Medicaid change will affect almost all recipients in Rio Grande Valley

The rollout on March 1 of managed-care Medicaid for the Rio Grande Valley and beyond is “a historic policy shift,” State Rep. Richard Peña Raymond, D-Laredo, said this week.

The change is expected to affect more than 400,000 Medicaid clients in a 10-county service area. They were asked to enroll in managed-care plans by last Friday.

In the face of the state budget crisis last year, proponents said the change would cut costs because managed care would help avoid duplicate services for clients. Those who had been against managed care for Medicaid said the likely reduced reimbursements would hurt services and clients.

Now, the big change is 15 days away.

“I did not support shifting to the HMO system, which is what this is,” Raymond said, referring to health maintenance organizations. “The argument by those who support it, was that it would save money. It remains to be seen.”

The change has been criticized by a group of Valley pharmacists who said their Medicaid reimbursements would go down, potentially passing the cost on to clients.

Raymond said that he and other legislators had been fighting off the change for years, but now his task as chairman of the House Health and Human Services Committee is to monitor the implementation of the new system.

He said a formal report on his committee’s findings about the managed-care rollout will likely be ready late this year and will be presented to the Legislature when it convenes in 2013.

Providers have expressed reservations about how quickly the massive rollout will occur, and questions about service linger. The affected counties are Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy and Zapata.

The five managed-care plans clients must choose from will operate under programs called STAR, which is generally for children and families, or STAR+PLUS, which is for the elderly or those with disabilities.

Managed care is used for Medicaid clients in other parts of the state, but it’s just now coming to South Texas.

“I, and others, worked to keep it out,” Raymond, a member of the Legislature for 17 years, said. “The reason that it was not in there before, I felt — and a lot of others felt — that the system we had already was a good system and that changing it to an HMO system would risk putting people in a situation where they needed health care but might find it harder to get it.”

Earlier this month, the Brownsville Community Health Center was host to a fair to discuss the Medicaid changes. BCHC marketing director, Alix Flores, said almost 900 people attended but some were recipients of Medicare as opposed to Medicaid and were unaffected.

Flores said 350 clients were enrolled in a managed-care plan during the fair.

In general, he said, BCHC clients found the process to be complicated. Some were unsure if they would be affected at all, and others were concerned about whether they would keep their own doctor.

Clients also wanted to know what types of services the plans offered. Flores has said that the plans will have the same basic benefits but services called "value adds" will be different.

A HHSC spokeswoman said that if a Medicaid client missed the Feb. 10 deadline to choose a plan, they would automatically be enrolled in one of the managed-care programs. Efforts will be made to make sure their plan includes their current doctor, she said.

According to a press release from Raymond’s office, after the deadline if a client wishes to change their plan they can do so but the change will not be effective for 30 days.

Raymond expressed concern about managed-care plans being a middleman in a patient’s care process.

“Partly, what you have to look out for is you don’t have a system where the services that a doctor or medical personnel believe you need, you’re not given because the HMO says they don’t think you need it,” he said. “That’s the biggest thing I think you’ve got to watch out for.”

New reimbursement rates for pharmacists serving Medicaid clients are currently only a proposal, but they are “very low,” Raymond said. He acknowledged the concerns of local independent pharmacists.

“There are many, many places where you can’t allow those pharmacies to shut down,” he said in reference to smaller communities that lack a corporate retailer such as CVS or Walgreens. “There’s no way many of them would be able to survive, and I’m very concerned about that as well. Nothing is finalized yet, but it’s getting close.”

He also said it’s uncertain if the large number of Medicaid recipients in the area will be enrolled by the date the new system goes into effect — a problem that has been seen in other regions of Texas.

And there may be confusion if a client gets into a plan that doesn’t allow them to see their regular doctor, he said.

“Just because it’s in other parts of the state doesn’t mean it’s working well,” he said of managed care for Medicaid clients. “In fact, I think some would argue that it wasn’t. We felt that it was not the right fit for South Texas.”

As March 1 comes closer at least one managed-care Medicaid plan, Driscoll Children’s Health Plan, has announced the opening of an office in the Valley — in Edinburg — to help administer its contract in the region.

Raymond said a briefing last month in Austin brought together local providers, client advocates, representatives of the state Health and Human Services Commission, as well as representatives of all five managed-care plans and the state’s enrollment broker, Maximus Inc., to identify obstacles and help promote understanding.

“I’m absolutely committed to making sure that we do have a good health-care system and doctors can provide the services that they’re trained to do and the patients can receive the services that they need,” Raymond said. “That’s the bottom line for me.”