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Managed Care Long Term Care Model The Texas Experience

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Managed Care Long Term Care Model The Texas Experience Presentation to: San Diego County LTCIP October 26, 2001 Cindy Adams STAR+PLUS Comprehensive capitated managed ... – PowerPoint PPT presentation

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Title: Managed Care Long Term Care Model The Texas Experience


1
Managed Care Long Term Care ModelThe Texas
Experience
  • Presentation to
  • San Diego County LTCIP
  • October 26, 2001
  • Cindy Adams

2
STARPLUS
  • Comprehensive capitated managed healthcare model
  • SSI and SSI-related Aged and Disabled Population
  • Provides a continuum of care with a wide range of
    options and increased flexibility to meet
    individual needs

3
STARPLUS
  • Medicaid pilot project designed to integrate
    delivery of acute and long-term care services
    through a managed care system
  • Requires two Medicaid waivers
  • 1915 (b) - to mandate participation
  • 1915 (c) - to provide home and community-based
    services

4
STARPLUS Program Funding
  • STARPLUS is funded by federal and state monies
  • The STARPLUS Medicaid pilot integrates funding
    for acute care services traditionally paid for by
    TDH with funding for long term care services
    traditionally paid for by DHS into one funding
    stream

5
STARPLUS Objectives
  • Provide the appropriate amount and types of
    services to help individuals stay as independent
    as possible
  • Serve people in the least restrictive
    community-based setting consistent with their
    safety needs
  • Improve care access, quality and outcomes
  • Increase accountability for care, and
  • Control costs

6
STARPLUS History
  • Policy Initiatives/Enabling Legislation
  • August 1993 - pilot for State of Texas Access
    Reform (STAR), to provide Medicaid services
    through a capitated HMO and PHP single health
    care delivery system in Travis County
  • 1995 - Senate Bill 10 (SB10) authorizes Texas
    Health and Human Services Commission (HHSC) to
    comprehensively restructure the statewide Texas
    Medicaid program incorporating managed delivery
    systems
  • 1995 - Senate Concurrent Resolution (SCR55)
    directed the Texas Medicaid Office to develop
  • an integrated managed care pilot program for
    long-term care for the elderly and persons with
    disabilities and
  • an integrated managed care pilot program for
    mental health and substance abuse services

7
STARPLUS History Continued
  • 1997 - HHSC to contract with at least one HMO in
    each managed care service area either managed or
    created by a hospital district in that region
  • November 1997 - STAR expanded into the Harris
    Service Area (Houston)
  • January 1998 - STARPLUS pilot program was
    introduced in the Harris Service Area
  • September 1999 - removed nursing facility
    residents from mandatory STARPLUS enrollment

8
Medicaid Organization in Texas
9
STARPLUS Program Contractors
  • Texas Department of Human Services (DHS) is the
    state STARPLUS contract holder
  • State contracts with Health Plans to provide
  • Care Coordination
  • Acute care
  • Institutional and community based long term care
  • Behavioral health services
  • Two health plans operate STARPLUS in Harris
    County
  • Health plans contract with providers for delivery
    of care

10
STARPLUS Health Plans
  • Amerigroup
  • HMO Blue (Administered by Lifemark)
  • Texas Health Network (PCCM)

11
STARPLUS Enrollment
  • Maximus - state contracted enrollment broker
  • Mails potential enrollees STARPLUS enrollment
    kit
  • Individuals have 30 days to make an active choice
    of plan and primary care provider (PCP)
  • Potential enrollee
  • Returns enrollment form via mail
  • Completes an enrollment form at an enrollment
    event, or
  • Calls Maximus and enrolls via phone
  • Default
  • Individuals who do not make an active enrollment
    choice are assigned a plan and a PCP

12
STARPLUS Enrollment Continued
  • Community education prior to STARPLUS roll-out
  • Public hearings
  • State in partnership with HMOs
  • Maximus
  • Provider Associations
  • Maximus outreach to STARPLUS enrollees
  • Home visits on request
  • Targeted enrollment fairs (DAHS, Community
    Centers, Nursing Facilities)
  • Partnerships with Community Based Organizations
  • Follow up telephone contact
  • Closed caption videos, audio tapes,
    multi-languages

