Choosing A Medicaid Managed Care Health Plan. Ginger Mayeaux June 25, 2014

Transcription

1 Choosing A Medicaid Managed Care Health Plan Ginger Mayeaux June 25, 2014

2 What is Medicaid Managed Care? Unlike fee-for-service (traditional) Medicaid, in Medicaid Managed Care (MMC), beneficiaries must: o Enroll in a Medicaid managed care health plan (Molina, Amerigroup, United Healthcare, Superior, and Healthspring). o Follow the plan s rules for accessing services including: Choosing a primary care provider Obtaining prior authorization for medical services Receiving in-network treatment This is a result of Senate Bill 7/Medicaid Managed Care Law passed in the 83rd Legislative session. For more background on SB7 go to

3 Broad Timeline of Implementation Sept. 1, 2014: Acute (medical) care rolls into STAR+PLUS. Sept.1, 2017: TxHmL rolls into STAR+PLUS. Sept. 1, 2016: MDCP rolls into STAR KIDS. 2020: All other waivers (LTSS) roll into STAR+PLUS. **Individuals who have a waiver in 2020 may keep their waiver instead of moving into STAR+PLUS!

4 Acute/Medical Care STAR+PLUS WHAT IS ACUTE CARE? Medical Services, such as: doctors visits, prescriptions, durable medical equipment (wheelchairs), supplies (gloves) September 1, 2014, acute care services will be delivered through STAR+PLUS for: People in community-based Intermediate Care Facilities for Individuals with Intellectual Disabilities or Related Conditions (ICF-IID) People served in ICF-IID 1915 (c) waivers HCS, CLASS, TxHmL, DBMD People not included in the move to STAR+PLUS: People in a state supported living center People getting both Medicare and Medicaid Children and young adults under age 21 receiving SSI or SSI-related services are voluntary and may choose to sign up for STAR+PLUS services

5 Enrollment Timeline May 2014 You will receive an introduction letter You should speak with your doctors about becoming part of the provider network You should start collecting historical medical records. June 2014 You will receive ENROLLMENT PACKETS Packets will include an MCO comparison chart, provider directory, enrollment form, and frequently asked questions handout. August 15, 2014 You, unless you are 20 and younger, MUST CHOOSE an MCO. If you do not choose one, you will be auto-assigned by the state. You may select by phone [ ] or mail and may change at any time. September 1, 2014 MCO enrollment takes effect (medical care moved to managed care). You will continue to receive their long-term services and supports as you do today.

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7 Services in all plans All services you can currently receive with your Your Texas benefits card will now be available in your Managed Care plan. Traditional Medicaid Health Care Services Examples: All health plans offer the same traditional Medicaid services Doctor and clinic visits Help getting a ride to the doctor Dialysis for kidney problems 24-hour Emergency Care Family planning services Eye checkups, glasses, and contact lenses Hospital care Hearing tests and aids Shots for children age 20 and younger Surgery Home health services Texas health steps medical and dental checkups Ambulance service Chiropractors Unlimited prescriptions Lab and x ray services Podiatrists Mental health services Major organ transplants Help for drug and alcohol problems Yearly adult check up To view all the comparison charts, go to:

8 Important Note: STAR+PLUS will NOT provide long term services and supports (LTSS) at this time. You will continue to receive LTSS like you are now. You will only receive medical services through STAR+PLUS in (STAR+PLUS waiver is separate)

9 What Health Plans are in Your Area?

10 What Health Plans are in Your Area?

11 How do I choose the best health plan for me? 1. Look at provider networks 2. Look at report cards 3. Look at health plan profiles 4. Compare value added services You may switch plans at anytime by calling Texas Enrollment Broker Helpline at

12 Look at the doctors in your network Look at doctors in network: **Online directories have the most up to date information (networks change frequently, so printed material is not always accurate) Look at primary care AND specialists Decide what's most important for you. If your doctor(s) aren't in network: Contact your doctors/specialist and encourage them to enroll in the Health Plans in your area (health plans must offer a contract to traditional providers.) or ask for other options (single case agreements). Contact the health plans and tell them which doctors/specialists are important to you.

