Medicaid Managed Care STAR Expansion Acute Care Provider Training - PowerPoint PPT Presentation

Medicaid Managed Care STAR Expansion Acute Care Provider Training February 2011

What is Medicaid Managed Care? • Establish a medical home for Medicaid clients through a Primary Care Provider (PCP) • Emphasize preventative care • Improve access to care • Ensure appropriate utilization of services • Improve health outcomes • Improve quality of care • Improve client and provider satisfaction • Improve cost effectiveness • Disease Management

Current Medicaid Managed Care Models Current Medicaid Managed Care Delivery Models • STAR (State of Texas Access Reform) • Capitated, Health Maintenance Organization (HMO) model for non-disabled pregnant women and children. • Provides acute care services. • STAR+PLUS • Capitated HMO model for disabled Medicaid clients and dual eligibles (Medicaid and Medicare). • Provides acute and long-term services and supports (LTSS). • STAR Health • Capitated HMO model for foster care children. • Provides acute care services with emphasis on behavioral health and medication management. • Primary Care Case Management (PCCM) • Non-capitated service delivery model. • Includes non-disabled pregnant women, children and disabled adults • Acute care services only.

Proposed Geographic Distribution of Managed Care Delivery Models Dallam Sherman Hansford Ochiltree Lipscomb Hartley Moore Hutchinson Roberts Hemphill Oldham Potter Carson Gray Wheeler Deaf Smith Randall Armstrong Donley Collingsworth Tarrant * Parmer Castro Swisher Briscoe Hall Childress Hardeman Bailey Lamb Hale Floyd Motley Cottle Wilbarger Wichita Foard Clay Montague Lamar King Baylor Cooke Grayson Red River Cochran Hockley Lubbock Crosby Dickens Knox Archer Fannin Dallas * Bowie Delta Lubbock Jack Titus Garza Kent Wise Denton Collin Yoakum Terry Lynn Stonewall Haskell Throckmorton Young Hopkins Franklin Hunt Morris Cass Camp Palo Rockwall Rains Wood Marion Gaines Dawson Borden Scurry Fisher Jones Pinto Parker Tarrant Dallas Shackelford Stephens Upshur KaufmanVan Zandt Harrison Gregg Hood Johnson Ellis Smith Andrews Martin Howard Mitchell Nolan Eastland Erath Taylor Callahan Somervell Henderson Panola Rusk Navarro Hill Comanche El Paso Ector Midland Glasscock Coke Bosque Loving Winkler Runnels Cherokee Sterling Anderson Shelby Coleman Brown Hamilton Freestone Nacogdoches McLennan Limestone Ward Mills Hudspeth Culberson Crane Tom Green San Augustine Upton Reagan Coryell Reeves Concho Houston Sabine Irion Leon Falls Angelina McCulloch Lampasas San Saba Trinity Bell Robertson Madison El Paso Jasper Schleicher Menard Newton Pecos Burnet Milam Polk Tyler Walker Jeff Davis Crockett Mason Llano Williamson Brazos Jefferson San Jacinto Grimes Sutton Kimble Burleson Travis Hardin Gillespie Lee Montgomery Blanco Terrell Washington Liberty Orange Bastrop Kerr Hays Waller Presidio Edwards Austin Kendall Jefferson Val Verde Real Bandera Caldwell Fayette Harris Chambers Brewster Comal Colorado Guadalupe Fort Bend Harris Gonzales Bexar Galveston Kinney Uvalde Medina Lavaca Wharton Wilson Brazoria De Witt Jackson Atascosa Karnes Zavala Frio Matagorda Victoria Maverick Goliad Bee Calhoun Travis Dimmit La Salle McMullen Live Oak Refugio Aransas San Patricio Webb Jim Wells Nueces Duval Kleberg Bexar Nueces Jim Hogg Brooks Zapata Kenedy Starr Willacy Hidalgo Cameron Hidalgo HHSC, Health Plan Operations September 2010 Page 4

