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Cross-Border Health Care: The California Experience and the P ossibilities for Texas. By Dr. David Warner, Rachel Maguire, Kelly Shanahan, & Kimberly Tucker LBJ School of Public Affairs, University of Texas at Austin. October 15, 2004. Presentation Overview. Agenda : California

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Presentation Transcript
slide1

Cross-Border Health Care: The California Experience and the Possibilities for Texas

By

Dr. David Warner,

Rachel Maguire, Kelly Shanahan, & Kimberly Tucker

LBJ School of Public Affairs, University of Texas at Austin

October 15, 2004

presentation overview
Presentation Overview

Agenda:

  • California
    • History of cross-border healthcare
    • Current cross-border insurance plans
    • Lessons from California
  • Texas
    • Case Studies
      • El Paso/Juarez
      • Lower Rio Grande Valley
      • Dallas/Fort Worth
    • History of Cross-border Legislation
    • Future of Cross-border Health Insurance in Texas
history of cross border activities legislation in california
History of Cross-border Activities & Legislation in California

PRIVATE INSURANCE PLANS SELF-FUNDED PLANS

1957 WGA Health Benefits

1972 WGA Mexico Panel added

1974 ERISA passed

1975 Knox-Keene Health Care Service Plan Act

1983 Amended to address MEWAs

1994 SB 1430

1996 HIPPA Provisions

1997 DOC issues Cease and Desist Orders

1998 SB 1658

2000 SIMNSA licensed, Access Baja launched

2001 Salud Con Health Net launched

2003 SB 798, Salud Mexico, Access Baja

Dependent Plan

2004 SB 1347

current requirements for cross border hmo products in california
Current requirements for cross-border HMO products in California

The product must:

  • Be licensed by California DMHC
  • Meet certain financial standards
  • Be sold to employers at group rates through brokers, agents and TPAs
  • Provide emergency and urgent care coverage in the U.S.
basic plan definitions
Basic Plan Definitions
  • Single Network – doctor network available only on one side of the border.
  • Dual Network – doctor networks available on both sides of the border.
  • Self-funded Plans – employer-sponsored, federally-regulated plans. These are ERISA plans that are not subject to the same strict regulation as private insurance plans.
  • Latino-oriented Plans – insurance products specifically designed for and marketed to the Hispanic population in the U.S.
slide6

California: Current Cross-border Plans

  • Private Insurance Companies
    • Single Network:
      • SIMNSA, S.A.
      • Blue Shield - Access Baja
      • Health Net - Salud Mexico
    • Dual Network:
      • Health Net - Salud Con Health Net
      • Blue Shield – Access Baja Dependent Plan
    • Latino-oriented Plans:
      • Pacificare
      • Health Net
  • Employer-Sponsored Plans (ERISA)
    • Dual Network:
      • Western Growers Association
single networks
Single Networks

Plans:

  • Sistemas Medicos Nacionales, S.A. de C.V. (SIMNSA) (2000)
  • Blue Shield - Access Baja (2000)
  • Health Net – Salud Mexico (2003)
single network
Single Network

Plan Model

  • HMO, PPO plans
  • Area Network – Doctor/Hospital Networks in Mexico
  • Out-of-Area Network: Emergency and Urgent Care only

Plan Members

  • Members must reside within 50 miles of the border
  • Focus is on Mexicans and Mexican Americans
  • Approximately 50% live in California and 50% live in Mexico
single network9
Single Network
  • Employer industries include:
  • Service (Hotels/Restaurants)
  • Textiles
  • Landscape
  • Agriculture
  • Construction
  • Quality Control
  • Certification: Mexican Government, California Department of Managed Care
  • Audits
  • Grievance Process
  • Legal Recourse
single networks plan comparisons
Single Networks: Plan Comparisons

SIMNSA

  • Mexican-owned company (Legally allowed to advertise and sell employer-sponsored plans in US)
  • 12,300 members (4000 subscribers)
  • 90% 1st Generation Mexicans
  • Coverage Area: San Diego, Tijuana/Imperial Valley, Mexicali
  • Less expensive than Access Baja

Health Net – Salud Mexico

  • US company, contracts with SIMNSA network

Blue Shield – Access Baja

  • US company, contracts with General de Seguros, S.A.
  • 2000 members (subscribers and dependents)
    • 50 employers
  • Coverage Area: San Diego, Tijuana/Imperial Valley, Mexicali
  • 2 Different plans offered (Gold Plan & Silver Plan)
dual networks
Dual Networks

Dual Network – doctor networks available on both sides of the border.

