Too many Texans can't get Medicaid and SNAP, despite being eligible.
An effective Medicaid and SNAP eligibility and enrollment system forms the foundation for meeting food and health care needs of eligible, low-income Texans. Its most basic function is to process eligibility accurately and without delay. Texas’ crisis-ridden system is doing neither. When our eligibility system fails, Texas loses out on billions of federal dollars that fuel our state and local economies, and hard-working, low-wage Texas families face food insecurity and barriers to health care.
Every Texan’s tracker highlights key developments related to Texas’ strained eligibility system as Texas re-checks eligibility for all 6 million Texans with Medicaid, following a nationwide pause on disenrollments during the pandemic. This process is referred to as Medicaid unwinding.
This is an enormous undertaking for Texas’ Medicaid and SNAP eligibility and enrollment system. Yet, the Legislature failed to fully fund the effort, and Governor Abbott has failed to address paperwork backlogs and coverage losses for eligible kids, seniors, and individuals with disabilities. Texas started the process behind because of an eligibility worker shortage, Medicaid and SNAP paperwork backlogs, and an unrealistic timeline that crammed too many Medicaid renewals into too few months.
Millions of Texans, mostly children of color in low-income families, are at risk of losing their health insurance despite remaining eligible for Medicaid and are also unable to get their SNAP applications processed on time. As the system failures continue, the hardships faced by Texans applying for Medicaid and SNAP have worsened .
Texas Unwinding Timeline
We’re following key unwinding updates month by month. Every Texan’s Tracker was last updated June 25, 2024.
This information must be submitted to CMS within 30 days.
The letters from USDA, dated May 21, 2024, are regarding the state’s continued timeliness issues with SNAP applications and backlogs. As of May 24, there were over 48,000 SNAP applications in the backlog. The letters also state that USDA has not approved HHSC’s Corrective Action Plan, which has now been resubmitted by the state three times, as it was deemed insufficient and did not show a root cause for the low timeliness application rate.
USDA also found that Texas is out of compliance with work requirements and time limits in the SNAP program. The Fiscal Responsibility Act of 2023 increased the age of SNAP participants who are subject to the Able-Bodied Adults Without Dependent (ABAWD) work requirements and time limits and added new groups of individuals who are exempted from these requirements. State agencies were required to implement these changes beginning September 1, 2023. Additionally, effective Oct. 1, 2023, the same bill increased the age of those subject to the ABAWD time limit and work requirements to age 52 and required states to apply age-based exceptions to new applications received as of Oct. 1, 2023.
HHSC notified the Food and Nutrition Service (FNS) it had implemented the required policy changes to ensure eligible SNAP clients did not improperly lose benefits while the system changes were finalized. However, FNS found in January 2024 that HHSC was not properly screening SNAP applications for exceptions to the ABAWD requirement, clients are not being properly informed, and several cases in which discretionary exemptions should have been applied to the client and were not.
Finally, a letter from USDA to HHSC dated April 29, 2024, states HHSC is out compliance with USDA regulations as it relates to the SNAP Employment and Training Program , including failure to provide support and source documents for costs incurred by the Employment and Training program. HHSC also failed to comply with a corrective action plan to address the non-compliance initially. The letter asks HHSC to immediately validate that all federal SNAP spending related to the Employment and Training program are reasonable, necessary, and directly related to the program. If HHSC cannot provide evidence within 30 days that they are complying with all federal fiscal requirements, federal funding for SNAP in the amount of over $8 million will be disallowed and federal SNAP employment and training funds could be suspended. HHSC’s response can be found here , including an updated corrective action plan.
Texas Congressman Rep. Lloyd Doggett has issued a press statement on the letters here .
CMS announced it will require states to continue to release monthly Medicaid renewal data, even after their Unwinding process is over. This is a great win for continued transparency into the Medicaid and CHIP programs in Texas! As described in the linked letter, state reporting on Medicaid renewal outcomes will continue after the Consolidated Appropriations Act 2023 requirements end on June 30, 2024. CMS will continue to report state and national data publicly to continue providing transparency into Medicaid and CHIP eligibility and enrollment processes as well as individuals’ ability to renew their coverage.
Georgetown Center for Children and Families published a report today on the change in child Medicaid enrollment since the unwinding began. There is a wide variation in child disenrollment levels by state, due to state policy choices and approaches to the unwinding. The report found that:
Due to Texas’ rushed unwinding timeline, our high levels of procedural denials, and extremely low ex-parte rates, these numbers are not surprising but should be a call to action to ensure eligible children are re-enrolled in a timely fashion or given another door to health care coverage.
A brief published today by the Perryman Group estimates the economic costs of the disenrollment of over 2 million Texans from Medicaid since the unwinding began a year ago. The Group estimates the economic costs of decreasing the number of Texans covered by health insurance by 2.1 million to be:
The brief argues, as the number of uninsured continues to rise as a result of the unwinding, health related spending decreases, the level of uncompensated care rises, and higher levels of uncompensated care result in rising insurance premiums, in addition to decreased productivity caused by an increase in negative health outcomes for those left without access to care.
