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Illinois deals with Medicaid application backlogs

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Vincent Guerrero applied Dec. 10. Donald Weeks, a diabetic who suffered a heart attack a few years back, submitted his application Dec. 23.

Three months later, neither man has gained coverage under Medicaid, the state-federal health insurance program that was expanded Jan. 1 for hundreds of thousands of low-income Illinoisans as part of the Affordable Care Act.

Their applications are among a backlog of more than 200,000, some that date to October. Unprecedented demand for the taxpayer-funded coverage caught the state flat-footed.

Illinois officials initially expected 200,000 people to sign up for Medicaid under the expansion in 2014. But through last week, more than double that number have applied. And amid a marketing blitz, officials expect a surge of additional applications by the end of the year.

Unlike new commercial insurance products, which consumers can purchase through March 31, there's no deadline to sign up for Medicaid. By the end of the year, state officials expect about 350,000 new users to be enrolled in the program.

The growing backlog is causing concern among health care providers worried about getting paid, and confusion, frustration and anger among consumers, whose coverage was supposed to begin in January.

"This is the first time I've ever been uninsured, and it's really nerve-racking," said Guerrero, a 26-year-old who lives in the Avondale neighborhood and works part time at a Mariano's grocery store.

Because of his low income, Guerrero, who was previously covered by his mother's employer-based coverage and a short-term, high-deductible plan, doesn't qualify for federal subsidies to buy a private plan. He was counting on Medicaid coverage to kick in three months ago.

But since submitting his application, Guerrero hasn't heard from the state.

"The thing I'm most frustrated with is all the sweet talk about how this was supposed to be so easy. Somebody has to step up and say, 'We messed up,'" he said. "It's inexcusable."

Last year, Illinois added about 800 workers to help process the expected boom of Medicaid applications, but it has had to make additional emergency hires in recent months. About 25,000 applications per week are being processed, up from about 8,000 a week in November.

"We certainly apologize for the delays, and we recognize their need for health coverage," said Jennifer Wagner, an associate director within the Illinois Department of Human Services. "We ask them to continue to be patient to the extent possible. We've got to get through these bumps in the road, and once we do, it's going to be great."

Patience is wearing thin for many consumers, some of whom held off on buying policies because they expected Medicaid coverage would kick in.

Under the health law, Illinois extended coverage to any adult making up to $15,500 a year or a family of four with annual adjusted income of $31,700.

Donald Weeks, 55, is on four medications for diabetes and heart problems that were previously covered by employer-sponsored insurance that he lost in June when he was laid off. The Bristol, Ill., resident, who is interviewing for jobs, applied for Medicaid on Dec. 23, hoping his coverage would begin Jan. 1.

Weeks, who has a hearing problem and does not use a computer, has been relying on his mother to help him navigate the process.

As of last week, Weeks hadn't heard from the state, and when his mother, Josephine Hanlon, calls or logs on to the state website, his status shows as "submitted."

He was supposed to see a physician this week for a checkup because of his heart condition, but because his coverage has not been approved, he had to cancel.

"It's a nightmare," Hanlon said. "You just thank God that nothing severe has happened. With your health, you just can't tell what tomorrow will bring."

Because of the backlog, Wagner said, the state has implemented emergency measures to prioritize applications for certain patients with immediate health needs. But, she said, the state has no way of identifying those people unless they call Human Services representatives or go to a hospital.

Hospitals and doctors also are feeling the effects of the backlog. Some report not being paid for more than six months for services they have provided Medicaid patients.

As of last week, Rush University Medical Center on Chicago's Near West Side had more than 900 patient accounts in limbo pending Medicaid approvals. The average account has been pending for 216 days, Rush said.

At Swedish Covenant Hospital on the North Side, the growing backlog "is creating some concern about getting reimbursed at an appropriate time," said Nick Przybyciel, a spokesman. "Once (patients) do get approved, it's often another three to six months before we get paid, and sometimes those bills can be quite high."

Advocate Health Care, the state's largest hospital chain, said it is seeing delays of about five months to process Medicaid applications. In response, it is advising patients who require daily pharmacy benefits or frequent doctor visits to file paper applications, said Susan Clarke, executive director of patient access.

"Those (who) are taking that step still have delays, but it is around 60 to 90 days rather than 150 to 180 days," she said.

State officials blamed the growing backlog on several compounding factors, the largest of which was the unexpected volume of applications that vastly outstripped workers' ability to process them.

At the same time applications began flowing in, Illinois rolled out a new benefits application website and overhauled an internal eligibility processing system. While the new systems, financed largely by the federal government, allow for faster, more accurate and more efficient application processing, their implementation required a massive retraining of workers, Wagner said.

"These are all good things, but they're major changes that have taken some time to get through," she said.

On top of that, the state had to implement new methods of determining eligibility among consumers, who could now qualify based on modified adjusted gross income and tax-filing status rather than other factors, like age and relationships.

Further complicating the process was the launch of HealthCare.gov, the federally run marketplace where consumers in 36 states, including Illinois, were directed to sign up for new health policies offered under the law.

The federal website was supposed to transfer completed applications electronically to the state in real time. But problems crippled the system, and it wasn't until mid-January that the federal government began sending across a cache of more than 100,000 applications, some dating to early October.

"Before we even touched (those applications), we were backlogged," Wagner said.

So far, only about 9,000 of the state's new Medicaid enrollees are among those who submitted applications through the federal website, according to state data.

Illinois is among at least 26 states that opted to expand the program, a provision of the health law that became optional after a U.S. Supreme Court ruling.

The states that expanded Medicaid eligibility and use the federal marketplace appear to be those having the most problems, said Matt Salo, executive director of the National Association of Medicaid Directors.

"I can't answer whether the extent of the problem is as bad in other states, but I do know for sure that Illinois is by no means alone," Salo said.

Many frustrated consumers who didn't know whether their application was received or processed turned elsewhere to reapply, either through community groups or the Illinois website, ABE.Illinois.gov.

As a result, an unknown number of pending applications are likely duplicates or even triplicates, state officials say, requiring additional time to rectify.

Application workers have found that some applicants already are enrolled in Medicaid and that others don't qualify because of income or residency status.

More still — an estimated 30 to 50 percent — didn't submit complete applications and require follow-up by caseworkers to verify or request additional information like Social Security numbers, pay stubs and tax returns, Wagner said.

"Some people apply multiple times on multiple forms, and when we're this far behind and people are confused … it just snowballs," Wagner said.

Michael Manaa-Hoppenworth, a part-time physical therapist who lives in the Andersonville neighborhood, is among those who have applied many times, desperate to get coverage for his three children, ages 13, 10 and 8.

On his first attempt, in December, the glitch-ridden HealthCare.gov website informed him that only one of his children would qualify for Medicaid, an error. He called a federal call center worker who he said told him an Illinois caseworker would call him to sort out the problem.

Three months later, after hearing nothing from the state, he reapplied March 13, this time finding that all his children qualify for coverage. To ensure that his application was received, he again called the federal call center, where an agent told him someone from Illinois would call by March 17.

The call never came.

"I still don't know exactly what I'm going to do," Manaa-Hoppenworth said. "I'm nervous about it, and my wife is more nervous about it. If we have an injury or something, we're screwed."

pfrost@tribune.com

Twitter @peterfrost

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