13
STARPLUS Enrollment Continued
  • Voluntary Enrollment
  • January, February, March 1998
  • Mandatory Enrollment and Default
  • April 1998

14
STARPLUS Default Methodology
  • Maximus administers the default process
  • Follows the STAR default methodology
  • Percentage of default is driven by plan
    performance on elective enrollments
  • Order for assigning a recipient to a plan and PCP
    is determined by
  • Prior enrollment history with a plan and PCP
  • Claims history
  • Proximity

15
STARPLUS Eligibility Criteria
  • Resident of Harris County (Houston)Texas
  • Elderly or have a physical or mental disability
    and qualify for Supplemental Security Income
    (SSI) benefits or for Medicaid due to low income
  • Financial eligibility established by the Social
    Security Administration (SSA) for SSI, or by DHS
    for Medical Assistance Only (MAO)

16
STARPLUS Eligibility Criteria
  • Mandatory Participation HMO
  • SSI-eligible (or would be except for COLA)
    clients age 21 and over
  • MAO clients who qualify for the Community Based
    Alternatives (CBA) waiver
  • Clients who are Medicaid-eligible because they
    are in a Social Security exclusion program

17
STARPLUS Eligibility Criteria
  • Mandatory Participation HMO or PCCM
  • SSI clients under age 21
  • MHMR clients diagnosed with Serious and
    Persistent Mental Illness (SPMI)
  • PCCM is only available to non-Medicare clients

18
STARPLUS Eligibility Criteria
  • Voluntary participation HMO
  • Dual eligible clients under age 21

19
STARPLUS Eligibility Criteria
  • Excluded
  • STARPLUS HMO members who have been in a nursing
    facility for more than 120 days
  • Individuals already residing in a nursing
    facility at the time they become otherwise
    eligible for STARPLUS
  • Clients in several small limited waiver programs
  • Residents of Intermediate Care Facilities for the
    Mentally Retarded (ICF-MR)
  • Clients not eligible for full Medicaid benefits
    (1929(b) program, QMB, SLMB, QDWI, undocumented
    aliens)
  • Individuals not eligible for Medicaid
  • Children in state foster care

20
STARPLUS CBA Eligibility
  • MAO Applicants for CBA Waiver Services
  • TDHS informs applicant that services are provided
    through an HMO and allows applicant to select HMO
  • TDHS informs selected HMO and requests
    pre-enrollment assessment be completed
  • HMO completes
  • Medical necessity form
  • CBA eligibility assessment
  • HMO provides results of assessment activities to
    TDHS
  • HMO is authorized payment for assessment
    regardless of final eligibility determination

21
STARPLUS CBA Eligibility
  • THDS notifies applicant and HMO of their
    eligibility determination
  • Applicant eligible
  • HMO notified of applicant eligibility and
    effective date
  • Applicant will be enrolled in HMO
  • HMO will initiate ISP on date of enrollment
  • Applicant ineligible
  • Applicant notified and provided information on
    their right to appeal the adverse determination
  • HMO not notified if applicant is ineligible

22
STARPLUS CBA Eligibility
  • SSI Member CBA Upgrades
  • Currently enrolled members who meet screening
    criteria based on TDHS Risk Assessment Indicator
    (RAI)
  • Care Coordinator completes
  • Medical Necessity Form
  • MDS-HC
  • Complete Personal Attendant Services (PAS) tool
  • Assesses current equipment and supplies
  • Completes cover sheet
  • Submits to TDHS Regional Nurses for review and
    eligibility determination

23
STARPLUS CBA Eligibility
  • Denial of CBA Upgrade
  • Regional nurse notifies HMO
  • HMO authorizes identified medically necessary
    services
  • No increase in capitation
  • Approval of CBA Upgrade
  • Regional nurse notifies HMO
  • HMO authorizes identified medically necessary
    services
  • Member enters 120-day wait
  • At end of 120-days capitation increases to CBA
    payment amount

