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Medicaid Managed Care Stakeholder Forum DallasTarrant Service Areas

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Title: Medicaid Managed Care Stakeholder Forum DallasTarrant Service Areas

1
Medicaid Managed Care Stakeholder Forum
Dallas/Tarrant Service Areas

September 2009 Managed Care Operations Medicaid/CH
IP Division
2
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

3
Dallas and Tarrant Service Areas

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

4
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.

5
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.

6
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.

7
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.

8
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.

9
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

10
Review of Current Models
11
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.

12
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.

13
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.

14
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.

15
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.

16
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.

17
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.

18
About STARPLUS
19
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.

20
About STARPLUS

STARPLUS Enrollment in August 2009

21
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

22
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

23
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.

24
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.

25
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

26
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.

27
About STARPLUS
28
About STARPLUS
29
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.

30
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.

31
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.

32
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.

33
Discussion and Questions
Request for Stakeholder Input
34
HHSC Managed Care Operations