Limiting the lookback window in retroactive coverage for new Medicaid patients and giving states flexibility in how they deliver services to people with intellectual disabilities, plus a moratorium on certain eligibility and enrollment provisions, top the Texas Medical Association’s list of new federal provisions it is monitoring that impact Medicaid and the Children’s Health Insurance Plan (CHIP).
Although a number of Medicaid changes in the One Big Beautiful Bill Act (OBBBA) are projected to affect Texas less profoundly than states that chose to expand Medicaid, TMA is monitoring notable provisions that will impact physicians in the Lone Star State. TMA staff point out those delayed provisions provide the U.S. Department of Health and Human Services time to formulate and offer guidance, while states can prepare implementation strategies.
Medicaid eligibility in Texas is focused on low-income children and pregnant women with household incomes of about twice the federal poverty level, as well as seniors and individuals with disabilities who meet certain income or medical needs-based criteria.
One OBBBA element set to begin Jan. 1, 2027, is a narrowing of the period of retroactive coverage. In Texas, this change will have the effect of shortening the so-called “lookback window” from three to two months before the month the individual submitted their application for Medicaid or CHIP. In states with an expansion population, OBBBA shortened this window to one month for expansion enrollees.
“Three months is sometimes not even enough time to navigate the system, given the intricacies and the steps in the process,” which may be further hindered by the narrower time frame, said Nancy Binford, MD, an Austin obstetrician-gynecologist with People’s Community Clinic and a member of TMA’s Committee on Medicaid, CHIP, and the Uninsured.
“That’s going to further unravel our deteriorating systems,” Dr. Binford said, concerned the shortened timelines will further complicate Medicaid eligibility and hamper access to care for those who otherwise can’t afford it.
And for those who can’t secure retroactive coverage, “We still provide the care … it just burdens our accounting.”
While federally qualified health centers like People’s can take on more Medicaid and even uninsured patients than small private practices operating on thin margins, Dr. Binford notes absorbing the cost of uninsured health care takes its toll.
“Not only does it hurt patients, but it hurts the system,” she said. “It hurts physicians. It hurts our souls to not be able to provide care, but it hurts our souls to not be able to provide for our families.”
Starting in 2027, Texas also will be beholden to federal measures OBBBA intends to reduce fraud, waste, and abuse in Medicaid, in part, by enhancing the accuracy of recipient addresses and conducting eligibility verifications more frequently, including quarterly death record file checks, in an effort to keep deceased individuals from remaining enrolled.
A Texas Health and Human Services Commission (HHSC) spokesperson points out the state already implements comprehensive safeguards in its Medicaid management, including getting updated addresses from the U.S. Postal Service, the National Change of Address database, and managed care organizations, as well as doing monthly matching checks with the Social Security Administration’s Death Master File (in addition to receiving death verification information through the Birth Verification System) to identify deceased Medicaid recipients.
CHIP in Texas may also potentially be affected by an OBBBA moratorium on specific eligibility and enrollment (E&E) regulations promulgated in 2024 prior to its passage. The moratorium bars the Centers for Medicare & Medicaid Services from implementing, administering, or enforcing these regulations for the length of the moratorium window, or from July 4, 2025, through Sept. 30, 2034.
During this timeframe, states are no longer required to perform certain duties, like requirements to follow up on individuals disenrolled for a failure to return requested information and to continue an individual’s enrollment and benefits during the state’s review of its decision to disenroll an individual from CHIP.
Vigilant of the moratorium’s limited application to the E&E regulations, TMA and four statewide medical organizations have called on HHSC to clarify state policy, reminding the agency the moratorium does not apply to portions of the E&E regulation promulgated in 2024.
In an Oct. 7 letter, TMA asks HHSC for a public timeline and workplan, as well as opportunities for stakeholder input, while the agency develops proposals to implement the E&E regulations still in effect, like prohibitions on waiting periods before CHIP coverage kicks in and prohibitions on annual or lifetime dollar limits on services covered by CHIP.
Those reforms, which went into effect on June 3, 2024, “represent a significant federal effort to simplify enrollment and keep children covered,” per the letter. Since that time, HHSC has been working to implement these provisions, some of which are now temporarily barred under OBBBA. Thus, the letter serves as a reminder to HHSC to not let the still in effect E&E regulations fall through the cracks.
TMA is encouraged, meanwhile, by an OBBBA initiative set to take effect on Jan. 1, 2028, aiming to expand access to home and community-based services for individuals with conditions such as intellectual disabilities who do not meet an institutional level of care need.
“Ever since I’ve been in the business, this has been a neglected item for the state to address,” said Cynthia Peacock, MD, chair of TMA’s Committee on Medicaid, CHIP, and the Uninsured.
While potentially providing funding for new populations under a Home and Community-Based Services (HCBS) waiver program, TMA notes coverage under this new flexibility is dependent on HHSC’s (and the state’s) willingness to utilize the waiver, and if so, the extent of the coverage under the waiver will also be dependent on the amount of funds the state allocates for such a purpose.
Dr. Peacock adds it would take “billions with a B” to serve all those on the waitlists providing these types of services under the state’s HCBS umbrella. According to HHSC, close to 110,000 people are on what the agency calls “interest lists” to get this state assistance.
Continue to read Texas Medicine Today for OBBBA updates and keep up with TMA’s federal advocacy efforts.
Phil West
Associate Editor
(512) 370-1394
phil.west[at]texmed[dot]org
Phil West is a writer and editor whose publications include the Los Angeles Times, Seattle Times, Austin American-Statesman, and San Antonio Express-News. He earned a BA in journalism from the University of Washington and an MFA from the University of Texas at Austin’s James A. Michener Center for Writers. He lives in Austin with his wife, children, and a trio of free-spirited dogs.