STAR+PLUS Expansion March 2012 Are You Ready? Presented June 24, 2011

1. STAR+PLUS ExpansionMarch 2012Are You Ready?Presented June 24, 2011

2. Topics • What is STAR+PLUS? • What areas of Texas are affected by STAR+PLUS? • What will it mean to clients? • Clients that will be in STAR+PLUS? • Services provided through STAR+PLUS? • Changes in contracting process? • Changes in case management process? • Significant Traditional Providers?

3. STAR+PLUS Program Information • STAR+PLUS is a capitated health maintenance organization (HMO) model for Medicaid clients with disabilities and dual eligible clients (have Medicaid and Medicare): • Provides acute and long term services and supports (LTSS). • Is currently based on a combined 1915(b) and 1915(c) waiver. • Goal: Achieve a seamless continuum of care by integrating acute and long-term services and supports (LTSS) in a managed care environment. • Promotes delivery of home and community-based services. • Managed care organizations (MCOs) are responsible for coordinating acute and LTSS through the use of a service coordinator.

4. STAR+PLUS Program Information • Service Coordinators are responsible for: • Formulating an individualized plan covering acute and LTSS. • Overseeing smooth transition from acute care to LTSS. • Making home visits and assessing members’ needs: • Authorizing community LTSS. • Arranging acute care services. • STAR+PLUS Medicaid-only members can choose or be assigned a primary care provider (PCP). • Service Coordinators are required to coordinate as needed with the Medicare physician, member and other service providers.

5. STAR+PLUS: March 1, 2011

6. Health Maintenance Organization • State pays a monthly premium for each enrolled member. • HMOs are at risk for service levels that exceed capitated premium. • There must be at least two HMOs in a service area to give members a choice.

7. HMO Member Benefits • Traditional Medicaid benefit package. • Provider directories – physicians, specialists, and LTSS. • PCP to coordinate health care of patient (Medicaid only). • Member services helpline (through their health plan). • Member handbooks and health education. • Service Coordination. • Value Added Services – vary by health plan.

8. Who are STAR+PLUS Members? • SSI adults will participate in STAR+PLUS, if they are: • Not in a nursing facility or other institution. • Not currently being served through a Home and Community Based Waiver program, EXCEPT for Community Based Alternatives (CBA). • SSI adults who are in CBA will participate in STAR+PLUS. • Non-SSI adults who qualify for 1915 (c) Nursing Facility Waiver services will participate in STAR+PLUS in order to receive those services. • SSI children, under age 21, may voluntarily enroll in STAR+PLUS.

9. LTSS in STAR+PLUS • Personal Attendant Services (PAS) – both Primary Home Care (PHC) and CBA attendant services will be delivered by the HMO. • Day Activity and Health Services (DAHS). • Also known as adult day care. • 1915 (c) Nursing Facility Waiver Services: • Services provided through CBA in traditional Medicaid.

10. DADS Open enrollment. Licensure. Contract. Program specific. STAR+PLUS HMO Enrollment negotiated individually. Acceptance of additional providers dependent on network adequacy. Contract by service, not program. May add licensed providers that are not contracted with DADS. Contracting Method

11. DADS Established on a statewide basis for each program. Based on cost reports filed by providers. Same for all providers. STAR+PLUS HMO Can be 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

12. DADS Voluntary program that provides enhanced rates which is intended to be passed through to the attendants. Providers choose the “level” they wish to participate in – and provide reports to DADS. Enrollment conducted by DADS. STAR+PLUS HMO Will pay an Attendant Care Enhancement rate to providers currently receiving one from DADS and monitor for compliance. May choose not duplicate method or amount paid by DADS before Managed Care implementation. Should be clearly identified in the contract between the provider and the HMO. Attendant Care Enhancement

13. DADS Claims are paid through the claims management system. Claims are edited and payment is based on authorization. May be paid in 7 days. STAR+PLUS Claims are submitted to and paid by the HMO. Contract requires 98% of all clean claims to be paid in 30 days or less (Average is 14 days for existing HMOs). Claims

14. DADS Individuals needing assistance must contact DADS or be referred by family, provider, or community for assessment and authorization. STAR+PLUS Members contact the HMO for any assistance needed. All members are contacted by HMO after enrollment and at least twice annually, and informed of available services. Risk questionnaire, conducted by phone, may lead to assessment and authorization for services. Access

15. DADS DADS case managers assess the need for long-term services and supports (LTSS). DADS authorize Home and Community Support Services (HCSS) agencies to complete the medical necessity level of care form and Form 3671 (for the individual service plan) for applicants for CBA. STAR+PLUS HMO Service Coordinators assess need for LTSS services. HMO is responsible for functional assessment for 1915 (c) Nursing Facility Waiver services. Assessment

16. DADS Some providers, such as DAHS, may initiate services to SSI recipients prior to authorization. STAR+PLUS Providers must follow the terms of their agreement with the HMO and, if applicable, obtain authorization prior to initiating services. Authorizations

17. DADS Individuals are offered a choice of all contracted providers to deliver services. Authorizations for PHC and DAHS are in force until changed. CBA services are authorized on an annual plan. STAR+PLUS Members are offered a choice of HMO network providers. Authorization for services may be limited. Authorization for 1915 (c) Nursing Facility Waiver services are based on annual plan. Authorizations are service specific. Authorization

18. DADS Individuals are reminded of their right to a Fair Hearing when services are denied, reduced or terminated. Individuals are reminded of that right when they are determined ineligible for CBA. STAR+PLUS Members may appeal to HMO and/or file Fair Hearing request if services are denied, reduced or terminated. Members and applicants are notified by the state if determined not eligible for 1915 (c) Nursing Facility Waiver services. Appeals and Fair Hearings

19. DADS Initial point of contact is the regional contract manager. STAR+PLUS Initial point of contact is the HMO. Provider Complaints

20. Provider Complaints • Medicaid managed care providers may file complaints with HHSC if they find they did not receive full due process from the respective managed care health plan. • Appeals, grievances or dispute resolution is the responsibility of each managed care HMO. Providers must exhaust the complaints or grievance process with their managed care HMO before filing a complaint with HHSC.

21. Contacting HHSC for Provider/Member complaints Mail: HHSC Health Plan Management 11209 Metric Blvd, Bldg H Mail Code H-320 Austin, TX 78758 Email: • For STAR and STAR+PLUS: HPM_Complaints@hhsc.state.tx.us • For STARHealth: STAR.Health@hhsc.state.tx.us THINK HIPAA

22. Impact on DADS Contracts • For PHC and DAHS Title XIX contracts, services to STAR+PLUS members must be authorized and paid by the HMO. • CBA contracts in STAR+PLUS service areas will be terminated. • All 1915 (c) Nursing Facility Waiver services in STAR+PLUS service areas will be delivered through STAR+PLUS HMOs.

23. Significant Traditional Providers • Significant Traditional Provider (STP) requirements relate to providers that have been providing services to Medicaid clients in some service areas. • HMOs are obligated to offer STP contractors the opportunity to be a part of the contracted HMO provider network. • HMOs will reach out to contact STPs; however, STPs may initiate the contact. • STP providers must accept HMO conditions for contracting and pass credentialing.

24. Next Steps • Become familiar with STAR+PLUS HMOs operating in counties where you are currently delivering services under contract with DADS. • Once HHSC announces the HMOs with which it will contract, you will need to get contracted and credentialed as quickly as possible. • Prepare to negotiate with the HMO for the delivery of services as part of the HMO network.

25. Questions?