Expansion to Contiguous Counties for September 1, 2011 Service Current Counties STAR Expansion HMOs Providing STAR STAR+PLUS HMOs Area Counties Expansion Providing Counties STAR+PLUS Bexar Atascosa, Bexar, Comal, Bandera Aetna Bandera Amerigroup Guadalupe, Kendall, Medina, Community First Molina Wilson Superior Superior El Paso El Paso Hudspeth El Paso First No Change No Change Superior Harris Brazoria, Fort Bend, Galveston, Austin, Matagorda, Amerigroup Austin, Matagorda, Amerigroup (incl’s Harris, Montgomery, Waller Wharton Wharton Community Health Choice Evercare Harris & Molina Molina Harris Exp Texas Children's Counties) United Jefferson N/A Chambers, Hardin, Amerigroup Chambers, Hardin, Amerigroup (New Svc Jasper, Jefferson, Jasper, Jefferson, Liberty, Community Health Choice Evercare Area – Liberty, Newton, Newton, Orange, Polk, Molina Molina Harris Orange, Polk, San San Jacinto, Tyler, Texas Children's Contig. Jacinto, Tyler, Walker Walker United Counties Lubbock Crosby, Floyd, Garza, Hale, Carson, Deaf Smith, FirstCare No Change No Change Hockley, Lamb, Lubbock, Lynn, Hutchinson, Potter, Superior Terry Randall, Swisher Nueces Aransas, Bee, Calhoun, Jim Brooks, Goliad, Amerigroup Brooks, Goliad, Karnes, Evercare Wells, Kleberg, Nueces, Refugio, Karnes, Kenedy, Live Kenedy, Live Oak Driscoll Superior San Patricio, Victoria Oak Superior Travis Bastrop, Burnet, Caldwell, Lee, Fayette Amerigroup Fayette Amerigroup Hays, Travis, Williamson Superior Evercare

STAR Program Information • STAR operates under the authority of a federal 1915(b) waiver. • Risk-based, capitated managed care. • Each STAR member is enrolled in a HMO and has a PCP. • PCP is chosen by member or assigned by state or HMO.

STAR Program • Populations mandatory for STAR include:  Temporary Assistance to Needy Families (TANF) recipients  Pregnant Women  Children receiving Medicaid assistance only • Populations excluded from STAR include:  Medicaid recipients who reside in institutions  Dual-eligible Medicaid recipients (clients with both Medicaid and Medicare)  Medically needy  Foster children  Refugees • SSI Medicaid recipients may volunteer to be in STAR or will be placed in traditional Medicaid effective September 1, 2011. Page 7

HMO vs. PCCM • HMO model offers improved utilization management over PCCM. • Improved utilization achieved through internal HMO processes and service coordination. • Similar service not available in PCCM. • Premium tax: • Premiums paid to Medicaid HMOs subject to state premium tax. • As part of HHSC’s check and balance on the HMOs, HHSC caps the amount of profit that may be earned.

HMO vs. FFS FFS STAR/STAR +PLUS Provider Directory Client has to locate willing • Includes PCP/Specialists/LTSS provider Member Handbook • Includes phone numbers for assistance, descriptions of benefits, complaints and 3 prescriptions per month for appeal information (esp useful for LTSS) adults Unlimited Prescriptions (non-duals) for adults Value Added Services (varies by HMO) No Primary Care Provider • Such as 24 hour nurse lines, additional (PCP) transportation help, cell phones for high risk clients, weight loss programs Member chooses PCP or is assigned a PCP – can change through the HMO • HMO must ensure access to physicians per contract requirements (emergency, urgent, routine care)

PCCM vs. Medicaid Managed Care Primary Care Case Management (PCCM)  State operated plan  Providers are contracted directly with state  Members assigned PCP, but can see any Medicaid specialist  Providers paid fee-for-service rates Medicaid Managed Care  Providers must contract and be credentialed with the HMO to provide STAR services  Rates are negotiated between the provider and the HMO Page 10

PCCM vs. Medicaid Managed Care Medicaid Managed Care (continued)  Authorization requirements may be different and must be obtained from the HMO  Providers must follow HMO 95 day billing requirements  Provides a medical home through a PCP and referral needed for specialty provider visits  Promotes preventive care and continuity of care  HMO may offer value-added services (ex: sports physicals, extra vision benefits, health and wellness benefits) Page 11

Claims STAR Medicaid Managed Care • Claims are paid by the HMO. • Providers must file claims within 95 days of Date of Service (DOS). • HMOs required to adjudicate within 30 days. Page 12

HMO Plan Identification Cards • All HMO Members receive a HMO Plan ID Card, in addition to their monthly Medicaid ID Card (Form 3087) from the State. • The card contains the following information:  Member’s name and Medicaid ID number  Identification of HealthCare Program (STAR)  HMO name  Primary care provider name & telephone number  Toll-free telephone numbers for member services and behavioral health services hotline  Additional information may be provided (e.g., date of birth, service area, primary care provider address) Page 13

Provider Complaints • Initial point of contact is HMO • May submit written complaint to HHSC at hpm_complaints@hhsc.state.tx.us • HHSC will intervene in issues when HMO is not complying with HHSC contract Page 14

Workgroup Updates Eligibility and Enrollment Systems Workgroup • Meetings with all system trading partners • Project testing underway • Proposed readiness review testing • Lessons learned – Best Practices Enrollment Broker Workgroup • Welcome letters/FAQs mailed out in April • Enrollment packets mailed out in June • Medicaid ID stuffer – August • Outreach and enrollment events – June/July/August Page 15