Brian Clark, 29, has to live with his parents in Enid because of his health. He has COPD, bullous emphysema, severe scoliosis and a lung that continues to collapse, so he requires various expensive medicines and inhalers.
He discovered he lost his SoonerCare coverage at a dentist appointment in early November, and it took over a month for him to get it back. He had to skip work and purchase partial refills to avoid complications that have sent him to the hospital in the past, like COPD exacerbations.
“All the medical anxieties and everything that I've had, I’m very worried about it happening again, or this lung collapsing, and not having the insurance,” Clark said.
Clark was among a current total of 307,109 Oklahomans who have lost SoonerCare coverage since March. This occurred because state agencies, including the Health Care Authority (OHCA) and Human Services, began removing ineligible people after a COVID-19 pandemic pause.
The Health Alliance for the Uninsured, which helps low-income, uninsured and underinsured clients navigate health referrals, estimates one in four Oklahomans are uninsured, and it can take nine to 12 months before people get reconnected to health insurance once they’ve lost it.
As Oklahoma nears the end of its process, providers, community partners and patients are reflecting on OHCA’s collaboration with partners, the confusion that ensued and how the unwinding impacted members overall.
What is the ‘unwinding,’ and how many Oklahomans are losing coverage?
Starting in March of 2020, states couldn't remove people from Medicaid even if they became ineligible. They could only do so if someone moved, died or asked. In exchange, states received enhanced federal funding.
That was until March 31, 2023, when the Center for Medicaid and Medicare Services’ continuous enrollment condition ended. From there, they had 12 months to initiate and 14 months to complete what is called the Medicaid unwinding process, which refers to states’ resumption of annual eligibility reviews.
The enhanced funding continues until the end of the year. OHCA’s public information officer Emily Long said it evaluated its budget and determined it could complete the process “effectively and thoughtfully” in nine months. OHCA began in April and Human Services began in March.
OHCA sent four letters to SoonerCare recipients saying renewals would resume, why they were ineligible and their coverage end date. It posted on social media, did media outreach, sent texts and emails, and reached out to providers to get the word out. Some of these communications began a year before the COVID-19 public health emergency ended.
Long said OHCA also hired an additional 32 staff members to meet the need. It has a total of 111 staff who work eligibility documents.
Unwinding occurred through a tiered approach that prioritizes reviewing people considered to be lower risk, including people who are 228% above the federal poverty level. Income requirements for SoonerCare are on the authority’s website.
Jeanean Yanish Jones, executive director of the Health Alliance for the Uninsured, said communications can become complicated when people aren’t paying attention or if they’ve moved since they last enrolled.
That became the case for Clark, who said he didn’t see the OHCA letters.
He lost his coverage through a procedural denial, which occurs when someone can't supply information to prove eligibility. So far, about 173,183 Oklahomans have lost coverage this way.
Oklahoma Primary Care Association’s director of communications, Cassidy Heit, said there is a particular concern for certain populations — like those who qualified for Medicaid expansion in 2021 and new parents. Both groups are likely participating in the redetermination process for the first time.
She said the most effective communication occurs when people make face-to-face connections, whether that's through conversations with someone they trust or in the exam room with providers. For Oklahomans on SoonerCare, those connections have been crucial.
What are providers saying about the process?
Sara Barry, Oklahoma Primary Care Association’s CEO, said federally qualified health centers met with state Medicaid Director Traylor Rains and some of his staff early on and requested lists of their patients who were losing coverage so they could reach out to them. Heit said 44% of the center’s patient population were on SoonerCare as of last year.
OHCA got federal approval to share this information without violating HIPAA. This way, they can connect with patients and refer them to wraparound services through the platform Unite Us.
One of these centers is Morton Comprehensive Health Services in Tulsa. It’s one of the largest in Oklahoma, with six locations in its system. It normally works to provide services like primary care, dentistry and optometry, but its CEO, Susan Savage, says the administrative burden of unwinding has fallen on practices.
“My impression is it has been chaos,” Savage said.
Grace Burke works at Morton Comprehensive Health Services as its director of programs and senior services. She’s taken on additional duties by helping patients with eligibility reviews.
Sometimes, people come in and don’t know their passwords, and others fall victim to long wait times for help desk call centers. She said they’ve been helping people from open to close — 8:30 a.m. to 5:30 p.m. — but the center is still losing patients.
“We had 10,000 on our rolls, about 5,000 of those were active patients, and we've lost half of them,” Burke said.
When asked about accessibility challenges related to the online SoonerCare portal, Long said OHCA is in the process of creating a technology strategy that “includes the holistic member experience.”
“We did make changes to how documents are uploaded and made the portal adaptive across devices in August 2021 based on member feedback,” Long said. “OHCA is always taking feedback and looking at what adjustments might need to be made to better serve our members.”
Burke said they’re also seeing confusion regarding the letters sent by OHCA about the redetermination process, and some people have lost coverage while their documents are still pending.
A group called Cover Oklahoma, which Burke participates in, met with Medicaid Director Rains a few weeks ago about this issue. Now, those still pending have temporarily reinstated coverage while the process continues into January. But she said the reinstatement letters OHCA is sending out are still confusing.
This process is additionally challenging for patients as the state transitions to its new managed care system, SoonerSelect. Christina Foss, deputy chief of staff for OHCA, said plans are open to certain Soonercare members, which includes mainly children, pregnant women and adults in SoonerCare’s expansion group.
Currently, this means SoonerCare recipients are required to choose between two dental plans by January 10, 2024. They’ll have to choose between three health plans later next year.
“It would have been really nice for the patients to not have another problem right now, or not have more things to do,” Burke said.
Long said the unwinding process wasn’t sped up to ensure OHCA could begin this transition.
Although Burke said the process has been challenging, she hopes her center’s efforts to connect with patients on SoonerCare eligibility continue beyond the unwinding.
“It's kind of like this double-edged sword thing, where you get kind of frustrated and a little unhappy with the stuff that's going on. But on the same hand, we get hugs every day,” Burke said.
What additional options are available?
In some ways, Yanish Jones from the Health Alliance for the Uninsured said it feels like Oklahoma is back to where it started before it expanded Medicaid.
“We were so excited we had Medicaid expansion, and the number of people that went on to Medicaid at that time is almost exactly the number of people that are coming off of it,” Yanish Jones said.
But additional options exist for Oklahomans. They can still apply for SoonerCare at their doctor’s office and get coverage same-day if they’re eligible, thanks to its real-time eligibility application process.
They can apply for Affordable Care Act plans, which have special enrollment periods for people who have lost Medicaid. They can also seek care at health centers and free and charitable clinics, like the Health Alliance.
“Our team will go through what we call a decision tree, and we start at the goal that every person would have insurance,” Yanish Jones said. “We're striving for that because that's going to be the best coverage for somebody overall and also help improve the health of our state.”
It’s those personal interactions that count for people like Brian Clark. When we talked in mid-November, he said the only thing he wanted was someone to help walk him through the process.
So that’s what we did. We figured out how to access his electronic messages in his portal and interpreted them together. And there it was — the letter from September telling Clark his coverage was about to end.
“I guess I need to check my email more. Lord have mercy,” Clark said.
Since then, his coverage has been reinstated. He’s one of the lucky ones. But even with the help of community organizations and providers, ultimately thousands of Oklahomans are navigating the “chaos” of the system on their own.
For more guidance on the unwinding process, head to the OHCA’s self-service page.
