Medicaid Managed Care Stakeholder Forum DallasTarrant Service Areas

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Medicaid Managed Care Stakeholder Forum
Dallas/Tarrant Service Areas

September 2009 Managed Care Operations Medicaid/CH
IP Division
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Presentation Topics

• Background
• Legislative Direction for New Managed Care Model
  in Dallas and Tarrant
• Review of Current Managed Care Models
• Recommendation to Expand STARPLUS
• About STARPLUS
• Differences Between STARPLUS and ICM
• Request for Stakeholder Input

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Dallas and Tarrant Service Areas

• Dallas SA Counties
• Dallas
• Ellis
• Hunt
• Kaufman
• Collin
• Navarro
• Rockwall
• Tarrant SA Counties
• Denton
• Hood
• Johnson
• Parker
• Tarrant
• Wise

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Background

• In May 2009, HHSC ceased operation of the
  Integrated Care Management (ICM) program.
• ICM provided care coordination services to 75,000
  seniors and persons with disabilities in the
  Dallas/Tarrant Service Areas since February 2008.
• June 1, 2009, these clients began receiving
  services through health-care programs that
  existed before the implementation of the ICM
  model traditional Medicaid and the State of
  Texas Access Reform (STAR) program.

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Legislative Direction

• Legislative Mandate
• 2010-11 General Appropriations Act
• (Article II, Special Provisions, Section 46, S.B.
  1, 81st Legislature, Regular Session, 2009)
• Requires HHSC to implement the most
  cost-effective integrated managed care model for
  aged, blind, and disabled (ABD) clients in the
  Dallas and Tarrant Service Areas.

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Legislative Direction

• Legislative Requirements
• The new model must
• Provide acute care and long-term care services.
• Demonstrate cost-effectiveness.
• Preserve revenues for hospital and physician
  payments under the current federal Upper Payment
  Limit (UPL) programs.

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Review of Current Models

• In response to the legislative requirement for
  Dallas and Tarrant, HHSC Strategic Decision
  Support (SDS) conducted an analysis of these
  existing Medicaid managed care models
• Primary Care Case Management (PCCM) -
  Fee-for-service system, primary care providers
  receive small additional payment for each
  assigned patient.
• STARPLUS - Partially capitated managed care
  program, created specifically for the Medicaid
  ABD population.
• Updated ICM - New ICM pilot would test an
  integrated but non-capitated service delivery
  model using lessons learned from previous
  experience.

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Review of Current Models

• Highlights of the review
• Cost-Effectiveness - The states experience
  indicates that STARPLUS delivers care at reduced
  costs in urban areas compared to non-capitated
  systems
• Estimated savings of 22 percent for in-patient
  care, 15 percent for acute out-patient care, and
  10 percent for long-term services and supports
  compared with fee-for-service Medicaid.
• Quality/Satisfaction National outcome measures
  consistently reveal few differences between
  STARPLUS clients and clients in other programs
  across a range of indicators.

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Review of Current Models

• Highlights of the review
• Impact on DSH and UPL - The three models all
  preserve full DSH and UPL payments.
• Integrated Delivery - STARPLUS and ICM
  coordinate acute and long-term services, provide
  all beneficiaries with a service coordinator,
  include unlimited prescriptions, and offer other
  value-added services.
• Conclusion
• While PCCM and ICM meet some of the evaluation
  requirements,
• STARPLUS is the only model that fulfills the
  criteria described by
• the legislation while offering comparable quality
  of care.
• For a copy of the SDS report, go to
• http//www.hhsc.state.tx.us/reports/ICS_SB1_Tarra
  ntCounty.pdf

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Review of Current Models
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Recommendation to Expand STARPLUS

• In addition to meeting all of the legislative
  requirements
• for managed care in Dallas and Tarrant,
  STARPLUS
• Created specifically to serve the elderly and
  persons with disabilities.
• Operation began in 1998 and currently serves over
  163,000 clients in 29 counties.
• Contains costs while maintaining quality of care
  for its members.
• STARPLUS members indicate that they are happy
• with the STARPLUS program in customer service
• surveys.

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About STARPLUS

• Background
• STARPLUS is based on a combined 1915(b) and
  1915(c) waiver.
• Implemented as a pilot in Harris County Service
  Area in 1998.
• 2007 - Expanded to the full Harris County Service
  Area, and to Bexar, Nueces, and Travis Service
  Areas in February 2007.
• Goal achieve a seamless continuum of care by
  integrating acute and long-term services and
  supports in a managed care environment.
• Promotes delivery of home and community-based
  services.
• Managed care organizations (MCOs) are responsible
  for coordinating acute and long-term services and
  supports (LTSS) through the use of a service
  coordinator.

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About STARPLUS

• STARPLUS is a partially-capitated model of
  managed care.
• In-patient hospital services are paid by the
  Texas Medicaid Healthcare Partnership (TMHP)
  through fee-for-service Medicaid.
• This carve out preserves current DSH and UPL to
  hospitals.

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About STARPLUS

• Program Goals
• Integrate acute care long-term care services.
• Provide the right amount and type of service to
  help members stay as independent as possible.
• Serve members in the most community-based setting
  consistent with their personal safety.
• Improve access and quality of care.
• Increase accountability for care.
• Improve outcomes of care.
• Control costs.

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About STARPLUS

• STARPLUS members have freedom of choice among
  the MCOs in their service area.
• STARPLUS members access services using providers
  in their plans provider network.
• STARPLUS MCOs offer service coordination to help
  members arrange their care, particularly
  long-term care services.

