By Neelam Bohra, The Texas Tribune

For seven years, Maricela Delcid has guided Texans through the Medicaid application minefield, working past language barriers and documentation issues out of a community center in Houston. But her clients have never been more confused or frustrated than now, since the state began booting people from the program after a years-long period of continuous coverage.

During the pandemic, federal regulations prohibited states from removing people from Medicaid, allowing access to nonstop health insurance coverage for about 3 million Texans who would’ve regularly lost coverage beginning in March 2020. But new federal funding legislation lifted these protections in April, and the state launched the process of removing people it thought would be ineligible.

Half a million Texans — mainly children, but also disabled adults and pregnant women — have lost coverage since then, leaving them in limbo without access to medical treatment. Some had become ineligible over the pandemic, whether they were children who aged out of the program, mothers who were past the time of prenatal coverage or those who have exceeded Texas’ strict income limit. But many remained eligible and were kicked off as a result of procedural issues, such as not receiving messages from the state, responding to them late or not including the correct documentation in their renewal application.

As a result, community health centers are bracing for a flood of people who don’t know their coverage has ended, and outreach centers that help navigate Medicaid are seeing their clients overwhelmed by the process.

Many of Delcid’s clients are parents whose children were denied, approved and denied Medicaid again within a two-week period after relying on it throughout the pandemic. Some sent their application in the mail a day late and now have to restart the entire process; others didn’t have exact employer information for the past few years and were denied.

“It gets to the point where clients just don't want to apply, and are like, ‘We're just going to leave it,’ which is not right,” said Delcid, who does outreach assistance for Epiphany Community Health Outreach Services in Houston, known as ECHOS, a church-based group that helps immigrants and refugees in the area access services.

“It’s not good for them to give up just because it's confusing and stressful,” she added.

But a majority of clients that she’s seen kicked off, Delcid said, should still be eligible.

One of Delcid’s clients, Erika, who asked for her last name to be withheld for privacy reasons, said she had spent the past two months trying to get her 15- and 5-year-old, Yurem and Yaretzi, back on Medicaid.

To find out if you’re still enrolled in Medicaid, you can log into YourTexasBenefits.com. To find out if you’re still eligible, you can call the state services number at 211 or reach out to your local community health center. You can also use any of these resources to apply for Medicaid.

“What if they get sick?” Erika said. “How am I going to be able to pay for medicine, or doctor visits, or anything like that?”

Erika said she sent in her papers on May 16, one day after the state’s deadline, and she is now being asked to restart the application process.

“It’s really unfair to the clients because they don't understand that all of a sudden they have to reapply,” said Cathy Moore, executive director of ECHOS. “It's no longer a renewal when all they've ever done is renewed, and so for people who are not reading newspapers, it is a very difficult process to navigate, to understand, to even know what's happening.”

For people who aren’t eligible anymore, advocates worry they may not be able to access other options because the state isn’t giving them alternatives. There is a policy for 90 days of retroactive coverage, but it requires applicants to jump through a lot of hoops and is “cumbersome” to access, said Adrienne Lloyd, health policy manager at Children’s Defense Fund-Texas.

Either way, the state is causing more problems for itself, Lloyd said.

“If you're kicking off a lot of eligible kids, hopefully, eventually they have to get back on, and that's just a lot more administrative work and ultimately adds some more dollars for the state to spend,” Lloyd said. “One of the things we've been really harping on is that Texas is going really fast — unnecessarily fast — in this plan.”

Texas is one of 11 states that has not expanded Medicaid and has relatively low enrollment because of that. The state has the highest rate of uninsured residents in the country.

Trying to access care

People who lose coverage risk paying the price with their health. Diabetes patients need to be able to pay for insulin, kids need consistent care and for those with severe diagnoses like cancer, a stoppage in treatment can be fatal. For example, at MD Anderson Cancer Centers, about 2% of patients rely on Medicaid and because treatment can’t stop, the hospitals have to work to help these patients get continuous treatment.

Christina Rodriguez, 32, lives in San Antonio and has two children who have relied on Medicaid their whole lives. She has felt many ups and downs in the past months since protections were lifted. She said she found out she lost coverage after trying to take her 10-year-old daughter to the dentist to start the process of getting braces. They told her she wasn’t covered.

She said she called 211, the phone number for assistance with the state’s social services, and was told she had been sent multiple letters — none of which she had received.

“I’ve started a whole new application and on the whole process all over maybe four times at this point,” Rodriguez said. “It’s just been an anxiety-ridden process because I have insurance for myself through work, but my kids don’t, and the fact that they are not covered and I wasn’t even made aware of it until they had an appointment is insanity.”

Jana Eubank, executive director for the Texas Association of Community Health Centers, said many people probably still don’t know their coverage has vanished and haven’t received the news, potentially because of outdated contact information.

Eubank said Texas’ federally-qualified community health centers, which are required to provide care for all patients, including those without insurance, were initially bracing for a deluge of patients once the unwinding began, but didn’t see the increase they expected. It shows that many Texans “don’t even know what is coming,” she said.

The amount of patients who arrive without insurance will also financially hurt the community health clinics that serve them, she said.

“They're going to come in thinking they're insured — and we think this is going to happen really significantly in August because a lot of people are going to want to bring their children in for well-child visits and immunizations as they're getting ready to go back to school — and they're going to find out at that point, when they present for care: You're not insured anymore,” Eubank said.

“There hasn't been a systematic and comprehensive outreach campaign being directed by the state, and so I think a lot of this is people just don't know,” she added.

For parents in similar situations taking their kids to the emergency room and finding out they’re not covered, it can mean a hefty bill that can throw off a lot of families, Lloyd said.

In a statement, HHSC spokesperson Tiffany Young said the agency used a “multi-pronged” strategy to reach people, including mailing notices, sending text messages, hosting events and collaborating with community partners. The state is also urging everyone who currently receives Medicaid or CHIP benefits to ensure their information is up to date at YourTexasBenefits.com.

In 2021, 32% of community health center patients used Medicaid coverage, Eubank said. A majority were children, while some were disabled adults and pregnant Texans needing prenatal care.

Normally, these patients don’t come in as much for preventative or routine health check-ups because it’s a balance between coming to the doctor and putting food on the table, Eubank said. But during the period of continuous coverage, she said there was an uptick in those services being provided at clinics.

"Without Medicaid, they're going to have to start making those really tough decisions about their child's care or their own care,” she said.

For Rodriguez, who works in business administration but is trying to find a different job and balance taking care of her kids, she said the entire system has just felt “wonky.”

“It’s made me feel more unstable than I already feel,” she said.

This article originally appeared in The Texas Tribune at https://www.texastribune.org/2023/07/21/texas-medicaid-removal/.

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