Texas Healthcare Transformation and Quality Improvement Program. Section 1115 Quarterly Report. Texas Health and Human Services Commission

Transcription

1 Texas Healthcare Transformation and Quality Improvement Program Section 1115 Quarterly Report Texas Health and Human Services Commission Demonstration Reporting Period: 2015 State Fiscal Quarter 2, December-February Demonstration Year 4 Quarter 2, January March

2 TABLE OF CONTENTS I. Introduction... 3 A. Managed Care Plans Participating in the Waiver Program... 3 B. Monitoring MCOs... 4 C. Demonstration Funding Pools... 4 II. Enrollment and Benefits Information... 4 A. Eligibility and Enrollment... 5 B. Enrollment Counts for the Quarter By Population... 9 C. Disenrollment D. Enrollment of Members with Special Health Care Needs E. Medicaid Eligibility Changes F. Anticipated Changes in Populations or Benefits Delivery Networks and Access A. Provider Networks B. GeoAccess C. Out-of Network Utilization III. Outreach/Innovative Activities to Assure Access A. Enrollment Broker and MCO Activities B. Dental Stakeholder Meeting C. Medicaid Managed Care Advisory Committee D. Independent Consumer Supports System E. HHSC Managed Care Initiatives IV. Collection and Verification of Encounter Data and Enrollment Data V. Operational/Policy/Systems/Fiscal Developments/Issues A. Update from Prior Quarter i Quarterly Report for the Section 1115 Waiver, February 2015

3 B. Litigation Update C. New Issues D. Claims Summary VI. Action Plans for Addressing Any Issues Identified VII. Financial/Budget Neutrality Development/Issues VIII. Member Month Reporting IX. Consumer Issues A. Hotline Call Volume and Performance B. Complaints and Appeals Received by Plans C. Complaints Received by the State X. Quality Assurance/Monitoring Activity XI. Demonstration Evaluation A. Overview of Evaluation B. Summary of Evaluation Activities C. Activities Planned in Next Quarter XII. Regional Healthcare Partnership Participants Enclosures/Attachments State Contacts Acronym list ii Quarterly Report for the Section 1115 Waiver, February 2015

4 I. INTRODUCTION Through the Texas Healthcare Transformation and Quality Improvement Program Section 1115 waiver, the State is able to expand its use of Medicaid managed care to achieve program savings, while also preserving locally funded supplemental payments to hospitals. The goals of the demonstration are to: Expand risk-based managed care statewide Support the development and maintenance of a coordinated care delivery system Improve outcomes while containing cost growth Protect and leverage financing to improve and prepare the healthcare infrastructure to serve a newly insured population Transition to quality-based payment systems across managed care and hospitals This report documents the State s progress in meeting these goals. It addresses the quarterly reporting requirements for the STAR and STAR+PLUS programs, as well as Children s Medicaid Dental Services (Dental Program), which are found in the waiver s Special Terms and Conditions (STCs), items 20, 39(a), 40(b) and (c), 52, 65, and 67. These STCs require the State to report on various topics, including: enrollments; anticipated changes in populations or benefits; network adequacy; encounter data; operational, policy, systems, and fiscal issues; action plans for addressing identified issues; budget neutrality; member months; consumer issues; quality assurance and monitoring; the demonstration evaluation; and Regional Healthcare Partnerships (RHPs). The State collects performance and other data from its managed care organizations (or plans ) on a State Fiscal Quarterly (SFQ) cycle; therefore, some of the quarterly information presented in this report is based on data compiled for 2015 SFQ2 (December-February) instead of Demonstration Year (DY) 4, Q2 ( 2015 D2, covering January-March). Throughout the report, the State has identified whether the quarterly data relates to 2015 SFQ2 or 2015 D2. A. MANAGED CARE PLANS PARTICIPATING IN THE WAIVER PROGRAM During the 2015 SFQ2, the State contracted with 18 STAR, 5 STAR+PLUS, and 2 Dental Program plans. Each MCO covers one or more of the 13 STAR service areas or 13 STAR+PLUS service areas, and each dental plan provides statewide services. Please refer to Attachment A for a list of the STAR, STAR+PLUS, and Dental plans by area. 3 Quarterly Report for the Section 1115 Waiver, February 2015

5 B. MONITORING MCOS The Health and Human Services Commission (HHSC) staff evaluates and routinely monitors managed care organization (MCO) performance reported by the MCOs or compiled by HHSC. If an MCO fails to meet a performance expectation, standard, schedule, or other contract requirement such as submission of deliverable timely or at the level of quality required, the managed care contracts give HHSC the authority to use a variety of remedies, including: Monetary damages (actual, consequential, direct, indirect, special, and/or liquidated damages (LD)) Corrective action plans (CAPs) C. DEMONSTRATION FUNDING POOLS The section 1115 demonstration establishes two funding pools, created by savings generated from managed care expansion and diverted supplemental payments, to reimburse providers for uncompensated care costs and to provide incentive payments to participating providers that implement and operate delivery system reforms. Texas worked with private and public hospitals, local government entities, and other providers to create RHPs that are anchored by public hospitals or other specific government entities. RHPs identified performance areas for improvement that may align with the following four broad categories to be eligible for incentive payments: (1) infrastructure development, (2) program innovation and redesign, (3) quality improvements, and (4) population focused improvements. The non-federal share of funding for pool expenditures is largely financed by State and local intergovernmental transfers (IGTs). Waiver activities are proceeding and detailed information on the status is included in the sections below. II. ENROLLMENT AND BENEFITS INFORMATION This section addresses STCs 39(a), 53, 65, and 67, including quarterly and biannual trends and issues related to STAR, STAR+PLUS, and Dental Program eligibility and enrollment; Medicaid eligibility changes; anticipated changes in populations and benefits; and disenrollment from managed care. Unless otherwise provided, quarterly managed care data covers the 2015 SFQ2 reporting period (December February) instead of 2015 D2 (January March). Similarly, biannual data covers the 2015 SFQ1-2 (September-February), instead of 2015 D1-D2 (October- March). 4 Quarterly Report for the Section 1115 Waiver, February 2015

