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Inside the effort to help thousands of N.H. residents hold onto Medicaid coverage when pandemic protections end

Sara Castonguay smiles next to her kid, who is wearing a blue shirt in a stroller.
Alli Fam
Sara Castonguay completed paperwork to redetermine her Medicaid coverage at an in-person event in Manchester.

Sara Castonguay, a new mom in Manchester, is usually overwhelmed at the thought of updating her Medicaid enrollment paperwork. She finds the state’s online registration portal hard to navigate. And when she’s tried calling for help, she sometimes ends up stuck on hold — often, she doesn’t have time to wait around for an answer.

“I find that there’s not enough hours in the day,” Castonguay said.

That’s why she was so relieved when, earlier this summer, she got a text from her Medicaid provider about an event offering in-person help with her enrollment paperwork. Hosted after her work hours at an elementary school in her neighborhood, it gave her a chance to speak face-to-face with state health officials and submit all of the documentation needed to keep her coverage.

“It is very helpful to see the community kind of come together with what they offer and to help everybody out,” she said.

During the COVID-19 pandemic, New Hampshire and other states have been required to keep people enrolled in Medicaid throughout the ongoing federal public health emergency — even if they haven’t filed key paperwork or have lost eligibility due to a change in income, for example. It’s not clear when the federal public health emergency will end, but when it does, about 90,000 Granite Staters could risk losing Medicaid access.

With that in mind, state officials and outside advocates have been making a push to help people like Castonguay, who are missing forms, hold onto their coverage. They’ve also tried to inform those who will no longer be eligible for Medicaid without the special protections about other coverage options. That effort has included letter campaigns, phone calls and in-person events.

Officials and advocates also hope to prevent a potential nightmare scenario: If too many people wait to update their paperwork, tens of thousands of people could end up flooding the state’s benefits portal, help lines and other assistance agencies right as those forms are due.

“We're concerned that there's going to be this wave of people contacting us and contacting the department at the end,“ said Ray Burke, the co-director of the Benefits Project at New Hampshire Legal Assistance.

But pushing people to update their information ahead of an ambiguous deadline can be challenging.

For one, the federal government has been extending its public health emergency declaration in 90-day increments, and there is still no official end date in sight. While this gives state officials more time to prepare for the end of the public health emergency, it also means there’s no clear “deadline” to communicate to people about when they must get their forms in. And it can be hard to inspire urgency for a deadline that doesn't yet exist.

There’s also the redetermination process itself. Even under the best of circumstances, it can be a confusing, time-consuming and documentation-heavy process. At times, just trying to navigate the system can wear people down.

“Repeatedly proving you're poor to a government that already knows is pretty demoralizing.” said Kathy Muck of Exeter, who was on Medicaid for years due to a disability and recently transitioned to Medicare. “It's one of the various prices you pay for existing with disability or poverty."

N.H. ramps up efforts to keep people covered but barriers to redetermine Medicaid coverage remain

State health officials have been ramping up efforts to prevent a wave of lost Medicaid coverage throughout the past year.

Last summer, New Hampshire’s Medicaid office began mailing notices to people at risk of losing coverage on special pink letterhead — part of a strategy to prevent the notices from getting lost in the shuffle of other incoming mail. That campaign received recognition from the federal government as a method other states could consider implementing.

To alert people who are at risk of losing coverage the state continues to send out pink forms to Medicaid users, urging people to get their information into the state as soon as they can. The forms also exist virtually, if people have an NH Easy account.
N.H. Department of Health and Human Services.
To alert people who are at risk of losing coverage the state continues to send out pink forms to Medicaid users, urging people to get their information into the state as soon as they can.

“I think it’s been really beneficial,” said Kristen Kather, a supervisor at the Manchester district office of the Department of Health and Human Services. Many people who’ve received the letters, she said, are “coming into the district offices in person, saying ‘OK. What am I missing?’”

In recent years, the state also hired 30 new staff to handle incoming calls about Medicaid enrollment and to call people at risk of losing coverage directly. Officials say call wait time has dropped to an average of 14 minutes, down from 45 minutes prior to the pandemic.

State officials have also enlisted the help of local health centers and community mental health centers. As part of that work, they state has helped clinics identify patients who are at risk of losing coverage so that case managers or other specialists can help with enrollment. Health centers said this strategy has worked well when patients are already in the building for an appointment, but some have reported difficulty reaching people over the phone.

Many of these initiatives have resulted in more people filling out their enrollment forms, said Chris Santoniello, an associate state health and human services commissioner. She said direct phone calls from her staff reach about 50 percent of people, and most of them are taking action to prevent coverage loss. Last month, nearly 6,000 Granite Staters completed redetermination forms.

Despite these efforts, the number of people at risk of losing their coverage continues to rise as Medicaid enrollment continues to grow.

Lessons learned

In their efforts to reach people affected by the end of the federal public health emergency, state officials are also learning lessons about what doesn’t work.

When the state held its first in-person Medicaid assistance event at the Broken Ground School in Concord, only a few people showed up. The location wasn’t easily accessible for families without transportation, and no shuttle or other transportation assistance was offered. Technical issues also prevented some of the people who did attend from completing their forms.

But at the next event in Manchester, where Castonguay completed her paperwork, things were different. The event was well advertised by local schools and community organizations, and there were other draws for families, like fire truck tours and a bookmobile. The event had the feeling of a neighborhood block party. More than 60 people attended, though not all came to do their redetermination forms.

At all of these in-person events, the state has enlisted help from outside agencies that specialize in serving people who don’t speak English as their first language.

Mathaus Tabé, a trilingual healthcare navigator, has attended several of these events on behalf of Health Market Connect, an organization that helps people access healthcare.

Tabé said he and of his colleagues draw on their own experience as non-native English speakers navigating these complex systems to both help people secure coverage and avoid getting discouraged along the way.

“Because we've been there, we understand how to handle those situations, and how to help people,” said Tabé.

Despite the success of this in-person outreach, advocates who help Granite Staters navigate Medicaid enrollment said technical issues with the state’s enrollment portal are still making it hard for people to maintain coverage. In some cases, they said, people have been locked out of their online accounts and can only get access by receiving a PIN number to verify their identity via the mail or by phone, rather than online.

New Hampshire Medicaid officials said the state is trying to improve its systems to address technical barriers that can prevent people from enrolling or maintaining coverage.

“We don't want anybody to fall through the cracks,” Santaniello said.

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