CORRECTION, April 1, 2023: The timeline of when notices will be sent by DHHS has been corrected. First notices will go out in April, not May. An additional note that DHHS will contact members by text message was also added to the end of the original story.
Before Covid, anyone enrolled in Medicaid had to reenroll annually in order to stay covered. A pandemic-era measure that suspended the need to reenroll ends today, March 31 – meaning that states will go back to evaluating (or “redetermining”) who is eligible to remain on Medicaid, as they did prior to 2020. Those deemed ineligible, or those who do not reapply, will be disenrolled.
But a return to the old normal might prove problematic for millions of Americans and hundreds of thousands of South Carolinians, three years into the new normal.
“We had three years of increased enrollment,” says Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation, or KFF.
In other words, a lot of people enrolled in Medicaid during the time when the need to reenroll was off the table. Consequently, Tolbert fears a lot of people will lose their coverage, but not because they don’t qualify to keep it.
“The problem is, we estimate that about half of those who will be disenrolled will actually remain eligible for Medicaid, but [will get] caught up in paperwork,” she says.
The South Carolina Department of Health and Human Services, or DHHS, manages the state’s Medicaid program through its Healthy Connections portal, where you can apply for Medicaid coverage. And while DHHS and numerous community organizations (more on these at bottom) provide application assistance to help you get through the online paperwork, the process can still be daunting and complicated.
That’s also true for those reenrolling.
“It’s not a seamless process,” Tolbert says.
Why South Carolina is especially vulnerable
South Carolina is one of 10 states that has not expanded Medicaid access. In 2021, 14 holdout states were offered extra incentive to adopt expansion under the American Rescue Plan Act (ARPA) – a two-year bump in funding to cover up to 400 percent of the cost of adopting expansion. Then-holdouts South Dakota, Missouri, Oklahoma, and, most recently, North Carolina have since expanded.
South Carolina Gov. Henry McMaster, however, effectively called the ARPA offer a bad deal for the state. In March of 2021, McMaster’s spokesman, Brian Symmes, told the Associated Press that “Gov. McMaster isn’t for sale.”
McMaster himself said, “The way to good health is good employment, good education. That’s the better way. It always produces positive results.”
How this comes into play with a return to Medicaid redetermination is that in non-expansion states, anyone booted from Medicaid coverage will have nowhere to turn.
“In these non-expansion states, there is no help,” Tolbert says, “I would say most of the adults who lose [their Medicaid] coverage will not be able to get [replacement] coverage because their income is too low. They will become uninsured.”
South Carolina DHHS also manages enrollment for federal Marketplace insurance coverage, which was made available under the Affordable Care Act. ACA coverage exists so that adults can find health insurance plans not available through their employers – which means enrollees in the Marketplace need to have a certain level of income. If you make too little money to qualify for a Marketplace plan, that’s where Medicaid comes into play.
'People need to be on the lookout for this renewal notice over the next year.'
So what Tolbert fears will happen in South Carolina and the nine other non-expansion states (Alabama, Florida, Georgia, Kansas, Mississippi, Tennessee, Texas, Wisconsin, and Wyoming) is that those who fall off the Medicaid rolls will fall into “the gap” – the space between making too much to qualify for Medicaid coverage and making too little to qualify for Marketplace coverage. This is the gap Medicaid expansion is intended to close.
According to KFF, 58 percent of people who land in the coverage gap are in families with at least one working member; 43 percent of those in the gap have jobs. This, for Tolbert, makes for an ugly irony.
“These are people who are working,” she says. “And that’s why they don’t qualify for Medicaid. But they’re working in low-paying jobs.”
And that’s why they don’t qualify for Marketplace coverage.
And for reference, South Carolina has the 12th-lowest rate of uninsured residents in the U.S., according to the Urban institute.
Don’t forget the children
Part of the Medicaid program is the Children’s Health Insurance Program, or CHIP. Medicaid advocates are worried that as parents are disenrolled over the next 12 months, children will also be kicked off CHIP. Many will age out of the program, having reached adulthood since being covered by CHIP these past three years; others, advocates fear, will get dropped because their parents get dropped.
CHIP allows for families to have higher incomes to qualify than Medicaid allows for singles. But even though “children and adults should be assessed separately,” Tolbert worries that this will not always work out for families.
“A concern in non-expansion states is that … low-income kids will remain eligible [for CHIP], she says, “but because parents may lose coverage, children may lose coverage.”
The Medicaid landscape in South Carolina going forward
Nationally, KFF estimates that between 5 million and 14 million Americans could lose their Medicaid coverage. In South Carolina, DHHS has estimated between 200,000 and 300,000 enrollees could get booted from coverage.
Prior to Covid, 1.05 million South Carolinians were enrolled (that’s about one in five residents, by the way). DHHS’s March numbers show 1.296 million enrollees in Medicaid managed care – which refers to benefits and additional services provided through contracted arrangements between state Medicaid agencies and managed care organizations that accept payments for services, as define at Medicaid.gov.
Quick math shows that the number of enrollees since 2020 and the number DHHS fears might lose coverage over the next year are eerily similar.
Sue Berowitz, director of SC Appleseed Legal Justice Center, says she that while the number of South Carolinians facing lost Medicaid coverage will be significant, “I don't think the numbers are quite that high. We do think that there are at least 105,000 people … not necessarily that are on Medicaid now, that have no other way of getting healthcare access.”
Jennifer Tolbert at KFF, on the other hand, doesn’t think DHHS’s estimates are too far off.
“We’re seeing some pretty extreme numbers across states,” Tolbert says. “South Carolina’s are probably in the ballpark.”
What’s important to keep in mind is that these numbers are all just guesses, and mainly worst-case scenario guesses.
Given the attention being paid to the end of pandemic reenrollment protections, she says more people could end up staying on Medicaid because they’re hearing how important it will be to reapply.
Redetermination and disenrollment will not happen immediately, and enrollees need to know that
The suspension of redetermination – the process of evaluating applications to stay enrolled in Medicaid – officially ends on April 1, 2023. But that doesn’t mean people will be dropped from Medicaid that day.
While DHHS will send out its first renewal notices this month, the first disenrollments are not likely to begin until June, as enrollees have 60 days to return notices, says Jeff Leiritz, spokesperson for DHHS.
This is a critical issue, says Tolbert.
“People need to be on the lookout for this renewal notice over the next year,” she says. “This is going to take a full year.”
She urges Medicaid enrollees not to think they’re safe this month or even in August just because they haven’t gotten a renewal notice in the mail. They will come, she says, throughout the next 112 months, and anyone on Medicaid needs to be alert for it – not to mention they need to read it and contact DHHS or a local social services agency to help them navigate reenrollment.
Some people will no longer qualify for legitimate reasons, such as that they qualify for other coverage. But many will get booted for “procedural reasons” that can be avoided, Tolbert says.
What you can do to maintain Medicaid coverage in South Carolina, and how to get help
- Be on the lookout for your renewal notice
- Contact DHHS when you receive yours
- Get help from community services organizations that have Medicaid application assisters, federally approved navigators, and information centers for Medicaid and health insurance coverage – they can walk you through the process.
Following is a partial list available to residents of South Carolina.
You can also check with your county library and with local NAACP chapters, many of which offer assistance with enrolling in Medicaid, CHIP, and Marketplace plans.
Berkowitz says SC Appleseed will also be working with local agencies and places of worship to get the word out about the importance of reenrolling over the coming year.
Leiritz says DHHS will also “text members who we have phone numbers for … and will send a follow up notice at the 30-day mark of that 60-day period if we have not heard back from members.”