6 A. ELIGIBILITY AND ENROLLMENT This subsection addresses the quarterly reporting requirements found in STC 67. Attachment B includes enrollment summaries for the three managed care programs. The enrollment data in this subsection are based on prospective managed care enrollment counts in the last month of the quarter and represent a snapshot of the number of members enrolled in Texas Medicaid managed care programs and health plans. Overall, the enrollment in Texas Medicaid managed care programs, Dental, STAR and STAR+PLUS, decreased by 1.20 percent in 2015 SFQ2. 1. STAR The number of members enrolled in STAR plans decreased by 1.49 percent from 2,910,410 in SFQ1 to 2,867,103 in SFQ2. Across the state, the largest increase in market share occurred within Blue Cross Blue Shield who experienced an increase in enrollment of 3.83 percent in SFQ2. Driscoll and Scott & White were the only other STAR MCOs to experience an increase in enrollment, but neither plan gained more than half a percent. All other MCOs experienced a decrease in enrollment by approximately a couple percentage points. By service delivery area (SDA), the enrollment decreased slightly in each SDA. El Paso SDA experienced the largest decrease in enrollment, still only 2.14 percent in SFQ2. Market Share by STAR MCO (2014 SFQ SFQ2) STAR 2014 Q Q Q Q2 Aetna 2.40% 2.47% 2.53% 2.50% 19.84% 19.79% 19.64% 19.63% BCBS 0.67% 0.73% 0.78% 0.82% CHC 7.91% 7.88% 8.00% 8.01% Christus 0.27% 0.25% 0.25% 0.24% Community 1st 3.58% 3.65% 3.76% 3.75% Cook Children's 3.20% 3.31% 3.42% 3.41% Driscoll 4.22% 4.29% 4.44% 4.52% El Paso 1st 2.15% 2.17% 2.21% 2.22% FirstCare 3.42% 3.37% 3.21% 3.19% Molina 3.73% 3.58% 3.56% 3.53% Parkland 6.37% 6.33% 6.40% 6.34% Scott & White 1.43% 1.49% 1.38% 1.40% Sendero 0.38% 0.41% 0.42% 0.42% Seton 0.49% 0.53% 0.57% 0.58% 25.25% 24.75% 23.96% 23.96% Texas Children's 10.69% 11.01% 11.44% 11.41% United 3.99% 3.99% 4.05% 4.05% 5 Quarterly Report for the Section 1115 Waiver, February 2015

7 2. STAR+PLUS The number of members enrolled in STAR+PLUS plans decreased by 0.2 percent from 518,152 in SFQ1 to 517,135 in SFQ2. Overall market share by MCO remained steady from the prior quarter, shown in the graph below. Market Share by STAR+PLUS MCO (2014 SFQ SFQ2) STAR+PLUS 2014 Q Q Q Q % 28.77% 26.59% 26.44% Cigna-HealthSpring 6.10% 6.09% 8.89% 8.89% Molina 22.02% 22.09% 17.79% 17.68% 27.07% 26.87% 27.49% 27.56% United 15.98% 16.17% 19.25% 19.43% The two graphs on the following pages show enrollment by program, SDA, and MCO in the last four quarters. 6 Quarterly Report for the Section 1115 Waiver, February 2015

8 STAR Program Enrollment by MCO and Service Area (2014 SFQ SFQ2) BEXAR DALLAS EL PASO HARRIS HIDALGO JEFFERSON LUBBOCK MRSA CENTRAL MRSA NORTHEAST MRSA WEST NUECES TARRANT TRAVIS 700K 650K 600K 550K 500K 450K CHC 400K 350K Molina 300K 250K 200K 150K 100K 50K 0K Feb Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 201 Enr Driscoll Texas Children's Aetna Molina Aetna Community 1st Molina Parkland Molina El Paso 1st United United CHC Texas Children's United FirstCare Scott & White FirstCare Christus Driscoll Cook Children's BCBS Sendero Seton 7 Quarterly Report for the Section 1115 Waiver, February 2015

9 STAR+PLUS Non-MRSA Program Enrollment by MCO and Service Area (2014 SFQ SFQ2) Service Area / Month of Date BEXAR DALLAS EL PASO HARRIS HIDALGO JEFFERSON LUBBOCK NUECES TARRANT TRAVIS 100K 80K Cigna-HealthSpring 60K Molina En 40K Molina Molina Molina 20K 0K Molina United Molina United United Feb Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 2014 Feb 2014 Nov 2015 Aug 2014 May 201 Cigna-HealthSpring United 8 Quarterly Report for the Section 1115 Waiver, February 2015

10 STAR+PLUS MRSA Program Enrollment by MCO and Service Area (SFY2015 through Q2) 40K Service Area / Month of Date MRSA CENTRAL MRSA NORTHEAST MRSA WEST 35K Cigna-HealthSpring 30K 25K 20K Enr 15K 10K United 5K 0K Feb 2015 Nov 2014 Feb 2015 Nov 2014 Feb 2015 Nov 201 United 3. Dental Program Total enrollment in the Dental Program decreased by 1.09 percent to 2,883,030 members in SFQ2. Market share in the Dental Program remained steady: DentaQuest has approximately 55 percent while MCNA has 45 percent. B. ENROLLMENT COUNTS FOR THE QUARTER BY POPULATION This subsection includes quarterly enrollment counts, as required by STC 67. Due to the time required for the data collection process, unique member counts per quarter are reported on a two quarter lag. The following table includes enrollment counts for the 2014 DY3 Quarter 4. Enrollment counts are based on persons, and not member months. 9 Quarterly Report for the Section 1115 Waiver, February 2015

