Overview of the STAR+PLUS Program in Texas

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1 Overview of the STAR+PLUS Program in Texas Marc Gold Department of Aging and Disability Services National Academy of State Health Policy Seattle, WA October 2013 History Legislative Direction to create STAR Pilot in Houston as (b)(c) waivers. 2007; 2011; 2012 Major expansions in 10 service delivery areas and 90 counties STAR+ became a 1115 waiver Significant changes made by Legislature. Increased access to community services. Improved coordination and efficiency between acute and LTSS. Page 2 1

2 What is STAR+ Integrated delivery system for acute and long term services and supports to provide coordinated health care, acute, and LTSS. Waiver authority: 1115 (was a b/c until December Risk-based, capitated model. Includes dual eligibles (Medicare and Medicaid) Page 3 What is STAR+ Delivered through licensed managed care organizations (at least two in each catchment area): Medicaid beneficiaries receive both acute and LTSS through Medicaid MCO Dual Eligible beneficiaries receive acute services through Medicare and Medicaid LTSS services through Medicaid MCO (Dual Eligible Project: 2015). Page 4 2

3 Who Qualifies for STAR+ Individuals with a physical disability or a mental health need and qualify at the SSI level of income. Individuals age 21 or older who receive Medicaid because they are in a social security exclusion program. Individuals who qualify for TX fee-for-service adult nursing facility waiver*. Individuals who are Dual eligible (55%). Children are voluntary (20%)*. Page 5 Who Doesn t Quality as of October 2013 NF residents*- will change. STAR+ members who have been in a NF for more than 120 days*- will change. Residents of ICFs for individuals with intellectual and developmental disabilities (IDD)*- may change. Individuals not eligible for full Medicaid. Individuals in IDD waivers*- may change. Children in foster care. Page 6 3