The Texas Health and Human Services Commission (HHSC) posted its April unwinding report , a monthly report required by the federal Centers for Medicare and Medicaid Services (CMS) that includes data for March. HHSC also posted its March End of Continuous Medicaid Coverage Dashboard report that contains some additional detail with data through March 11, 2024. The reports show:
As of March 11, 2024, 1.35 million children have lost Medicaid coverage during the unwinding process. Children are eligible for Texas Medicaid/CHIP at higher income levels and are likely to remain eligible at renewal. Experts project that 3 in 4 kids who lose Medicaid during unwinding will, in fact, still be eligible, and that kids of color are most at risk of losing Medicaid during unwinding despite remaining eligible.
The Texas Health and Human Services Commission (HHSC) posted its March unwinding report , a monthly report required by the federal Centers for Medicare and Medicaid Services (CMS) that includes data for February. It also posted its February End of Continuous Medicaid Coverage Dashboard report that contains some additional detail with data through February 20, 2024. The reports show:
On March 12, 2024, the National Health Law Program (NHeLP), Disability Rights DC at University Legal Services (DRDC) and Disability Rights Texas (DRTx), filed two complaints with the Department of Justice and the U.S. Department of Health and Human Services Office for Civil Rights alleging violations of the Americans with Disabilities Act in the Medicaid renewal process in the District of Columbia and Texas. The Texas complaint alleges Texas Medicaid does not meet the needs of Medicaid enrollees who receive home and community-based services (HCBS), as the Texas renewal process does not utilize existing information to automatically renew individuals coverage, forcing the individual to go through an administratively burdensome process. The complaint also alleges the 211 call center in Texas provides incorrect information to people with disabilities. Read the full Texas complaint here .
On March 5, 2024, Senate Finance Committee Chair Ron Wyden and House Energy and Commerce Committee Ranking Member Frank Pallone sent a letter to Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brookes- LaSure, requesting further information on how CMS is helping states correct unwinding-related eligibility and enrollment system issues that have surfaced in Medicaid and CHIP during the unwinding process. The letter identifies state areas of noncompliance, including failures to process applications in a timely manner and to automatically renew eligibility even when a state has the data needed to do so. The letter requests detailed state plans to fix these issues be made public and requests CMS continue to require and publish states monthly reports of eligibility and enrollment data, currently required under the Consolidated Appropriations Act of 2023, but ending in June 2024. The Congressional members requested a response from CMS by March 29, 2024.
The Texas Health and Human Services Commission (HHSC) posted its February unwinding report , a monthly report required by the federal Centers for Medicare and Medicaid Services (CMS) that includes data for January. It also posted its January End of Continuous Medicaid Coverage Dashboard report that contains some additional detail with data through January 9, 2024. The reports show:
Of the 1.22 million Texans removed from Medicaid for procedural reasons, more than 1 million (or 82%) are children. Children are eligible for Texas Medicaid/CHIP at higher income levels and are likely to remain eligible at renewal. Experts project that 3 in 4 kids who lose Medicaid during unwinding will, in fact, still be eligible, and that kids of color are most at risk of losing Medicaid during unwinding despite remaining eligible.
On February 9, the National Immigration Law Center (NILC) filed a multi-state complaint with the Department of Health and Human Services Office for Civil Rights (OCR) and Centers for Medicare and Medicaid Services (CMS). The complaint alleges that at least 13 states are systematically failing to provide individuals with Limited English Proficiency (“LEP”) reasonable language assistance they need to participate in redeterminations of their Medicaid eligibility during the unwinding process.
Texas’ portion of the complaint includes:
This is also consistent with a recent Protecting Immigrant Families (PIF) Medicaid Unwinding survey and letter to CMS. Every Texan advocated for improved language access in HHSC programs during the recent legislative session, including a bill that would direct the agency to develop a language access plan.
On February 8, Agriculture Secretary Tom Vilsack issued a letter to 47 Governors, including Texas Governor Greg Abbott, expressing concerns with the timely and accurate processing of Supplemental Nutrition Assistance Program (SNAP) benefits in Texas. As we have reported for months, Texas continues to face delays and backlogs in processing SNAP benefits applications and redeterminations, leaving families without access to food. As of January 26, 119,000 SNAP applications were backlogged and sitting in a queue, and 33% of new SNAP applications were delayed beyond the 30-day federal processing deadline.
The letter urges Governor Abbott to prioritize timely and accurate application processing for SNAP benefits. The most recent state data shows Texas has an application processing timeliness rate of 87.08%; Anything above 95% is considered acceptable. Texas is also underperforming in the case and procedural error rate, which monitors inaccurate denials, terminations, or suspensions of a household’s SNAP benefits. Families should not lose access to critical food benefits because of state agency delays and inaccurate processing of applications.