24
STARPLUS CBA Eligibility
  • CBA Annual Reassessments
  • Completed on all enrolled CBA waiver members
  • Up to 120-days prior to expiration of ISP
  • Care Coordinator completes
  • PAS Tool and MDS-HC
  • Assesses member for equipment and supplies
  • Completes Medical Necessity Form
  • Completes CBA cover sheet
  • Assessments completed and forwarded to TDHS
    Regional Nurses

25
STARPLUS Population
  • STARPLUS is the largest population enrolled in
    an integrated, acute and LTC managed care model
    in the country
  • 47 of the STARPLUS population are dual
    eligibles
  • Approximately 18 of the STARPLUS population are
    members under the age of 21
  • 2.7 of the STARPLUS population are CBA waiver
    members
  • 7 of the STARPLUS population have the diagnosis
    of SPMI
  • 85 of the total mandatory enrollees selected the
    HMO model

26
STARPLUS Current Enrollment as of 10/01/2001
  • HMO Blue STARPLUS 28,092
  • Amerigroup STARPLUS 20,242
  • Texas Health Network (PCCM) 8,235
  • STARPLUS Totals 56,569

27
STARPLUS Services
  • Acute care services (Medicaid only members)
  • Long term care services
  • Behavioral Health
  • Care coordination
  • Value added services

28
STARPLUSAcute Care Services
  • Hospital
  • Inpatient
  • Outpatient
  • Professional
  • Physician or physician extenders
  • Certified Nurse Midwife (CNM)
  • Lab and X-ray
  • Podiatric services
  • Vision
  • Ambulance services
  • Home health services/limited DME

29
STARPLUSAcute Care Services
  • Hearing Aid Services
  • Chiropractic
  • Ambulatory Surgical Center Services
  • Certified Nurse Midwife Services
  • Birthing Center
  • Maternity Clinic Services
  • Transplant Services
  • Adult Well Check
  • Family Planning

30
STARPLUSAcute Care Services
  • Genetics
  • EPSDT Medical Screens
  • EPSDT Comprehensive Care Program (CCP)
  • Non-emergent Screening and stabilization fees
  • Renal Dialysis
  • Total Parenteral Hyperalimentation (TPN)
  • PT/OT/Speech Therapies
  • Behavioral Health

31
STARPLUSCarve Out Services
  • EPSDT Dental (including Orthodontia)
  • Early Childhood Intervention (ECI)
  • MHMR Targeted Case Management
  • Mental Retardation Diagnostic Assessment (MRDA)
  • Mental Health Rehabilitation
  • Pregnant Women and Infants Case Management (PWI)
  • Texas School Health and Related Services (SHARS)
  • Texas Commission for the Blind (TCB)
  • Tuberculosis (TB) Clinic Services

32
Excluded STARPLUS
  • Pharmacy
  • Unlimited prescription for
  • Medicaid only
  • Less than 21
  • CBA
  • Duals who join same HMO for Medicaid and Medicare
  • 3 prescriptions per month
  • Duals enrolled for Medicaid LTC services only

33
STARPLUSLong Term Care Services
  • Day Activity and Health Services (DAHS)
  • In Home Respiratory Care Services
  • Nursing Facility Care (first 120 days after
    admission)
  • Personal Assistance Services

34
STARPLUS CBA Waiver Services
  • Adaptive aids
  • Adult foster home services
  • Assisted living/residential care services
  • Emergency response services
  • Medical supplies
  • Minor home modifications
  • Nursing services
  • Occupational therapy
  • Personal assistance services

35
STARPLUS CBA Waiver Services
  • Physical therapy
  • Respite care
  • Speech language therapy services
  • Home delivered meals
  • Durable medical equipment

36
STARPLUS HCBS Alternative Residential Settings
  • Assisted Living/Residential Care Facilities
  • Adult Foster Care
  • Personal Care Homes
  • Nursing Facilities
  • First 120 days of long-term placement
  • Subacute short-term stays

37
STARPLUS Behavioral Health Services
  • Under age 21
  • Early screening, diagnosis and treatment of
    behavioral disorders
  • Psychiatric hospital/facility (freestanding)
  • Hospital - inpatient services - mental health and
    chemical dependency treatment
  • Licensed master social workers - advanced
    clinical practitioners (LMSW - ACPs)
  • Licensed professional counselors (LPCs)
  • Psychology
  • Psychiatry
  • Chemical dependency treatment