4 El Paso Hudspeth Culberson Jeff Davis Presidio Reeves Ward Brewster Deaf Smith Parmer Bailey Cochran Yoakum Dallam Hartley Oldham Gaines Andrews Loving Winkler Ector Midland Pecos Crane Castro Lamb Hockley Terry Sherman Randall Martin Upton Terrell Moore Potter Dawson Swisher Hale Lubbock Lynn Hansford Hutchinson Carson Armstrong Borden Howard Glasscock Sterling Reagan Crockett Briscoe Floyd Crosby Garza Mitchell Irion Val Verde Ochiltree Roberts Gray Donley Dickens Kent Scurry Hall Motley Fisher Nolan Coke Tom Green Schleicher Sutton Lipscomb Hemphill Wheeler Collingsworth Childress Cottle King Stonewall Edwards Kinney Maverick Hardeman Taylor Runnels Foard Knox Haskell Throckmorton Young Jones Concho Menard Kimble Real Uvalde Zavala Dimmit Wilbarger Shackelford Stephens Callahan Coleman Baylor McCulloch Mason Kerr Bandera Webb Medina Frio La Salle Zapata Eastland Brown Gillespie Wichita Archer Llano Kendall Jim Hogg Starr Mills San Saba Comanche Blanco Bexar Atascosa Duval Clay Jack Palo Pinto Erath Hamilton Lampasas Burnet Comal Wilson Bee McMullenLive Oak Jim Wells Brooks Hays Guadalupe Gonzales Hidalgo Montague Parker Hood Johnson Somervell Coryell Travis Karnes Wise Bosque Aransas San Patricio Nueces Kleberg Bell Williamson Caldwell Kenedy Goliad Willacy Tarrant Bastrop De Witt Cameron Cooke Denton Hill McLennan Refugio Falls Milam Brazos Grimes Burleson Lee Ellis Fayette Lavaca Victoria Grayson Collin Rockwall Dallas Navarro Anderson Cherokee Shelby Freestone Nacogdoches Limestone Robertson Jackson Calhoun Fannin Hunt Washington Colorado Austin Waller Wharton Henderson Leon Madison Fort Bend Matagorda Lamar Delta Franklin Titus Hopkins Morris Camp Rains Wood Upshur Walker Smith Houston Montgomery Brazoria Red River Trinity San Jacinto Harris Gregg Rusk Polk Liberty Galveston Bowie Cass Marion Harrison Panola San Augustine Sabine Angelina Tyler Hardin Chambers Jasper Newton Jefferson Orange l 10/8/13 Members Served As of August 2013, there are currently 3,344,119 members enrolled in managed care in Texas Medicaid. 408,309 in STAR+PLUS. Page 7 El Paso El Paso Amerigroup, Molina Lubbock Amerigroup, Superior Hudspeth El Paso Culberson Jeff Davis Presidio Reeves Dallam Sherman Hansford Ochiltree Lipscomb STAR+PLUS Managed Care Service Hartley Moore Hutchinson Roberts Hemphill As of March 1, 2012 Oldham Potter Carson Gray Wheeler Areas Ward Lubbock Andrews Loving Winkler Ector Midland Brewster Deaf Smith Parmer Bailey Cochran Yoakum Gaines Pecos Crane Castro Lamb Hockley Terry Travis Martin Upton Terrell Travis Amerigroup, United Randall Swisher Hale Lubbock Lynn Dawson Howard Glasscock Reagan Bexar Armstrong Borden Crockett Briscoe Floyd Crosby Garza Val Verde Bexar Amerigroup, Molina, Superior Hidalgo Mitchell Sterling Irion Donley Kent Scurry Hall Motley Dickens Collingsworth Nolan Coke Tom Green Schleicher Sutton Childress Cottle King Stonewall Fisher Edwards Kinney Maverick Hidalgo Hardeman Taylor Runnels Foard Knox Jones Concho Menard Kimble Real Uvalde Zavala Dimmit Wilbarger Callahan Coleman Baylor Haskell Throckmorton McCulloch Mason Kerr Bandera Webb Medina Frio La Salle Zapata Eastland Brown Gillespie Young Shackelford Stephens HealthSpring, Molina, Superior Wichita Archer Hood Hamilton Tarrant * Llano Kendall Jim Hogg Starr Mills San Saba Comanche Kaufman Van Zandt Travis Blanco Bexar Atascosa Duval Clay Jack Palo Pinto Erath Lampasas Burnet Comal Wilson Bee McMullen Live Oak Jim Wells Brooks Hays Guadalupe Gonzales Nueces Hidalgo Montague Parker Somervell Coryell Karnes STAR+PLUS Service Areas Wise Bosque San Patricio Nueces Kleberg Bell Williamson Caldwell Kenedy Tarrant Amerigroup, HealthSpring Goliad Willacy Bastrop De Witt Cameron Cooke Tarrant Johnson Denton Hill McLennan Refugio Falls Milam Brazos Grimes Burleson Lee Fayett e Lavaca Victoria Aransas Grayson Rockwal Dallas Ellis Collin Navarro Anderson Cherokee Shelby Freestone Nacogdoches Limestone San Augustine Robertson Jackson Calhoun Kaufman Van Zandt Austin Fannin Hunt Washington Colorado Wharton Henderson Leon Madiso n Dallas * Waller Rains Fort Bend Jefferson Matagorda Lamar Delta Walker Harris Montgomery Brazoria HHSC, Health Plan Operations September 2010 Titus Hopkins Franklin Morris Wood Red River Smith Houston Trinity Camp Upshur San Jacinto Harris Nueces Superior, United Gregg Rusk Polk Liberty Galveston Bowie Angelina Cass Marion Harrison Panola Tyler Hardin Chambers Sabine Jasper Newton Jefferson Orange Dallas Molina, Superior Jefferson Amerigroup, Molina, United Harris Amerigroup, Molina, United 8 Page 8 4

