Texas Covered Day 2 Talks Medicaid, Maternal Health, & Managing Rx Costs

By: TAHP | Tuesday, November 4, 2025

Medicaid Director Takes Center Stage

• Speakers:
  • Emily Zalkovsky, State Medicaid Director, Texas HHSC
  • Valerie Mayes, Deputy State Medicaid Director
  • Ryan Van Ramshorst, MD, Chief Medical Director
  • Camisha Banks, DEC Managed Care
  • Michael Lopez, DEC for Operations
  • Moderator: Stephanie Stephens, Stephens Consulting Group
• HHSC's focus areas:
  • Execute major Medicaid payment, integration, and waiver changes (PDPM, duals transition, ILOS pilots).
  • Strengthen women's health and postpartum supports.
  • Modernize IT systems and provider experience infrastructure.
  • Prepare for Sunset recommendations and legislative oversight.
  • Maintain compliance with federal managed care and access reforms.
  • Sustain operational stability amid simultaneous modernization and policy shifts.

Medicaid - Federal Changes and State Pressures

• Up next: Former Medicaid leaders shared their insights on recent federal legislation, state priorities, and growing financial pressures.
  • Matt Salo, Founder and CEO Salo Health Strategies
  • Jami Snyder, President and CEO, JSN Strategies, LLC
  • Moderator/Speaker: Stephanie Muth, Principal, Stephanie Muth Consulting
• What they had to say to Medicaid health plans:
  • Execute major Medicaid payment, integration, and waiver changes (PDPM, duals transition, ILOS pilots).
  • Strengthen women's health and postpartum supports.
  • Modernize IT systems and provider experience infrastructure.
  • Prepare for Sunset recommendations and legislative oversight.
  • Keep up with compliance with federal managed care reforms.
  • Sustain operational stability amid simultaneous modernization and policy shifts.

Direct Primary Care Reshapes Health Plans

• The key question: Are direct contracting programs, like direct primary care (DPC), an opportunity or a threat for health plans?
• What we heard:
  • Federal tax law changes allow for HSA funds to be spent on direct primary care-valuable for employers.
  • Individual Coverage Health Reimbursement Arrangements (ICHRAs) have grown rapidly and will continue to attract employers.
  • DPC could work well when combined with a minimum essential coverage/catastrophic plan.
  • "Employer pain" around health care affordability is impacting the desire to find new models of coverage.

Innovation in Maternal Care

• Rethinking maternal health: Shameet Luhar (CEO of Vheda Health), Izzie Fulcher (Chief Scientific Officer of Delfina) & Travis Bias (Deputy Chief Medical Officer of Solventum) talked about impoving care for mothers and babies.
  • Coordinated, tech-enabled care models can help moms deliver healthy babies and reduce NICU admissions.
  • EHR data, risk stratification, and screening tools can identify high-risk moms early.
  • Partnerships that align KPIs, tailor workflows, and scale solutions can advance care goal
• How data and evidence can help: Shyamali Choudhury (Chief Commercial Officer of Pomelo Care) & Pati McCandless (VP of Texas Government Relations at HCSC/BCBSTX) shared how digital health and team-based care models have helped Pomelo Care address the maternal health crisis.
  • Pomelo Care identified over 70% of pregnancies in the first trimester by analyzing different data sources. Data identified high-risk pregnancies for maternal care program enrollment.
  • 24/7 virtual care, doulas, and remote monitoring increased aspirin use for preeclampsia prevention from 11% to over 60%, reducing NICU admissions and preterm births.
  • Pomelo Care shared supplemental encounter data to help health plans improve HEDIS scores, reduce NICU stays and discharge delays.

Tackling Drug Costs

• Up next: Travis Tate from CVS Health and Ryan Schmidt from Navitus Health Solutions shared how benefit design, biosimilars, provider collaboration, technology can cut pharmacy costs, and more.
• What's happening:
  • Specialty drugs make up just 3% of utilization but over 50% of the total spending on drugs.
  • Hep C drugs were the first to really push pricing. Now we're seeing pressure with drugs like GLP-1s.
  • GLP-1 competition is rising as employers increasingly look to cover the drugs. Look for increased pressure to lower prices and eventual broad market adoption.
  • The only way to get patients to move to biosimilars is to remove the brand from the formulary. Small changes in cost sharing won't drive a behavior change.
  • State mandates like formulary freeze and pharmacy closure laws ultimately reduce options for employers.

Alexa! Where can I get new socks?

• Last but not least: Dr. Gerry Stanley, CMO at Express Scripts by Evernorth, challenged plans to redefine what consumerism means for high performing health care services.
• What we learned:
  • Patients need a curated set of options that creates an exceptional experience. Limited options prevent patients from taking control of their own health, but too many choices can leave them lost.
  • Explaining options without price leaves patients with asymmetric information. What patients need more than choice is guidance.
  • Younger generations are bringing more DIY research to their medical care and don't share the same concerns about privacy of health care data.