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As Open Enrollment Begins Nov. 1, Central Health and Sendero are Expanding a Program Offering Private Insurance for Limited Group of Patients with Complex Medical Needs

As Open Enrollment Begins Nov. 1, Central Health and Sendero are Expanding a Program Offering Private Insurance for Limited Group of Patients with Complex Medical Needs

(Austin, TX) – As the 2020 Open Enrollment Period opens Friday, Nov. 1, Central Health and Sendero Health Plans, its nonprofit health maintenance organization (HMO), are expanding a program that pays health insurance premiums for Travis County residents with complex medical needs.

Under the premium assistance program, Central Health pays insurance premiums for a select group of chronically ill patients who meet specific health criteria and are enrolled in the Medical Access Program (MAP), the healthcare district’s coverage program for Travis County residents with low income. The plan, recommended last fall by Sendero leadership, takes advantage of funds offered through the Affordable Care Act’s (ACA) risk adjustment program. In return for insuring sicker patients, Sendero expects to earn millions of dollars for these members’ care from the risk adjustment program.

“The premium assistance program is working as planned,” said Dr. Guadalupe Zamora, long-time Austin physician and board chair of Central Health. “It is improving the health of the people we serve in a financially responsible manner. This year we hope to double the number of patients who choose to transition from MAP to Sendero, and we realize that will take an intensive outreach strategy to help patients understand their options and make the choice that is best for them.”

The risk adjustment program is designed to stabilize health insurance markets so that insurance companies with sicker members can draw down money from a pool of funds paid in by companies with healthier members. Central Health’s Board of Managers adopted the plan in September 2018, thereby funding insurance premiums for approximately 500 MAP enrollees with complex medical needs who enrolled in Sendero. Of the 500 members identified, more than 200 chose to move to Sendero’s IdealCare health plan.

Private insurance plans like IdealCare offer a broader network of physicians and more services and benefits than MAP or other government health coverage programs. The strategy was also designed to increase funding for care into Sendero, which in previous years had paid as much at $47 million into the risk adjustment program rather than drawing money out.

“By providing health care coverage to more of our community’s previously uninsured, chronically ill residents, and again offering low cost, high-quality plans to everyone, we are fulfilling our mission to expand coverage for the Austin area,” Sendero President & CEO Wesley Durkalski said. “We are proud of Sendero’s track record in working together with Central Health and our wide network of providers to build a healthier community for all.”

Central Health’s MAP provides health coverage for Travis County residents living at or below 100% of the Federal Poverty Level who are not eligible for other programs such as Medicaid/CHIP, Medicare, or private insurance. Earlier this year, Central Health expanded the program with the creation of MAP BASIC, which covers people with higher incomes but offers fewer benefits and higher copays than traditional MAP.

In Fiscal Year (FY) 2019, Central Health’s Board of Managers budgeted $6 million for the premium assistance program. For FY 2020, the board budgeted $7 million with a goal of enrolling between 300-350 current MAP and MAP BASIC members in Sendero. To qualify, patients must have been enrolled in MAP or MAP BASIC during the past year, not be eligible for Medicaid or Medicare, and have a current medical diagnosis of “chronic.” At the same time, Sendero is reaching out to members currently enrolled in the premium assistance program and offering them the opportunity to re-enroll next year. It’s anticipated between 150-175 members will choose to remain in the program.

The annual open enrollment period for the Health Insurance Marketplace is Nov. 1 through Dec. 15.  The Marketplace, part of the ACA, is where people without insurance get enrolled in a health plan for the year to come. For most, this single 45-day window is the only time of the year they can enroll.