13 Find Out What Doctors Are Already in Network If you do not see your doctor in the printed directory you received with your STAR+PLUS enrollment packet, use these websites or numbers. Superior Molina Amerigroup m/ United Health Care Cigna-Health Spring It may be helpful to call and verify with the doctor you choose that they are taking STAR+PLUS.

14 Look at STAR+PLUS Report Cards How the Health Plans Measure Up : HHSC asked people in your area to share their thoughts about their health plan, and looked at the medical bills each plan sent to Medicaid and CHIP. See which plan got the highest ratings in the issues that mean the most to you. If your area hasn t had STAR+PLUS in the past, you will not receive a report card in your enrollment packet.

15 Look at STAR+PLUS Report Cards: To view the report card for health plans in your area (if available):

16 Look at Health Plan Profiles: For all the Health plan profiles:

17 Value Added Services: To view the full list of value added services in plans in your area:

18 Value Added Services: Examples of value added services (not all plans offer all of these and there are services offered, not mentioned here) 24 hour nurse line Extra dental services (routine cleaning, x rays or other services at a discount) Extra vision services Help for members with asthma (allergy free mattress cover and pillow cases each yr.) Pest control Gift programs (gift cards for reaching healthy goals, attending weight watchers, etc) Educational materials for pregnant women Healthy play and exercise programs (boys and girls club or 4H membership for individuals under 18) Drug store services (allowance for over-the counter medicines) Home visits (extra respite for adults) Health and wellness services (stop smoking products, weight watchers memberships, home delivered meals) Extra behavioral health services

19 Three Steps to Enrollment Step 1 Sep 2 Step 3 Pick a Health Plan Choose your main doctor (primary care provider) from the network of the plan you chose. Let STAR+PLUS know what you chose Choose the plan best for you based on which doctors are in network, value added services, report cards, etc If your current doctor is in the network, you will not change doctors. If they are not, use the online provider directory to choose a new doctor. You may do this online, by mail, phone, or in person.

20 Once You Choose a Plan: Enroll You may enroll by: o Mail (in packet) o Online YourTexasBenefits.com o Phone: Call: o In Person at a benefits office To find an office: Be sure to enroll by August 15 th!

21 What if I do not pick a health plan? You will be automatically enrolled in one as follows: NON-MRSA Areas Default Process Initiated for mandatory candidates who have not selected an MCO. (No further action taken will be taken for voluntary candidates.) Mandatory candidates will be defaulted to a STAR+PLUS MCO that includes their PCP in the provider network when possible. Remaining mandatory candidates will be evenly distributed among MCOs available in that area. MRSA Areas ( rural areas) Default Process Initiated for mandatory candidates who have not selected an MCO. No further action will be taken for voluntary candidates. If mandatory candidate is served in STAR and their STAR MCO will be a STAR+PLUS MCO in the candidates service area, the candidate will be defaulted to their existing plan for STAR+PLUS services Remaining mandatory candidates will be defaulted to a STAR+PLUS MCO that includes their PCP in the provider network when possible Mandatory candidates that still remain will be defaulted to the MCO that has received the fewest defaulted members. Once the number of defaulted members is equalized, any remaining mandatory candidates will be evenly distributed among MCOs available in that area.

22 Private Health Insurance and HIPP You may continue to use your private health insurance You will be required to enroll in a managed care plan The Health Insurance Premium Payment Program (HIPP) will continue

23 Still Have Questions or a Problem Enrolling? STAR+PLUS: A Preview of What to Expect: STAR+PLUS: Enrollment Tips: Need to change plans? Changes take between 15 to 45 days to complete. Members can change plans by calling the Texas Enrollment Broker Helpline at MAXIMUS I/DD Helpline:

24 Next Steps: The Promise: No one will lose services or supports they currently receive. Share your experience with this roll out and as SB7 continues to evolve. Important to keep an active voice at the table. Seven years (Three sessions) to evaluate and make changes. Need to secure the protections we have in the law, currently (three sessions can be good or bad). Educate individuals on Acute Care MCO enrollment! State Medicaid managed care: The Arc of Texas current initiatives: ame=events_special