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Pa. Medicaid reenrollment: What you need to know to keep your health insurance or find other options

by Katie Meyer of Spotlight PA |

People on Medicaid must renew coverage this year after the re-enrollment process had been paused for several years.
Leise Hook / For Spotlight PA

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HARRISBURG — If you’re one of the nearly 3.7 million Pennsylvanians who use Medicaid for health insurance, you’ll need to requalify for coverage over the next year.

The process can be complicated, and it could be trickier this time around because reenrollment has been paused since the pandemic began. That’s why Spotlight PA has put together a list of tips and tools that can help.

First, some context. For the past three years, a pandemic-era federal moratorium prevented states from kicking people off Medicaid even if they no longer met income or other eligibility requirements. That policy ended on April 1, but nobody will lose their coverage right away.

The state conducts eligibility assessments on a rolling basis. If a recipient is found to no longer be eligible, they have the right to appeal. And if someone has trouble with the appeal process or feels they’re being wrongly deprived of benefits, many health care access groups around the commonwealth offer their services for free.

If you’re already enrolled in Medicaid and have all your contact information up to date, you’ll hear from Pennsylvania’s Department of Human Services (DHS) several times ahead of your renewal date. The department has been sending Medicaid enrollees renewal paperwork throughout the continuous enrollment period, and if you’ve been keeping up with it, there’s a good chance your next experience will be similar.

As you go through the enrollment process, it’s worth keeping in mind that staffing shortages and high workloads in the offices that assess Medicaid eligibility could mean backlogs and delays on the state’s end.

Read on to learn the basics about the reenrollment process, how to appeal, and more. Email us at tips@spotlightpa.org if you think your problem needs a closer look.

How should I prepare for reenrollment?

There are a few key places where Medicaid recipients can go for overall assistance. These resources will come up repeatedly in this guide.

One is Compass, a DHS portal where enrollees in a range of federal benefit programs, including Medicaid, can log in, see their personal information, and make updates as needed. That’s one of the easiest ways to make sure addresses are correct and income information is current. You can also download a Compass app to your phone.

You should also know the number for the DHS Statewide Customer Service Center, which will allow you to check or update your information over the phone. Call 215-560-7226 if you’re in Philadelphia, and 1-877-395-8930 outside Philadelphia.

Medicaid recipients can also contact their local county assistance offices with questions and can visit in person if necessary, no appointment needed. You can find a list of those offices here.

The most important step you can take to make sure your Medicaid reenrollment goes smoothly is this: Confirm that DHS has your up-to-date contact information.

Online using Compass, or over the phone at the Customer Service Center, check that your mailing address, phone number, and email address are all entered and correct. DHS can use all these channels to get in touch with you.

You can also call the Customer Service Center to make sure DHS knows your language preferences.

When will I know it’s time to reenroll?

Most people will reenroll at the same time every year: the same month that they first signed up for Medicaid.

Since DHS never stopped sending reenrollment paperwork during the three-year continuous coverage period, you’ve probably been getting this paperwork annually if you’ve kept your information up to date.

If you aren’t sure when your date is, no worries. You can always check when it’ll be time for you to reenroll on your Compass account, or by calling the Customer Service Center or your county assistance office.

In the lead-up to your reenrollment, DHS will contact you in a number of different ways.

The first notice of impending renewal will come about 90 days before your reenrollment date, in the form of a letter mailed to you by DHS. About 60 days before the date, you’ll be mailed additional information about completing your reenrollment using Compass. And about 30 days before your due date, you’ll get a paper application in the mail. Here’s a list of all the communications you can expect from the department.

DHS will also be electronically communicating throughout that period, department head Val Arkoosh said at a recent state Senate budget hearing. “If we have people’s mobile phones, we are texting them. If we have an email, we are emailing them,” Arkoosh said. Learn more about making sure you get texts and emails here.

