Medicaid Managed Care STAR Expansion Acute Care Provider Training - - PowerPoint PPT Presentation

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Medicaid Managed Care STAR Expansion Acute Care Provider Training - - PowerPoint PPT Presentation

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Medicaid Managed Care STAR Expansion Acute Care Provider Training February 2011 What is Medicaid Managed Care? Establish a medical home for Medicaid clients through a Primary Care Provider (PCP) Emphasize preventative care

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Medicaid Managed Care STAR Expansion Acute Care Provider Training February 2011

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SLIDE 2

What is Medicaid Managed Care?

  • Establish a medical home for Medicaid clients

through a Primary Care Provider (PCP)

  • Emphasize preventative care
  • Improve access to care
  • Ensure appropriate utilization of services
  • Improve health outcomes
  • Improve quality of care
  • Improve client and provider satisfaction
  • Improve cost effectiveness
  • Disease Management
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SLIDE 3

Current Medicaid Managed Care Models

Current Medicaid Managed Care Delivery Models

  • STAR (State of Texas Access Reform)
  • Capitated, Health Maintenance Organization (HMO) model for non-disabled

pregnant women and children.

  • Provides acute care services.
  • STAR+PLUS
  • Capitated HMO model for disabled Medicaid clients and dual eligibles (Medicaid

and Medicare).

  • Provides acute and long-term services and supports (LTSS).
  • STAR Health
  • Capitated HMO model for foster care children.
  • Provides acute care services with emphasis on behavioral health and medication

management.

  • Primary Care Case Management (PCCM)
  • Non-capitated service delivery model.
  • Includes non-disabled pregnant women, children and disabled adults
  • Acute care services only.
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Page 4

Proposed Geographic Distribution of Managed Care Delivery Models

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

Bexar Lubbock Harris El Paso Dallas *

HHSC, Health Plan Operations September 2010

Palo Pinto Comanche Hamilton El Paso McMullen Maverick

Travis

Orange Sabine Newton Colorado Houston

Tarrant *

Nacogdoches San Jacinto Jasper

Nueces

Washington Jefferson Chambers Harris

Hidalgo Jefferson

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Expansion to Contiguous Counties for September 1, 2011

Service Area Current Counties STAR Expansion Counties HMOs Providing STAR STAR+PLUS Expansion Counties HMOs Providing STAR+PLUS Bexar Atascosa, Bexar, Comal, Guadalupe, Kendall, Medina, Wilson Bandera Aetna Community First Superior Bandera Amerigroup Molina Superior El Paso El Paso Hudspeth El Paso First Superior No Change No Change Harris (incl’s Harris & Harris Exp Counties) Brazoria, Fort Bend, Galveston, Harris, Montgomery, Waller Austin, Matagorda, Wharton Amerigroup Community Health Choice Molina Texas Children's United Austin, Matagorda, Wharton Amerigroup Evercare Molina Jefferson (New Svc Area – Harris Contig. Counties N/A Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler, Walker Amerigroup Community Health Choice Molina Texas Children's United Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler, Walker Amerigroup Evercare Molina Lubbock Crosby, Floyd, Garza, Hale, Hockley, Lamb, Lubbock, Lynn, Terry Carson, Deaf Smith, Hutchinson, Potter, Randall, Swisher FirstCare Superior No Change No Change Nueces Aransas, Bee, Calhoun, Jim Wells, Kleberg, Nueces, Refugio, San Patricio, Victoria Brooks, Goliad, Karnes, Kenedy, Live Oak Amerigroup Driscoll Superior Brooks, Goliad, Karnes, Kenedy, Live Oak Evercare Superior Travis Bastrop, Burnet, Caldwell, Lee, Hays, Travis, Williamson Fayette Amerigroup Superior Fayette Amerigroup Evercare

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STAR Program Information

  • STAR operates under the authority of a federal 1915(b)

waiver.

  • Risk-based, capitated managed care.
  • Each STAR member is enrolled in a HMO and has a

PCP.

  • PCP is chosen by member or assigned by state or HMO.
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STAR Program

  • Populations mandatory for STAR include:
  • Temporary Assistance to Needy Families (TANF) recipients
  • Pregnant Women
  • Children receiving Medicaid assistance only
  • Populations excluded from STAR include:
  • Medicaid recipients who reside in institutions
  • Dual-eligible Medicaid recipients (clients with both Medicaid and

Medicare)

  • Medically needy
  • Foster children
  • Refugees
  • SSI Medicaid recipients may volunteer to be in STAR or will be

placed in traditional Medicaid effective September 1, 2011.

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SLIDE 8

HMO vs. PCCM

  • HMO model offers improved utilization management
  • ver PCCM.
  • Improved utilization achieved through internal HMO

processes and service coordination.

