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Medicaid Managed Care for Elderly and Persons with Disabilities Pam Coleman Texas Health and Human Services Commission O

Medicaid Managed Care for Elderly and Persons with Disabilities Pam Coleman Texas Health and Human Services Commission October 11, 2006. Pilot implemented in Harris County (Houston) in 1998 Risk-based, capitated managed care

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Medicaid Managed Care for Elderly and Persons with Disabilities Pam Coleman Texas Health and Human Services Commission O

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  1. Medicaid Managed Care for Elderly and Persons with DisabilitiesPam ColemanTexas Health and Human Services CommissionOctober 11, 2006

  2. Pilot implemented in Harris County (Houston) in 1998 Risk-based, capitated managed care Integrates Medicaid funding and service delivery of long term and acute care Serves 60,000 aged and disabled not in a nursing facility STAR+PLUSHarris County

  3. Legislative direction (SCR 55, 74th session) Improve coordination of physical health care needs with personal care needs Improved access to community based long-term care support services Promote coordination of Medicaid and Medicare Increase cost effectiveness Why STAR+PLUS?

  4. Children, Adults and Other are 74% of the Medicaid population and 37% of costs. Aged and Disabled are 20% of the Medicaid population but 62% of costs (all funds). Total $18 Billion Texas Medicaid Expenditures Texas Medicaid in Perspective, HHSC, April 2004

  5. Texas MedicaidManaged Care Growth

  6. Supplemental Security Income (SSI) adults who are not in a nursing facility or other institution and who are not currently being served through a Home and Community Based Waiver program, other than Community Based Alternatives (CBA), must enroll in STAR+PLUS. Non-SSI adults who qualify for 1915 (c) Nursing Facility Waiver services must enroll in STAR+PLUS to receive those services. SSI children, under age 21, may voluntarily enroll in STAR+PLUS. STAR+PLUS Members

  7. Traditional Medicaid benefit package Unlimited Prescription drugs (Medicaid only) Annual adult well checks Removal of limit for length of stay for hospitalization (STAR only) PCP provider directories PCP coordinates health care of patient 24-hour nurse helpline (through their health plan) Member services helpline (through their health plan) Member handbooks and health education Case management for members with special health care needs HMO Member Benefits

  8. STAR+PLUS LTC Services • Medical supplies • Home modifications • Respite care • Therapies • Emergency response • Personal assistance • Day activity and health • 1915(c) waiver services • Adaptive aids • Adult foster home • Assisted living

  9. DADS Open Enrollment Licensure Contract Program specific STAR+PLUS HMO Negotiated Individually Additional providers dependent on network adequacy Contract by service, not program May add licensed providers that are not contracted with DADS Contracting Method

  10. DADS Established on a statewide basis for each program. Based on cost reports filed by providers Same for all providers STAR+PLUS HMO Negotiated with each provider May establish fixed rates for each service or can negotiate different rates Provider can offer additional service for additional compensation Rates

  11. DADS Individuals needing assistance must contact DADS or be referred by family, provider or community for assessment and authorization STAR+PLUS All members are contacted within 30 days of enrollment Informed about services available Telephonic risk questionnaire may lead to assessment and authorization for services Access

  12. External quality review study completed July 2003 SSI clients in STAR+PLUS were compared to SSI PCCM clients Significant cost difference – particularly for the highest acuity clients ($3,226 mo in STAR+PLUS vs. $13,160 mo in PCCM) Lower inpatient and ER use in STAR+PLUS Care Coordination Results

  13. Overall Expenditures STAR+PLUS vs. PCCM

  14. Cost savings result frommanaging care by: Early identification and treatment of health problems Promoting wellness and healthy lifestyles Avoiding higher cost services and products when lower-cost, clinically appropriate services can be rendered Coordinating care effectively and reducing duplication of services Cost Savings

  15. Have 9 SNPs operating in Texas. Two have STAR+PLUS plans with over 20,000 enrolled for both programs SNP plans would like to see expansion of STAR+PLUS We pay a premium to the SNP plans to cover Medicaid cost share obligation STAR+PLUS and Special Needs Plans

  16. Unable to expand the program due to potential loss of UPL to public hospitals. Medicaid laws prohibit hospitals from receiving UPL if they are paid by a capitated HMO. Texas plans to implement alternative models including hospital carve-out and non-capitated managed care programs, but effectiveness and efficiency will be compromised. Expansion Issues

  17. STAR+PLUS is expanding to 4 new areas January 2007 STAR+PLUS will carve out inpatient hospital services from the HMO capitation Capitates physician, ER, outpatient, and community-based long-term support services. STAR+PLUS Expansion

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