In the letter, the U.S. Department of Agriculture offers to work with Texas to implement options available under current federal law to make accessing and keeping SNAP benefits easier for families. Suggestions include increasing the certification period for a household so that families can keep their benefits for a longer period of time before they are forced to renew. Texas currently requires households to recertify their SNAP benefits every six months. Increasing certification periods would reduce the administrative burden on families and agency staff, helping them to climb out of the application backlog they’ve been facing for months.
The U.S. Department of Agriculture announced the Summer Electronic Benefits Transfer program will become a permanent state option beginning Summer 2024. This program allows states to provide low-income families with funds during the summer months to help cover the cost of groceries while children are out of school. The Summer EBT program helps to fight the food insecurity children can face when school is not in session. States had until January 1, 2024 to let the federal government know if they would participate in the program this summer. More than 30 states have opted-in to the Summer EBT program for 2024, but Texas is not one of them.
With the ongoing delays in processing SNAP applications for families, not opting into the Summer EBT program is a missed opportunity that could benefit Texas families and about 3.7 million Texas children. Implementing this program in Texas will require collaboration between the Texas Education Agency, the Department of Agriculture, and the Health and Human Services Commission, with the majority of the workload falling on the already overly burdened HHSC. HHSC has indicated current resource constraints at the state agency level, the level of effort needed to implement the program, and new appropriations needed from the legislature (states are required to fund 50% of the program administrative costs) made 2024 implementation not feasible. Texas will have an opportunity to implement Summer EBT in 2025 and Every Texan will advocate for HHSC to have all of the resources it needs from the legislature and the processes in place to implement this important program.
The Texas Health and Human Services Commission (HHSC) posted its January End of Continuous Medicaid Coverage Dashboard report, a cumulative report that offers the most comprehensive picture we have to date of the Medicaid unwinding process. The latest update contains data from the beginning of the unwinding, April 1, 2023, through January 9, 2024. The report shows that Texas has reached an unfortunate milestone in the unwinding:
On January 31, the National Health Law Program (NHeLP), the Electronic Privacy Information Center (EPIC), and Upturn filed a formal complaint with the Federal Trade Commission (FTC) to investigate Deloitte Consulting regarding inaccurate and unreliable Medicaid eligibility determinations in Texas. The state’s automated eligibility system (known as TIERS) was developed by Deloitte. The complaint asks the FTC to look into concerns with TIERS, including: the unreliability of ex parte or administrative renewal redeterminations, failure to make accurate eligibility determinations, and the system reliably recognizing when requested documentation has been submitted.
The Texas Health and Human Services Commission (HHSC) posted its January unwinding report , a monthly report required by the federal Centers for Medicare and Medicaid Services (CMS) that includes data for December. It also posted its December End of Continuous Medicaid Coverage Dashboard report that contains some additional detail with data through December 13, 2023. The reports show:
On December 18 th , the Secretary of Health and Human Services, Xavier Becerra, sent letters to 9 states, including Texas, urging them to better protect children from losing access to Medicaid and CHIP. The 9 states called out (Texas, Arkansas, Florida, Georgia Idaho, Montana, New Hampshire, Ohio, and South Dakota) have the largest number or highest percentage of children who have lost Medicaid or CHIP coverage since the unwinding began. The letter urges states to ensure that no eligible child loses their healthcare coverage due to avoidable “red tape.”
Several proactive actions and policy changes are suggested to prevent eligible children from losing coverage, many of which Every Texan has been consistently advocating for over the last several months, including changes to the eligibility system to improve ex parte rates and section (e)(14) flexibilities to make renewals easier. Unfortunately Texas has only adopted four of these flexibilities, even though data show states that have pursued policy changes to make renewals easier have seen fewer children disenrolled from Medicaid and CHIP.
Data released by the federal government on the same day also reveals the states with the largest number of children losing Medicaid are states that have not expanded Medicaid. The 10 states (including Texas) that have not expanded Medicaid eligibility have disenrolled more children than all of the expansion states combined. The letter from HHS urges Texas to expand Medicaid, as thousands of youth with Medicaid or CHIP who turned 19 during the unwinding are now at risk of losing their healthcare coverage and falling into the coverage gap. Texas children are eligible to remain on Medicaid and CHIP until they turn 19. CMS estimates these youth account for about 27% of disenrollments among children during the unwinding in states that have not expanded Medicaid. Youth ages 19-25 in non-expansion states already had some of the highest uninsured rates of any group in the country prior to the pandemic. Unfortunately, it appears that the rates of uninsured young adults will continue to climb in Texas as the Governor and the Legislature refuse to expand Medicaid eligibility to low-income adults. Expanding Medicaid would ensure eligible young adults are able to maintain their healthcare coverage and ensure access to necessary preventative and behavioral healthcare services.
