Texas Medicaid Managed Care Basics

1. Texas Medicaid Managed Care Basics Michelle Apodaca John Berta November 2011

2. Topics • Key Features • Managed Care Operations • Managed Care Contracting • Resources • Reimbursement and Out-of-Network Issues

3. STAR Service Areas – March 1, 2012

5. Rural Service Areas – March 1, 2012

7. STAR+PLUS Service Areas – March 1, 2012

9. CHIP Service Areas March 1, 2012

11. What is Managed Care? • Term used to describe a variety of techniques designed to ensure better access to health-care services; improve quality; promote more appropriate utilization of services. • Risk-based, Capitated payments to MCO. • Contains costs for the State and brings in $$ from Premium Tax paid by Medicaid MCOs.

12. Managed Care Features • Medical home • Defined network of providers • Utilization review and utilization management • Quality assessment and performance improvement

13. Managed Care Features (cont’d) • Each client may choose a PCP who is responsible for ensuring the continuity and quality of care. The PCP is also responsible for administering preventive and primary care, including medical screens and immunizations. • When specialized or acute care is necessary, the PCP serves as the manager of care by referring the client to other health care providers for those services.

14. Forms of Managed Care in Texas • STAR - primarily serves non-disabled children, low-income families, and pregnant women. • STAR Health - statewide program designed to provide coordinated health services to children and youth in foster care and kinship care. • Primary Care Case Management (PCCM) is a non-capitated network of PCPs and hospitals under contract with HHSC. (3/1/12 THIS PROGRAM WILL NO LONGER BE VALID). • STAR+PLUS. • Childern’s Health Insurance Program (“CHIP”).

15. STAR Program- Excluded populations Populations excluded from STAR include: • Supplemental security income (SSI) recipients. • Medicaid recipients in institutions. • Dual-eligible Medicaid recipients (clients with both Medicaid and Medicare). • Medically needy. • Foster children. • Refugees.

16. What is STAR+PLUS? • A managed care system for persons on SSI. • Integrates acute care and LTSS. • Dual eligibles enrolled for long-term care “insurance policy”. • Improved access to community based LTSS. • MCOs are responsible for coordinating acute and LTSS through the use of a service coordinator.

17. STAR+PLUS Members • Medicaid recipients who must participate in STAR+PLUS: • SSI adults who are not: • Residing in a Nursing Facility or other institution. • Being served through a Home and Community Based Waiver program other than Community Based Alternatives (CBA). • Non-SSI adults who qualify for 1915(c) Nursing Facility Waiver services must enroll in STAR+PLUS to receive those services. • Medicaid recipients who can choose to participate in STAR+PLUS: • SSI children, under age 21, may voluntarily enroll in STAR+PLUS. SSI children that do not volunteer will be in traditional Medicaid effective 09/01/2011.

18. STAR+PLUS Program Information • Service coordinator is 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: • Authorize community LTSS. • Arrange acute care services. • STAR+PLUS Medicaid only members can choose or be assigned a PCP. • Service coordinators are required to assist with Medicare physician and service coordination.

19. Maximus – Enrollment Broker • Eligibility Support Services and Enrollment Contractor for Medicaid, food stamps, TANF programs and for Children’s Health Insurance Program (CHIP); • Assists in educating clients who are enrolling in Medicaid managed care (STAR) and CHIP about health plan and PCP choices; • Enrolls clients in STAR and CHIP. • 1-800-964-2777, Monday through Friday, 8 a.m. to 8 p.m. Central Time.

20. Maximus – STAR Expansion • Introduction letters and FAQs sent to potential members beginning 10/17. • Enrollment packets will be sent between November 28th and January 15th. • Recipients can enroll any time after they receive the enrollment packets, but services in the expansion service areas will not begin until March 1st. If recipients return enrollment forms after cut-off in February (2/15/12), they cannot begin receiving services until April 1st.

21. Managed Care Operations

22. STAR and STAR+PLUS MCOs Contract Individually. Additional providers dependent on network. May limit network. MCOs are encouraged to contract with Significant Traditional Providers (STP). Contracting Method

23. Verify Eligibility • Health Plan ID Card. • State Medicaid 3087 Form. • Health Plan Website. • Contact the plan directly. • Automated Inquiry System (AIS). • Medicaid Eligibility SAVERR Authorization Verification System (MESAV). • For after hour eligibility verification, call the health plan.

24. Authorizations STAR and STAR+PLUS • Members are offered a choice of HMO network providers. • Authorization for services may be limited. • Authorizations are service specific. • HHSC will require the MCOs to honor TMHP prior authorizations for at least 3 months during initial transition.

25. STAR and STAR+PLUS Claims are paid by the MCO. Providers must file claims within 95 days of Date of Service (DOS). MCOs required to adjudicate within 30 days. Claims

26. STAR and STAR+PLUS Members may still appeal to HMO and/or file Fair Hearing request if services are denied, reduced, or terminated. Applicants are still notified by the State if determined not eligible. Appeals and Fair Hearings

27. Initial point of contact is MCO May submit written complaint to HHSC at hpm_complaints@hhsc.state.tx.us HHSC will deal with issues when MCO is not complying with HHSC contract Provider Complaints

28. HHSC Monitors MCOs • HHSC monitors the HMO performance quarterly for these key indicators: • Network Adequacy • Claims Processing time • Hotline Performance • Complaint processing • Additional contract requirements and performance is also monitored on ongoing basis.

