Medicaid Managed Care Initiatives Information Session. June 3, 2014

Transcription

1 Medicaid Managed Care Initiatives Information Session June 3, 2014

2 Topics What is managed care? Overview of STAR and STAR+PLUS New managed care initiatives Next steps Questions Presentation available at Page 2

3 What is Managed Care? Healthcare provided through a network of doctors, hospitals and other healthcare providers responsible for managing and delivering quality, cost-effective care The State pays a managed care organization (MCO) a capitated rate for each member enrolled, rather than paying for each unit of service provided Page 3

4 Emphasize preventive care Improve access to care Goals of Managed Care Ensure appropriate utilization of services Improve client and provider satisfaction Establish a medical home for Medicaid clients through a primary care provider (PCP) Improve health outcomes, quality of care, and cost-effectiveness Page 4

5 Managed Care Programs in Texas STAR (State of Texas Access Reform) STAR+PLUS STAR Health CHIP (Children s Health Insurance Program) CHIP and Children s Medicaid Dental Page 5

6 Medicaid Managed Care Enrollment As of November 2013: About 3.6 million clients enrolled in Texas Medicaid About 2.9 million members are enrolled managed care STAR 2.5 million STAR+PLUS 412,000 STAR Health 31,000 Page 6

7 Managed Care Organizations MCOs provide a medical home through a PCP and referrals for specialty providers, when needed Exception: Clients who receive both Medicare and Medicaid (dual eligibles) get acute care services and a PCP through Medicare MCOs may offer value-added services (e.g. extra dental services, extra vision services, health and wellness services) Page 7

8 MCO Plan Identification Cards All members receive an MCO plan ID card, in addition to a Your Texas Benefits Medicaid card from the State The plan ID card contains the following information: Member s name and Medicaid ID number Healthcare program (e.g. STAR, STAR+PLUS) MCO name PCP name and phone number Toll-free phone numbers for member services and behavioral health services hotline Additional information may be provided (e.g. date of birth, service area, PCP address) Page 8

9 Managed Care Organizations Providers must contract and be credentialed with an MCO to provide STAR or STAR+PLUS services Rates are negotiated between the provider and the MCO Processes such as authorization requirements and claims processing may be different between MCOs Page 9

10 Provider Claims Providers must file claims within 95 days of the date of service (DOS) MCOs are required to adjudicate most claims within 30 days 18 days for electronic pharmacy claims Page 10

11 STAR Provides acute care services (like doctor visits, hospital visits, and prescriptions) mostly for children and pregnant women About 2.5 million members currently served Each member is enrolled in an MCO Primary care provider (PCP) serves as the medical home and coordinates care Statewide service areas: Bexar, Dallas, El Paso, Harris, Hidalgo, Jefferson, Lubbock, Medicaid Rural Service Areas (MRSA) Central, Northeast, and West, Nueces, Tarrant, and Travis Page 11

