in January of 2014. She previously worked as an OK Policy intern. A Kansas City native, Carly graduated from the University of Tulsa in December 2013 with a BA in Sociology and Women’s and Gender Studies. As a student, she was a participant in the National Education for Women (N.E.W.) Leadership Institute and interned with Planned Parenthood. She is graduate of the Oklahoma Center for Nonprofits Nonprofit Management Certification Program, the Oklahoma Developmental Disabilities Council’s Partners in Policymaking program, and The Mine, a social entrepreneurship fellowship in Tulsa. She previously served as board president for United Campus Ministry at the University of Tulsa. At OK Policy, Carly supervises policy staff and conducts research focusing on health care and the safety net.

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