29. HHSC Uniform contract with Plans

30. Managed Care Contract Provisions Between HHSC and MCOs • HHSC Uniform Managed Care Contract • http://www.hhsc.state.tx.us/medicaid/UniformManagedCareContract.pdf

31. Managed Care Contract Provisions • Definitions • Clean Claims • Underpayments, Overpayments and Recoupment • Covered Services • Enrollee or Member • Medically Necessary or Medical Necessity • Participating Provider • Policies & Procedures

32. Managed Care Contract Provisions • Credentialing • Utilization Review Obligations • Quality Assurance Program • Audit, Retroactive Review, Concurrent Review, etc. • Provider Insurance & Tail Coverage • Dispute Resolution • Never Events

33. Resources

34. Rules : Texas Administrative Code • TITLE 1ADMINISTRATION • 15 TEXAS HEALTH AND HUMAN SERVICES COMMISSION • CHAPTER 353 MEDICAID MANAGED CARE • SUBCHAPTER ESTANDARDS FOR THE STATE OF TEXAS ACCESS REFORM (STAR)

35. Rules – cont’d • §30.21 General Provisions • §30.22 Definitions • §30.23 Enrollment • §30.24 Marketing • §30.25 Selection of Managed Care Organizations (MCO) • §30.26 Scope of Services • §30.27 Accessibility of Services • 30.28 Managed Care Benefits and Services for Children Under 21 Years of Age • §30.29 Member Complaint Procedures • §30.30 Quality Improvement • §30.32 Financial Standards

36. Reimbursement • Check your contracts with health plans • Medicaid Manual and bulletins (http://www.tmhp.com/default.aspx)

37. Rural Hospitals – Rider 40 • 40. Payments to Hospital Providers. Until the Health and Human Services Commission (HHSC) implements a new inpatient reimbursement system for Fee-for-Service (FFS) and Primary Care Case Management (PCCM) or managed care, including but not limited to health maintenance organizations (HMO) inpatient services, hospitals that meet one of the following criteria: 1) located in a county with 50,000 or fewer persons according to the U.S. Census, or 2) is a Medicare-designated Rural Referral Center (RRC) or Sole Community Hospital (SCH), that is not located in a metropolitan statistical area (MSA) as defined by the U.S. Office of Management and Budget, or 3) is a Medicare-designated Critical Access Hospital (CAH), shall be reimbursed based on the cost-reimbursement methodology authorized by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) using the most recent data. Hospitals that meet the above criteria, based on the 2000 decennial census, will be eligible for TEFRA reimbursement without the imposition of the TEFRA cap for patients enrolled in FFS and PCCM. For patients enrolled in managed care other than PCCM, including but not limited to health maintenance organizations (HMO), inpatient services provided at hospitals meeting the above criteria will be reimbursed at the Medicaid reimbursement calculated using each hospital's most recent FFS rebased full cost Standard Dollar Amount for the biennium.

38. Rider 40 Considerations • Rates are Negotiated • Contract Terms are Negotiated • Hospitals that do not contract are considered out-of-network • Contracted hospitals need to follow contract terms

39. Uniform Managed Care Contract Manual : http://www.hhsc.state.tx.us/medicaid/UMCM/default.html

40. Uniform Managed Care Manual : http://www.hhsc.state.tx.us/medicaid/UMCM/default.html

41. Reports http://www.hhsc.state.tx.us/medicaid/mc/about/reports/confirmed_eligibles_report.html

42. MCOs provider relation staff http://www.hhsc.state.tx.us/medicaid/mc/ProviderInformation.html42

43. Rate Analysishttp://www.hhsc.state.tx.us/medicaid/programs/rad/ManagedCare/MngCare.html

44. Sanctionshttp://www.hhsc.state.tx.us/medicaid/ContractorSanctions/index.htmlSanctionshttp://www.hhsc.state.tx.us/medicaid/ContractorSanctions/index.html

45. Medicaid Managed Care Enrollmenthttp://www.hhsc.state.tx.us/research/index.html

46. 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 • HHSC STAR+PLUS Website: http://www.hhsc.state.tx.us/starplus/Overview.htm • TMHP Website: http://www.tmhp.com/Pages/PCCM/STAR_Expansion.aspx • Email: ManagedCare_Exp2011@hhsc.state.tx.us

47. Out of Network Providers

48. Out of Network - Considerations • Rates are Negotiated • Contract Terms are Negotiated • Hospitals that do not contract are considered out-of-network • Contracted hospitals are obligated to follow contract terms – (preauthorization, other) • Rules apply to out-of-network providers • MCO Adequate Network Requirements are in place

49. Out of Network Providers – HHSC Rules • Texas Administrative Code • Title 1 • Part 15 • Chapter 353 • Subchapter A • RULE §353.4 • Applies to MCO contracts executed after 8/31/2006

50. Out of Network – Patient Referrals • MCO shall allow referral to an out-of-network provider when: • Medicaid covered services are medically necessary and these services are not available through an in-network provider; • A provider currently providing authorized services to the member requests authorization for such services to be provided to the member by an out-of-network provider; and • The authorized services are provided within the time period specified in the MCO's authorization. And • The MCO shall: • Timely issue the proper authorization for such referral; and • Timely reimburse the out-of-network provider for authorized services provided.