Managed Care Long Term Care Model The Texas Experience

1. Managed Care Long Term Care ModelThe Texas Experience Presentation to: San Diego County LTCIP October 26, 2001 Cindy Adams

2. STAR+PLUS • Comprehensive capitated managed healthcare model • SSI and SSI-related Aged and Disabled Population • Provides a continuum of care with a wide range of options and increased flexibility to meet individual needs

3. STAR+PLUS • Medicaid pilot project designed to integrate delivery of acute and long-term care services through a managed care system • Requires two Medicaid waivers: • 1915 (b) - to mandate participation • 1915 (c) - to provide home and community-based services

4. STAR+PLUS Program Funding • STAR+PLUS is funded by federal and state monies • The STAR+PLUS Medicaid pilot integrates funding for acute care services traditionally paid for by TDH with funding for long term care services traditionally paid for by DHS into one funding stream

5. STAR+PLUS Objectives • Provide the appropriate amount and types of services to help individuals stay as independent as possible • Serve people in the least restrictive community-based setting consistent with their safety needs • Improve care access, quality and outcomes • Increase accountability for care, and • Control costs

6. STAR+PLUS History Policy Initiatives/Enabling Legislation • August 1993 - pilot for “State of Texas Access Reform” (STAR), to provide Medicaid services through a capitated HMO and PHP single health care delivery system in Travis County • 1995 - Senate Bill 10 (SB10) authorizes Texas Health and Human Services Commission (HHSC) to comprehensively restructure the statewide Texas Medicaid program incorporating managed delivery systems • 1995 - Senate Concurrent Resolution (SCR55) directed the Texas Medicaid Office to develop: • an integrated managed care pilot program for long-term care for the elderly and persons with disabilities; and • an integrated managed care pilot program for mental health and substance abuse services

7. STAR+PLUS History Continued • 1997 - HHSC to contract with at least one HMO in each managed care service area either managed or created by a hospital district in that region • November 1997 - STAR expanded into the Harris Service Area (Houston) • January 1998 - STAR+PLUS pilot program was introduced in the Harris Service Area • September 1999 - removed nursing facility residents from mandatory STAR+PLUS enrollment

8. Medicaid Organization in Texas

9. STAR+PLUS Program Contractors • Texas Department of Human Services (DHS) is the state STAR+PLUS contract holder • State contracts with Health Plans to provide: • Care Coordination • Acute care • Institutional and community based long term care • Behavioral health services • Two health plans operate STAR+PLUS in Harris County • Health plans contract with providers for delivery of care

10. STAR+PLUS Health Plans • Amerigroup • HMO Blue (Administered by Lifemark) • Texas Health Network (PCCM)

11. STAR+PLUS Enrollment • Maximus - state contracted enrollment broker • Mails potential enrollees STAR+PLUS enrollment kit • Individuals have 30 days to make an active choice of plan and primary care provider (PCP) • Potential enrollee • Returns enrollment form via mail • Completes an enrollment form at an enrollment event, or • Calls Maximus and enrolls via phone • Default • Individuals who do not make an active enrollment choice are assigned a plan and a PCP

12. STAR+PLUS Enrollment Continued • Community education prior to STAR+PLUS roll-out • Public hearings • State in partnership with HMOs • Maximus • Provider Associations • Maximus outreach to STAR+PLUS enrollees • Home visits on request • Targeted enrollment fairs (DAHS, Community Centers, Nursing Facilities) • Partnerships with Community Based Organizations • Follow up telephone contact • Closed caption videos, audio tapes, multi-languages

13. STAR+PLUS Enrollment Continued • Voluntary Enrollment • January, February, March 1998 • Mandatory Enrollment and Default • April 1998

14. STAR+PLUS Default Methodology • Maximus administers the default process • Follows the STAR default methodology • Percentage of default is driven by plan performance on elective enrollments • Order for assigning a recipient to a plan and PCP is determined by: • Prior enrollment history with a plan and PCP • Claims history • Proximity

15. STAR+PLUS Eligibility Criteria • Resident of Harris County (Houston)Texas • Elderly or have a physical or mental disability and qualify for Supplemental Security Income (SSI) benefits or for Medicaid due to low income • Financial eligibility established by the Social Security Administration (SSA) for SSI, or by DHS for Medical Assistance Only (MAO)

16. STAR+PLUS Eligibility Criteria • Mandatory Participation: HMO • SSI-eligible (or would be except for COLA) clients age 21 and over • MAO clients who qualify for the Community Based Alternatives (CBA) waiver • Clients who are Medicaid-eligible because they are in a Social Security exclusion program

17. STAR+PLUS Eligibility Criteria • Mandatory Participation: HMO or PCCM* • SSI clients under age 21 • MHMR clients diagnosed with Serious and Persistent Mental Illness (SPMI) * PCCM is only available to non-Medicare clients