You may also see other kinds of public communication from the department, Arkoosh added. DHS is “doing a very public-facing campaign with radio ads, digital ads, ads on public transportation, sort of everything that we can think of,” along with public events.

If you think you should be getting these communications and aren’t, double-check your information on Compass or call the Customer Service Center or a county assistance office.

How will I know if I’m still eligible?

Before getting into the nitty-gritty of Medicaid eligibility, a note: DHS says that even if you think you’re no longer eligible for Medicaid, you should apply anyway.

In her recent state Senate budget hearing, Arkoosh said that DHS has been trying to create a “warm handoff” between Medicaid and Pennie, Pennsylvania’s health insurance marketplace.

“We’re encouraging everybody to send us their paperwork even if they think they’re no longer eligible, because by doing so, we can hand them off to Pennie,” Arkoosh said. “Pennie will have their information, and then Pennie will work with them to find a plan that suits their needs.”

An unusually high number of people will likely have to switch from Medicaid to private insurance this year because people have been barred from losing coverage for so long, regardless of eligibility. The commonwealth’s total number of Medicaid recipients is about 30% higher than it was before the pandemic, and the Shapiro administration estimates that hundreds of thousands of people will no longer meet income or other eligibility requirements.

If you don’t fall into several special categories that would qualify you for some other form of assistance — say, you’re over 64 or have a disability — the general rule of thumb for Medicaid qualification is that you are eligible if you are an adult with an income at or below 133% of the federal iIncome poverty guidelines.

For a single person, that’s $19,391 per year; for a family of four, it’s $39,900. You can check this chart for more numbers, including monthly income thresholds.

But those numbers don’t account for the many other factors that could impact your Medicaid eligibility, including whether you are a pregnant parent, whether you have children, the number and ages of your children, and whether you have a range of other income beyond gross pay, including interest and dividends, Social Security, or a pension.

You can check this DHS informational page for eligibility information that applies to your particular circumstances. If you really want to get technical, read the commonwealth’s medical assistance eligibility handbook here.

How do I reenroll?

You’ll have a few options when it comes time to renew your Medicaid.

You can reenroll:

  • By mail. When DHS mails you your paper application, just fill it out and mail it back using the return envelope included in your renewal packet.

  • By dropping off physical documents. You can bring your completed paper application in person to your county assistance office. These offices can also offer assistance if you’re struggling with completing your forms. You can find the nearest location here; large counties have multiple offices.

  • Online. You can complete and submit your application online using the Compass website.

  • By phone. If you call DHS’ Consumer Service Center at 1-866-550-4355, you can complete your application over the phone.

What if the state says I’m not eligible, but I think I am?

DHS expects hundreds of thousands of people will lose Medicaid because they no longer qualify. But the state also fears hundreds of thousands are also at heightened risk of wrongly losing coverage because of logistical issues related to reenrollment like bad contact information or blown deadlines.

This concern is compounded by staffing woes at the DHS offices that handle reenrollments, which means caseworkers could get overloaded.

Put simply, it’s always possible for DHS caseworkers to make a mistake. If you think that’s the case, you have some options. Community Legal Services of Philadelphia, the Pennsylvania Health Access Network, and the Pennsylvania Health Law Project have a list of actions to take if you’re concerned you’re being wrongfully denied coverage. Key points are summarized below.

First, appeal.

If you’re found to be ineligible for Medicaid, DHS should inform you in a letter. This letter will include an appeal form, and you will have at least 30 days from the time the letter was mailed to initiate an appeal. You may get more time if you didn’t receive a letter, or if it wasn’t in your preferred language.

Some important things to know about appeals:

  • If you don’t get a letter, the advocacy groups mentioned above advise that you can use any piece of paper that says “MA appeal” and includes your signature and the date.

  • You have the right to ask for an interpreter if you need one.

  • You can submit your appeal to your county assistance office in person, or mail the appeal. If you choose the latter option, the groups advise that you try to use certified mail so you have proof of the date you sent the appeal.