11 Enrollment Counts (DY3 Q4, July-September 2014) Demonstration Populations Total Number Adults 340,292 Children 2,765,350 Aged and Medicare Related (AMR) 382,883 Disabled 439,625 As a result of the carve-in of nursing facility services into managed care, approximately 47,000 individuals statewide transitioned from fee-for-service to STAR+PLUS. Approximately 50 percent of those transitioning to managed care selected to enroll with a particular MCO; the rest were auto-assigned by the state. This rate was consistent with the choice enrollment rates for recent expansions, such as members transitioning to STAR+PLUS in the MRSAs. C. DISENROLLMENT This subsection of the report addresses STC 39(b). In 2015 SFQ1 and SFQ2, the enrollment broker, MAXIMUS, reported 2,495 plan changes processed, an increase of approximately 30 percent. Regarding disenrollment requests from Medicaid managed care to the fee-for-service delivery model, the state received the following in SFQ1 and SFQ2: 47 disenrollment requests for STAR, 75 for STAR+PLUS, and none for the Dental Program. Members or their representatives initiated all disenrollment requests in SFQ1 and SFQ2. HHSC ensured that MCOs resolved member grievances related to their disenrollment requests, and because of these efforts no members were disenrolled from managed care in SFQ1 or SFQ2. Managed Care Disenrollment Requests (SFY2014 Q3 to SFY2015 Q2) 10 Quarterly Report for the Section 1115 Waiver, February 2015

12 D. ENROLLMENT OF MEMBERS WITH SPECIAL HEALTH CARE NEEDS This subsection of the report addresses STC 39(b) regarding the enrollment into managed care for people with special healthcare needs. The state s Medicaid application asks potential enrollees to identify any family members that have special health care needs (MSHCN). MSHCN means a member including a child, or children with special health care needs (CSHCN) who (1) has a serious ongoing illness, a chronic or complex condition, or a disability that has lasted or is anticipated to last for a significant period of time, and (2) requires regular, ongoing therapeutic intervention and evaluation by appropriately trained health care personnel. The state s enrollment broker conveys this and other information concerning potential members with special healthcare needs (MSHCN) to health and dental plans, who then verify whether the members meet the plans assessment criteria for MSHCN. All STAR+PLUS members and Former Foster Care Children (FFCC) enrolled in STAR are deemed to be MSHCN. Health and dental plans must also develop their own processes for identifying MSHCN, including CSHCN and others with disabilities or chronic or complex medical and behavioral health conditions. HHSC has developed additional contract requirements related to MSHCN effective March The new language requires MCOs to include additional populations to the groups that must be identified as MSHCN including pregnant women identified as high risk and Early Childhood Intervention program participants. In addition, the new language defines contractual requirements regarding service management and developing appropriate service plans for MSHCN. 1. Reporting In the past, HHSC has provided the enrollment broker's MSHCN data in the annual reports. This data showed the number of self-identified MSHCN for the quarter, and did not reflect the total number of verified MSHCN. HHSC requested MCOs to submit the total number of MSHCN that they have verified. The data presented in Attachment Q of this report shows a snapshot of the total number of MSHCN for the month of February HHSC is developing a template for the MCOs to submit MSHCN data on a regular basis. 2. Analysis All STAR+PLUS plans reported 100% MSHCN, as required in the contract. STAR+PLUS plans are required to provide service coordination to all members. In February 2015, there were a total of 46,790 children and adults that were identified as members with special health care needs in all STAR MCOs, which is less than two percent (1.63%) of all STAR members. See Attachment Q for detail by service area and MCO. 11 Quarterly Report for the Section 1115 Waiver, February 2015

13 Half of all STAR members with special health care needs are concentrated in the Harris, Tarrant, and Hidalgo SDAs. Four STAR plans reported more than two percent of members were classified as MSHCN: Cook (5.72%), CHC (5.10%), (3.51%), and Sendero (2.57%). The remaining plans reported less than one percent of MSHCN. Total STAR Members Identified as MSHCN and Total STAR Enrollment by MCO and SDA (February 2015) MS 12K 10K 8K 6K 4K 2K 0K 700K CHC CHC SDA Cook Plan Aetna BCBS CHC CHRISTUS Community First Cook Driscoll El Paso First FirstCare Molina Parkland Scott & White Sendero Seton Texas Children's United 600K 500K CHC 400K All 300K Driscoll Molina Aetna 200K 100K Parkland FirstCare 0K United FirstCare Bexar Dallas El Paso Harris Hidalgo Jefferson Lubbock MRSA Central United MRSA N ortheast MRSA West Driscoll Cook Nueces Tarrant Travis STAR MCOs rely on various mechanisms to identify and verify MSHCN in addition to member self- identification. HHSC does not provide MCOs an all-inclusive list of conditions that should be included in MSHCN criteria. Most STAR MCOs employ a combination of methods including provider referrals, risk assessments, and utilization reviews. For example, Cook relies on a combination of member screening and predictive modeling to identify members. Sendero identifies members as MSHCN if they meet specific diagnosis criteria. Only a couple of STAR MCOs use predictive modeling and specific diagnosis criteria. The number of MSHCN has increased over time for some plans that have changed identification processes. For example CHC, reported 322 in August 2014 and 11,717 in February CHC 12 Quarterly Report for the Section 1115 Waiver, February 2015