12 STAR and Medicaid Rural Service Areas (effective March 1, 2012) El Paso El Paso Hudspeth Hudspeth El El Paso Paso El Paso First, Molina, Superior Medicaid Rural Service Area (MRSA) Medicaid Rural Service Area (MRSA) El Paso Geographic Distribution of Managed Care STAR Service Areas (effective March Delivery 1, 2012) Models Dallam Dallam Hartley Hartley Oldham Oldham Deaf Smith Deaf Smith Sherman Sherman Moore Moore Potter Potter Randall Randall Hansford Hansford Hutchinson Hutchinson Carson Carson Armstrong Armstrong Ochiltree Ochiltree Roberts Roberts Parmer Castro Swisher Briscoe Hall Childress Parmer Castro Swisher Briscoe Hall Childress Hardeman Hardeman Bailey Lamb Hale Floyd Motley Cottle Wilbarger Bailey Lamb Hale Floyd Motley Cottle Foard Wilbarger Wichita Foard Wichita Clay Clay Montague Cochran Hockley Lubbock Crosby Dickens King Knox Baylor Archer Cooke Grayson Lamar Montague Fannin Red River Cochran Hockley Lubbock Crosby Dickens King Knox Baylor Archer Cooke Grayson Lamar Fannin Red River Delta Bowie Delta Bowie Jack Titus Yoakum Terry Lynn Garza Kent Stonewall HaskellThrockmorton Young Wise Denton Jack Collin Hunt Hopkins Titus Yoakum Terry Lynn Garza Kent Stonewall Haskell Throckmorton Young Wise Denton Collin Franklin Morris Hunt Hopkins Franklin Cass Morris Camp Cass Dallam Sherman Hansford Ochiltree Lipscomb Palo Rockwall Rains Camp Gaines Dawson Borden Scurry Fisher Jones ShackelfordStephens Parker Tarrant Dallas Wood Marion Pinto Palo Rockwal Rains Upshur Gaines Dawson Borden Scurry Fisher Jones ShackelfordStephens Parker Tarrant Dallasl Wood Marion Pinto Upshur Hartley Moore Hutchinson Roberts Hemphill Kaufman Van Zandt Kaufman Harrison Hood Van Zandt Gregg Harrison Johnson Andrews Oldham Martin Potter HowardCarsonMitchell Gray Wheeler Nolan Taylor Callahan Eastland Erath Ellis Smith Gregg Hood Johnson Andrews Martin Howard Mitchell Nolan Taylor Callahan Eastland Erath Ellis Smith Somervell Henderson Panola Somervell Henderson Rusk Navarro Panola Deaf Smith Randall Armstrong Donley Collingsworth Hill Rusk Comanche Navarro Loving Winkler Ector Midland Glasscock Coke Sterling Runnels Comanche Bosque Hill Coleman Brown Anderson Cherokee Loving Winkler Ector Midland Glasscock Coke Bosque Parmer Castro Swisher Briscoe Hall Childress Tarrant * Shelby Sterling Runnels Coleman Brown Hamilton Freestone Anderson Cherokee Shelby Hamilton Freestone Nacogdoches Hardeman McLennan Ward Limestone Mills Nacogdoches Culberson San Augustine Ward Crane Bailey Lamb Hale Floyd Motley Cottle Wilbarger McLennan Limestone Foard Wichita Reeves Upton Reagan Tom Green Mills Culberson Coryell San Augustine Crane Irion Concho Clay Leon Sabine Upton Houston Reeves Reagan Tom Green Coryell Irion Concho Angelina McCulloch Montague Lampasas Cochran Hockley Lubbock Crosby Dickens King Knox Baylor Archer San SabaCooke Grayson Lamar Fannin Red RiverFalls Leon Houston Sabine Angelina McCulloch San Saba Lampasas Trinity Bell Bowie Robertson Delta Jack Lubbock Dallas Trinity Bell * Schleicher Robertson Yoakum Terry Lynn Garza Kent Stonewall Haskell Throckmorton Menard Madison Jasper Young Wise Denton Collin Franklin Titus Hunt Hopkins Morris Pecos Schleicher Menard Madiso Jasper Burnet Milam Cass Polk Jeff Davis Crockett Mason Llano Camp Walker Tyler Newton Pecos Burnet Palo RockwallWilliamson Rains Milam n Brazos Polk Jeff Davis Crockett Mason Gaines Dawson Borden Scurry Fisher Jones Shackelford Stephens Parker Llano Tarrant Dallas Wood Marion Walker Tyler Newton Pinto Williamson Upshur Brazos Sutton Grimes San Jacinto Kimble Kaufman Van Zandt Burleson Harrison Sutton Grimes San Jacinto Kimble Gregg Hood Burleson Johnson Andrews Martin Howard Mitchell Nolan Taylor Callahan Eastland Erath Gillespie Ellis Travis Smith Lee Somervell Terrell Blanco Montgomery Hardin Gillespie Travis Henderson Panola Rusk Washington Terrell Blanco Lee Montgomery Hardin Navarro Liberty Comanche Hill El Paso Loving Winkler Ector Midland Glasscock Coke Kerr Bosque Hays Bastrop Washington Orange Liberty Presidio Sterling Edwards Runnels Coleman Brown Anderson Cherokee Brewster Kerr Kendall Hays Bastrop Shelby Austin Waller Orange Presidio Val Verde Hamilton Freestone Brewster Edwards Jefferson Real Bandera Kendall Nacogdoches Ward Val Verde McLennan Limestone Hudspeth Mills Comal Caldwell Austin Waller Fayette Harris Chambers Jefferson Culberson Crane Upton Reeves Reagan Tom Green Real Bandera Coryell Comal Caldwell FayettSan Augustine Harris Chambers Irion Concho Falls Leon Houston Sabine e Angelina McCulloch San Saba Lampasas Guadalupe Colorado Trinity Fort Bend Bell Bexar Robertson Guadalupe Colorado Madison Gonzales Jasper Fort Bend Schleicher Menard Pecos Kinney Uvalde Medina Lavaca Galveston Bexar Gonzales Burnet Milam Polk Jeff Davis Crockett Mason Llano Walker Tyler Newton Kinney Uvalde Medina Lavaca Galveston Wharton Williamson Brazos Sutton Wilson Grimes San Jacinto Wharton Brazoria Kimble Burleson Wilson De Witt Jefferson Brazoria Gillespie Travis Lee Terrell Blanco Montgomery Hardin De Witt Washington Jackson Bastrop Liberty Orange Kerr Zavala Frio Atascosa Karnes Hays Presidio Edwards Kendall Austin Waller Victoria Matagorda Val Verde Maverick Zavala Frio Atascosa Karnes Jackson Jefferson Brewster Real Bandera Comal Caldwell Fayette Harris Chambers Goliad Victoria Matagorda Maverick Guadalupe Colorado Goliad Fort Bend Bexar Gonzales Kinney Uvalde Dimmit Bee Medina Lavaca Galveston Calhoun Harris Dimmit La Salle McMullenLive Oak Wharton Bee Calhoun Wilson Brazoria Refugio Travis La Salle McMullenLive Oak De Witt Refugio Jackson Zavala Frio Atascosa Karnes Aransas Victoria Matagorda Maverick San Patricio Aransas Goliad San Patricio Travis Dimmit Bee Calhoun La Salle McMullen WebbLive Oak Refugio Nueces Travis Jim Wells Webb Duval Jim Wells Nueces Duval Aransas San Patricio Webb Jim Wells Nueces Kleberg Duval Kleberg Kleberg Bexar Zapata Jim Hogg Brooks Bexar Jim Hogg Bexar Zapata Jim Hogg Zapata Brooks Brooks Kenedy Kenedy Kenedy Lubbock Lubbock Amerigroup, FirstCare, Superior Hidalgo Driscoll Children s, Molina, Superior, UnitedHealthCare Page 12 Gray Gray Lipscomb Lipscomb Hemphill Hemphill Wheeler Wheeler Donley Collingsworth Donley Collingsworth Blue Cross and Blue Shield of Texas, Sendero, Seton, Superior Aetna, Amerigroup, Community First, Superior Hidalgo Starr Hidalgo Willacy Starr Starr Cameron Nueces Hidalgo Hidalgo Willacy Willacy Cameron Cameron Tarrant Tarrant Aetna, Amerigroup, Cook Children s Nueces HHSC, Health Plan Operations September 2010 Dallas Amerigroup, Molina, Parkland Dallas Jefferson Harris Jefferson Amerigroup, Community Health Choice, Molina, Texas Children s, United Harris Amerigroup, Community Health Choice, Molina, Texas Children s, United Nueces Christus, Driscoll Children s, Superior HHSC, Health Plan Operations Page Page June