  • Similar service not available in PCCM.
  • Premium tax:
  • Premiums paid to Medicaid HMOs subject to state

premium tax.

  • As part of HHSC’s check and balance on the HMOs,

HHSC caps the amount of profit that may be earned.

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HMO vs. FFS

STAR/STAR +PLUS

Provider Directory

  • Includes PCP/Specialists/LTSS

Member Handbook

  • Includes phone numbers for assistance,

descriptions of benefits, complaints and appeal information (esp useful for LTSS)

Unlimited Prescriptions (non-duals) for adults Value Added Services (varies by HMO)

  • Such as 24 hour nurse lines, additional

transportation help, cell phones for high risk clients, weight loss programs

Member chooses PCP or is assigned a PCP – can change through the HMO

  • HMO must ensure access to

physicians per contract requirements (emergency, urgent, routine care)

FFS

Client has to locate willing provider 3 prescriptions per month for adults No Primary Care Provider (PCP)

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PCCM vs. Medicaid Managed Care

Primary Care Case Management (PCCM)

  • State operated plan
  • Providers are contracted directly with state
  • Members assigned PCP, but can see any Medicaid

specialist

  • Providers paid fee-for-service rates

Medicaid Managed Care

  • Providers must contract and be credentialed with

the HMO to provide STAR services

  • Rates are negotiated between the provider and the

HMO

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PCCM vs. Medicaid Managed Care

Medicaid Managed Care (continued)

  • Authorization requirements may be different and

must be obtained from the HMO

  • Providers must follow HMO 95 day billing

requirements

  • Provides a medical home through a PCP and

referral needed for specialty provider visits

  • Promotes preventive care and continuity of care
  • HMO may offer value-added services (ex: sports

physicals, extra vision benefits, health and wellness benefits)

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Claims

STAR Medicaid Managed Care

  • Claims are paid by the HMO.
  • Providers must file claims within 95 days of

Date of Service (DOS).

  • HMOs required to adjudicate within 30

days.

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Page 13

HMO Plan Identification Cards

  • All HMO Members receive a HMO Plan ID Card,

in addition to their monthly Medicaid ID Card (Form 3087) from the State.

  • The card contains the following information:
  • Member’s name and Medicaid ID number
  • Identification of HealthCare Program (STAR)
  • HMO name
  • Primary care provider name & telephone number
  • Toll-free telephone numbers for member services and

behavioral health services hotline

  • Additional information may be provided (e.g., date of

birth, service area, primary care provider address)

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Provider Complaints

  • Initial point of contact is HMO
  • May submit written complaint to HHSC at

hpm_complaints@hhsc.state.tx.us

  • HHSC will intervene in issues when HMO is

not complying with HHSC contract

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Page 15

Workgroup Updates

Eligibility and Enrollment Systems Workgroup

  • Meetings with all system trading partners
  • Project testing underway
  • Proposed readiness review testing
  • Lessons learned – Best Practices

Enrollment Broker Workgroup

  • Welcome letters/FAQs mailed out in April
  • Enrollment packets mailed out in June
  • Medicaid ID stuffer – August
  • Outreach and enrollment events – June/July/August
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Workgroup Updates

DADS/HHSC Workgroup

  • Coordinating transition plan
  • Coordination of clients (long-term services and

supports)

  • Provider information
  • Lessons learned – Best Practices

Client Outreach

  • HHSC will coordinate STAR program outreach and

education sessions

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Page 17

Next Steps

  • Become familiar with STAR HMOs operating in

counties where you are delivering services.

  • All plans are here today to help answer your specific

questions.

  • Sign and return contracts & credentialing applications

to the HMOs in order to become a participating provider and to be listed in the HMO Provider Directory.

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STAR Program

  • STAR HMOs El Paso expansion area:
  • El Paso First
  • Superior HealthPlan
  • El Paso STAR Service Area includes:
  • EL Paso County currently
  • Hudspeth County effective September 1, 2011
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STAR and STAR+PLUS HMO Representative Contact Information

  • El Paso First
  • Frank Dominguez 915-298-7198 x1085

fdominguez@epfirst.com

  • Superior
  • Network Development 1-877-391-5923 x22534

SHP-NetworkDevelopment@centene.com

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Managed Care Resources

  • HHSC Managed Care Proposals Website:

http://www.hhsc.state.tx.us/medicaid/MMC-Proposals.shtml

  • HHSC STAR Website:

http://www.hhsc.state.tx.us/medicaid/mc/about/faq.html

  • TMHP Website:

http://www.tmhp.com/Pages/PCCM/STAR_Expansion.aspx

  • Email: ManagedCare_Exp2011@hhsc.state.tx.us