5 Service coordination: Makes home visits; Special Features Develops individual plan of care for acute/ltss; Authorizes LTSS; Arranges and coordinates acute services; Assists with Medicare physician. Unlimited prescriptions (Duals receive drugs through Medicare Part D). No limit on inpatient psychiatric services. Value-added services (dependent on each managed care organization). Enrollment broker. Page 9 Adult Services State Plan: Acute all state plan services primary preventive doctor hospital lab x-ray. Attendant* and day activity and health services. Mental Health and Substance Abuse. *Consumer-directed Option Page 10 5

6 Adult Services Waiver services: Respite* Nursing* Therapies* Adaptive aids Minor home modifications Adult Foster Care Services within assisted living Dental Emergency response Home delivered meals *Consumer-directed Option Page 11 Children s STAR+PLUS Services Children s Medicaid package PCP Community-based LTSS Service Coordinator Unlimited necessary hospital days Page 12 6

7 STAR+ Impact on Rebalancing LTSS Individuals at the SSI level receive waiver services as an entitlement. Increased retention of individuals in community and prevention of returning to an institutional setting. Significant decrease on NF waiver waiting lists. Overall, more efficient system and easier access to services. Page 13 Capitated/Risk Model Four capitation rates dependent on: if the individual is Medicaid only or dual eligible. eligible for lower-level State Plan programs or full waiver services based on NF eligibility criteria. Rates are region specific. Rate structure will change in September Page 14 7

8 Capitated/Risk Model % of Revenues MCO Share State Share 0-3% 100% 0% 3-5% 80% 20% 5-7% 60% 40% 7-9% 40% 60% 9-12% 20% 80% >12% 0% 100% Page 15 Capitated At-Risk Capitation Rate At-Risk methodology is dependent on the outcome of pre-identified performancebased measures. Uniform Managed Care Contract (UMCC) includes a provision which puts up to five percent of the MCO s capitation at risk. The objective is that all MCOs achieve performance levels that enable to receive the full at-risk amount. HHSC identifies no more than 10 at-risk performance indicators for each MCO Program. Page 16 8

9 Cost Effectiveness Reduced costs in STAR+ compared to noncapitated systems, savings as percentage reductions include: 22% for in-patient. 15% for acute out-patient. 10% for LTSS. Page 17 Quality Challenge Award HHSC reallocates any unearned funds from the performance-based, at-risk portion of a MCO s capitation rate to the MCO Program s Quality Challenge Award. HHSC determines the number of MCOs that will receive Quality Challenge Award funds annually based on the amount of the funds to be reallocated. Separate Quality Challenge Award payments are made for each of the MCO programs. HHSC works with the EQRO and the MCOs to identify the performance indicators for which their capitation will be placed at risk. Page 18 9