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

14 Mandatory Populations in STAR Temporary Assistance for Needy Families (TANF) recipients Pregnant women Newborns Low income families and children Adults age 21 and older, residing in the MRSA: Receiving SSI benefits, but not Medicare, or Enrolled in certain DADS 1915(c) waiver programs Page 14

15 Voluntary Populations in STAR Children and young adults under age 21, residing in the MRSA who are: Receiving SSI benefits, but not Medicare, or Enrolled in certain DADS 1915(c) waiver programs Children would continue to receive waiver services in fee-forservice if they volunteer for STAR Page 15

16 Populations Excluded from STAR Medicaid recipients residing in institutions Medically needy program participants Children in foster care Refugees Clients who receive both Medicare and Medicaid (dual eligibles) Page 16

17 Traditional Medicaid benefits Primary care provider (PCP) Unlimited prescriptions Unlimited necessary days in a hospital Value-added services Adult STAR Benefits Page 17

18 Children s Medicaid benefits Primary care provider (PCP) Unlimited prescriptions Children s STAR Benefits Unlimited necessary days in a hospital Children in traditional Medicaid also receive unlimited prescriptions and unlimited necessary days in a hospital Value-added services Page 18

19 STAR+PLUS Designed to integrate the delivery of acute care and long-term services and supports (LTSS) through a managed care system 412,000 members currently served Each member is enrolled in an MCO Main feature - service coordination Specialized care management service that is available to all members and performed by an MCO service coordinator Current Service Areas: Bexar, Dallas, El Paso, Harris, Hidalgo, Jefferson, Lubbock, Nueces, Tarrant, and Travis Page 19