14 attributes this increase to several factors: the inclusion of additional groups as MSHCN, increased efforts to reach members, and incorporating data analytics to identify members based on claims data. is also using the enrollment broker data file to identify MSHCN resulting in higher numbers. E. MEDICAID ELIGIBILITY CHANGES No eligibility changes were made to the 1115 waiver populations in F. ANTICIPATED CHANGES IN POPULATIONS OR BENEFITS Effective March 1, 2015, the STAR+PLUS MCOs became responsible for the delivery and payment of nursing facility services for STAR+PLUS members. Also effective March 1, 2015, under the Dual Demonstration, HHSC began testing an innovative delivery model that combines health services for people with both Medicaid and Medicare coverage into one plan. The Texas plan involves a three-party agreement between a Medicare- Medicaid health plan, the state, and the federal Centers for Medicare and Medicaid Services (CMS), to provide individuals with the full array of Medicaid and Medicare services. The demonstration includes full-dual eligible adults (age 21 and above) who reside in a STAR+PLUS service area that currently receive their Medicaid benefits through the STAR+PLUS managed care program. The goal of the project is to better coordinate the care those individuals receive. The demonstration has been implemented for all dual-eligible members, except individuals in nursing facilities, in the following six counties: Bexar, Dallas, El Paso, Harris, Hidalgo and Tarrant. Beginning June 1, 2015, STAR+PLUS MCOs will be required to make Community First Choice (CFC) a benefit for certain individuals who meet an institutional level of care for a hospital, an intermediate care facility for individuals with intellectual disabilities or a related condition (ICF- IID), nursing facility or institution for mental disease (IMD) and upon assessment are determined to require attendant, habilitation, emergency response services (ERS) or support management. HHSC anticipates the following caseload changes in managed care enrollment as shown in the chart below. Medicaid Average Monthly Caseload Forecasts (FFY2014-FFY2017) Current World FY 2014 FY 2015 FY 2016 FY 2017 Total FFS 735, , , ,000 Total Managed Care 3,012,000 3,346,000 3,449,000 3,537,000 Total Medicaid 3,747,000 4,079,000 4,200,000 4,308,000 % Managed Care 80% 82% 82% 82% 13 Quarterly Report for the Section 1115 Waiver, February 2015

15 After Expansions FY 2014 FY 2015 FY 2016 FY 2017 Total FFS 735, , , ,000 Total Managed Care 3,012,000 3,527,000 3,704,000 3,957,000 Total Medicaid 3,747,000 4,079,000 4,200,000 4,308,000 % Managed Care 80% 86% 88% 92% * HHSC System Forecasting, December 2014 DELIVERY NETWORKS AND ACCESS This subsection addresses the quarterly reporting requirements found in 39(a) and 67. Supporting data is located in Attachments C through K. HHSC routinely reviews various measures related to network adequacy, including those reported in the following section of this report: provider network counts, geoaccess, and out-of-network utilization. HHSC monitors these measures in combination with member complaints in order to assess the adequacy of MCO provider networks. A. PROVIDER NETWORKS This subsection includes quarterly healthcare and pharmacy provider counts for STAR and STAR+PLUS, and dental provider counts for the Dental Program. The provider network methodology is contained in Attachment C1, provider network counts are reported in Attachment C2, and provider termination counts are reported in Attachment C3. 1. Primary Care Providers (PCPs) MCOs are required to assign 100 percent of non-dual members to a PCP within 5 business days of MCO enrollment. HHSC confirmed that all MCOs assign members to a PCP, and all adult members have access to at least one PCP and children to at least two age-appropriate PCPs within established mileage standards, as outlined in the following section of this report. Across the STAR program statewide, the MCOs reported a total of 16,372 unique PCP providers, an increase of 235 from the prior quarter. The MCOs reported 12,842 unique PCP providers in the STAR+PLUS program statewide, an increase of 245 from the prior quarter. 2. Specialists (non-pharmacy) Across the STAR program statewide, the MCOs reported a total of 52,964 unique specialty providers, an increase of 1,726 from the prior quarter. The MCOs reported 42,687 unique specialty providers in the STAR+PLUS program statewide, a decrease of 692 providers. Aetna STAR in Bexar SDA reported a 45 percent increase in provider network specialist counts in SFQ2. HHSC is working with the plan to determine the cause of this increase, which may just 14 Quarterly Report for the Section 1115 Waiver, February 2015

16 be a reporting error on the network file. If Aetna submitted an inaccurate network report, then HHSC will determine an appropriate remedy. 3. Provider Terminations Attachment C3 details data reported by the MCOs regarding the number of PCPs and specialists terminated in 2015 SFQ2. The MCOs reported a variety of reasons for provider termination, including: termination requested by provider, MCO terminated for cause, provider left group practice, and provider closed. Driscoll STAR, Molina STAR and STAR+PLUS, and Sendero STAR reported an increase in the number of terminated providers in SFQ2 due to review of network files to remove inactive or duplicated providers. 4. Pharmacy Providers Across the STAR program statewide, the MCOs reported a total of 4,852 unique pharmacies, an increase of 60 pharmacies from the prior quarter. The MCOs reported 4,793 unique pharmacies in the STAR+PLUS program statewide, an increase of 96 pharmacies from the prior quarter. A few MCOs reported statewide pharmacy counts rather than counts limited to the SDA in SFQ2. All MCOs contract with the pharmacies outside the SDA to ensure members have access to a pharmacy if traveling outside the SDA. 5. Dental Program Provider Counts In 2015 SFQ2, DentaQuest reported a total of 4,930 unique dental providers, an increase of 3 dental providers from the prior quarter. MCNA reported 4,290 unique dental providers, an increase of 234 dental providers from the prior quarter. B. GEOACCESS This subsection includes quarterly geoaccess information based on geomapping data provided by HHSC Strategic Decision Support (SDS) and self-reported by MCOs, in accordance with STC 39(a). Attachments E, G and H show HHSC geomapping results by plan and SDA for the following provider types and populations: All STAR and STAR+PLUS members: open panel PCP; pharmacy Children in STAR and STAR+PLUS: otolaryngologist (ENT) Dental members: main dentists; endodontic; oral surgery; orthodontic; periodontist; prosthodontist 15 Quarterly Report for the Section 1115 Waiver, February 2015

