State agency to ask lawmakers for $300 million to fix “significant neglect” in Texas’ Medicaid enrollment system

Texas Health and Human Services Commission is asking the state Legislature for $300 million next legislative session to improve the Medicaid enrollment process. (Credit: Pu Ying Huang for The Texas Tribune)

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In Texas, health advocates often find themselves playing defense to encourage leaders to preserve the state’s relatively frugal public service offerings while also pushing for more.

That’s why a $300 million ask to lawmakers next year from the state’s social services agency — the Texas Health and Human Services Commission — to improve the agency’s complicated Medicaid application process has thrilled the state’s nonprofit policy groups.

If granted, it could mean more than 1,000 new workers and millions spent upgrading a decades-old computer system to make it easier for Texans to apply for Medicaid health insurance for adults and children, food stamps and other programs.

This move could allow vulnerable Texans to be enrolled in these critical programs in weeks rather than the months they’re experiencing now.

“That very much stands out for us,” said Peter Clark, spokesperson for Texans Care For Children, which advocates on behalf of Texas children and families and has put improvements to the state’s Medicaid eligibility system at the top of its list for state lawmakers when the Legislature convenes in January.

The agency-initiated request is a response to the incredible backlog of applications for Medicaid and food stamps after the federal unwinding of a pandemic-era policy that suspended the need for periodic renewal of benefits. Hundreds of thousands of Texans lost their Medicaid coverage because they didn’t get their renewal applications filed quick enough or they were procedurally removed from the program because of paperwork issues.

In its legislative appropriations request, the agency notes that federal rules require food stamp applications be reviewed within 30 days and Medicaid applicants within 45 days. Since 2019, that has not been the case.

As of Nov. 22, the wait time for a Medicaid application for an adult or child to be processed was 71 days and 131,869 applications were waiting to be completed. As of Dec. 5, the wait time was slightly improved at 59 days.

“The TIERS eligibility system has suffered significant neglect due to the exceptional demands of” the COVID-19 pandemic, the agency’s request to the Legislature states. “Fully funding this request provides the level of resourcing needed to keep up with routine demands, and allows (state tech workers) to address the backlog of modification requests targeting timeliness mandates and client experience.”

Each year, there are as many as 50,000 maintenance service requests for the enrollment system filed by staff members.

The legislative request document calls for at least 1,772 new positions, but agency officials have provided specifics on what else they would spend the rest of the $300 million. If the state approves the $300 million, it could receive an additional $100 million in funding, including from the federal government.

In the last year, the health agency employed more than 2,100 eligibility workers to help reduce the backlogs, reporting that more than 96% of eligibility workers are filled.

As a result of those efforts, the agency has eliminated the food stamp applications backlog last month, HHSC spokesperson Jennifer Ruffcorn said.

Why do Medicaid applications take so long? 

When a Texan applies for Medicaid health insurance or food stamps, they can do so through the agency’s Texas Benefits website or the agency’s Your Texas Benefits app.

But miles away, a state worker has to take that applicant’s information and manually input all the data into an unforgiving 20-year-old computer system with the most bureaucratic of names: the Texas Integrated Eligibility Redesign System, or TIERS.

To say it’s a time-consuming process is an understatement.

“You remember The Oregon Trail, it’s like that,” said Diana Forester, director of health policy for Texans Care For Children, referring to the static, 1985 video game played via keyboard prompts.

When it was introduced as a pilot in 2003, TIERS was hailed as a system that would create cost savings. But from the start, there were snafus that forced the state to change contractors and pour an additional $56 million to fix some of the problems in 2006. An audit the following year found TIERS “cumbersome to use.”

Last year, the system’s flaws were made even more apparent for low-income Texans — children, the disabled and elderly — when Texas abruptly kicked more Medicaid recipients off the program faster than any other state after keeping them on continuously through the pandemic.

Forester, who worked for the state health agency for six years before becoming a health policy advocate in 2022, said using TIERS can be so tedious that workers must repeatedly type the same information in different places of what can be a 30-page Medicaid application for it to be successfully submitted.

The slow process is by design, said Anne Dunkelberg, who retired as health policy director for progressive policy group Every Texan earlier this year.

“Texas has many decades of making enrollment and renewal difficult,” she said.

The system forces caretakers to block out hours if not days to push an application into the system after gathering the required documents.

“It requires eternal vigilance,” Dunkelberg said. “We had some pretty bad statistics coming out of COVID. The time is ripe to upgrade some of the things to prevent losing so many eligible people, mostly kids, into the program.”

What applying for help looks like on the ground

As the deputy coordinator of Mercedes-based Texas RioGrande Legal Aid’s public benefits group, Bernadette Segura and her team help Texans, often Spanish-speaking, apply for Medicaid and food stamps.

“The delays are shorter, but there are still delays,” Segura said last week. “It’s taking (state health agency staff) forever to make decisions.”

Anyone applying for either benefits must prove they are either citizens or lawfully living in the United States by submitting birth certificates and verification of income, rent, utility bills and school enrollment for children who are old enough to attend.

Segura often hears from clients who have to resubmit documents multiple times because the state has said it hasn’t received them.

One client, a single father, waited more than a year after applying to receive food stamps, and it took an administrative appeal to do so, she said.

To apply for benefits requires a lot of patience, Segura said.

“You have to have a fully charged phone and a lot of time to stay on hold,” she said. It also requires a certain amount of tech savvy. If a Texas resident applies online from their phone, they have to know how to enlarge small print and know how to scan their documents into the application.

While they wait, many rely on local food banks, many of which also assist their customers with applying for food stamps.

Another impediment, Segura noted, is the fact that Medicaid and food stamp applications come in only Spanish and English. For those qualifying non-English speakers from the Middle East, Asia and Africa who need assistance, the language barrier can act as a strong deterrent, she said.

“There’s confusion based on an applicants’ level of English,” Segura said, who added she’d like to see applications available in Arabic, Chinese and Vietnamese. “There’s a need all the time for language translation.”

Forester, with Texans Care For Children, said the system can also pepper an applicant incessantly with confusing notifications. “It’s not user-friendly for an applicant,” she said. Go to any community center helping applicants and you’ll see “lines of families with a stack of notifications. Some contradict each other,” she said,

Applicants get overwhelmed and they can’t find out what the status of their applications is by logging in, she said.

“We don’t need more people,” Forester said. “We need better tech.”

Disclosure: Every Texan and Texans Care for Children have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.