20 El Paso El Paso Amerigroup, Molina Hudspeth Deaf Smith Parmer Dallam Hartley Oldham Castro Sherman Hansford Ochiltree Lipscomb Moore Hutchinson Roberts Hemphill Potter Swisher Carson Briscoe Gray Randall Armstrong Donley Collingsworth Hall Wheeler Childress Hardeman Bailey Lamb Hale Floyd Motley Cottle Wilbarger Foard Wichita Clay Cochran Hockley Lubbock Crosby Dickens King Knox Baylor Archer Montague Cooke Grayson Fannin Lamar Red River Delta Bowie Yoakum Terry Lynn Garza Kent Stonewall HaskellThrockmorton Young Jack Titus Wise Denton Collin Hunt HopkinsFranklin Morris Cass Camp Palo Rockwal Rains Gaines Dawson Borden Scurry Fisher Jones ShackelfordStephens Pinto Parker Tarrant Dallasl Wood Upshur Marion Kaufman Van Zandt Harrison Gregg Hood Johnson Andrews Martin Howard Mitchell Nolan Taylor Callahan Eastland Erath Ellis Smith Somervell Henderson Panola Rusk Navarro Comanche Hill Loving Winkler Ector Midland Glasscock Coke Bosque Sterling Runnels Coleman Brown Anderson Cherokee Shelby Hamilton Freestone Nacogdoches Ward McLennan Limestone Mills Culberson San Augustine Crane Upton Reeves Reagan Tom Green Coryell Irion Concho Falls Leon Houston Sabine Angelina McCulloch San Saba Lampasas Trinity Bell Robertson Schleicher Menard Madiso Jasper Jeff Davis Pecos Burnet Milam n Polk Crockett Mason Llano Walker Tyler Newton Williamson Brazos Sutton Kimble Burleson Grimes San Jacinto Gillespie Travis Terrell Blanco Lee Montgomery Hardin Washington Liberty Kerr Hays Bastrop Orange Presidio Brewster Edwards Kendall Austin Waller Val Verde Jefferson Real Bandera Comal Caldwell Fayett Harris Chambers e Guadalupe Colorado Fort Bend Bexar Gonzales Kinney Uvalde Medina Lavaca Galveston Wharton Wilson Brazoria De Witt Zavala Frio Atascosa Karnes Jackson Victoria Maverick Matagorda Goliad Dimmit Bee Calhoun La Salle McMullenLive Oak Refugio Lubbock Amerigroup, Superior Travis Amerigroup, United Webb Jim Wells Duval Current STAR+PLUS Service Areas Tarrant Amerigroup, HealthSpring Aransas San Patricio Nueces Dallas Molina, Superior Jefferson Amerigroup, Molina, United Harris Amerigroup, Molina, United Bexar Amerigroup, Molina, Superior Kleberg Zapata Jim Hogg Brooks Kenedy Starr Willacy Hidalgo Cameron Nueces Superior, United Hidalgo HealthSpring, Molina, Superior Page 20

21 STAR+PLUS Service Coordination MCO nurses, social workers, and other professionals with the necessary skills to coordinate care Service coordinators make home visits and assess member needs Coordinate with Medicaid and Medicare providers Authorize community-based LTSS Arrange for other services (e.g. medical transportation) Coordinate community supports (e.g. housing, utilities, legal) Page 21

22 Mandatory Populations in STAR+PLUS Adults age 21 and older who: Have a physical or mental disability and qualify for SSI benefits or Medicaid because of low income Qualify for Medicaid because they receive STAR+PLUS HCBS waiver services Page 22

23 Voluntary Populations in STAR+PLUS Most children and young adults under age 21 receiving SSI or SSI-related benefits may choose to enroll in STAR+PLUS or remain in traditional Medicaid Page 23

24 Medicaid Only Traditional Medicaid benefits Primary care provider (PCP) Community-based LTSS Service coordination Unlimited prescriptions Value-added services Adult STAR+PLUS Benefits Dual eligibles receive LTSS through STAR+PLUS and acute care through Medicare Page 24

25 Children s Medicaid benefits Primary care provider (PCP) Community-based LTSS Service coordination Unlimited prescriptions Children s STAR+PLUS Benefits Unlimited necessary days in a hospital Children in traditional Medicaid also receive unlimited prescriptions and unlimited necessary days in a hospital Value-added services Page 25