18. STAR+PLUS Eligibility Criteria • Voluntary participation: HMO • Dual eligible clients under age 21

19. STAR+PLUS Eligibility Criteria • Excluded • STAR+PLUS HMO members who have been in a nursing facility for more than 120 days • Individuals already residing in a nursing facility at the time they become otherwise eligible for STAR+PLUS • Clients in several small limited waiver programs • Residents of Intermediate Care Facilities for the Mentally Retarded (ICF-MR) • Clients not eligible for full Medicaid benefits (1929(b) program, QMB, SLMB, QDWI, undocumented aliens) • Individuals not eligible for Medicaid • Children in state foster care

20. STAR+PLUS CBA Eligibility • MAO Applicants for CBA Waiver Services • TDHS informs applicant that services are provided through an HMO and allows applicant to select HMO • TDHS informs selected HMO and requests pre-enrollment assessment be completed* • HMO completes: • Medical necessity form • CBA eligibility assessment • HMO provides results of assessment activities to TDHS * HMO is authorized payment for assessment regardless of final eligibility determination

21. STAR+PLUS CBA Eligibility • THDS notifies applicant and HMO of their eligibility determination • Applicant eligible: • HMO notified of applicant eligibility and effective date • Applicant will be enrolled in HMO • HMO will initiate ISP on date of enrollment • Applicant ineligible: • Applicant notified and provided information on their right to appeal the adverse determination • HMO not notified if applicant is ineligible

22. STAR+PLUS CBA Eligibility • SSI Member CBA Upgrades • Currently enrolled members who meet screening criteria based on TDHS Risk Assessment Indicator (RAI) • Care Coordinator completes: • Medical Necessity Form • MDS-HC • Complete Personal Attendant Services (PAS) tool • Assesses current equipment and supplies • Completes cover sheet • Submits to TDHS Regional Nurses for review and eligibility determination

23. STAR+PLUS CBA Eligibility • Denial of CBA Upgrade • Regional nurse notifies HMO • HMO authorizes identified medically necessary services • No increase in capitation • Approval of CBA Upgrade • Regional nurse notifies HMO • HMO authorizes identified medically necessary services • Member enters 120-day wait • At end of 120-days capitation increases to CBA payment amount

24. STAR+PLUS CBA Eligibility • CBA Annual Reassessments • Completed on all enrolled CBA waiver members • Up to 120-days prior to expiration of ISP • Care Coordinator completes: • PAS Tool and MDS-HC • Assesses member for equipment and supplies • Completes Medical Necessity Form • Completes CBA cover sheet • Assessments completed and forwarded to TDHS Regional Nurses

25. STAR+PLUS Population • STAR+PLUS is the largest population enrolled in an integrated, acute and LTC managed care model in the country • 47% of the STAR+PLUS population are dual eligibles • Approximately 18% of the STAR+PLUS population are members under the age of 21 • 2.7% of the STAR+PLUS population are CBA waiver members • 7% of the STAR+PLUS population have the diagnosis of SPMI • 85% of the total mandatory enrollees selected the HMO model

26. STAR+PLUS Current Enrollmentas of 10/01/2001 • HMO Blue STAR+PLUS 28,092 • Amerigroup STAR+PLUS 20,242 • Texas Health Network (PCCM) 8,235 STAR+PLUS Totals 56,569

27. STAR+PLUS Services • Acute care services (Medicaid only members) • Long term care services • Behavioral Health • Care coordination • Value added services

28. STAR+PLUSAcute Care Services • Hospital • Inpatient • Outpatient • Professional • Physician or physician extenders • Certified Nurse Midwife (CNM) • Lab and X-ray • Podiatric services • Vision • Ambulance services • Home health services/limited DME

29. STAR+PLUSAcute Care Services • Hearing Aid Services • Chiropractic • Ambulatory Surgical Center Services • Certified Nurse Midwife Services • Birthing Center • Maternity Clinic Services • Transplant Services • Adult Well Check • Family Planning

30. STAR+PLUSAcute Care Services • Genetics • EPSDT Medical Screens • EPSDT Comprehensive Care Program (CCP) • Non-emergent Screening and stabilization fees • Renal Dialysis • Total Parenteral Hyperalimentation (TPN) • PT/OT/Speech Therapies • Behavioral Health

31. STAR+PLUSCarve Out Services • EPSDT Dental (including Orthodontia) • Early Childhood Intervention (ECI) • MHMR Targeted Case Management • Mental Retardation Diagnostic Assessment (MRDA) • Mental Health Rehabilitation • Pregnant Women and Infants Case Management (PWI) • Texas School Health and Related Services (SHARS) • Texas Commission for the Blind (TCB) • Tuberculosis (TB) Clinic Services

32. Excluded STAR+PLUS • Pharmacy • Unlimited prescription for: • Medicaid only • Less than 21 • CBA • Duals who join same HMO for Medicaid and Medicare • 3 prescriptions per month: • Duals enrolled for Medicaid LTC services only

33. STAR+PLUSLong Term Care Services • Day Activity and Health Services (DAHS) • In Home Respiratory Care Services • Nursing Facility Care (first 120 days after admission) • Personal Assistance Services