38
STARPLUS Behavioral Health Services
  • Age 21and over
  • Screening for behavioral health disorders
  • Hospital - inpatient services - mental health and
    chemical dependency treatment
  • Licensed master social workers - advanced
    clinical practitioners (LMSW -ACPs)
  • Licensed professional counselors (LPCs)
  • Psychology
  • Psychiatry
  • Chemical dependency treatment

39
STARPLUS Value Added Services
  • In addition to all traditional Medicaid and other
    mandatory services, each STARPLUS HMO offers its
    own set of value added services.
  • Over and above services paid for by the state
  • Incentives for members to join
  • All HMOs offer CBA waiver services to members not
    in a waiver slot if service is medically
    necessary
  • PCCM model does not offer value added services

40
STARPLUS Value Added Services
  • Examples
  • Transportation assistance
  • Adult dental
  • Eyeglasses
  • Medication dispensers
  • Smoke detectors
  • Pest control
  • Medical alert ID
  • Nightlights
  • Bathmats

41
STARPLUS Value Added Services
  • Examples behavioral health
  • Partial hospitalization/extended day treatment
  • Intensive outpatient/day treatment
  • Off-site services
  • Forensic services
  • Freestanding psychiatric facility
  • Residential services
  • Crisis clinics
  • Team interventions

42
STARPLUS Healthplan Structure
  • Member services
  • Care coordination
  • Utilization management
  • Quality management
  • Network management
  • Claims and encounters
  • Finance

43
STARPLUS Network
  • Significant Traditional Providers (STPs)
  • Template contracts require state approval
  • Language for mandatory provisions supplied by
    state
  • Texas Medicaid certification
  • Credentialing/recredentialing
  • Network adequacy/geographic accessibility
  • PCPs 24/7 access

44
STARPLUS Network
  • Long Term Care Providers
  • Network built through contracts with STP
    providers contracted with TDHS
  • State Licensed
  • Enrolled as Medicaid providers
  • Credentialing and oversight policies and
    procedures developed by HMO

45
STARPLUS Care Coordination
  • Qualified and trained personnel to serve as
    contact for members
  • Telephonic team in office
  • Field team set up with the technology to work
    from home
  • Care Coordinator Associates assist field team
    telephonically acting as liaisons between the
    member, Care Coordinator and physician and/or
    provider(s)

46
Care Coordinator
  • Texas licensed registered nurse (RN) or licensed
    vocational nurse (LVN)
  • Master level social worker (LMSW)
  • Unlicensed (telephonic staff)
  • Coordinate, facilitate, investigate, advocate
  • Foster a person-centered approach
  • Liaison with member, family, caregiver, PCP

47
Care Coordination Responsibilities
  • Assess members for service needs
  • Facilitate/coordinate services with the members
    PCP
  • Intervene to assure appropriate care is provided
  • Placement options
  • Cost effectiveness
  • Ensure members health needs are met
  • Act as plan resource
  • Member/patient advocate
  • Coordination of benefits with other payers

48
Care Coordination Responsibilities - Assessments
  • New enrollees - health status/orientation within
    30 days of enrollment
  • Transitioning members - within 30 days of
    enrollment
  • All members over 21 years of age receiving long
    term care services - Minimum Data Set (MDS-HC)
  • Initial assessment
  • Pediatric assessment
  • Maternal/child assessment
  • Personal Attendant Services scoring tool
  • Risk Assessment Indicator (RAI)
  • Medical necessity determination

49
Care Coordination Model
  • Who
  • RN or licensed Masters level social worker (with
    specific cultural and linguistic expertise)
  • Responsibilities
  • Coordinator, facilitator, investigator, liaison,
    advocate, empowered to authorize services
  • Leads team of service providers
  • Close collaboration with medical providers,
    patient, and family
  • Knowledge of TPL/Medicaid/Medicare resources