17 Attachments I, J, and K provide a summary of the plans self-reported geomapping data by plan and SDA for several provider types. The requirements for provider types vary by program and population as described below. All STAR and STAR+PLUS members: open panel PCPs; obstetrician/gynecologist for female members; outpatient behavioral health services; acute care hospitals; pharmacy Adults and children in STAR and children in STAR+PLUS: allergist/immunologist; orthopedic surgery Children in STAR and STAR+PLUS: ENT Adults in STAR+PLUS: cardiology; gastroenterology; nephrology; pulmonology Dental members: main dentists; endodontic; oral surgery; orthodontic; periodontist; prosthodontist For all STAR and STAR+PLUS service areas, the following benchmarks were applied for access to PCPs and specialists: 90 percent access to at least one open panel PCP for adults and two open panel PCPs for children 90 percent access to at least one of all other provider types for adults and children If the MCO does not meet the mileage or out-of-network standards, it may submit a time-limited special exception request. The request must include supporting documentation explaining why the exception should be granted. HHSC staff review the special exception request and supporting documentation. HHSC staff may consider additional factors such as known marketplace issues. HHSC may grant an exception for up to three state fiscal quarters and plans will not be subject to remedy. 1. Access to PCPs and ENTs Geoaccess to PCPs and ENTs is reported on Attachments E and I. In SFQ2 across the state, the STAR and STAR+PLUS programs exceeded the State s 90 percent benchmarks for access to PCPs and ENTs. The following MCOs failed to meet the access standard for children access to an ENT in 2015 SFQ2: STAR in MRSA West SDA FirstCare STAR in MRSA West SDA United STAR in Hidalgo and Jefferson SDAs STAR+PLUS in MRSA West United STAR+PLUS in Jefferson, MRSA Central, and MRSA Northeast SDAs 16 Quarterly Report for the Section 1115 Waiver, February 2015

18 STAR and STAR+PLUS and FirstCare STAR failed to meet the access standard for ENT in MRSA West due to a shortage of ENT physicians enrolled with Texas Medicaid. submitted a special exception request which is pending approval from HHSC, so the plan may not be subject to remedy. HHSC approved a special exception request from FirstCare for SFQ2 and SFQ3 in 2015; the plan will not be subject to remedy. To minimize access to care issues, the plan assisted members with scheduling appointments and provided medical transportation when necessary. United failed to meet geoaccess standards due to inaccurate network files submitted to HHSC; HHSC is in the process of developing the appropriate remedy. 2. Access to Specialty Care Attachment I shows the geoaccess measures by MCO for specialty care. The following MCOs failed to meet the standards for children and/or adults accessing allergists/immunologist: STAR in MRSA West SDA FirstCare STAR in MRSA West SDA STAR in MRSA West SDA STAR+PLUS in MRSA West SDA Cigna-HealthSpring STAR+PLUS in MRSA Northeast SDA STAR+PLUS in MRSA West SDA United STAR+PLUS in MRSA Northeast SDA submitted a special exception request which is pending approval from HHSC, so the plan may not be subject to remedy. received approval from HHSC for a special exception request for SFQ2 through SFQ4 of 2015, and is attempting to recruit additional allergists and immunologists. FirstCare and Cigna-HealthSpring received approval for a special exception from HHSC for SFQ2 through SFQ3.Cigna-HealthSpring is attempting to recruit new providers, and Firstcare is always accepting new provider-credentialing applications. United failed to meet geoaccess standards due to inaccurate network files submitted to HHSC; HHSC is in the process of developing the appropriate remedy. STAR+PLUS in MRSA West failed to meet additional access standards for specialty care, bulleted below. submitted a special exception request which is pending approval from HHSC, so the plan may not be subject to remedy. Access for children to an orthopedic surgeon Access for children to an outpatient behavioral health provider Access for adults to an gastroenterologist Access for adults to a pulmonologist 17 Quarterly Report for the Section 1115 Waiver, February 2015

19 Molina STAR in Jefferson SDA failed to meet the access standards for access to an acute care hospital in SFQ2 by two percent. The plan is attempting to recruit providers to increase the network. STAR+PLUS in MRSA West failed to meet the geoaccess standard for adult access to gastroenterologist and pulmonologist. received approval from HHSC for a special exception request for SFQ2 through SFQ4 of Access to Pharmacy Attachment G provides summaries of HHSC geomapping data by plan and SDA for pharmacies. For all STAR and STAR+PLUS service areas, the following benchmarks applied: 80 percent access to a network pharmacy in urban counties within 2 miles (75 percent in STAR MRSAs) 75 percent access to a network pharmacy in suburban counties within 5 miles (55 percent in STAR MRSAs) 90 percent access to network pharmacy in rural counties within 15 miles 90 percent access to a 24-hour pharmacy in all counties within 75 miles (only available on MCO self-reported data) Certain areas continued to have deficiencies in meeting access standards in SFQ2. The greatest shortfalls are pharmacies in the MRSAs. It is important to note that 100 percent of members have access to mail order pharmacies. This is a particularly important accessibility benefit for members who require maintenance medications to manage chronic health conditions. It is also important for members who lack access to transportation. In addition, according to the Pharmacy Benefits Managers (PBMs) for all MCOs, Medicaid members may access any network pharmacy enrolled with the Texas Medicaid Vendor Drug Program, within or outside of the distance criteria. 4. Dental GeoMapping Dental geomapping results are divided into eleven Texas regions. Within each region, HHSC generates a report on the percentage of members in urban and rural areas with access to main dentists, endodontists, oral surgeons, orthodontists, periodontists, and prosthodontists. Attachment H provides summaries of HHSC geomapping information for both dental plans and Attachment K provides geomapping from both dental plans. The dental contracts require plans to provide access to at least two providers within the following benchmarks and travel distances: 18 Quarterly Report for the Section 1115 Waiver, February 2015