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About STARPLUS

• Mandatory Population
• Supplemental Security Income (SSI)-eligible adult
  clients (age 21 and over).
• Medical Assistance Only (MAO) clients who qualify
  for the 1915(c) Nursing Facility Waiver.
• Adult clients who are Medicaid-eligible because
  they are in a Social Security exclusion program.
• Voluntary Population
• Children under the age of 21.

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About STARPLUS

• Clients with Medicaid and Medicare receive acute
  care
• services, including prescription drugs, from
  Medicare.
• These clients are called dual eligible clients.
• Dual eligible clients can see any Medicare
  providers they choose.
• Medicaid provides some services to help cover
  treatment if Medicare does not cover it
  completely these are called wrap-around
  services.
• Medicaid provides long-term care services to dual
  eligible clients who need them.

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About STARPLUS
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About STARPLUS

• Enrollment in STARPLUS (mandatory clients)
• Client is identified as a candidate for
  STARPLUS.
• Medicaid enrollment broker mails information
  about STARPLUS and health plan choices to
  client.
• Client has 30 days in which to respond to the
  enrollment broker and select a health plan.
• Client is assigned to a health plan by the
  enrollment broker if they have not selected one
  within the time allowed.
• Voluntary clients may enroll at any time by
  calling the enrollment
• broker and selecting a STARPLUS health plan.

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About STARPLUS

• STARPLUS Enrollment in August 2009

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About STARPLUS

• Acute Care Benefits/Services
• Unlimited prescription drugs
• Ambulance services
• Audiology services, including hearing aids for
  adults
• Behavioral Health Services
• Chiropractic services
• Dialysis
• Durable medical equipment and supplies
• Emergency Services
• Family planning services
• Home health care services
• Hospital services, outpatient

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About STARPLUS

• Acute Care Benefits/Services (continued)
• Laboratory
• Optometry, glasses, and contact lenses, if
  medically necessary
• Podiatry
• Prenatal care
• Preventive services including an annual adult
  well check for patients 21 years of age and over
• Primary care services
• Radiology, imaging, and X-rays
• Specialty physician services
• Therapies physical, occupational and speech
• Transplant of organs and tissues
• Vision services

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About STARPLUS

• Service Coordination is key in STARPLUS
• Service coordinators are HMO nurses and social
  workers who are responsible for
• Formulating an individualized plan of care
  covering acute care and long-term services and
  supports.
• Overseeing smooth transition from acute care to
  long-term services and supports.
• Making home visits and assessing members needs
• Authorize community LTSS.
• Arrange acute care services.
• STARPLUS members are also assigned a primary
  care provider.

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About STARPLUS

• Community-based Long-Term Care Services for
• Members who meet Functional Requirements
• Personal Assistance Services (PAS) services to
  assist the member with activities of daily living
  in their home, such as bathing, grooming, meal
  preparation, and household chores.
• Day Activity and Health Services (DAHS) services
  provided in a licensed facility which meet the
  physical, mental, medical, and social needs of
  the member up to 10 hours per day, Monday through
  Friday.

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About STARPLUS

• Community-based Long-Term Care Services for
  Members who meet Nursing Facility Level of Care
  Requirements
• 1915 (c) Waiver Services, including
• In-Home or Out-of-Home Respite Services
• Nursing Services (in home)
• Emergency Response Services (Emergency call
  button)
• Home Delivered Meals
• Dental services
• Respite Care
• Minor Home Modifications
• Adaptive Aids and Medical Equipment

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About STARPLUS

• Community-based Long-Term Care Services for
  Members who meet Nursing Facility Level of Care
  Requirements (continued)
• Medical Supplies not available under the Texas
  Medicaid State Plan/1915(b) Waiver
• Physical Therapy, Occupational Therapy, Speech
  Therapy
• Adult Foster Care
• Assisted Living
• Consumer Directed Services
• Transition Assistance Services.

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About STARPLUS
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About STARPLUS
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Differences Between STARPLUS and ICM

• ICM was similar to STARPLUS since it offered
  both
• acute care and long-term services and supports.
• However, there are some significant differences
• STARPLUS is capitated. This means the STARPLUS
  MCOs are at risk for the cost of covered services
  to members. Thus, the MCOs have an incentive to
  ensure members receive regular, timely preventive
  and routine care.

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Differences Between STARPLUS and ICM

• STARPLUS health plans pay claims directly to
  providers.
• STARPLUS health plans can negotiate payment
  rates with the providers in their network.
• STARPLUS health plans determine which services
  require prior authorization.
• STARPLUS health plans authorize and coordinate
  long-term services and supports directly with
  members and providers.

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Differences Between STARPLUS and ICM

• Clients have a choice of different health plans
  and can change their health plan if they choose.
• STARPLUS health plans can offer extra benefits
  (called value-added services) to their members
  at no cost, such as transportation to
  appointments and additional vision and dental
  services.
• STARPLUS has a proven record of success serving
  the elderly and disabled Medicaid population in
  other parts of Texas.

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Request for Stakeholder Input

• If the decision is to expand STARPLUS into the
  Dallas
• and Tarrant Service Areas
• HHSC would issue a Request for Proposals (RFP)
  for Managed Care Organizations (MCOs) to serve as
  the STARPLUS health plans in these Service
  Areas.
• The program could be implemented in January
  2011.

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Discussion and Questions
Request for Stakeholder Input
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HHSC Managed Care Operations

• Pamela Coleman
• pamela.coleman_at_hhsc.state.tx.us
• [phone]
• Gary Young
• gary.young_at_hhsc.state.tx.us
• [phone]
• Heather Powell
• heather.powell_at_hhsc.state.tx.us
• [phone]