This is a guest blog by Melissa McChesney, health policy advisor for UnidosUS.
View specific recommendations made by Texas advocates to the Texas Health and Human Services Commission (HHSC) on how it can ensure eligible clients stay enrolled in their Medicaid coverage here.
Two programs—Medicaid and the Children’s Health Insurance Program (CHIP)—provide health care coverage for more than 5 million Texans; primarily children, pregnant women, and seniors and people with disabilities who are in or near poverty. Unfortunately, before the pandemic, enrollment in Medicaid and CHIP was declining. But due to a useful provision in the Families First Coronavirus Response Act (FFCRA), enacted in March 2020, enrollment in Medicaid has increased, reversing the downward trend.
Under the FFCRA, so long as the federally declared public health emergency (PHE) remains in force, Medicaid beneficiaries are generally able to maintain health coverage. To offset the cost of covering additional people, Texas is receiving a 6.2 percentage point increase in its Federal Medical Assistance Percentage (FMAP) match for Medicaid .
The Build Back Better (BBB) legislation passed by the House would remove the connection between Medicaid enrollment and the federal PHE. Under the BBB, states will continue to receive the 6.2 percentage point FMAP increase until April 2022, regardless of when the PHE expires (that declaration will continue to affect other important public health policies). Then, beginning in April, states may resume disenrollment of Medicaid beneficiaries who have either been determined ineligible or who simply missed a required step in the renewal process and can be disenrolled with no actual eligibility determination (a “procedural denial”). The bill also provides important guardrails to determine how a state should resume Medicaid disenrollment. The overarching goal of these guardrails is to minimize the number of eligible people who lose Medicaid for a procedural reason. If a state follows these provisions, it will receive a 3.0 percentage point FMAP increase through June and a 1.5 percentage point increase through September 2022.
Medicaid is currently working as it should, as a bulwark that supports families, including during an unprecedented national emergency such as the pandemic. Yet, when Medicaid disenrollments resume, the more than 5 million Texans who rely on Medicaid will become highly vulnerable to the loss of coverage and care. For this reason, the Texas Health and Human Services Commission (HHSC), the legislature, and leadership must take necessary steps to:
- Minimize the number of still-eligible people who will lose coverage for procedural reasons once states are allowed to restart Medicaid disenrollments in 2022, and
- Ensure individuals who are no longer eligible are successfully transitioned to other coverage such as CHIP and the Affordable Care Act (ACA) Health Insurance Marketplace, or to the Healthy Texas Women program.
The stakes in Texas are high. Without careful planning and execution by HHSC, resuming routine Medicaid renewals and disenrollments could cause widespread harms that ripple through the state and its health care system.
Potential for widespread loss of coverage
Poor planning or execution in Texas could trigger a mass disenrollment of eligible individuals from Medicaid. For example, Utah suspended renewals for its Children’s Health Insurance Program (CHIP) at the beginning of the pandemic, and when renewals resumed, an unprecedented 41% of children in the CHIP program lost coverage, the vast majority (around 89%) because of a procedural issue, not because the state determined they were no longer eligible. Similar coverage losses have been seen in other states where renewals were temporarily suspended.
Further, nearly two-thirds of Texans enrolled in Medicaid are from communities who have suffered disproportionate health and economic impacts from the pandemic (15% of Texas Medicaid enrollees are Black and 49% are Latino). Coverage losses of this magnitude would be devastating for the low-income children and families who rely on Medicaid and would only deepen existing racial and ethnic disparities.
Harm to the Texas health care system
Widespread coverage loss among eligible people would also wreak havoc on Texas’ health care system. When individuals lose Medicaid coverage, have a gap in coverage and then re-enroll, their health care costs are often higher than if they received continuous coverage. A gap in coverage may lead to interruptions in access to medications, therapies, and other medical treatments. Delayed or skipped treatment often leads to worsening conditions and greater use of high-cost care. Safety net providers, already reeling from pandemic-related disruptions and demands, would face increased uncompensated care. Further, the ongoing health risks associated with the pandemic make it of the utmost importance that Texas take the necessary steps to avoid massive coverage losses in 2022.
Harm to HHSC’s eligibility and enrollment systems
Given the current state of the eligibility and enrollment systems in Texas, stakeholders have grave concerns about the impact that restarting Medicaid disenrollments will have on an already overloaded system. Under normal circumstances, Texas’ timeliness for processing Supplemental Nutrition Assistance Program (SNAP) and Medicaid applications within federally-required timeframes was consistently above 90%. However, beginning in late 2019, high turnover of eligibility workers led to significant delays in processing applications. In the months leading up to the pandemic, SNAP and Medicaid timeliness was far lower than the norm. While timeliness improved temporarily in 2020, SNAP timeliness for October 2021 was below 70% for new applications, and only 10% of SNAP renewals were processed in a timely manner. Due to these application processing issues, Texas HHSC took the rare step of pushing SNAP renewals out 6 months. This decision appears to have improved SNAP timeliness for November, but it is still far below the norm (83% for new applications, and 25% for renewals).
Texas Should Take Steps to Avoid These Harms
The approach that HHSC takes over the next several months is critical. Texas advocates have made specific recommendations to HHSC on how it can best achieve these goals by creating a comprehensive plan that follows federal law, regulations, guidance, and established best practices.
Key recommendations include:
- To avoid further overloading Texas’ eligibility and enrollment systems, HHSC should follow federal guidance and limit the number of renewals they attempt in any given month after the Medicaid continuous coverage provision is lifted.
- If the BBB plan passes, HHSC should follow the guardrails outlined by the bill in order to reduce coverage losses of eligible beneficiaries and to draw down the additional FMAP dollars for the state’s Medicaid program from April through September 2022.
- HHSC should increase efficiencies in the administrative renewal process, which will go a long way to reducing workload for HHSC eligibility and enrollment staff, call center workers, and community-based assisters.
- When unable to administratively renew a person’s Medicaid, HHSC must provide adequate time – a minimum of 30 days – for clients to return requested information and should accept reasonable explanations of inconsistencies or to allow for self-attestation of certain eligibility criteria for which documentation may be difficult for individuals to obtain.
- HHSC should take proactive steps to get updated contact information and mailing addresses for Medicaid clients, including getting address updates from the US Postal Service and Managed Care Organizations, and making it much easier and quicker for Medicaid clients to update their contact information.
- HHSC should conduct more intensive outreach via multiple modalities to remind Medicaid clients of anticipated changes to their coverage and to obtain needed information.
- HHSC must also ensure that individuals who are no longer eligible for Medicaid are successfully transitioned to other coverage options. In September 2021 the Urban Institute estimated that 1.3 million Texas enrolled in Medicaid at the end of 2021 would be ineligible and, therefore, disenrolled in 2022 when the continuous coverage provisions ended. Texas HHSC must take all necessary steps to transition these individuals to other programs for which they may be eligible, such as CHIP, Healthy Texas Women, and the ACA Health Insurance Marketplace, and to reduce the number of individuals who become uninsured following a Medicaid denial.
View the full recommendations here.