Texas Managed Care The State of the CHIP and Medicaid Programs

1
Texas Managed CareThe State of the CHIP and
Medicaid Programs

• Presented by Chris Bowers
• October 26, 2004
• Texas Association of Community Health Centers
• Annual Conference

2
Presentation Outline

• Review Current Texas Medicaid and CHIP Program
• Review Medicaid and CHIP Program Changes and
  Impact
• Managed Care Expansion
• Statewide Procurement (RFP)
• Rural CHIP EPO Implementation
• Impact on FQHCs
• Superior Contracting Opportunities

3
Current Program Operations

• Medicaid
• STAR
• Covers 1,079,705 Members across Texas
• 10 participating health plans including THN
• 8 Service Delivery Areas
• STARPLUS
• HMO managed care for the SSI Population
• Covers 64,604 Members in Harris County only
• Two participating health plans

4
Current Program Operations

• CHIP
• HMO
• Covers 256,220 Members across Texas
• 12 participating health plans
• 8 Service Delivery Areas
• EPO
• Managed care program for the rural population
• Sole source insurance provider
• Covers 91,925 Members in 170 non-HMO counties

5
Texas Program Changes

• Legislative Budget Reductions
• Administrative complications for eligibility
• Reduced funding to Providers
• Eligibility reductions to Medicaid
• Increased cost-sharing for CHIP
• Benefit reductions in CHIP and Medicaid

6
Impact of Legislative Budget Changes

• Program Change Results
• Rapidly declining CHIP caseloads
• -31 decline in membership from Sept 2003
• Stagnant Medicaid enrollment
• 22 growth in 2003
• 3 growth since January 2004
• Increased pressure on safety net providers

7
Looking Forward

• Managed Care Expansion
• Lewin Report recommended the expansion of the
  managed care program to control state health care
  costs and achieve quality goals.
• STAR, STARPLUS and CHIP HMO expansion
• No PCCM competition in STAR HMO markets
• PCCM expansion in rural unmanaged counties
• EPO program continuation in rural CHIP counties

8
Program Expansion

• Medicaid
• STAR HMO expansion
• Nueces Service Delivery Area (SDA) 9 counties
• All current SDAs
• STARPLUS
• Expands on current Harris SDA 5 additional
  counties
• All current STAR SDAs (6) 46 counties
• New Nueces SDA 9 counties

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STAR Program Expansion
10
STARPLUS Program Expansion
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Program Expansion

• CHIP
• HMO expansion
• Reconfigure current Core SDAs for consistency
• Webb SDA only area without STAR STARPLUS
• Continues to allow for optional counties
• EPO
• Maintaining all non-HMO counties

12
CHIP Program Expansion
13
Statewide HMO Procurement

• Procurement Goals
• Managed Care Program Expansion
• Best Value Purchasing
• Performance Based Contracting
• Service Area Consistency
• Secure Adequate Competition

14
Statewide HMO Procurement

• Procurement Timeline
• Final RFP release June 29, 2004
• RFP response submitted September 8, 2004
• Contract Awards expected mid-November 2004
• Staggered Program Implementation
• Existing STAR and CHIP HMO areas, July 2005
• STAR and STARPLUS expansion areas, September 2005

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CHIP EPO Implementation

• EPO Contract awarded May 21, 2004 to Superior
  HealthPlan Network
• Implementation date September 1, 2004
• Current Membership just over 90,000
• High membership density in the lower Rio Grande
  Valley (approximately 30-35)
• Participation of approximately 12,000 providers
  statewide
• PCP Phase-in on December 1, over 30 member
  selection through October 15th
• Rural population has high reliance on FQHCs

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Impact on FQHCs

• Changing contractors
• EPO
• More/new HMO participants
• More managed care
• Very little traditional FFS remaining rural PCCM
  for Medicaid
• Medical home care model
• Continuity of care increases
• More provider support
• More Member support

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Superior Contracting Opportunities

• Contracting Models for CHIP and Medicaid
• Fee For Service
• Risk-Sharing Bonus arrangements
• Superior Advantage
• Philosophy Physician Driven
• Simplicity and Responsiveness in Provider
  Services
• Financial Stability
• Risk-Sharing Contracting
• Exclusivity Incentives