Plans:

  • Salud con Health Net
  • Blue Shield – Access Baja Dependent Plan
dual networks12
Dual Networks

Salud Con Health Net

Plan Model

Combines Health Net Providers in California with SIMNSA providers in Mexico

20,000 members

  • Primarily 1st Generation Mexicans

2 Product Lines:

  • Full Network
    • Adds Mexican Provider Group to Offering
  • Narrow Network
    • Adds Mexican Provider Group to Offering
    • Provides “narrow” network in Los Angeles
    • Lower cost health plan option

Plan is 30-40% less expensive than Kaiser

latino oriented plans
Latino-oriented Plans

Latino-oriented Plans – insurance products specifically designed for and marketed to the Hispanic population in the U.S.

Plans

  • Pacificare
  • Health Net
slide14

PacifiCare Latino

  • Founded: in 2002 - Latino Health Solutions Initiative
  • Membership: 585,000 Latino members in the USA
  • over 500 companies have bought the Latino product
  • Services:
  • Offers the same products that PacifiCare does
  • 1-800 number in Spanish
  • Web based solutions in Spanish
  • Emphasis on education and information
  • Does not offer Cross-Border services
  • Offered in 8 states: CA, AZ, TX, OK, CO, WA, OR, and NV
health net
Health Net

Targets Latino Population (including low-income) through various outreach programs, community involvement

  • La Opinion

Combines government-sponsored programs with private insurance products to cover families

  • MediCal/Healthy Families

Accepts Mexican Matricula Consular card as Identification

self funded plans erisa
Self-funded Plans (ERISA)

Self-funded Plans – employer-sponsored, federally-regulated plans. These are ERISA plans that are not subject to the same strict regulation as private insurance plans.

Plans

  • Western Growers Association (Dual Network)
slide17

Western Growers Association

  • Plan Background
    • Founded: 1926 as a trade association
    • Membership: 3000 regular and associate members in CA and AZ fresh produce industry
    • Services: Many different services, including health care coverage.
    • Health Benefits:
      • 1957 - Creation of Western Growers Assurance Trust
      • (Not-for-profit, self-funded, and self-governed)
      • 1972 - Cross-border option (aka Mexican Panel) started
slide18

Western Growers Association

Plan Model

  • Tailor-made for company’s needs
  • For care in US, work with:
    • Blue Cross of California
    • Blue Cross Blue Shield of Arizona
    • Pinnacle Claims Management, Inc. (3rd party administrator)
    • Blue Cross Life & Health, Vision Services Plan, RESTAT Pharmacy
  • 250 full-time customer service employees
  • Most seasonal workers are on “Harvest Series” plan (100% employer contribution)
slide19

Western Growers Association

Mexican Panel

Optional “Rider” attached to plan

95,000 subscribers (employees + dependents) have rider

Physicians/Facilities:

    • 23 PCP contracts
      • 16 PCP subcontracts
    • 90 specialty care physicians
    • 10 hospitals (ER and surgical services)
    • 15 dental clinics

Location of Services on the Border:

  • Tijuana
  • Mexicali
  • Palaco
  • Los Algodones
  • San Luis
  • Agua Prieta
slide20

Western Growers Association

  • Mexican Panel
    • Required Coverage:
    • No “required” services
    • WGA determines what services are available in Mexico
    • 95% of the demand for services can be met by Mexican Panel
    • Cost = $29-35
  • Plan Membership
  • 110,000 of member employees and their families
  • 2002 = $90,000-100,000 paid in claims for Harvest Series plans - care received in US
  • 2002 = 30,000 Mexico claims
slide21

Latino Oriented Plans

PacifiCare

HealthNet

  • No cross-border services
  • Aimed at Latino population

Dual Network Plans

Western Growers

Salud con HealthNet

Access Baja Dependent plan

  • Services provided in both countries
  • Larger target market

Single Network Plans (Mexico)

Access Baja

SIMNSA

Salud Mexico (HealthNet)

  • 50-mile radius from border
  • Small target market

Provider Network Model

slide22

Future of Cross-border Plans

  • Growth in individual plans
  • Target small and mid-size businesses
  • Expansion of dependent coverage into the interior of Mexico
  • Rent network to other Blue/U.S. Carriers in other states
  • Expansion of self-funded cross-border plans
lessons from california
Lessons from California
  • Small market niche
  • Inexpensive
  • Culturally sensitive healthcare
  • Education necessary to teach value of health insurance
texas
Texas

