Since pandemic-era protections for health care coverage ended in March, more than 900,000 Texans have lost Medicaid coverage. For the first time in three years, many families and kids are caught up in the state's re-enrollment process, a multi-step system of complex paperwork, deadlines and financial requirements.
Now, whistleblowers who say they work in the Texas Health and Human Services Commission (HHSC) are alleging people have been denied coverage in error because of mismanagement within the agency.
How does Texas determine Medicaid eligibility?
Texas is one of only 10 states that hasn't expanded Medicaid eligibility, which means only specific groups can access it, like kids, the elderly, pregnant people and people with disabilities. According to HHSC, about 6 million people use Medicaid across Texas – about a third of whom were added since 2020.
Medicaid is comprehensive health care that covers everything from doctor's appointments to prenatal vitamins. It also requires re-enrollment every year, which can mean submitting forms online or in-person to confirm things like identity, address, income, and employment.
The state sent out renewal packets through the mail to about 1.4 million Texans earlier this year to prepare people for the process, along with robocalls, texts, emails and messages online at YourTexasBenefits.com.
But Diana Forester with Texans Care for Children told KERA back in March she was worried people might not receive a notice because they changed addresses since enrolling.
"The bad address thing really hampers the ability for people to receive information timely and to be able to respond timely," she said.
Applications can also be rejected because of procedural reasons, like someone not returning paperwork, missing deadlines, or not submitting the correct eligibility forms. Since the Medicaid unwinding process started in April, more than 70% of people lost Medicaid because of procedural reasons, not because they weren't eligible anymore.
The state also determines enrollment on an "ex parte basis," which the Centers for Medicare and Medicaid Services (CMS) also calls auto-renewal or administrative renewal.
Ideally, this process streamlines renewals by comparing electronic data to check eligibility, like SNAP, the DMV, state unemployment, and Women, Infants and Children Program. People with Medicaid then confirm or update missing details to be re-enrolled.
Typically, applications take about 45 days to either be accepted or rejected (which is also called "disposed"). But Texas had issues with completing applications within that time frame before this renewal process even started. Back in March, the state was processing a little over half of new Medicaid applications on time.
People can fight denials, delays or reductions in benefits through an appeals process, which can take up to 90 days for a decision.
How does Texas Medicaid re-enrollment compare to other states?
Children and pregnant people were among the first cohort of Medicaid recipients HHSC reviewed in the renewal process.
Most pregnant people who lost Medicaid no longer qualified for coverage. Since the state hasn't expanded Medicaid, pregnant people only have insurance for two months postpartum.
But pregnancy complications, including postpartum depression, can manifest up to a year after giving birth. Texas is among the worst states in the country for maternal mortality, with bleeding, mental health issues and chronic conditions as some of the leading causes of death.
This year, Texas lawmakers passed HB 12, a bill that extends postpartum Medicaid coverage to a year. But passing the law doesn't automatically extend this coverage for pregnant Texans: the state has to submit documents called a State Plan Amendment to CMS, which CMS then has to approve it before the law goes into effect.
HHSC Press Officer Tiffany Young said the extension "is expected to occur in early 2024," depending on CMS approval, but said HHSC has not submitted the State Plan Amendment yet. A spokesperson for CMS confirmed the department has not received any plans from Texas as of Sept. 18.
But the largest group that has lost coverage is Texas children. The state already has the highest rate of uninsured children in the nation, around 11%.
According to a report by the Kaiser Family Foundation (KFF), almost 70% of people disenrolled from Medicaid during the unwinding in Texas were kids. That's as if everyone in Arlington and Garland lost health insurance. Nationally, it's closer to 40%.
Texas has also purged the most people from the Medicaid rolls in the country: about 917,000 people. Florida is second highest with a little over 700,000 people. Other states like Arkansas, Ohio and New York have disenrolled between 330,000 and 375,000 people.
The state also has the second-lowest ex parte renewal rate: About 9% of all renewals were done that way. In comparison, North Carolina had the highest rate, with 99% of renewals done on an ex parte basis, according to KFF data.
Why has Texas kicked the most people off Medicaid in the country?
Whistleblowers claiming to work for HHSC have said it's because the department is unprepared to handle this many renewals at once.
The letters, sent between July and September to Gov. Greg Abbott and HHS Executive Commissioner Cecile Young, detail a department that is plagued by IT issues, erroneously denying thousands of applications, and taking well beyond 75 days to process new applications.
The group calling themselves "Concerned Texans" allege in May 2023, HHSC errors caused about 68,000 people to lose coverage, which was then reinstated in August. It left people without health insurance for three months.
The whistleblowers also allege close to 6,000 pregnant people had their Medicaid denied and did not receive the two months of coverage during the postpartum period.
In the latest letter from Sept. 19, the Concerned Texans said they needed "help" and "leadership” as the “health and well-being of innocent Texans hang in the balance.”
"We will continue to bring these critical issues to our agency’s leadership in hopes someone has the fortitude to stop the chaos," they wrote.
The high rate of children being kicked off Medicaid also concerned CMS, which sent a letter in August to every state Medicaid director in the country.
Since Texas has not expanded Medicaid, the eligibility requirements are some of the strictest in the United States. For parents and caretakers of kids who are covered by Medicaid, a family of four with two parents has to make at or below $285 a month to be eligible.
CMS reported states may be incorrectly removing children who would have coverage because their ex parte procedures are looking at the entire family, rather than just the members who would be eligible. CMS also said some states are disenrolling everyone in a household when renewal forms aren't returned promptly.
HHSC hasn't admitted fault with the procedures or any of the delays, but has to submit monthly data to CMS on how Medicaid unwinding is going in the state.
How can Texas fix this?
Both the whistleblower letters and CMS suggest a need for the state to pause the redetermination process until they've corrected the errors.
In August, 15 organizations from across the state, including the Texas Medical Association, the Texas Pediatric Society and the Texas Hospital Association, sent a letter to HHSC Executive Commissioner Young outlining their recommendations to fix Medicaid unwinding.
They recommend the agency increase the number of ex parte renewals; upgrade the YourTexasBenefits website to allow clients to finish their renewals if they were denied for procedural reasons; and modify the timetable for Texas to process these applications.
The organizations said these changes will minimize loss of coverage, which "will be beneficial not only for individuals, but also for HHSC eligibility workers and the health care delivery system."
Texas will be reviewing these applications until June 2024, with hundreds of thousands of people each month sorting out their eligibility. HHSC encourages people to update their information to ensure there's not a gap in coverage. People can do so online, through the mail, by calling 211, or by visiting an HHSC office or community partner.