HOUSTON – A lot of children and moms in our area who are on Medicaid may lose access to their doctors in 2025.
In total, 450,000 of the state’s most vulnerable kids and pregnant women may lose access to some of the top pediatric providers in Texas.
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Amanda Navarette uses the Texas Children’s Hospital STAR (Medicaid) for her daughter and was enrolled herself during her pregnancy and postpartum.
“If it’s taken away... I’ll definitely be struggling with having to cover the costs of taking care of my daughter and taking her to the appointments,” Navarette said.
“We’re obviously very disturbed about the potential outcome,” said Michael Murphy, President of Texas Children’s Health Plan. “When you find somebody, you can work well with to really navigate the health care system effectively, and you have to break that bond and go find somebody new and start all over in that process. That is highly, highly disruptive to everybody’s personal lives.”
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It could be most disruptive for parents of children with disabilities who have built an entire medical team, and in some cases have specialists who may only exist at a facility like Texas Children’s Hospital.
“When you have a high dependency where you need to see that specialist on a regular recurring basis at a high frequency, that’s very, very difficult to manage,” Murphy said. “The kids are going to suffer as part of that process, and that certainly isn’t acceptable.”
Of course, some patients on Medicaid may choose find providers elsewhere. While there are several facilities across Texas whose contracts are currently in limbo, the Centers for Medicare & Medicaid Services (CMS) said patients are not going to lose coverage.
“CMS is committed to its ongoing work with states to strengthen and expand access to care for all Medicaid enrollees. Please reach out to the state Medicaid agency if you have questions about their Medicaid program or Medicaid managed care plans,” a CMS spokesperson told KPRC 2 Health Reporter Haley Hernandez.
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So, we asked the state for further information, specifically whether they were negotiating a new contract for 2025.
Here’s a statement from HHSC from August 6, 2024:
A change in managed care organizations (MCOs) holding contracts with HHSC does not affect whether a Medicaid recipient receives services, nor does it affect the services that a recipient is eligible to receive. MCOs are contractually required to provide continuity of care for both newly enrolled recipients and recipients transferring from another MCO. HHSC requires that the transition to a new MCO be as seamless as possible for Medicaid recipients and their providers. Established recipients and provider relationships, existing treatment protocols and ongoing service plans are important parts of any transition.
The Request for Proposals (RFP) No. HHS0011152 STAR CHIP Managed Care Services was posted on the Electronic State Business Daily (ESBD) on 12/7/2022. Article III of the published RFP explains the proposal evaluation and award process.
HHSC announced contract awards (Notice of Intent) following a competitive solicitation where all respondents were scored using the same evaluation criteria. The resulting awards across all service areas were to MCOs that received the highest scores. This will provide the best value to the state and quality of care and service to all STAR & CHIP recipients.
Once final contracts are awarded and before MCOs begin serving recipients, HHSC conducts a robust readiness review to ensure MCOs are operationally ready to fulfill obligations under the contract and can provide all contracted services. Readiness activities, performed by HHSC staff, include ongoing desk reviews, trainings, trading partner IT systems testing, review of MCO documented processes and workflows, interviews with key MCO staff, review of provider networks, claims payment testing and other activities. When the readiness activities are completed, HHSC determines if the MCO is operationally prepared to provide the contracted services. Operations are targeted to begin in the first quarter of state fiscal year 2025.
Although the RFP has been posted, responded to, and evaluated, it remains an open procurement until all protests and appeals submitted by respondents have been resolved, and contracts have been executed. As such, to maintain the integrity of the process, HHSC is limited in the ability to comment publicly.
Additional documents are posted on the website including the protest documents. In addition, I’m providing you a letter from Executive Commissioner Young that has more details.
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For Amanda Navarette, this does not ease her mind. She said she feels overwhelmed trying to keep her household afloat amid rising costs while working a part time job at $16/hour. She is unsure what kind of healthcare she could provide for her daughter if she didn’t have STAR and reflects on the care she received postpartum that may have saved her life.
“I had had migraines for like three days straight, three or four days straight,” she remembers telling a nurse she saw after birth. “She was like, ‘we need you to go to the hospital like, now.’ And I wouldn’t have thought that. I would not have had that without her.”
“The state essentially believes that they know better than the members themselves, who the right providers and the right plan, health plans are for them. That certainly isn’t actually the case,” Murphy said. “I think there’s a fair number of unintended consequences with this particular decision. It’s not like we’re buying staplers. We’re actually taking care of kids’ health care and adult health care for expectant mothers.”
Affected Texans would be shifted to new insurers next year if Health and Human Services sticks to its plan.
“It blessed my life. It blessed my daughter... So, I pray that it does continue,” Navarette said.
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Texas Children’s Hospital said they’re not done fighting the decision.
“We have formally appealed this decision and are pursuing all legal remedies necessary as HHSC has violated the law during this process. We will also leave no stone unturned in protecting and advocating for our members and the families we serve. Again, we want to assure all Texas Children’s Health Plan members and their families that there will be no disruptions in coverage at this time and that the health of our members remains our top priority,” Murphy said.
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