34. STAR+PLUS CBA Waiver Services • Adaptive aids • Adult foster home services • Assisted living/residential care services • Emergency response services • Medical supplies • Minor home modifications • Nursing services • Occupational therapy • Personal assistance services

35. STAR+PLUS CBA Waiver Services • Physical therapy • Respite care • Speech language therapy services • Home delivered meals • Durable medical equipment

36. STAR+PLUS HCBS Alternative Residential Settings • Assisted Living/Residential Care Facilities • Adult Foster Care • Personal Care Homes • Nursing Facilities • First 120 days of long-term placement • Subacute short-term stays

37. STAR+PLUS Behavioral Health Services • Under age 21 • Early screening, diagnosis and treatment of behavioral disorders • Psychiatric hospital/facility (freestanding) • Hospital - inpatient services - mental health and chemical dependency treatment • Licensed master social workers - advanced clinical practitioners (LMSW - ACPs) • Licensed professional counselors (LPCs) • Psychology • Psychiatry • Chemical dependency treatment

38. STAR+PLUS Behavioral Health Services • Age 21and over • Screening for behavioral health disorders • Hospital - inpatient services - mental health and chemical dependency treatment • Licensed master social workers - advanced clinical practitioners (LMSW -ACPs) • Licensed professional counselors (LPCs) • Psychology • Psychiatry • Chemical dependency treatment

39. STAR+PLUS Value Added Services • In addition to all traditional Medicaid and other mandatory services, each STAR+PLUS HMO offers its own set of “value added” services. • Over and above services paid for by the state • Incentives for members to join • All HMOs offer CBA waiver services to members not in a waiver slot if service is medically necessary • PCCM model does not offer value added services

40. STAR+PLUS Value Added Services • Examples: • Transportation assistance • Adult dental • Eyeglasses • Medication dispensers • Smoke detectors • Pest control • Medical alert ID • Nightlights • Bathmats

41. STAR+PLUS Value Added Services • Examples behavioral health: • Partial hospitalization/extended day treatment • Intensive outpatient/day treatment • Off-site services • Forensic services • Freestanding psychiatric facility • Residential services • Crisis clinics • Team interventions

42. STAR+PLUS Healthplan Structure • Member services • Care coordination • Utilization management • Quality management • Network management • Claims and encounters • Finance

43. STAR+PLUS Network • Significant Traditional Providers (STPs) • Template contracts require state approval • Language for mandatory provisions supplied by state • Texas Medicaid certification • Credentialing/recredentialing • Network adequacy/geographic accessibility • PCPs 24/7 access

44. STAR+PLUS Network • Long Term Care Providers • Network built through contracts with STP providers contracted with TDHS • State Licensed • Enrolled as Medicaid providers • Credentialing and oversight policies and procedures developed by HMO

45. STAR+PLUS Care Coordination • Qualified and trained personnel to serve as contact for members • Telephonic team in office • Field team set up with the technology to work from home • Care Coordinator Associates assist field team telephonically acting as liaisons between the member, Care Coordinator and physician and/or provider(s)

46. Care Coordinator • Texas licensed registered nurse (RN) or licensed vocational nurse (LVN) • Master level social worker (LMSW) • Unlicensed (telephonic staff) • Coordinate, facilitate, investigate, advocate • Foster a person-centered approach • Liaison with member, family, caregiver, PCP

47. Care Coordination Responsibilities • Assess members for service needs • Facilitate/coordinate services with the member’s PCP • Intervene to assure appropriate care is provided • Placement options • Cost effectiveness • Ensure member’s health needs are met • Act as plan resource • Member/patient advocate • Coordination of benefits with other payers

48. Care Coordination Responsibilities - Assessments • New enrollees - health status/orientation within 30 days of enrollment • Transitioning members - within 30 days of enrollment • All members over 21 years of age receiving long term care services - Minimum Data Set (MDS-HC) • Initial assessment • Pediatric assessment • Maternal/child assessment • Personal Attendant Services scoring tool • Risk Assessment Indicator (RAI) • Medical necessity determination

49. Care Coordination Model • Who • RN or licensed Master’s level social worker (with specific cultural and linguistic expertise) • Responsibilities • Coordinator, facilitator, investigator, liaison, advocate, empowered to authorize services • Leads team of service providers • Close collaboration with medical providers, patient, and family • Knowledge of TPL/Medicaid/Medicare resources Care Coordinator Member Family or Representative PCP Summary: Care Coordinators are the key to establishing a comprehensive, individualized Plan of Care to serve the member in the least restrictive environment, with the most quality oriented, cost effective care/services.

50. Care Coordination Model Overview • All plan members are assigned to a care coordinator • Promotes member/care coordinator relationship • “Across the board” integration of member education • Incorporates a disease management approach • Integration of acute and long term care into a unique individual care plan • Plan transitions • Coordination with community resources • Discharge planning • Post-hospitalization follow up