STAR Health Judicial Presentation 9/15/2017 SHP_20151177
Superior HealthPlan Superior HealthPlan provides health care for Texans enrolled in Medicaid, CHIP, Medicare, and the new healthcare marketplace exchange. • Currently serving over 960,000 lives statewide • Became the first organization in the country to serve as a state’s exclusive managed care company for children placed in foster care (April 1, 2008) • Shares expertise nationwide: – 4 Sole-Source States – Texas, Mississippi, Florida and Washington – 6 Multi-Source States – Missouri, Louisiana, Kansas, New Hampshire, Indiana and California • Awarded STAR Health contract renewal (September 1, 2015) 9/15/2017 2
STAR Health Enhancements
STAR Health Interactions 1-866-912-6283 Ad Hoc Opportunities • Impact Pro predictive modeling tool Service Coordination and Management • Member Service calls • Service Coordination: Telephonic support • Psychotropic Medication for coordinating on-going health care by a Utilization Reviews bachelor’s level staff or social worker • Nurse Advice Line follow up General Health Screenings • Service Management services: Clinical Case • ER Utilization follow up Management by a registered nurse and/or • Welcome calls include overview, Texas • DFPS Individual Case Staffing licensed clinician Health Steps medical/dental checkups, • Specialized Programs: Clinical Case general health screenings (GHS) and Management for Members with specific community resources diagnosis and/or high acuity needs. • GHS identifies health care needs and (Complex Case Management, Transitioning triggers referrals to Service Youth Program, Discharge Planning for members Coordination, Service Management, who are inpatient, START Smart for Your Baby Disease Management or Specialized program for pregnant members, Transplant Programs specific program, Diabetes dual case • GHS are completed within 30 days for management, Smart Nutrition and Activity all new STAR Health Members Program and Personal Care Services,) • Placement Changes trigger the • Disease Management: On-going clinical support completion of a new GHS for Members diagnosed with asthma and/or Intellectual Developmental Disabilities (IDD) 9/15/2017 4
STAR Health Checklist Concerns about health Unknown health Frequent Placement conditions or diagnosis Changes? conditions? Has a new General Health Has a Texas Health Steps Has a General Health Screening checkup been completed? Screening been completed? been completed? Are they enrolled in service Are there recommendations that Are they enrolled in Service were not scheduled or followed? Management? Coordination or Management? Medical or psychiatric Frequent trips to the hospital admission? Emergency Room? Going out of State? Were follow up appointments Do they know about the 24/7 Do medications need to be filled attended? Nurse Advice Line? or health care services accessed? Were medications, supplies and/or Do they know where their local equipment received? Urgent Care Clinics are? Psychotropic Medication No Medical History is Is the youth turning Concerns known 18 soon? Have they been on the Has Health Passport been medication for 60+ days so a accessed to review “Patient Has a referral been made to Psychotropic Medication History” for medical claims and participate in the Utilization Review (PMUR) “Medication History” for Transitioning Youth Program? can be completed? pharmacy claims? To initiate services, 9/15/2017 5 we recommend utilizing the established STAR Health process
STAR Health Process • For assistance, any authorized caller can contact Member Services at 1-866-912-6283 • Assistance is available 24/7/365 Step 1 • Caregivers should report STAR Health barriers to the assigned DFPS caseworker • DFPS caseworkers should report STAR Health barriers to their Regional Well Being Specialist • IMPORTANT: Details of the barrier are important to include such as who at STAR Health they Step 2 spoke with and when so resolution can be expedited • The DFPS Regional Well Being Specialist will escalate an inquiry to their designated STAR Health Liaison for internal review • Upon research or resolution, the STAR Health Liaison will report back to the DFPS Regional Well Step 3 Being Specialist the findings/case update • If concerns remain unresolved or if dissatisfaction is expressed, complaints can be reported to STAR Health directly by calling 1-866-912-6283 or by contacting the Texas Health and Human Step 4 Services Commission at 1-866-566-8989 or by email at HPM_Complaints@hhsc.state.tx.us.
Senate Bill 125 in Action • Child and Adolescent Needs and Strength Assessment • Texas Health Passport – Assessments, Monthly Reviews and Point of Contact for DFPS, Providers, Medical Consenters and STAR Health. – www.canstraining.com • In order to administer the CANS assessment on and after 09-01-2016 Network Providers submit their Certificate of Completion to – CBHNetworkDEV@cenpatico.com • Member Connections representatives support Medical Considers in connecting for assessment and counseling services.
Case Scenarios Can be accessed Medicaid Services that are not If services are needed with a without a court medically necessary Specialist, a referral may be Covered order as long as cannot be paid for required by the Primary they are medically Services by STAR Health Medical Provider (PCP) necessary Care grants, value added Non-Medicaid STAR Health does services & case by case Court Ordered Non- not pay for Non- services may be Medicaid Covered Services Covered Medicaid Covered considered (if appropriate) become the financial Services Services and do not require a court responsibility of DFPS order to be accessed The orthodontist must complete an evaluation to To start the process, the Must be medically child/youth must be seen determine if services are Orthodontia necessary for by their dentist for a medically necessary for STAR Health to pay referral to an orthodontist Medicaid services to be covered. Placement is not a Caseworkers must contact Medicaid covered Placement considerations their Regional Well Being Placement benefit and cannot must be secured through Specialists to begin the court be paid for by DFPS ordered placement process STAR Health
Judicial Point of Contact Regions 1, 2 & 9 Region 3 Region 4 Region 5 Rich Capodagli Tara Hosch Gloria Fobbs Easter Spates 806-474-2861 214-603-9344 469-265-5842 713-591-2341 rcapodagli@cenpatico.com thosch@cenpatico.com gfobbs@cenpatico.com espates@cenpatico.com Region 7 Region 8 Region 10 Region 6 Naijean Bernard-Onwere Lucy Reyes Araceli Salcedo Michael Migura 512-923-4620 210-381-5142 214-399-4228 512-484-5137 nonwere@cenpatico.com lreyes@cenpatico.com asalcedo@cenpatico.com mmigura@cenpatico.com Foster Care MedQuestions@cenpatico.com Region 11 Training Manager Rita Sandt Mary Armstrong STAR Health Staff will respond to general questions within five 361-446-1795 business days and contact the Requesting Judge for 214-287-3961 rsandt@cenpatico.com additional information if needed. marmstrong@cenpatico.com
Thank You! STAR Health Member Services 1-866-912-6283 9/15/2017
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