10 STAR+PLUS MRSA Expansion. Expands STAR+PLUS into the Medicaid Rural Service Area (MRSA). Proposed to serve an estimated 81,506 additional members in STAR+PLUS. Projected expansion date: September 1, Service Areas: Central, Northeast and West Texas. Page 19 Dal la m Hartley Ol dh am Sherman Hansford Ochiltree Li ps com b M oore Hutchi ns on Roberts He mph il l Wh eel er Po t e r Carson Gra y Medicaid Rural Service Area (MRSA) Regions El Pa so Hu ds pet h MRSA West Texas STAR - Am erigroup, Firs tcare, Superior *S TAR+P LUS Amerigroup, Superior Deaf Smith Parmer Ba iley Ca stro La mb Ra nd al l Armstrong Do nl ey Swisher Hal e Briscoe Floyd Ha l Motley Collingsworth Chi ld re ss Cottle Ha rd ema n Foard Dim mit Wilbarger Cl ay Co ch ra n Ho ckl ey Lu bb ock Crosby Di ck ens King Knox Ba yl or Archer Mon t agu e Co oke Gray son Lamar Fannin Red Ri ve r Del ta Bowie Ja ck Titus Yo aku m Terry Lynn Ga rz a Kent Stonewall Ha ske lthrockmorton Young Wise Den ton Co l in Hunt Ho pki ns Franklin Camp Morris Cass Palo Roc kwal Rai ns Wood Gai ne s Daws on Borden Scury Fi sher Jon es ShackelfordStephens Pinto Parker Tarrant Dal la sl Marion Ups hu r Kaufman Va n Za ndt Harison Hood Gregg Andrews Martin Howard Mi t che l Nol an Taylor Ca l ah an Ea st land Erath Johnson El l is Smith Somervell Henders on Pa nola Navarro Rusk Com anc he Hi l Loving Wi nkler Ector Mi dl an d Gl ass coc k Co ke Bos que Sterling Run ne ls Co le man Brown Anders on Cherok ee Sh elby Hami l to n Frees tone Mc Le nna n Na cog do che s Ward Mil l s Limestone Culberson Crane San Augustine Ree ves Upton Re ag an Tom Green Coryel Irion Con cho Falls Le on Hou ston Sa bine Angelina McCul oc hsan Saba La mpa sa s Bell Trinity Robertson Schleicher Mad is o Jasper Me na rd Pec os Burnet Mi l am n Polk Jeff Davis Crock ett Ma son Ll an o Wa lk er Tyler Newton Williamson Brazos Grimes San J acinto Sutton Kimble Burles on Gil l esp ie Trav is Blanc o Le e Montgomery Hardin Terrell Washington Kerr Hay s Bas trop Liberty Orange Pres idio Brewster Edwards Val Verde Kendal Aus tin Wa l er Jefferson Real Bandera Co mal Ca ld we l Fa yett Harris Chambers e Gua da lu pe Colorado Fort Bend Bexar Gon zal es Kinney Uval de Med in a La vac a Ga lv eston Wharton Wi ls on Braz oria De Witt Zavala Frio At a sco sa Karnes Jac kso n Victoria Matagorda Ma ve ri ck Gol i ad We bb La Salle Zapata Wichita Bee McMu l en Li ve Oak Jim Hogg Starr Duv al Ji m We l s Brooks Hid al go Aransas San Patric io Kleberg Nu ec es Ke nedy Wi l ac y Cameron Refug io Cal hou n MRSA Northeast Texas STA R - Am er igroup, Superior *S TAR+PLUS HealthSpring, United MRSA Central Texas STA R - Am er igroup, Sc ott & White, Superior *STAR+PLUS - Superior, United *STAR+PLUS con tr acts are tentativ e until successful negotiation and execution of contracts. HH S C, Medic ai dc HIP Septmember2013 Page 20 10

11 Nursing Facility Carve-In Historically excluded from managed care, nursing facility services will soon be provided through STAR+PLUS statewide. Expected to improve quality of care for current nursing facility residents and to promote care in the least restrictive, most appropriate setting. Proposed implementation date: September 1, ,497 estimated nursing facility residents will transition to STAR+PLUS. Page 21 IDD Carve-In Transition of the following persons into STAR+PLUS for acute care services: Individuals who receive services in community-based Intermediate Care Facilities for Individuals with Intellectual Disabilities. Individuals who receive services in ICF-IID 1915 (c) waivers: Home and Community-Based Services, Community Living Assistive and Support Services, Texas Home Living, and Deaf- Blind Multiple Disabilities. Not included: Individuals residing in a state supported living center. Dual eligibles. Children under age 21 receiving SSI or SSI-related services are voluntary. Projected implementation date: September 1, Page 22 11

12 Future of STAR+/Managed Care Full statewide coverage of STAR+. Inclusion of Nursing Facility: 9/2014. Inclusion of Medicaid behavioral health services. Creation of a mandatory managed care program for children at SSI level of income: STAR Kids. Testing models for inclusion of individuals with intellectual and developmental disabilities. Inclusion of Community First Choice. Page 23 Gary Jessee Deputy Medicaid Director, Managed Care Health and Human Services Commission (512) Contact Marc Gold Special Advisor for Policy and Promoting Independence Texas Department of Aging and Disability Services (512) Page 24 12

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