  • When you file the appeal, you can ask to keep your Medicaid coverage while you wait for a hearing.

  • Don’t be afraid to ask a legal aid group for assistance. You can find a list of local groups and their contact information here.

Second, ask for reconsideration.

If you lose access to your Medicaid because of a renewal issue, you have up to 90 days to ask the state to reopen your case. If you lose access for some other reason, you have 60 days.

Contact your county assistance office or the Statewide Customer Service Center (call 215-560-7226 in Philadelphia, 1-877-395-8930 elsewhere) and say you want your Medicaid cutoff to be reconsidered. You can also ask for reconsideration by submitting any paperwork that was missing from your initial application.

Third, apply again.

If you still believe you qualify for Medicaid, you can always initiate a new Medicaid application using any of the methods listed above: Compass, a paper application, or a phone call to your county assistance office or the Customer Service Center.

How can I keep my kids covered?

If your child had health insurance under Medicaid but you’re concerned that your family is no longer eligible, you still have options through the Children’s Health Insurance Program.

In Pennsylvania, CHIP offers insurance to any child under the age of 19. It has higher income floors than Medicaid, so even if your family no longer qualifies for that program, CHIP may still provide free insurance for your kids. It also includes low-cost options for a slightly higher income tier, and full-cost insurance options for all income tiers.

If, for instance, you have a family of four and a gross income between $39,900 and $62,400, any minor in your household aged six to 18 gets free CHIP coverage. The income floor for kids younger than six in this scenario is $47,100, because younger children have a slightly higher income ceiling to qualify for Medicaid.

The full 2023 income guidelines and CHIP tiers are laid out in this chart. If your income is lower than any of the income thresholds listed, your family likely qualifies for Medicaid coverage.

If you no longer qualify for Medicaid but do qualify for CHIP, your county assistance office is supposed to automatically refer your case to the CHIP program.

If you think your children should qualify for CHIP but you haven’t been referred, contact your county office and ask. If you qualify for CHIP, you’ll now be getting your insurance through a private company that contracts with the state. You should go to this provider with questions about benefits and premiums.

Lots of families will likely transition from Medicaid to CHIP this year.

In a letter to DHS earlier this year, a consortium of groups that advocate for health insurance access estimated that “tens of thousands” of children currently enrolled in Medicaid will become eligible for and likely transfer to CHIP during this year’s reenrollment, generally because their family now makes too much to qualify for Medicaid.

If you have already been using CHIP, be aware that there’s a significant change coming to the system this year. Starting April 17, all CHIP eligibility assessments will be conducted through DHS, rather than through a health care provider.

This means CHIP reenrollment materials will now come from DHS, and any questions about reenrollment should now be directed to your county assistance office or the statewide customer service center (call 1-877-395-8930 for assistance, or 215-560-7226 in Philadelphia).

Are there any other options if I don’t qualify for Medicaid?

A few! But only if you fall into certain categories — and you might already be using them.

If you are younger than 19, you may qualify for CHIP. See the above section for more details on figuring out if you’re eligible, and how to get the process rolling.

If you are 65 or older or have been getting Social Security disability payments for more than two years, you may be able to get Medicare, a federal insurance program. You can apply using the Social Security Administration (SSA) website, or by calling the administration’s main toll-free line at 1-800-772-1213. You can also contact Pennsylvania Medicare Education and Decision Insight, or PA MEDI, at 1-800-783-7067.

If you are 19 or older and don’t qualify for Medicaid or Medicare, you may be able to get insurance through Pennie, the health insurance marketplace for Pennsylvania residents.

Because of the “warm handoff” between DHS’ Medicaid offices and Pennie, DHS should automatically mail you information about Pennie if you’re found ineligible for Medicaid.

You can also get additional help with Pennie insurance from the nonprofit Pennsylvania Health Access Network by calling 1-877-570-3642.

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