26 Personal Assistance Services (PAS) Day Activity and Health Services (DAHS) LTSS in STAR+PLUS STAR+PLUS HCBS Waiver similar to CBA in traditional Medicaid: Assisted living Adaptive aids Minor home modifications Personal assistance services Respite care Emergency response Transition assistance services Home delivered meals Nursing services Medical supplies Adult foster care Dental Therapies Financial management services Cognitive Rehabilitation Therapy (March 1, 2014) Supported Employment and Employment Assistance (September 1, 2014) Page 26

27 Upcoming Managed Care Initiatives

28 STAR+PLUS Expansion September 1, 2014 Expands STAR+PLUS statewide to the Medicaid Rural Service Areas MRSA Central, MRSA Northeast and MRSA West Estimated to serve an additional 80,000 members in STAR+PLUS. Page 28

29 Dallam Hartley Oldham Deaf Smith Sherman Hansford Ochiltree Lipscomb Moore Hutchinson Roberts Hemphill Wheeler Potter Carson Gray Randall Armstrong Donley Collingsworth STAR+PLUS Medicaid Rural Service Areas (MRSA) (effective September 1, 2014) Parmer Castro Swisher Briscoe Hall Childress Hardeman Bailey Lamb Hale Floyd Motley Cottle Wilbarger Foard Wichita Cochran Hockley Lubbock Crosby Dickens King Knox Baylor Archer Yoakum Terry Lynn Garza Kent Stonewall Haskell Throckmorton Young Gaines Dawson Borden Scurry Fisher Jones Shackelford Stephens Clay Montague Cooke Grayson Lamar Fannin Red River Delta Bowie Jack Titus Wise Denton Collin Hunt Hopkins Franklin Morris Cass Camp Palo Rockwal Rains Wood Parker Tarrant Dallas Marion Pinto l Upshur MRSA Northeast Texas Cigna-HealthSpring, UnitedHealthcare El Paso Hudspeth Loving Culberson Reeves Jeff Davis Andrews Winkler Ector Ward Crane Pecos Kaufman Van Zandt Harrison Gregg Hood Johnson Martin Howard Mitchell Nolan Taylor Callahan Eastland Erath Ellis Smith Henderson Somervell Panola Rusk Navarro Comanche Hill Midland Glasscock Coke Bosque Sterling Runnels Coleman Brown Anderson Cherokee Shelby Hamilton Freestone Nacogdoches McLennan Limestone Mills San Augustine Upton Reagan Tom Green Coryell Irion Concho Falls Leon Houston Sabine Angelina McCulloch San Saba Lampasas Trinity Bell Robertson Schleicher Menard Madiso Jasper Burnet Milam n Polk Newton Crockett Mason Llano Walker Tyler Williamson Brazos Sutton Grimes San Jacinto Kimble Burleson Presidio Brewster Terrell Val Verde Edwards Kinney Maverick Gillespie Travis Lee Blanco Montgomery Hardin Washington Liberty Kerr Bastrop Orange Hays Kendall Austin Waller Jefferson Real Bandera Comal Caldwell Fayett Harris Chambers e Guadalupe Colorado Fort Bend Bexar Gonzales Uvalde Medina Lavaca Galveston Wharton Wilson Brazoria De Witt Jackson Zavala Frio Atascosa Karnes Victoria Matagorda Goliad MRSA West Texas Dimmit La Salle Bee Calhoun McMullenLive Oak Refugio Aransas San Patricio Amerigroup, Superior HealthPlan Webb Jim Wells Nueces Duval Kleberg Zapata Jim Hogg Brooks Kenedy MRSA Central Texas Superior HealthPlan, UnitedHealthcare Starr Hidalgo Willacy Cameron Page 29

30 Assessments & Authorizations MCO service coordinators assess need for LTSS MCO is responsible for functional and medical assessments Form 2060 Medical Necessity/Level of Care (MN/LOC) Existing authorizations for LTSS are honored for 6 months or until the MCO does a new assessment Existing authorizations for acute care services are honored for 90 days or until the MCO does a new assessment Page 30

31 Behavioral Health Services On September 1, 2014 two additional behavioral health services will be added to managed care: Mental health rehabilitation and mental health targeted case management Currently provided through fee-for-service and delivered through the Local Mental Health Authorities (LMHAs) The NorthSTAR program in the Dallas service area will not be affected The State must also: Develop two health home pilots and a Behavioral Health Integration Advisory Committee Create community collaboratives for persons who are homeless, with mental illness, and/or with a substance abuse problem Establish and maintain a mental health and substance abuse treatment public reporting system Page 31