20 100 percent open practice main dentist in urban areas within 30 miles 100 percent open practice main dentist in rural areas within 75 miles 95 percent specialists in urban and rural areas within 75 miles In SFQ2, both DentaQuest and MCNA maintained mostly sufficient provider networks for main dentists in rural and urban counties as well as pediatric dentists statewide. Access to dental specialty providers is limited in some parts of Texas, as depicted in Attachment H. This is, in part, due to overall provider shortages in these areas. Both dental managed care organizations, known as DMOs, report continuing activities to monitor the State Licensing Board website and HHSC claims administrator website, and utilize other internet resources in an effort to identify potential recruitment opportunities. HHSC received and approved a special exceptions from DentaQuest for 2015 SFQ1 and SFQ2 and from MCNA for SFQ2. C. OUT-OF NETWORK UTILIZATION As required by Texas law, 1 the State monitors health and dental plans use of out-of-network (OON) facilities and providers. 2 In each service area, OON utilization should not exceed the following thresholds: 15 percent of inpatient hospital admissions 20 percent of emergency room (ER) visits 20 percent of total dollars billed for other outpatient services Attachment D details the OON utilization rates by program, MCO and SDA. The following plans exceeded OON utilization standards in SFQ2 of 2015: Aetna STAR in Bexar SDA STAR in Dallas and Harris SDAs Community First STAR in Bexar SDA Molina STAR in Dallas, El Paso, and Harris SDAs Scott & White STAR in MRSA Central Texas Children s STAR in Harris SDA STAR+PLUS in Harris, Jefferson, MRSA West, and Tarrant SDAs Cigna-HealthSpring STAR+PLUS in Hidalgo and Tarrant SDAs Molina STAR+PLUS in Dallas, El Paso, and Harris SDAs STAR+PLUS in Dallas SDA 1 Texas Government Code (a)(11). 2 1 Texas Administrative Code 353.4(e)(2). 19 Quarterly Report for the Section 1115 Waiver, February 2015

21 United STAR+PLUS in Harris and MRSA Central SDAs Within the STAR and STAR+PLUS programs in 2015 SFQ2, OON utilization was generally higher in Dallas and Harris SDAs. This trend is due to strained contract negotiations between hospitals and MCOs. HHSC approved special consideration requests from MCOs listed above and none will be subject to remedy. The State will continue to monitor these plans, and will require corrective action or other remedies if appropriate. A description of the special consideration request process is detailed below. Under certain circumstances, plans may request time-limited exemptions from the OON standards if the plans provide evidence warranting special consideration. In order to be granted an exemption the plan must demonstrate both that admissions or visits to a single OON facility account for 25 percent or more of the plan's admissions or visits in a reporting period; and the plan can demonstrate that it made good faith reasonable efforts to contract with an OON facility to no avail. If the state grants the special consideration, it removes the non-contracted provider from the plan s compliance calculations and recalculates the utilization rate. HHSC evaluates the recalculated OON rates to determine whether OON standards are met. MCOs with approved special considerations are not subject to remedies or assessed liquidated damages (LDs). Attachment D provides utilization data, including recalculated rates, by program, MCO, and SDA. Dental plans continued to report OON utilization well below the 20 percent threshold at less than 0.5 percent, as shown in the figure below. In the Dental Program, the 20 percent standard for other services applies to out-of-network dental services. III. OUTREACH/INNOVATIVE ACTIVITIES TO ASSURE ACCESS This section addresses the quarterly requirements for STC 67 regarding outreach and other initiatives to ensure access to care. The Dental Stakeholder Update addresses STC 40(c), the Medicaid Managed Care Advisory Committee meeting update also addresses STC 65. A. ENROLLMENT BROKER AND MCO ACTIVITIES The state s Enrollment Broker, MAXIMUS, performs various outreach efforts to educate potential clients about their medical and dental enrollment options. During the 2015 D2 Demonstration period (January-March 2015), MAXIMUS sent 326,937 enrollment mailings to potential STAR and STAR+PLUS clients, and 218,080 mailings to potential Dental Program clients. MAXIMUS field staff completed 24,866 home visit attempts for these programs, and 89,695 phone call attempts. Additionally, MAXIMUS completed 2,134 field events, which included enrollment events, community contacts, presentations, and health fairs. The full report is available in Attachment L. 20 Quarterly Report for the Section 1115 Waiver, February 2015

22 The state s managed care contracts also require health and dental plans to conduct provider outreach efforts and educate providers about managed care requirements. Plans must conduct training within 30 days of placing a newly contracted provider on active status. Training topics that promote access to care include: Covered services and the provider s responsibility for care coordination The plan s policies regarding network and OON referrals Texas Health Steps benefits The state s Medical Transportation Program To promote access to care, health and dental plans must update their provider directories on a quarterly basis, and online provider directories at least twice a month. Plans also must mail member handbooks to new members no later than five days after receiving the state s enrollment file, and to all members at least annually and upon request. The handbooks must describe how to access primary and specialty care. Through the member handbooks and other educational initiatives, plans must instruct members on topics such as: How managed care operates The role of the primary care physician or main dentist How to obtain covered services The value of screening and preventative care How to obtain transportation through the State s Medical Transportation Program B. DENTAL STAKEHOLDER MEETING In the absence of a dental director, HHSC is evaluating options for ongoing communication with dental stakeholders. HHSC staff continues to answer questions submitted to the State's dental stakeholder box. HHSC also participated in a meeting with the Texas Dental Association and the DMOs on January 10, 2015 to discuss provider concerns and issues. The topics discussed included: main dental home assignments, dental quality initiatives, and policy issues and updates. C. MEDICAID MANAGED CARE ADVISORY COMMITTEE The State Medicaid Managed Care Advisory Committee (SMMC) serves as the central source for stakeholder input on the implementation and operation of Medicaid managed care. The link to the SMMC web page, which lists the members and affiliations, is located here: The SMMC did not meet during SFQ The next meeting took place on April 29, Quarterly Report for the Section 1115 Waiver, February 2015

