Medicaid Managed Care for Elderly and Persons with Disabilities Pam Coleman Texas Health and Human Services Commission October 11, 2006

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Medicaid Managed Care for Elderly and Persons
with DisabilitiesPam ColemanTexas Health and
Human Services CommissionOctober 11, 2006
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STARPLUSHarris County

• Pilot implemented in Harris County (Houston) in
  1998
• Risk-based, capitated managed care
• Integrates Medicaid funding and service delivery
  of long term and acute care
• Serves 60,000 aged and disabled not in a nursing
  facility

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Why STARPLUS?

• Legislative direction (SCR 55, 74th session)
• Improve coordination of physical health care
  needs with personal care needs
• Improved access to community based long-term care
  support services
• Promote coordination of Medicaid and Medicare
• Increase cost effectiveness

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Texas Medicaid Expenditures

• Children, Adults and Other are 74 of the
  Medicaid population and 37 of costs. Aged and
  Disabled are 20 of the Medicaid population but
  62 of costs (all funds). Total 18 Billion

Texas Medicaid in Perspective, HHSC, April 2004
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Texas Medicaid Managed Care Growth
HMO PCCM FFS Total
FY2006 809,418 (31) 970,931 (35) 932,599 (34) 2,770,268
FY2007 1,060,358 (42) 760,071 (27) 848,502 (30) 2,791,482
FY2008 1,134,851 (45) 732,521 (25) 852,094 (30) 2,877,952
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STARPLUS Members

• Supplemental Security Income (SSI) adults who are
  not in a nursing facility or other institution
  and who are not currently being served through a
  Home and Community Based Waiver program, other
  than Community Based Alternatives (CBA), must
  enroll in STARPLUS.
• Non-SSI adults who qualify for 1915 (c) Nursing
  Facility Waiver services must enroll in STARPLUS
  to receive those services.
• SSI children, under age 21, may voluntarily
  enroll in STARPLUS.

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HMO Member Benefits

• Traditional Medicaid benefit package
• Unlimited Prescription drugs (Medicaid only)
• Annual adult well checks
• Removal of limit for length of stay for
  hospitalization (STAR only)
• PCP provider directories
• PCP coordinates health care of patient
• 24-hour nurse helpline (through their health
  plan)
• Member services helpline (through their health
  plan)
• Member handbooks and health education
• Case management for members with special health
  care needs

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STARPLUS LTC Services

• Medical supplies
• Home modifications
• Respite care
• Therapies
• Emergency response

• Personal assistance
• Day activity and health
• 1915(c) waiver services
• Adaptive aids
• Adult foster home
• Assisted living

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Contracting Method

• DADS
• Open Enrollment
• Licensure
• Contract
• Program specific

• STARPLUS HMO
• Negotiated Individually
• Additional providers dependent on network
  adequacy
• Contract by service, not program
• May add licensed providers that are not
  contracted with DADS

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Rates

• DADS
• Established on a statewide basis for each
  program.
• Based on cost reports filed by providers
• Same for all providers

• STARPLUS HMO
• Negotiated with each provider
• May establish fixed rates for each service or can
  negotiate different rates
• Provider can offer additional service for
  additional compensation

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Access

• DADS
• Individuals needing assistance must contact DADS
  or be referred by family, provider or community
  for assessment and authorization

• STARPLUS
• All members are contacted within 30 days of
  enrollment
• Informed about services available
• Telephonic risk questionnaire may lead to
  assessment and authorization for services

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Care Coordination Results

• External quality review study completed July 2003
• SSI clients in STARPLUS were compared to SSI
  PCCM clients
• Significant cost difference particularly for
  the highest acuity clients (3,226 mo in
  STARPLUS vs. 13,160 mo in PCCM)
• Lower inpatient and ER use in STARPLUS

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STARPLUS vs. PCCM

• Overall Expenditures

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Cost Savings

• Cost savings result from managing care by
• Early identification and treatment of health
  problems
• Promoting wellness and healthy lifestyles
• Avoiding higher cost services and products when
  lower-cost, clinically appropriate services can
  be rendered
• Coordinating care effectively and reducing
  duplication of services

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STARPLUS and Special Needs Plans

• Have 9 SNPs operating in Texas. Two have
  STARPLUS plans with over 20,000 enrolled for
  both programs
• SNP plans would like to see expansion of
  STARPLUS
• We pay a premium to the SNP plans to cover
  Medicaid cost share obligation

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Expansion Issues

• Unable to expand the program due to potential
  loss of UPL to public hospitals.
• Medicaid laws prohibit hospitals from receiving
  UPL if they are paid by a capitated HMO.
• Texas plans to implement alternative models
  including hospital carve-out and non-capitated
  managed care programs, but effectiveness and
  efficiency will be compromised.

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STARPLUS Expansion

• STARPLUS is expanding to 4 new areas January
  2007
• STARPLUS will carve out inpatient hospital
  services from the HMO capitation
• Capitates physician, ER, outpatient, and
  community-based long-term support services.

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