Starting Saturday, states across the country will be able to drop large numbers of people off Medicaid who were allowed to stay in the program during the COVID-19 pandemic. That includes some 1.5 million Minnesotans in low-income health programs, many of whom will soon be in danger of losing needed coverage.

Those at risk who are still eligible can stay on the Medicaid rolls without seeing a gap in coverage, but only if they complete the renewal process by the state’s rolling deadlines.

Worried about the potential staggering impact of hundreds of thousands of Minnesotans losing their health coverage, officials are working now to re-up those affected. But it’s a daunting task, one the state system could make more difficult.

“We are estimating anywhere from 15 to 30 percent may lose access or not renew,” said Dr. Nathan Chomilo, director of Medicaid at the Minnesota Department of Human Services. “Out of those, anywhere from 25 to 50 percent will likely be able to renew within the next six months and so indicating that they likely would have maintained eligibility if they had gotten through the process.” 

Mountains of paperwork

Medicaid is a health insurance program administered by states according to federal requirements that supports people who are low-income. Eligibility is based on income and asset levels. Once in the program, recipients go through a regular reevaluation process where their income is assessed to ensure they continue to meet the limits for coverage. 

For three years, that renewal process was put on pause as the COVID-19 pandemic swept the country. To keep people from losing health insurance when they needed it most, the federal government boosted funding to states that enacted continuous Medicaid coverage. Since then, states generally haven’t kicked people off the program unless they asked to be removed. 

States have about a year to complete the reenrollment, with each approaching the process differently. In Minnesota, people who are enrolled in two different programs are being evaluated: Medical Assistance — the state’s name for its Medicaid program — as well as MinnesotaCare, a state-specific program for people who make too much to qualify for Medicaid. 

For Medical Assistance, renewals are being processed on a rolling basis, with people placed in different cohorts based on the date that they originally enrolled in coverage. 

While that may make it easier for officials processing the paperwork, it creates its own challenges for those affected. “You might hear about it and think you’re ready. But then you have to wait until the actual kind of month of your renewal. And so it does add a different layer,” Chomilo said. 

That process can be complicated, a reality people who work in local clinics know intimately. 

Geraldine Cereceda remembers her first encounter with the complex U.S. health care system after her son got sick shortly after she immigrated with her family from Peru to Minnesota.

“I had no idea where to start, the system was terrible. [It was] difficult for me to understand it,” she recalled. 

Cereceda went to Southside Community Health Services, a federally qualified health center in south Minneapolis, and got the help she needed. For the last 22 years, she’s been giving that help back as a patient advocate, and now the clinic’s community engagement manager. She and her small team help educate people about their options and get signed up for coverage through MNsure, the state’s health insurance marketplace. 

The team is busy, and they don’t expect things to let up anytime soon as a majority of the patients they see prepare to go through the Medicaid renewal process. 

Minnesota, however, is one of only a few states where coverage cannot be renewed online. The only way to complete the renewal is through the paper forms sent to recipients in the mail.

While some insurance navigators said that an online system wouldn’t necessarily fix everything, Cereceda at the Southside clinic said having the option would make a difference. 

“Everybody has access, even if they don’t have a computer, to their phone,” she said. “Why is that not possible? Everybody knows how to manage their phones.” 

State officials said that the infrastructure for an online system has been in the works since February 2022. But with Medicaid reevaluations coming up, DHS officials didn’t want to rush the rollout, and said they’re working to support applicants in other ways. 

“We are also working with many partners and community organizations to ensure enrollees are supported through community outreach efforts, assistance with completing their renewals including completing forms over the phone, enhanced staffing and follow up when someone does not return their form,” officials said in a statement. 

With so much of the renewal process reliant on the mail, that’s placed increased pressure on recipients, and the insurance navigators aiding them, to ensure county and tribal offices, who work with the state to administer the program, have the correct information on file. And that this crucial paperwork doesn’t end up at the wrong place. 

That’s no small problem. An analysis from the nonprofit Kaiser Family Foundation found that people who have moved since the start of the pandemic, those with limited proficiency in English and people with disabilities are at the highest risk of losing Medicaid coverage during this process. National estimates suggest 15 million people could be dropped during this process, and nearly half of those (6.8 million) would lose coverage despite still being eligible. 

For Marlon Hernandez, a MNsure navigator at Neighborhood Health Source in northeast Minneapolis, that means spending a lot of time on the phone with patients and county officials updating addresses. Some are easier than others. 

“For example, if I have Anna coming in to me [and] she lives in Anoka County, we can definitely make a phone call. It might take 20 minutes for us to get to somebody and let them know that Anna’s address has been changed,” he said. Others, like Hennepin County, answer almost instantly, he said, and have the address changed quickly.

While changing an address is only a small part of the process, and the system is set up for recipients to be able to complete this and other processes on their own, patients may find it easier to have a navigator there with them. Some patients may have language or education barriers, or are overwhelmed by the process itself.

“Most of our communities that we serve, they’re in poverty. So poverty in of itself is a major barrier,” said Stella Whitney-West, CEO of Northpoint Health & Wellness Center in north Minneapolis. “So when folks are trying to deal with housing and just basic needs, this becomes another layer of complexity to their lives. It’s amazing to me how we pile on the most on top of people who have the least.”

But with hundreds of thousands of people at risk of losing coverage, there aren’t enough navigators to help every single person who might need them. Like other health-related professions, navigators have seen staffing turnover and shortages since the pandemic.

To ease some of the burden on Medicaid recipients and navigators, on Monday, the Minnesota Senate passed a bill that would add more flexibility into the Medicaid renewal process and more funding for MNsure navigators. The House is expected to take up the bill this week. 

Meantime, at the Southside clinic, navigators try to see as many patients as they can. Appointments are scheduled two months out, so they try to connect with more patients in between meetings or squeeze them in if someone cancels, but the team is stretched thin.

The already long wait time has raised concerns about whether or not they’ll be able to see all the patients they need to before their Medicaid renewal paperwork is due. While Cereceda said she’s confident they’ll be able to move people through the process, she’s worried about the strain on herself, her team and the organization. 

As a federally qualified health center, the clinic won’t refuse service, and offers a sliding-fee scale that people can access if they have a lapse of coverage during this process, but she said she’s concerned about how to sustain that for everyone who might now need it. 

“I can see all the weight — the bearing weight is going to come on us, and we’re going to be struggling with funds,” she said. “We are here to help the consumer to have easy access for health, but if we don’t have the tools, it’s gonna get tough.”