Case Manager Shares Impact of Cook Children's Health Plan's Potential Medicaid Contract Loss

Written by Charlotte Settle

On March 7, 2024, Cook Children’s Health Plan (CCHP) was denied a new contract for STAR & CHIP Managed Care Services by the Texas Health and Human Services Commission (HHSC). Though CCHP’s initial protest to this decision has been denied, the team refuses to back down and is currently fighting for a reversal in the courts.

If not reversed, this decision will result in a serious disruption in care for nearly 125,000 low-income CCHP Members , pregnant women and medically complex children. It could also leave hundreds of CCHP employees—who work tirelessly to serve their community—in search of a job.

CCHP Complex Case Manager, Jami Jensen, RN, CCM, shared some of the crucial ways she helps patients navigate the complex health care system daily—and the potentially devastating consequences of a STAR & CHIP contract denial.

ABOUT CCHP CASE MANAGEMENT

CCHP case managers advocate for vulnerable families and children in our community all day, every day, through three vital areas of focus:

• Social determinants of health
• Coordination of care
• Education

These services have been proven to increase preventive care, decrease ER visits, and empower low-income local residents as they navigate health care.

THE CCHP DIFFERENCE

Unlike national health plans, CCHP is intertwined with Cook Children’s Health Care System and the local community.

“Some of us have worked within the Cook Children's Health Care System, and some of us have children of our own who have been through the system as a patient,” Jensen said. 

Because of their close proximity, case managers can communicate with providers seamlessly, get Members answers quickly, and even offer occasional on-site support. 

“I have gone to clinic appointments with patients before, and we’ll sometimes even meet complex patients at the hospital or in their home,” Jensen said.

CCHP case managers maintain an open-door policy—even for Members who have left the health plan.

“Even if they just have a simple medication issue, they know who to call,” Jensen said. “It’s so easy for them to reach out to us if they need something.”

SOCIAL DETERMINANTS OF HEALTH

Social determinants of health are the non-medical factors that influence health outcomes, such as socioeconomic status and access to basic needs. Before concentrating on health care issues, people must have their basic needs met.

Many CCHP Members lack reliable transportation, access to consistent food sources, and knowledge of community resources. That’s where CCHP case managers step in—to help families acquire all of the local benefits they qualify for. The knowledge and resources that come from building relationships between case managers and Member families are invaluable.

COORDINATION OF CARE

Case managers constantly collaborate with nurses, social workers, and providers within the Cook Children’s Health Care System to communicate Members’ needs, coordinate appointments and follow-ups, and close gaps in care.   

Oftentimes, when families are overwhelmed with a child being in the hospital, crucial steps for care get overlooked during discharge. Case managers bridge those gaps by reviewing each patient’s record, following up after their admission, and ensuring the family has all necessary next steps and appointments in order.

EDUCATION

Case managers go above and beyond to solve any and all types of Member needs. From helping families apply for state programs for children with special needs, to helping new moms find Medicaid-covered formulas, there’s nothing CCHP won’t do to make Members’ lives easier. 

With the help of staff members, who have extensive nursing backgrounds, CCHP has also been able to implement preventative programs and services for high-risk populations, including members with diabetes, asthma, and pregnancy risks.

CONSEQUENCES OF STAR & CHIP CONTRACT DENIAL

If the STAR & CHIP contract is ultimately denied, approximately 125,000 Members and children could be forced to switch providers and find new, in-network doctors.

Patients relying on life-saving treatments and medical equipment, such as ventilators, might have to find new suppliers and undergo lengthy authorization processes. These delays could cause serious harm to their health.

The loss of on-the-ground support from CCHP would force Members to navigate national call centers for support through these disruptive transitions—and there’s no guarantee that their new plans will offer knowledge of local resources.

“These families already have so much on their plates and it’s a lot of new information they might not understand,” Jensen said. “It’s so awful thinking how much stress this will add for them.”

WHAT’S NEXT?

Though Health Plan case managers continue to work tirelessly to support their Member families, they are also battling the anxiety of potential unemployment. A denial of the contract would more than likely threaten the sustainability of CCHP as a whole.

The CCHP team laments the potential loss of the heart, soul, and hard work they have poured into making health care more accessible for the most vulnerable Members of our community. National, for-profit insurers—favored over CCHP by the HHSC—cannot match the exceptional commitment and dedication that CCHP has demonstrated for over 20 years.

“We're not in this line of business for the profit,” Jensen said. “We are doing, and have always done what's best for the children in our community.”