Since Nevada Medicaid resumed eligibility checks for beneficiaries in June of last year, only an average of 5 percent of Nevadans deemed ineligible for the publicly funded insurance program each month have managed to enroll in a plan through the state’s health insurance exchange.

Beneficiaries no longer eligible for Medicaid or the Children’s Health Insurance Program (CHIP) coverage are being removed after the end of a pandemic-era policy that kept recipients continuously enrolled regardless of fluctuations in income. At a pandemic peak, about 1 in 3 Nevadans, more than 958,000 people, were covered by Medicaid, but roughly 200,000 Nevadans’ health care coverage is expected to be affected by the more frequent checks, called “redetermination.”

Though the 5 percent enrollment rate is low, Russell Cook, the director of Nevada’s health insurance exchange, Nevada Health Link, said the numbers don’t account for people who lost coverage because they didn’t complete a renewal application or have since signed up for new insurance through an employer.

“[The rate] derive[s] exclusively from the subset of consumers that have lost Medicaid or CHIP coverage for that reason of excess income,” Cook said in an interview with The Nevada Independent. “So other than that, it’s essentially a blind spot.”

Nevada Health Link offers government-subsidized health plans for Nevadans who do not qualify for Medicaid or Medicare or do not get coverage through their employer. Nine out of 10 enrollees qualify for premium reductions, and nearly half pay less than $100 per month.

Cook said that in any given month the exchange receives referrals from Nevada Medicaid for approximately 10,000 to 12,000 people who no longer qualify for Medicaid or CHIP because their household income is above the eligibility threshold. However, some are duplicate referrals for the same households. He added that those referrals do not include people who were booted off for inability to reply to requests for information or those who were terminated for a “procedural reason” (which makes up the majority of terminations).

Still, he said the exchange would like to see higher rates of people who lost Medicaid have access to insurance and is focusing on ensuring the public is informed about a special enrollment period for those kicked off Medicaid because of the public health emergency unwinding process. 

As part of that goal, he said the exchange, in partnership with Nevada Medicaid, is rolling out a text messaging campaign that he estimated will reach more than 80,000 residents and clear a backlog of approximately 40,000 households that lost Medicaid or CHIP coverage more than 60 days ago.

But he said it’s important to remember that the unwinding process is a return to pre-COVID-19 pandemic standard practices. 

“Had the [Public Health Emergency] never been enacted in the first place, all of these folks would have been redetermined,” Cook said.

A Medicaid enrollment and unwinding tracker from health policy research group KFF indicated that as of Tuesday, Nevada has a 36 percent disenrollment rate for completed reviews (pending renewals are excluded), placing the Silver State in the top 20 highest disenrollment rates across all reporting states.

Officials from Nevada Medicaid said in a statement that as the unwinding process has occurred, approximately 80 percent of those enrolled in Medicaid have been renewed. Of those disenrolled for “procedural reasons,” the statement said typically, about 30 percent reapply and are determined to be eligible.

For families who have been disenrolled, officials said that they can reapply if circumstances change or if they forgot to turn in paperwork; they can also request medical coverage for the three previous months from the application date.

“Historically, Medicaid enrollment has always fluctuated, people move, people gain insurance through employers, and it has always been a struggle to reach the unhoused population,” the statement said.

Regaining coverage

The exchange offers two options for people no longer eligible for Medicaid coverage. 

If the eligibility loss occurred within the last 60 days, families or individuals can enroll through the exchange with no gap in coverage. If the loss of coverage occurred more than 60 days prior, a special health insurance enrollment window, open through Nov. 30, allows families or individuals to enroll in coverage that begins on the first of the following month, but assistance from the Nevada Health Link call center will be required to process the enrollment.

Though applying for coverage within the 60-day window is ideal, and anything beyond that timeframe won’t qualify for retroactive coverage, Cook said anyone who lost Medicaid coverage since April 2023 can enroll in health insurance coverage through the exchange without waiting for the annual open enrollment window.

Cook added that some of those who lose Medicaid coverage are receiving health insurance through work, noting that Nevada Health Link does not track the number of people doing that. 

What is known, he said, is that each month, between 20 percent and 30 percent of people who lost Medicaid coverage and submitted an application through the exchange don’t qualify for subsidies because their income is too high.

Others do qualify for subsidies, but don’t take advantage of them. In any given month, Cook said fewer than half of the people who apply to the exchange after no longer qualifying for Medicaid and who, on average, qualify for several hundred dollars worth of tax credits that would reduce their monthly premium, don’t enroll in the exchange coverage.

He said his biggest worries surround these individuals who may make too much to qualify for Medicaid but struggle to afford health insurance, even with the subsidies offered through the exchange.

“My biggest concern is that these folks don’t have any other options for coverage and that even with the tax credits that they qualify for, that the net premium that they’re left with is still going to be out of their reach after transitioning off of Medicaid coverage,” Cook said. “And that’s really not an issue that is easy to solve.”

Reaching residents

Throughout the unwinding period, Cook said the exchange has made a consistent effort to reach out to community groups and advertise information about the special enrollment period for those who are no longer eligible for the Medicaid program in addition to the standard 76-day open enrollment period for health or dental care plans that runs from Nov. 1 to Jan. 15.

Data from Nevada Health Link indicate a surge in enrollment during the standard open enrollment period from people who no longer qualify for Nevada Medicaid, reaching 13.4 percent in December and 16.2 percent in January. 

Cook said this indicates an opportunity to communicate with people who no longer qualify for Medicaid or CHIP in a “more accessible manner,” such as through the recently launched text messaging campaign.

“We’ve really tried to hone in on that [message of], ‘Hey if you lost Medicaid coverage at all, come to Nevada Health Link, you can get enrolled in coverage,’” he said. “And if you happen to be within the 60 days, we can do [that] with no gap.”

Cook said that finding out you’ve lost Medicaid coverage while at a doctor’s appointment or other health care visit can be an “abrasive” experience. He said the exchange has done everything possible to ensure that the latest information is available and is aiming through the new initiative to provide simple instructions and links to enrollment assistance in a convenient format.

“We’re trying to come at this from all angles,” he said.

One of the challenges with people who have recently lost Medicaid is that they may not have a current mailing address on file with the agency, Cook said, and may be unaware that they’re no longer covered under Medicaid. He said that reaching people via text message may be a more effective way to communicate with them.

The Federal Communications Commission relaxed guidance last year in anticipation of the unwinding that gave state-based exchanges authority to contact people who were transitioning off of Medicaid or CHIP coverage to ensure continuity of care. If the texting campaign is successful, Cook said he would consider continuing it, but it depends on if the contact is still allowed when the special unwinding enrollment period ends.

As of early May, Cook said the exchange had a backlog of approximately 40,000 households that had lost Medicaid or CHIP coverage more than 60 days before and the exchange will focus on that cohort while messaging people who lost coverage more recently. He estimated that the backlog could be cleared by the middle of June.

“By the beginning of June, I expect that individuals who have an SMS-enabled phone number on file, and who lost their Medicaid coverage within the previous couple of weeks, will get the text message from us,” Cook said.