SANTA FE, N.M. (AP) — Medicaid recipients will face co-pays for some treatments and have their medical services tracked as part of a program overhaul that is intended to lower the costs of providing health care, Gov. Susana Martinez's administration announced Monday.
There will be no changes in determining who qualifies for Medicaid, which serves about a quarter of New Mexico's population.
The state Human Services Department said President Barack Obama's administration had given approval to the state to implement the changes, which will start next year and are intended to try to slow the rising costs of the health care program for the poor while improving service.
One of the main goals of the revamped program known as "Centennial Care" is to better coordinate the care provided to recipients to improve their health or keep medical conditions from worsening and becoming more costly to treat.
Managed-care organizations under contract with the state for Medicaid will hire "care coordinators" to track medical and behavioral health services.
"It's going to change the way we do business and it's just going to increase health outcomes," Human Services Secretary Sidonie Squire said in an interview.
Reimbursement rates to health care providers will remain the same, as will eligibility.
But much like in private insurance plans, Medicaid recipients will face co-pays for some services. That will include going to an emergency room for routine medical care or using a brand name drug when a generic one is available.
By requiring people to take responsibility for some costs of their health care decisions, the state hopes to better control part of the growth of Medicaid, which is financed jointly by the state and federal governments.
The fee will be $3 for brand name drugs, but that will not apply to children and pregnant women. The fees for using an emergency room will vary according to a person's income, but could range from $3 to $50 per visit. Native Americans will be exempt from the co-pays.
The state also will offer incentives to encourage good health practices. Recipients can earn points toward gifts if they take certain steps for better health, such as seeing a dentist at least once a year, completing a prenatal care program or having certain diabetes testing.
Medicaid is expected to cost New Mexico taxpayers nearly $1 billion this year and account for 16 percent of the state budget. The federal government provides almost $3 for every $1 spent by the state.
New Mexico will implement the changes at the same time it expands the program to cover an additional 170,000 low-income adults under terms of the federal Affordable Care Act. The program currently offers services to about 550,000 New Mexicans, mostly uninsured children in lower-income families, the disabled, elderly in nursing homes and low-income pregnant women.
Native Americans who qualify for Medicaid will have the option of receiving care through managed-care organizations or continuing with a fee-for-service system. American Indians needing nursing home care will obtain their services through managed care, however.
The state initially had proposed requiring managed care for all eligible Native Americans, but tribal leaders worried that could make it more difficult for Indians in remote areas to get access to medical providers who might not be part of a managed care network.
Squier said Native Americans who enroll in managed care will be able to use their current primary care providers through the federal Indian Health Service or other tribal health systems.
The state negotiated with the federal Centers for Medicare and Medicaid Services for about a year before winning final approval of its proposed overhaul.
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