Case Studies:

  • El Paso/Ciudad Juarez
  • Lower Rio Grande Valley
  • Dallas/Fort Worth
el paso juarez
El Paso/Juarez
  • Latino Population = 81% are Hispanic (2002 – El Paso County)
    • 25% born in Mexico (2002)
    • 76% of those age 5+ speak Spanish in the home (2002)
  • Ciudad Juarez – 1.42 million (2004)
    • Combined with El Paso County – 2.14 million (2004)
  • Uninsured = 33%
    • Least insured major city of the U.S.
  • Uncompensated care
    • Thomason General Hospital - $103 million (41% of total gross patient revenue)
    • Thomason + 9 private hospitals - $217 million
slide26

El Paso/Juarez

  • Employment Sectors
    • Service
      • Call centers/back office operations
      • Health care
      • Business support
    • Wholesale/retail trade
    • Government
    • Manufacturing
  • Employer-sponsored health insurance (non-elderly pop)
    • El Paso = 49%
    • Nationwide average in large urban areas = 67%
  • Many large employers have ERISA plans
    • school districts
slide27

El Paso/Juarez

  • Border crossings (north from Juarez to El Paso - 2003)
    • In general
      • 30,278 buses
      • 14,486,294 cars
      • 8,939,791 pedestrians
    • Work-related
      • 44,651 daily (2002 average)
  • Current Cross-border Activities
    • Medical Care Referral Group
  • Provider networks in Ciudad Juarez (ISES)
    • Plan Seguro
    • Mapfre Tepeyac
    • Seguros Inbursa
  • Medical facilities in Ciudad Juarez
    • Centro Médico de Especialidades
    • Poliplaza Médica
    • FEMAP/SADEC - Hospital de la Familia
lower rio grande valley
Lower Rio Grande Valley
  • Cameron and Hidalgo Counties specifically
  • Latino Population = 88% of population (total pop = 958,144)
  • Uninsured rate = 32-33% (1999)
  • Mexican Cities on Border = Matamoros, Reynosa
  • Industries:
    • Agriculture
    • Trade, Transportation, & Utilities
    • Government, Education, & Health Services
    • Manufacturing
    • Hospitality Industry
  • Current Cross-border Activities:
    • Difficult to gauge
    • Hidalgo Independent School District
    • Interest in Western Growers plans
  • Medical facilities, provider networks in Mexico
    • Facilities identified in Matamoros, Reynosa, and Nuevo Progreso
dallas fort worth
Dallas/Fort Worth
  • Latino Population = 22% of DFW pop (Latino pop = 1,120,350)
    • 79% is Mexican-origin
    • Uninsured rate = 37% (325,000 Mexican-origin)
  • Industries:
    • Construction
    • Manufacturing
    • Hospitality Industry
    • Education, Health & Social Services
    • Professional Services
  • Current Latino-Oriented Healthcare Options:
    • Limited Latino-oriented private insurance
    • Discount cards
    • Private clinics
  • Medical facilities
    • Parkland (Dallas), John Peter Smith (Ft Worth)
    • Community Health Centers (Los Barrios Unidos)
    • Private Practices
legislative history of cross border in texas
Legislative History of Cross-border in Texas
  • May 2001 - Texas Cross Border Health Care Act (SB 1826)
    • Coverage in Mexico for Mexican citizens and residents
    • Died in Committee!
  • Legal Obstacles to Cross-border Coverage
    • Definition of “provider” in a health plan
  • June 2003 - Texas Consumer Choice of Benefits Health Insurance Plan Act (SB 541)
the future of cross border health insurance in texas
The Future of Cross-border Health Insurance in Texas

Potential Plans

There is flexibility in…

  • Who a plan is designed to target
  • Plan structure and who offers it
the future of cross border health insurance in texas32
The Future of Cross-border Health Insurance in Texas

Potential Target Groups

  • Individuals who live in Mexico, work in US
  • Individuals who live in US, dependents are in Mexico
  • Spanish-speaking, low-income families in US
the future of cross border health insurance in texas33
The Future of Cross-border Health Insurance in Texas

Potential Plan Structures

  • HMOs
  • PPOs
  • Self-funded Plans (ERISA)
  • Consumer Driven Plans
    • Consumer Choice Plans
    • Health Savings Accounts