32 Eligible Populations Mental health rehabilitation and mental health targeted case management services are available to the following Medicaid recipients who are assessed and found eligible: Adults with a severe and persistent mental illness such as schizophrenia, major depression, bipolar disorder or other severely disabling mental disorders Children and adolescents ages 3 through 17 years with a diagnosis of a mental illness or exhibit a serious emotional disturbance Page 32

33 September 1, 2014 Clients with Intellectual and Developmental Disabilities (IDD) Persons transitioning into STAR+PLUS for acute care services only: Individuals receiving services in community-based Intermediate Care Facilities for Individuals with Intellectual Disabilities or Related Conditions (ICF-IID) Individuals receiving services in certain DADS 1915(c) waiver programs: Home and Community-based Services (HCS) Community Living Assistance and Support Services (CLASS) Texas Home Living (TxHmL) Deaf Blind Multiple Disabilities (DBMD) Page 33

34 Not included: Populations Excluded and Voluntary Individuals residing in a state supported living center Dual eligibles (receiving both Medicare Part B and Medicaid) Children and young adults under age 21 receiving SSI or SSI-related benefits are voluntary Page 34

35 March 1, 2015 Nursing Facility Services Nursing facility services will be provided through STAR+PLUS statewide Intended to improve quality of care and promote care in the least restrictive, most appropriate setting Between 50,000-60,000 nursing facility residents will transition to STAR+PLUS Page 35

36 Nursing Facility STAR+PLUS Populations Adults age 21 and older who are in a nursing facility, who have been determined eligible for Medicaid, and who meet STAR+PLUS criteria will be mandatory Children and young adults under age 21 will be excluded Truman W. Smith Children s Care Center residents will be excluded State veteran s home residents will be excluded Page 36

37 Significant Traditional Providers (STP) Providers who have been serving Medicaid clients MCOs are obligated to offer STP contractors the opportunity to be a part of the contracted MCO network MCOs will reach out to STPs STPs may initiate the contact STPs must accept MCO conditions for contracting and credentialing Page 37

38 Impact on DADS Providers CBA contracts in STAR+PLUS service areas will be canceled All 1915(c) CBA services in STAR+PLUS service areas will be delivered through STAR+PLUS MCOs PHC and DAHS for STAR+PLUS members must be authorized and paid by the MCO This does not include DADS IDD waiver clients Page 38

39 May 2014 Enrollment Activities Clients will be sent introduction letter, including MCO comparison chart, and links to provider directories June 2014 Clients will be sent enrollment packets with provider directory, MCO comparison chart, enrollment form, and frequently asked questions August 15, 2014 Mandatory managed care clients must choose an MCO or the State will auto-assign the client to an MCO Clients may choose an MCO by phone or mail, and may change at any time September 1, 2014 MCO enrollment takes effect Page 39

40 Provider Trainings HHSC is hosting a series of STAR+PLUS Provider Trainings between June and July face-to-face trainings have been scheduled for: San Antonio, El Paso, Houston, Dallas, Tyler, McAllen, Austin, Abilene, Waco, and Lubbock Webinars will also be offered throughout the summer More information on HHSC s website Page 40

41 Appeals and Fair Hearings Members may appeal to the MCO and/or file a fair hearing request with the State if services are denied, reduced, or terminated Services may continue during the review if the appeal or fair hearing is requested within the adverse action period and the member requests continued services pending the appeal Page 41

42 Provider Complaints Providers initially contact the MCO to file a complaint and must exhaust the MCO resolution process before filing a complaint with HHSC Appeals, grievances, or dispute resolution is the responsibility of the MCO Providers may file complaints with HHSC if they did not receive full due process from the MCO Page 42

43 HHSC HPM Complaints P.O. Box 85200, MC H-320 Austin, TX Complaints Contacts Remember to follow HIPAA guidelines and always send patient information securely. Page 43

44 Next Steps Become familiar with STAR and STAR+PLUS MCOs operating in counties where you currently deliver services Begin contracting and credentialing process with MCO as quickly as possible Prepare to negotiate with the MCO to become a member of the MCO provider network Page 44

45 Questions? Managed Care Initiatives Webpage Page 45