High disability claims among S.C. applicants for insurance

07/24/2014 11:06 PM

07/24/2014 11:08 PM

Many of the nearly 16,000 people involved likely misunderstood the confusing question on the marketplace website and will be turned down for Medicaid coverage.

South Carolinians who applied for coverage on the new federal health insurance marketplace claimed disabilities at twice the state’s typical disability rate.

Many of the nearly 16,000 people involved likely misunderstood the confusing question on the marketplace website and will be turned down for Medicaid coverage. Checking the eligibility of those claims for disability will put an extra burden on the S.C. Department of Health and Human Services, which handles Medicaid in the state.

The work will be handled by moving some responsibilities around and bringing in a few temporary workers, said Beth Hutto, deputy director for eligibility, enrollment and member service at HHS.

“It is hard to understand,” Hutto said of the federal application’s questions on disabilities. “I’m a lawyer, and I have trouble understanding it.”

Hutto doesn’t suspect applicants were trying to cheat the system. “They just wanted coverage, and this looked like an avenue for coverage,” she said.

The federal Centers for Medicare and Medicaid Services in early May sent information to the state about 37,000 applications involving about 90,000 people. Those were the S.C. residents who had applied for coverage on the health insurance marketplace and were considered likely to be eligible instead for Medicaid.

State officials were surprised to find that 15,000 of those cases, accounting for 16,000 people, were considered potentially eligible for Medicaid based on disabilities or because they needed long-term care. That’s about twice the normal rate of applicants in those categories, Hutto said. Typically, low-income parents and children are the majority of Medicaid cases.

State officials don’t know what to make of the increase in disability claims. HHS director Tony Keck wondered if many belong to a group more likely to be disabled that had been “disenfranchised from the system” in the past – such as the homeless. The Affordable Care Act paid for marketing and outreach efforts to draw in applicants.

Part of that outreach involved navigators hired to help people through the application process. Wanda Pearson, who led the local navigator effort for The Cooperative Ministry, said the higher percentage who reported disabilities doesn’t surprise her.

Because the state’s leaders turned down the expansion of Medicaid for low-income residents, a disability would have been their most likely route for getting on government health care rolls. Also, the threshold for disability consideration appeared to be low on the application. Two questions asked if applicants had trouble performing tasks of daily living, such as getting out of bed or going to the bathroom without assistance. A “yes” to those along with certain income levels would have kicked the application to the Medicaid list.

“I think there were people who had tried before (to gain Medicaid eligibility) and been turned down,” Pearson said. “They saw the landscape changing and decided to try again.”

Navigators also said the federal application didn’t make it clear that simply answering “yes” to those questions might put applicants in the potential Medicaid disability pool.

“A vast majority of them probably don’t realize they put themselves in that position,” said Loreen Myerson, a navigator with the S.C. Progressive Network in Charleston. “It was not a defacto request for Medicaid. Many of them will be surprised when they are contacted.”

Hutto said it would be easy for someone with diabetes or some other chronic disease to read those questions and check “yes.” Those conditions do “interfere with daily life, but they don’t rise to the Medicaid definition of a condition that interferes with daily life.”

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