23 D. INDEPENDENT CONSUMER SUPPORTS SYSTEM HHSC submitted a plan to CMS on May 1, 2014, describing the structure and operation of the Independent Consumer Supports System (ICSS) that aligns with the core elements provided in STC 20. The Texas ICSS consists of the HHSC Medicaid/CHIP Division, the Office of the Ombudsman, the State managed Enrollment Broker (EB, MAXIMUS), and community support from the Aging and Disability Resource Centers (ADRCs). HHSC and CMS held a phone call on January 6, 2015, to discuss the ICSS plan and in response to that discussion HHSC resubmitted the report to CMS with additional information on February 9, HHSC will provide relevant updates regarding ICSS in this section of the report each quarter. 1. Office of the Ombudsman Within the Office of the Ombudsman, the Medicaid Managed Care Helpline (MMCH) team is undergoing an expansion to 17 positions to ensure consumers are receiving the support they need. In addition to the existing Manager and Team Lead, the number of Advocates answering the toll-free line has been increased from eight to ten. Two additional positions have been authorized to act as in-house escalation positions to work on cases needing additional follow-up. An additional position has been authorized to serve as a planning and training coordinator and another two positions are planned to focus on coordination with ICSS components within the HHS agencies, as well as with community partners. 2. Aging and Disability Resource Center The statewide expansion of the Aging and Disability Resource Center (ADRC) Program was completed in SFQ2. Statewide ADRC training webinars have been implemented each month with a focus on standardized information and referral processes regarding a variety of target populations. To date, trainings have included information on access to long term services and supports with a targeted focus on veterans, children with special needs and family caregivers. A number of ADRC providers and local partner networks have also engaged in cross-training activities related to local support resources, managed care organizations, and enrollment broker roles. These ADRCs have knowledge of the appropriate referral for consumer supports, including the enrollment broker and Office of the Ombudsman and most have direct relationships with specific service coordinators from managed care organizations in their region. Some have managed care representatives present at monthly ADRC steering committee meetings. Most ADRCs report they have been trained about the roles and responsibilities of the enrollment broker, but have not had formal training about the roles and responsibilities of the Office of the Ombudsman and referral processes for such. In the upcoming quarter, state level ADRC program staff will work to schedule a statewide Office of the Ombudsman webinar for ADRCs to ensure 22 Quarterly Report for the Section 1115 Waiver, February 2015

24 local ADRCs understand the appropriate resources and referral processes within the independent consumer support system. The ADRC toll-free number was successfully launched in January Some ADRCs report calls regarding access to Medicaid services, access to a service coordinator, or concerns about service delivery. State level ADRC staff, in coordination with the Department of Aging and Disability, Access and Intake staff, is developing a matrix of toll-free numbers for consumers based on their individual needs. A workgroup will develop uniform language to be shared across access points. Enrollment Broker and Office of Ombudsman staff are providing input to these revisions and referral processes to ensure statewide consumer experience across appropriate access points. E. HHSC MANAGED CARE INITIATIVES HHSC representatives traveled extensively across the state to meet with providers and provider associations, as well as clients and family members, advocacy organizations, and community groups to present on managed care and the upcoming initiatives. HHSC hosted provider trainings across the state December through February 2015 for providers affected by the nursing facility transition to managed care, roll out of Dual Demonstration, and implementation of CFC. MCO representatives were on hand at all of these meetings to present and answer questions. The Enrollment Broker held enrollment events in nursing facilities across the state November 2014 February 2015 for residents newly eligible for STAR+PLUS starting March 1, HHSC held various trainings, meetings, educational and outreach events related to the roll out of Dual Demonstration this quarter. In the months of December 2014 through February 2015, HHSC held eight provider trainings and seven stakeholder meetings across the state. In addition, the enrollment broker (MAXIMUS) has been conducting outreach and educational events to educate clients and family members on enrollment. The State Health Insurance Assistance Programs (SHIP)s and the Area Agency on Aging (AAA) have been working with HHSC, and the SHIPs are listed on some of the letters MAXIMUS sends out as a resource. The AAAs are hosting consumer events with MAXIMUS, and outreach staff have coordinated events with community organizations. More information can be found at the Texas Medicaid Events Website: In preparation for the implementation of CFC, HHSC held 12 provider trainings across the state between January and February 2015 to educate providers about managed care. In addition, HHSC held 13 stakeholder meetings between December 2014 and February More information can be found at the Community First Choice website: 23 Quarterly Report for the Section 1115 Waiver, February 2015

25 For more information on all upcoming managed care initiatives, please visit the Expansion of Medicaid Managed Care webpage on the HHSC website: IV. COLLECTION AND VERIFICATION OF ENCOUNTER DATA AND ENROLLMENT DATA The state manages enrollment in a 24-month window that includes one prospective month and 23 prior period adjustment months. During successive processing cycles, this allows the state to verify prior enrollments and implement adjustments to enrollments as necessary. The types of adjustments include revisions for newborns, deaths, change of service areas, and the addition of Medicare eligibility or eligibility attributes. The state continues to conduct the quarterly MCO encounter financial reconciliation process for 2015 SFQ2. The state will contact each plan that did not achieve the financial reconciliation threshold, and advise them of the necessary steps to achieve contract compliance and, ultimately, certification. V. OPERATIONAL/POLICY/SYSTEMS/FISCAL DEVELOPMENTS/ISSUES This section addresses STC 67, regarding operational issues identified during the quarter. It also addresses pending lawsuits that may potentially impact the Demonstration, and new issues identified during the reported quarter. A. UPDATE FROM PRIOR QUARTER HHSC has not identified any ongoing issues in the relevant subject matter sections of this report. B. LITIGATION UPDATE Below is a summary of pending litigation and the status. HHSC Legal is unaware of any threatened litigation affecting healthcare delivery. Legacy Community Health Services, Inc., v. Janek (official capacity) and Texas Children s Health Plan. Filed on January 7, 2015, in the U.S. District Court for the Southern District of Texas. Plaintiff Legacy is a Federally Qualified Health Center (FQHC) and a Medicaid provider that was in Texas Children s Health Plan s (TCHP s) provider network. TCHP notified Legacy in December that Legacy was to be terminated as a provider in TCHP s plan. Legacy brought suit against both TCHP and HHSC s Executive Commissioner, alleging that HHSC s method of paying FQHC s is contrary to federal law. FQHCs are guaranteed an encounter rate calculated under a methodology prescribed under 42 U.S.C. 24 Quarterly Report for the Section 1115 Waiver, February 2015

