Background. Migrant families encounter numerous barriers on a daily basis seeking the employment they need to feed, clothe and house their families. Not surprisingly, obtaining health care services is also a formidable task for these children and their families. High mobility, lack of transportation, language and cultural barriers, inaccessibility to health care services, low socioeconomic status and lack of health insurance coverage are only a few obstacles faced by this population in accessing care.

Estimates on the number of Migrant and Seasonal Farmworkers (MSFW) who reside in Texas range from 200,000 to 300,000. Further it is estimated that there are at least 100,000 migrant children in the state. The average migrant farmworker family lives below the federal poverty level (FPL) and 98.7 percent have annual incomes of less than $10,000 (US Department of Labor- DoL). Due to the low income levels of this population, a majority of farmworker families, particularly women of child bearing age and children, should be eligible for Medicaid or CHIP. The DoL estimates, however, that only 13 percent of eligible farmworkers or their families used needs-based services such as Medicaid.

For migrant children who are actually enrolled in the Texas Medicaid Program, or CHIP, the coverage becomes practically moot as soon as they leave the state with their parents to seek work in agriculture. While providers in other states can enroll to be Texas Medicaid providers, relatively few do, and those who do are mostly specialty care providers and hospitals. Furthermore, many migrant families do not know how to locate those primary care physicians in other states who will accept Texas Medicaid.

Program Design. In order to assist migrant families maintain health coverage and access health care services while traveling out-of-state, an approach has been conceived that has substantial precedent in law, and is operationally possible. It includes enrolling both in- and out-of-state clinicians and Federally Qualified Health Centers (FQHC) providers in the Texas Medicaid Program to provide access to preventative care, primary care, specialty care, hospitals, dental services, mental health services and pharmacy services.

Before leaving Texas, the migrant families will be provided with information on providers, by specialty and community, who are enrolled in the Texas Medicaid, to assist the families locate a provider for their children while they are temporarily out-of-state for agricultural employment. TACHC is promoting that the state support an 800 number, available 24 hours a day and staffed by nurses, that will be provided to all TX MCN participants in order to provide triage services and assist migrant families locate the nearest medical care. The Texas Migrant Care Network approach is no different than an HMO that covers out-of-state care under certain circumstances, as enumerated in its member agreement. Essentially, all out-of-state services furnished to farmworker members signed up with the Texas MCN would be classified as in-state services, and would save considerable money by assuring that children are provided services while traveling out-of-state with their families. It also should be noted that in the case of migrant children enrolled in Medicaid managed care areas of the state, Texas already is paying a premium to the insurer for 6-months of coverage – even though these migrant children are out-of-state for four to six months out of the year.

It is important to note that establishing a Migrant Care Network is not an expansion of benefits or expanded eligibility under Texas Medicaid. It only provides a mechanism to help migrant families maintain existing health insurance coverage while they are traveling out-of-state for agricultural employment. To participate in such a program, Texas migrant farmworkers and their children would have to be enrolled in Medicaid before they left the state.

Challenges. It will take more than outreach activities and the establishment of a network of providers to make this a successful solution to the problem. Other challenges include initial enrollment into Texas Medicaid and recertification at the end of the child’s six months of eligibility if it occurs while the family is traveling outside of Texas. TACHC is urging the state to include continuous eligibility provisions or innovative re-enrollment procedures for this population who, since highly mobile, do not get timely mailings for re-enrollment, and rarely have all the documents with them at all times which might be needed to re-enroll. Furthermore, targeted outreach needs to be done with this population to let them know that it is not futile to enroll or maintain their Texas Medicaid coverage any longer because they will be able to see a provider while they are out-of-state.

In our experience with this population, migrant families are often fearful or suspicious of governmental entities as evidenced by the lack of response the state has experienced in requesting that migrant families self identify on the joint Medicaid and CHIP applications. Migrant families are much more likely to accept information and respond to organizations and groups that they deal with frequently such as schools, churches, promotoras and Federally Qualified Health Centers (FQHC). Any outreach campaign targeting migrant children should utilize this existing support network to help promote and enroll children into Medicaid and CHIP and encourage parents to self-declare on the Medicaid application if the are migrant farmworkers.

This population also needs to be educated about proper utilization of health care and the importance of preventative and regular primary health care services. The aforementioned groups, in particular schools and FQHCs, can be used to promote and coordinate the use of preventative health care services available under Medicaid. The Texas Migrant Care Network would alleviate many of the barriers that these families face. By establishing a comprehensive network of health care providers and offering intensive outreach, transportation and health education services, migrant families will be able to access health care services while in state and out-of-state.