It’s enough to make you loopy: inside the Kafka-esque world of Medicaid “loopers”

Remember the Medicaid loopers? These were the folks who applied for coverage through the health insurance Marketplace only to be told they – or a family member – were not eligible because the Marketplace assessed them as eligible for Medicaid coverage. In some cases, parents did not learn that their child was not on their Marketplace plan until they showed up in the pediatrician’s office. They were then told to apply to their state Medicaid agency for an eligibility determination. If the state finds these families not eligible for Medicaid, they are then entitled to re-apply to the Marketplace for financial assistance and enrollment in a Marketplace plan. State and federal officials have referred to them as “loopers” because they have had to “loop” between the Marketplace to the state Medicaid agency and back again.

We at CHIR – and at our sister center, the Georgetown Center for Children and Families – have been attempting to keep tabs on these folks. Are they getting the coverage they need, when they need it? Unfortunately, the bureaucratic hurdles don’t always end when a family is finally allowed to re-apply and enroll in coverage through the Marketplace. In many cases – such as the one we learned about this week – families have had to go without coverage for months and have incurred significant health care costs while uninsured.

Take the case of the Ohio family that applied for health insurance through on December 5th, 2013. They chose a health plan, with coverage to start January 1, 2014. But when they got their notice, the parents were listed, but not the children. They were told it was because their kids had been assessed as eligible for Medicaid. As they were processing this news, one of their children got sick and had to be taken to the hospital. Hospital staff helped the family complete a Medicaid application. Unfortunately, the state ultimately denied Medicaid to both children, at which point the family sought and received a special enrollment period to re-apply to the Marketplace. They are all now enrolled in coverage effective May 1, 2014.

But what to do about the medical bills for the child’s hospital stay while the family was in coverage limbo, bounced between the Marketplace and the state Medicaid agency? Who’s responsible for paying those bills?

This family did everything as they should have, and in good faith. They applied for coverage for their children on December 5th, well in time for coverage to begin on January 1. Yet the system failed them.

At this point, the best we can advise them is to file an appeal with the Marketplace, asking that their coverage be made retroactive to the date at which it should have been effective – January 1, 2014. Unfortunately, the Marketplace appeals system remains a black box. Appellants are told to submit their appeal form to an address in Lexington, Kentucky. But it’s not clear what happens to it after it arrives there. Who will review this appeal, and under what time frame will it be adjudicated? And in the meantime, who is going to pay that hospital bill?

This Ohio family’s situation is hardly unique. We should have a better answer for them.

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The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.