26 1396a(bb). HHSC ensures compliance with this provision by requiring MCOs to pay FQHCs the full encounter rate, and includes funds for such payments in the capitated rate paid to MCOs. Legacy asserts that HHSC must make supplemental ( wrap ) payments directly to FQHCs. District Judge Keith Ellison conducted a hearing on January 28, 2015, and denied Legacy s request for a preliminary injunction. Legacy then non-suited TCHP, but continues to maintain its claims against HHSC. The case remains pending. Texas Children s and Seattle Children s Hospital v. Burwell (official capacity), Tavenner (official capacity), and CMS. Filed on December 5, 2014, in the U.S. District Court for the District of Columbia. District Judge Emmet Sullivan granted a preliminary injunction request by Plaintiffs, and required CMS to discontinue enforcing its policy published as FAQ Number 33 and involving the inclusion of revenues associated with patients having coverage under both Medicaid and private insurance. The court also expressly prohibited CMS from taking action to recoup past Disproportionate Share Hospital (DSH) program overpayments based on a state's compliance with FAQ No. 33. HHSC notes that the same issue was litigated in state court. In 2013, Texas Children s Hospital (TCH) sued HHSC in state court alleging that by following CMS s FAQ 33, HHSC had improperly altered its method of calculating uncompensated care, adversely affecting TCH s disproportionate share and uncompensated care payments. That lawsuit was dismissed on March 29, However, TCH and co-plaintiff Seattle Children s now assert substantially the same theory against CMS in federal court litigation. Although HHSC is not a direct party to this federal litigation, HHSC recognizes that the outcome of this case could have a significant bearing on the hospital disproportionate share and uncompensated care payment programs. Until the issue is resolved with clarity, the litigation may result in delays and uncertainty concerning the appropriate method of making the uncompensated care calculations for future payments and for recouping past DSH and uncompensated-care overpayments. Dr. Essa Kawaja, DDS; Summit Dental Center, Dental Smiles; Dr. Anila Shah, DDS, PA. v. HHSC, Suehs, Delta Dental, Dentaquest USA, and Managed Care of North America. Filed on February 28, 2012, in state district court in Travis County. Dental providers complained of the default enrollment procedures for Medicaid managed care clients that do not choose a provider. They asked the court to restrain HHSC and the Medicaid DMOs from implementing the default enrollment procedures and to declare those procedures illegal. HHSC voluntarily delayed the dental home requirement until May 31, 2012, to allow clients more time to notify their dental plan of their preferred dentist without any disruption in service. Plaintiffs withdrew their request for a temporary restraining order following HHSC's action. The Office of the Attorney General has filed a general denial and a plea to the jurisdiction. The case has been dormant since June 2012, and was placed on the DWOP (dismissal for want of prosecution) 25 Quarterly Report for the Section 1115 Waiver, February 2015

27 docket, but remains pending at this time. Of all the lawsuits filed in challenging HHSC's expansion of the Medicaid managed care delivery model, Kawaja is the sole case still pending. All others have been dismissed or resolved. Filed in 1993, Frew, et al. v. Janek, et al. (commonly referred to as Frew), was brought on behalf of children birth through age 20 enrolled in Medicaid and eligible for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefits. The class action lawsuit alleged that the Texas EPSDT program did not meet the requirements of the federal Medicaid Act. The Texas EPSDT program, known as Texas Health Steps (THSteps), provides comprehensive and preventive medical and dental services for children through age 20 enrolled in Medicaid. The parties resolved the Frew litigation by entering into an agreed consent decree, which the court approved in The decree sets out numerous state obligations relating to THSteps. It also provides that the federal district court will monitor compliance with the orders by the Health and Human Services Commission (HHSC) and the Department of State Health Services (DSHS) and that the federal district court will enforce the orders if necessary. In 2000, the court found the state defendants in violation of several of the decree s paragraphs. In 2007, the parties agreed to 11 corrective action orders to bring the state into compliance with the consent decree and to increase access to THSteps services. The corrective action orders touch upon many program areas, and generally require the state to take actions intended to ensure access to or measure access to Medicaid services for children. The Texas Medicaid program must consider these obligations in many policy and program decisions for Medicaid services available for persons from birth through 20 years of age. In 2013, the court vacated two of the eleven corrective action orders: (1) Checkup Reports and Plans for Lagging Counties and (2) Prescription and Non- Prescription Medications, Medical Equipment, and Supplies, and related paragraphs of the consent decree, after finding that the state defendants had complied with the required actions. Most recently, on January 20, 2015, the U.S. district court vacated the correction action order related to an Adequate Supply of Health Care Providers and several paragraphs of the consent decree relating to an adequate supply of healthcare providers. The court found that the state had satisfied the terms of those orders by taking realistic and viable measures to enhance recipients access to care through ensuring an adequate supply of healthcare providers (both primary care and specialists) by using targeted recruitment efforts, increasing reimbursement rates, and using best efforts to maintain updated lists of providers for both recipients and other providers. C. NEW ISSUES HHSC has not identified any new issues in the relevant subject matter sections of this report, other than those already reported in previous sections. There were no issues outside of the 26 Quarterly Report for the Section 1115 Waiver, February 2015