Care Coordinator
Member
Family or Representative
PCP
Summary Care Coordinators are the key to
establishing a comprehensive, individualized
Plan of Care to serve the member in the least
restrictive environment, with the most quality
oriented, cost effective care/services.
50
Care Coordination Model Overview
  • All plan members are assigned to a care
    coordinator
  • Promotes member/care coordinator relationship
  • Across the board integration of member
    education
  • Incorporates a disease management approach
  • Integration of acute and long term care into a
    unique individual care plan
  • Plan transitions
  • Coordination with community resources
  • Discharge planning
  • Post-hospitalization follow up

51
Care Coordination Assignment
  • Service - driven based on
  • Risk group placement
  • Acute episodic events
  • Health Status Screen/review
  • Disease management
  • Transition from
  • DHS care plan
  • Individual Service Plans (CBA)
  • Other program contractors

52
Level I Average caseload 11800
  • Telephone care coordination
  • Stable population with episodic support
  • Authorizations done by licensed staff
  • Staffing includes non-licensed, LVN, LMSW and RN
  • Orientation/Health Status Screen
  • Initial and annual HSS
  • Unable to Locate - attempt to reach member
    every 6 months
  • Assignment criteria Authorizations for short
    term needs, I.E. Respite, 1x only DME

53
Level 2Average caseload 1150
  • Field and Telephonic Care Coordination
  • Members receiving LTC services
  • Adult Day Care (DAHS)
  • All Licensed staff
  • Care Coordinator Associates
  • Reassessments every 90 -180 days
  • Field Assessments
  • CBA/SSI upgrade
  • MDS-HC completion
  • Assignment criteria
  • Adult Day Care (DAHS),
  • PAS lt120 hrs per month,
  • ER/Hosp visits 2 within 6 months

54
Level 3Average caseload 1200
  • Field care coordination
  • Members receiving CBA services
  • All licensed staff
  • Care coordinator associates
  • Reassessments lt90 days
  • Field assessments
  • CBA/SSI upgrade
  • MDS-HC
  • Assignment criteria
  • CBA Members

55
Continuum of LTCPlacement Options
Most Restrictive
Least Restrictive
Specialty Unit within a nursing facility
Skilled Nursing Facility
Adult Care Home
Adult Foster Care Home
Personal Care Home
Assisted Living/ Residential Care
DAHS
Home or Apartment
56
Care Coordinator Associate Support
  • Member/care coordinator liaison
  • Direct member contact
  • Assigned to care coordinators
  • Ratio 14
  • Assist care coordinators with
  • Post E.R. Follow up
  • Fax/mail authorizations
  • Transitional notifications
  • Provider/PCP contact with service DS.
  • Care coordination caseload reports
  • Produces monthly reports

57
Care Coordination Integration with Concurrent
Review
58
Case Management Information Systems
  • Care Management
  • Assessments
  • Cost effectiveness studies/care plan modeling
  • Care plans
  • Case notes
  • Eligibility and claims
  • Placements
  • Extended authorizations
  • MDS-HC
  • Ability to complete and transmit member data to
    the State

59
STARPLUS Capitation
  • DHS pays health plans prospectively on a
    capitated, per member per month basis by client
    risk group
  • There are six risk groups with amounts differing
    by Medicare status, care setting and status at
    enrollment
  • Rates for Medicaid only members are higher than
    those for dual eligibles to reflect HMO liability
    for acute care
  • Capitation rates are discounted 2 from projected
    fee-for-service nursing facility costs and 5
    from projected fee-for-service acute and long
    term care costs

60
Development of STARPLUS Capitation Rates
  • Information used in rate development
  • Reduced fee-for-service (FFS) methodology
  • Calendar year 1997 FFS experience data trended
    forward
  • Relativity factor for Harris Co.
  • Assumed all-plans cost increase of 6 (FY2002)
  • Assumptions
  • STARPLUS program must be cost neutral so
    aggregate claims and average costs become the
    balancing items with PCCM and FFS
  • Equitable distribution of risk among plans
  • Costs for CBA waiver members are comparable to
    1997 FFS nursing facility claims costs

