Central Texas Medicaid, CHIP recipients will soon lose most popular health plan
Errin Smith did what she was told to do. The Round Rock mom knew about Medicaid "unwinding" and the need for the state to redetermine that her daughter Bailee, 10, still qualified for the health care program. In September, she did all the paperwork and submitted it before her October deadline.
In February, Bailee, who has had Medicaid since Smith was pregnant with her, became one of the 2.1 million people who lost Medicaid coverage in the state of Texas during the unwinding period — the 12 months states have to requalify their Medicaid participants who had been given continuous coverage during the pandemic.
Smith gained her own Medicaid coverage that same month because she is pregnant with a second daughter due in August. Smith, 30, who works at Austin Regional Clinic, has not had an income change. She doesn't know why Bailee lost coverage.
Even with that coverage, she will have to find a new provider after Superior HealthPlan, the most popular Medicaid company in Central Texas, soon becomes no longer be able to provide services in this area.
Medicaid is medical insurance available for pregnant women, children, seniors and people with disabilities who make below a certain income based on their age and circumstances.
Bailee is one of 10,812 Texas children who lost Medicaid coverage and then were enrolled in the state's Children's Health Insurance Program, which is similar to Medicaid but with a higher qualifying income level. On CHIP, parents must pay premiums for that insurance, whereas Medicaid has no premiums.
Getting enrolled in CHIP did not happen automatically. Smith said she was never told by the state to try to enroll Bailee in CHIP after Bailee lost her Medicaid. Instead, Bailee's doctor contacted a caseworker to help get Bailee enrolled in CHIP, but the plan doesn't take effect until June 1.
In the meantime, Bailee, who has asthma, has had a trip to the emergency room. Smith wasn't able to afford the $300 asthma medicine Bailee needed, but an advocate at Dell Children's Medical Center helped her get it.
Smith is waiting to see that hospital bill. "I'm going to take a wild guess that it's going to be a pretty penny. ... It's going to be a nice shiny one," Smith said. "What do I do?" she said about the bill. Her finances are about to become even harder with a baby coming and a maternity leave.
More: Austin families talk about being stuck in Medicaid red tape and living without coverage
For Bailee to stay on CHIP, Smith will now have to pay about $35 a month, money she doesn't have. "What I'm going to do is put what I can to the side and lean on God," Smith said. "I'm not going to lie."
A new generation of kids without Medicaid
Texas leads the country in the number of people disenrolled in Medicaid. Most of the more than 1.3 million people who were denied coverage lost it because of procedural reasons, not because they were determined to be ineligible, according to the April Medicaid unwinding dashboard by the Texas Health and Human Services Commission, the state department responsible for Medicaid and CHIP.
U.S. Rep. Lloyd Doggett, D-Austin, who has asked the federal Centers for Medicare and Medicaid Services and the Biden administration to intervene, said Texas' handling of the Medicaid unwinding is "total incompetence." "So many of them were removed through no fault of their own," he said.
Of the more than 4.5 million people who have gone through the Medicaid recertification process, 2.3 million have had their Medicaid renewed, but only 233,256 by using the ex parte process of cross-checking other records such as SNAP food benefits or pay records filed with the Texas Workforce Commission. The rest have had to send in their forms correctly with all the proper documentation, a process that encountered technology roadblocks.
More: What's gone wrong with Texas' Medicaid unwinding? Inside the problems with state agency.
"The impacts of the Medicaid unwinding are now painfully apparent on children every day," said Dr. Kimberly Avila Edwards, a pediatrician with Dell Children's, Dell Medical School and a member of the American Academy of Pediatrics' Committee on Federal Government Affairs. On a call about Medicaid unwinding hosted by the Center for Children and Families at Georgetown University, she mentioned infants not getting their wellness visits, prescriptions not being filled, and health and mental health problems going untreated.
"Medicaid is not a luxury," she said. "It's a vital program for tens of thousands of families."
The loss of a popular Medicaid and CHIP plan coming
Central Texans who did manage to stay covered on Medicaid or CHIP are about to see another shakeup with their health care. The largest provider of Medicaid and CHIP coverage in Central Texas, Superior HealthPlan, was not chosen by Texas' Health and Human Services Commission to continue as a Medicaid or CHIP provider in the Travis service area, which covers Austin and the surrounding counties. This does not affect the Star Plus plan for adults who have disabilities or are 65 or older.
Superior, which has provided Medicaid and CHIP plans in the Austin area since 2001, had the highest ratings of the plans available in the Travis area, according to the commission's own data. Superior had 4½ stars out of 5 compared with Blue Cross and Blue Shield's 2½ stars and Dell Children's health plan's 3 stars.
Blue Cross and Blue Shield and Dell Children's plans will remain available. The state chose Aetna to begin serving this area instead of Superior, beginning Sept. 1, 2025.
