Gov. Susana Martinez's administration is proposing to overhaul a program that provides health care to a fourth of the state's population, and the changes could require some needy New Mexicans to dig into their pockets to pay a fee if they go to an emergency room for medical care that's not considered an emergency.
One of the goals of the planned revision is to slow the rate of growth in Medicaid, which accounts for 16 percent of this year's state budget and costs New Mexico taxpayers nearly $1 billion.
"We think it's a broken system. We think we need to change it now," Human Services Secretary Sidonie Squier said Tuesday in an interview in which she outlined the proposed revisions, which will require federal government approval.
She emphasized that there will be no cuts in enrollment or changes in who's eligible to receive medical services, and there will be no reduction in rates paid to health care providers.
However, the state proposes to require "co-pays" for Medicaid recipients who go to an emergency room for routine medical care and for using a brand name drug when a generic drug is available. The fee will be $3 for brand name drugs but won't apply to certain drugs used to treat mental health conditions. The fees for using an emergency room will vary according to a person's income, but could range from $6 to $50.
The state hopes to have the revamped Medicaid program implemented in October 2013.
Currently, Medicaid is a host of health care plans that provide different services for various segments of the population, ranging from children without insurance to disabled adults and individuals with behavioral health problems. The program is jointly financed by the state and federal government, and has been among the fastest growing costs in New Mexico's state budget.
A key element of the overhaul calls for using fewer health care contractors to provide a broader range of medical services through managed care. Behavioral health services will no longer operate separately but will be part of the main consolidated Medicaid plan. Long-term health care services to the developmentally disabled will remain separate, however.
A managed care organization will need to offer services ranging from health care to newborns to long-term nursing services. The state currently contracts with seven managed care organizations for various Medicaid services. Squier wants to reduce that although there's no target number.
The changes should help simplify administration of Medicaid, but Squier said the proposed overhaul also is intended to improve the coordination of care and "help us get to healthy outcomes where people get better and they stay better."
"We don't know if we are getting good outcomes for all the money that we spend," said Squier. "That has to change. We have to know."
The state is proposing to offer rewards to Medicaid recipients "engaging in healthy behaviors," such giving people a retail store gift card if they follow a certain plan of care.
To try to expand access to health care, the state wants to use school-based health clinics to serve Medicaid patients in some parts of the state and expand a "telemedicine" program that uses online web-based conferencing to help train primary care providers in rural areas for treating complex medical conditions.
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