Federal exchange sends unqualified people to Medicaid

• Questionable Medicaid reports coming from states including Illinois%2C Texas and Michigan
• Woman due in February fears she%27ll be without insurance coverage when her baby is born.
• More complete Medicaid files going from HHS to states this week

The federal health care exchange is incorrectly determining that some people are eligible for Medicaid when they clearly are not, leaving them with little chance to get the subsidized insurance they are entitled to as the Dec. 23 deadline for enrollment approaches.

State and industry officials haven't quantified the problem yet, but the National Association of State Medicaid Directors may release information next week after following up on reports from around the country, says Executive Director Matt Salo.

Here's what happens: When consumers applying for insurance put their income information into subsidy calculators on HealthCare.gov — the exchange handling insurance sales for 36 states — it tells them how much financial assistance they qualify for or that they are eligible for Medicaid. If it's the latter, consumers aren't able to obtain subsidies toward the insurance, although they could buy full-priced plans.

If the Medicaid determination is wrong, consumers should file an appeal with the federal marketplace, says Department of Health and Human Services spokeswoman Joanne Peters, but she says she does not have an estimate on how long that would take.

Brokers are reporting that some of their clients are in insurance limbo as they wait for the error to be corrected by HHS or their states so they can reapply.

Jessica Waltman, top lobbyist for the National Association of Health Underwriters, says she's heard a number of reports from around the country of people making as much as $80,000 a year being told they qualify for Medicaid on HealthCare.gov.

"I have heard on multiple occasions from brokers in various states over the past eight weeks that they have had wacky Medicaid determinations with people who clearly make way too much money for Medicaid," she says.

HealthCare.gov is "working smoothly for the vast majority of users," says Peters, but she noted some people may have technical difficulties or complicated family or tax situations that require extra assistance.

HHS has added more call center employees and in-person assistants for people who need extra help, she says.

But insurance brokers say that when people call the HealthCare.gov "800" number to explain that they can't possibly be eligible for Medicaid, they are told they are eligible if the site says so.

"It's a very, very unfortunate state of affairs," says Waltman.

HHS said it will begin sending Medicaid application files to states this week given that HealthCare.gov's mechanism to transfer accounts to state Medicaid offices still isn't working. The data received up until now haven't given states enough information to determine Medicaid eligibility, says Salo, but he hopes that, as promised, the new files will.

"Claims from some states about our process for testing the Medicaid eligibility and enrollment systems are inaccurate," says Peters. "We are eager to work with states to ensure their systems are functioning properly and to extend Medicaid coverage to those who are eligible through the generous Medicaid funding made possible by the Affordable Care Act."

HHS is working "extremely hard" to make sure people will have coverage no matter what on Jan. 1, says Salo. While states support that goal, "some want more assurances that people enrolled in Medicaid are actually eligible," he says.

HHS has told states they won't be penalized if they enroll people in Medicaid who HHS erroneously said were eligible, says Salo.

That's little consolation for consumers who can't buy subsidized insurance on the exchange because of apparent mistakes.

Jacob Hawkins of Plano, Texas, makes about $50,000 a year as a self-employed pool builder, yet his family of three was deemed eligible for Medicaid. His wife, Holly, is due to have their second child in February and is worried she won't have insurance in time. She filed an appeal of the Medicaid determination, but doubts it will be approved before the Dec. 23 deadline.

"I'm frustrated, mad and there's no one to help," says Hawkins.

Being married with a $50,000 income will get you a decline from Medicaid, even with a pregnant wife, says Hawkins' broker, Connie Louanne Trebing. " I know, because I just had a couple declined in a similar situation," she says.

Some of the files of those supposedly eligible for Medicaid in Texas include people who don't live in Texas and who are already signed up for Medicaid, says Stephanie Goodman, spokeswoman for the Texas Health and Human Services Commission.

Illinois expects about 19,000 files shortly from HHS. Illinois state spokesman Mike Claffey says he doesn't know how many may have problems, but Chicago broker Jordan Wishner says seven of them will be from his office and definitely will be wrong.

He has three clients of his own and an agent in his office has another four who are clearly above 138% of the federal poverty limit ($32,499 for a family of four), yet are being told they are eligible for Medicaid, which blocks their efforts to buy subsidized insurance.

"What am I supposed to do with the clients that are being told they qualify for Medicaid when they actually do not?" asks Wishner, who owns The Health Insurance Shoppe, a retail insurance store. "Send in an appeal with 16 days left? Seriously?"

With this much uncertainty, "it's frustrating that there is no place for a broker to get help with errant cases and try to avert problems," says Waltman.

State exchanges and insurance companies have dedicated customer service support for insurance agents and brokers who try to correct problems "before they escalate," says Waltman. On the federal exchange, brokers call the same help line as consumers.

"We do not want this woman giving birth and not having coverage," says Waltman, referring to Hawkins. "This is absolutely what the law was trying to prevent from ever happening again."

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