This means that 92,864 people, or 57%, of those who have Medicaid or CHIP in Central Texas are losing their health care plan.
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Smith and Bailee and their newest family member will be part of that group. Superior's plan is the one the family has had since 2013, and it's who Smith choose for her pregnancy Medicaid coverage and for Bailee's CHIP coverage.
Smith said with Superior, she has never had any issues. "They are very communicative," she said. They've provided nurse coaching to help her with her daughter's asthma. "Honestly, if I could choose any health insurance, I would definitely choose Superior."
Why wasn't Superior chosen?
Superior has appealed the March decision by the commission to award the procurement to Aetna, Dell Children's and Blue Cross and Blue Shield of Texas in this area. The commission did choose Superior HealthPlan for the West Texas, Nueces and Lubbock service areas.
Based on the commission's proposal scorecard of all 18 proposals throughout the state, Blue Cross and Blue Shield ranked second, Aetna ranked third, Dell Children's ranked sixth and Superior ranked seventh. In the commission's request for proposals guide, the state limited the number of proposals to which it would award contracts by service area. The Travis service area was allocated only three providers. The state also limited the number of service areas a particular provider could be awarded to seven of the state's 13 areas. Superior was serving nine.
Superior, along with seven other health plans, filed a protest with the commission. "We don’t agree with the state’s decision, and we believe in the merits of our protest, given our high-quality scores, large provider network and steadfast commitment to serving Texans for the past 25 years," said Mark Sanders, president and CEO of Superior HealthPlan. It then filed another protest after learning that Aetna had received copies of competitors' proposals.
"There must be a fair and level playing field for all respondents in a competitive procurement process like the one Texas uses to award Medicaid contracts," Sanders said. "It’s clear that wasn’t the case here, which is why we believe these proposed contract awards should be canceled immediately."
The state has said the commission was following the procurement process it outlined.
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"All proposals were evaluated in the same fashion, using the best value criteria that was advertised in the solicitation," said Jennifer Ruffcorn, a spokesperson for the commission.
There isn't a set time frame for the commission to rule on the protest. If Superior is unsuccessful, it also can appeal to the Texas Health and Human Services Commission's executive commissioner, which it will do, Sanders said.
Preparing for the impact of a health plan change
"The loss of Superior ... is of significant concern for us because of the number of children potentially impacted by that," Edwards said.
This will be difficult for families but also for doctors and clinics, said Dr. Anas Daghestani, the CEO of Austin Regional Clinic. "A hundred thousand Medicaid patients are going to have to switch plans for an unclear reason," Daghestani said.
Superior was "the highest in quality," he said. "They were as easy as a health plan can be. ... They were very engaged. They were easy to solve problems with."
His clinics lose money by taking Medicaid because of the reimbursement rates, but transitioning patients from Superior to another plan will cause his clinics to spend more money, Daghestani said.
It will have to staff positions to help transition families to different plans and the billing and insurance verification staff will have to learn to work with a new provider. This is happening "at a time when we are already stressed out with staffing," Daghestani said.
While ARC does not plan to stop taking Medicaid and CHIP plans, Daghestani worries that some pediatric clinics will opt to not take Medicaid and CHIP because of the cost of this transition.
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CommUnityCare Health Centers, a federally qualified health center with 28 locations in Central Texas, said it already has had to intensify its efforts to help families get reenrolled in Medicaid or find other insurance.
"We are deeply concerned about the potential for escalating enrollment crises and the confusion among families due to the forthcoming changes in the Medicaid Managed Care Organizations (MCOs) operating in our region," said CommUnityCare's President and CEO Jaeson Fournier in a statement. "Superior Health Plan has consistently been a reliable partner, and we are committed to working with all MCOs and the Texas Health and Human Services Commission (HHSC) to mitigate such disruptions."
What should people with Superior HealthPlan do?
For now, you don't have to do anything. Once your renewal period comes up, you will have to choose another health plan for any period after Aug. 31, 2025.
Ruffcorn said recipients who will be losing their health plans will be informed by an enrollment broker of the need to choose a new plan about six months before Sept. 1, 2025. They also will receive an enrollment packet with comparison charts of the plans available, she said.
If people need additional help, they can call the enrollment broker helpline, 800-964-2777. Recipients also can go online to the Your Texas Benefits website, log into their account, and select Medicaid and CHIP services to search for providers, explore available plans, and make their plan and provider selection.
If a recipient does not pick a plan, "they will automatically be enrolled in a new health plan," Ruffcorn said. "A change in health plans in a service area will not cause a gap in coverage for recipients enrolled in Medicaid and CHIP."
This article originally appeared on Austin American-Statesman: Central Texas Medicaid, CHIP recipients to lose Superior HealthPlan
