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Cook Children’s sues health commissioner over insurance change

Thousands of Texans would have to find new health insurers if a state Medicaid shakeup is finalized.

FORT WORTH, Texas — Zechariah Sudolcan’s wall is covered in medical equipment. Wound dressings and trach cleaning kits fill boxes that hang near the bedroom’s doorway.

“There’s only 40 to 50 recorded medical cases of it,” his father Samuel said. “Even then, none have his exact duplication.”

A rare chromosomal anomaly affects the two-year-old’s heart, lungs, kidneys, brain, and development. He needs near-constant care, his mother Kathy Grace says.

Since Zechariah’s birth, the Sudolcans have relied on Cook Children’s Health Plan for health care coverage.

“It just made sense to us,” Samuel said. “They’re local. We’re already here. They’ve done so much for Zechariah up to this point — the Cook Medical Center has — that it just made sense to go with their health plan.”

There are about 125,000 people enrolled in the Cook Children’s Health Plan, serving Medicaid STAR and CHIP patients since 2000. Recipients are mostly lower-income families, children with serious health complications, and pregnant mothers.

But the Texas Health and Human Services Commission this year decided four, for-profit managed care organizations would provide better value to such patients. Using a new process for selecting insurers, the commissioner awarded its regional Medicaid contracts to Aetna, Molina, UnitedHealthCare and Blue Cross Blue Shield of Texas.

The state did not award a contract to Cook Children’s Health Plan, meaning its 125,000 enrollees will need to find a new coverage plan and, potentially, new doctors.

“(Zechariah) is used to the medical equipment he has,” Samuel said later. “We’re used to the medical equipment he has. We’re used to the providers and driving 15 minutes to go to the hospital. It would change everything.”

The HHSC has so far rejected Cook Children’s formal appeals, doubling-down on its commitment to the four providers awarded state Medicaid contracts.

Wednesday, Cook Children’s announced it’s suing the commissioner to prevent the insurance shakeup.

“They are taking over hundreds of thousands of lives, if this decision stands, on the basis of flawed methodology,” Cook Children’s Health Plan President Karen Love said.

Texas recently adjusted its Medicaid contract procurement process, essentially using a new rubric to grade organizations who bid on the contracts. State officials tweaked the process in response to a scathing 2018 audit, which found Texas wrongly awarded $3.4 billion in Medicaid contracts because of selection process flaws.

“The state did have problems in 2018,” Love said. “They brought in consultants to help right the ship and redo the procurement process. Not all of how that worked is transparent to us.” 

Love called the adjustments an “overcorrection.” In its lawsuit, Cook Children’s contends the HHSC did not properly vet the redesigned process.

They’ve asked a Travis County judge to prevent the commissioner from executing the new contracts. If the judge overturns the ruling, the state could renew existing Medicaid contracts or force the insurers to re-apply for new contracts using a different rubric.

If the contracts are executed, Love worries patients’ transition to a new coverage provider would not be smooth. In a best-case scenario, she said the move would create a paperwork headache for those families. 

Cook Children’s is not the only health plan affected by the contract procurement changes. As many as 1.8 million Texans could be forced to enroll with a new managed care organization.

“All of them will have to transition to a new health plan, all on the same day: September 1, 2025,” Love said. “My worry is… there will be gaps in care. People will show up to pharmacies, not be able to get their prescriptions because their coverage isn’t shown correctly.” 

The HHSC, which does not comment on pending litigation, noted that it requires the…

Read More: Cook Children’s sues health commissioner over insurance change

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