61
STARPLUS Capitation
62
STARPLUS Capitation Continued
63
STARPLUS Capitation Continued
64
Risk Adjusters
  • Risk Adjusters
  • Medicare status
  • Waiver status
  • Geographic relativity factor
  • Harris County - 14 higher medical costs that
    statewide average
  • Share of Cost
  • Members are required to contribute toward the
    cost of their care based on their income and type
    of placement
  • Provider is responsible for collecting the SOC
  • HMO payment to facility is based on total payment
    due facility less the members SOC

65
Risk Sharing
  • HMOs retain the first 3 of any profit, but split
    equally with the state any profit between 3 and 7
    percent
  • Any profit over 7 percent must be paid back to
    the state

66
STARPLUS Statutory and Regulatory Compliance
  • Compliance with federal, state and local laws
  • Program integrity
  • Fraud abuse compliance plan
  • Confidentiality
  • Non-discrimination
  • Notice and appeal
  • HMO process
  • State appeal process

67
STARPLUS Statutory and Regulatory Compliance
Continued
  • Quality Management
  • Quality improvement program (QIP) system
  • Written QIP plan
  • Summary report of member and provider complaints
  • Utilization reports

68
STARPLUS Quality Indicators
  • Focus Studies
  • Depression
  • Breast Cancer Screening
  • Diabetes in Adults
  • Semi-annual UM Reports
  • Behavioral Health
  • Physical Health
  • Long Term Care
  • Medical Record Audit
  • Provider Satisfaction
  • Member Satisfaction

69
Reporting/State Monitoring
  • Financial reports
  • Statistical reports
  • Arbitration/Litigation Claims report
  • Summary Report of Provider Complaints
  • Provider Network Reports
  • Member Complaints
  • Fraudulent Practices
  • Utilization Management Reports
  • Behavioral, Physical and LTC
  • Quality Improvement Reports
  • HUB Quarterly Reports
  • THSteps (EPSDT) Reports
  • Encounters

70
STARPLUS Program Outcomes
  • November 2000 - HHSC Medicaid Managed Care Review
    reported the to the Texas Legislature
  • STARPLUS has increased the number of available
    long-term care providers
  • In SFY 99, Primary Home Care utilization was
    higher than projected
  • Day Activity and Health Services utilization was
    lower than projected
  • Increased access to community-based long term
    care services in comparison to statewide average

71
STARPLUS Program Outcomes (Continued)
  • Utilization of new generation medications by
    individuals with serious mental illnesses
    increased both statewide and in Harris Co., but
    the Harris Co. increase did not occur until the
    implementation of STARPLUS
  • Inpatient hospital utilization decreased for this
    population
  • From January 1998 through August 1999 total
    STARPLUS savings was 2,171,085

72
Lessons Learned
  • Care Coordination is the key to integration of
    acute and LTC services
  • Single point of contact
  • True integration when all services are managed by
    one entity
  • Coordination of benefits important for dual
    eligibles when HMOs are only responsible for LTC
  • Education of all providers and stakeholders is
    key
  • Collaboration between competing HMOs and State is
    an essential piece of successful model
  • Program supports the Olmstead requirements

73
Recommendations
  • Structure 1915 (c) waiver to allow for
    cost-effective community-based services provided
    in the least-restrictive setting (supports
    Olmstead decision)
  • Allow for staggered phased-in enrollment
  • Eliminate PCCM
  • Include mechanism for upgrades of members to CBA
    waiver status without decreasing waiver slots
  • Implement and monitor the effectiveness of all
    HMOs using standard forms for processes related
    to
  • Clean claims definitions and requirements
  • Standard referral form
  • Standard credentialing package
  • Case management controlled or delegated by health
    plan
  • Integrate LTC and acute services into one program

74
Recommendations
  • Allow new entrants who have LTC experience into
    the market through a competitive bid process
  • Utilize 6 month lock-in or 6 month continuous
    eligibility to ensure continuity of care
  • Include nursing facility population for a full
    continuum of care
  • Utilize an HMO model that integrates acute and
    LTC services into one program with Care
    Coordination as the cornerstone

75
Recommendations (continued)
  • Mandatory vs. voluntary enrollment
  • Member issues/outreach and education important
  • Adverse selection - potential with voluntary
    enrollment
  • Critical mass
  • Eligibility determination
  • Financial
  • Member/functioning
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