Managed Care Long Term Care Model The Texas Experience Presentation to: San Diego County LTCIP...

Managed Care Long Term Care ModelThe Texas Experience

Presentation to:

San Diego County LTCIP

October 26, 2001

Cindy Adams

Long Term Care - The Texas ExperienceOctober 26, 2001 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


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


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


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


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


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


Medicaid Organization in Texas


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


STAR+PLUS Health Plans

Amerigroup

HMO Blue (Administered by Lifemark)

Texas Health Network (PCCM)


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


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


STAR+PLUS Enrollment Continued

Voluntary Enrollment January, February, March 1998

Mandatory Enrollment and Default April 1998


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


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)



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



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



Voluntary participation: HMO Dual eligible clients under age 21



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


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



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



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



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



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


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


STAR+PLUS Current Enrollment as 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


STAR+PLUS Services

Acute care services (Medicaid only members) Long term care services Behavioral Health Care coordination Value added services


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



Hearing Aid Services Chiropractic Ambulatory Surgical Center Services Certified Nurse Midwife Services Birthing Center Maternity Clinic Services Transplant Services Adult Well Check Family Planning



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


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


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


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


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


STAR+PLUS CBA Waiver Services

Physical therapy Respite care Speech language therapy services Home delivered meals Durable medical equipment


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


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


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


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



Examples: Transportation assistance Adult dental Eyeglasses Medication dispensers Smoke detectors Pest control Medical alert ID Nightlights Bathmats



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


STAR+PLUS Healthplan Structure

Member services Care coordination Utilization management Quality management Network management Claims and encounters Finance


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


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


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)


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


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


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


Care Coordination Model

Care Coordinator

Family orRepresentative

PCP

Member

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.

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 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


Care Coordination Assignment

Service - driven based on: Risk group placement Acute episodic events Health Status Screen/review Disease management Transition from:

DHS care plan Individual Service Plans (CBA) Other program contractors


Level I Average caseload 1:1800

Telephone care coordination Stable population with episodic support Authorizations done by licensed staff

Staffing includes non-licensed, LVN, LMSW and RN Orientation/Health Status Screen

Initial and annual HSS “Unable to Locate” - attempt to reach member every 6 months

Assignment criteria: Authorizations for short term needs, I.E. Respite, 1x only DME


Level 2Average caseload 1:150

Field and Telephonic Care Coordination Members receiving LTC services Adult Day Care (DAHS) All Licensed staff Care Coordinator Associates Reassessments every 90 -180 days Field Assessments

CBA/SSI upgrade MDS-HC completion

Assignment criteria Adult Day Care (DAHS), PAS <120 hrs per month, ER/Hosp visits = 2 within 6 months


Level 3Average caseload 1:200

Field care coordination Members receiving CBA services All licensed staff Care coordinator associates Reassessments <90 days Field assessments

CBA/SSI upgrade MDS-HC

Assignment criteria CBA Members


Continuum of LTCPlacement Options

MostRestrictive

Home orApartment

DAHS

Assisted Living/Residential Care

Personal Care Home

Adult FosterCare Home

AdultCare

Home

SkilledNursing Facility

Specialty Unitwithin a

nursing facility

LeastRestrictive


Care Coordinator Associate Support

Member/care coordinator liaison Direct member contact Assigned to care coordinators

Ratio 1:4 Assist care coordinators with:

Post E.R. Follow up Fax/mail authorizations Transitional notifications Provider/PCP contact with service DS. Care coordination caseload reports Produces monthly reports


Care Coordination Integration with Concurrent Review

Authorization Tech and/or Nurse

Member

Care Coordination

Hospital Case Manager/ Discharge Planner

Physician PCP

Concurrent Review


Case Management Information Systems Care Management

Assessments Cost effectiveness studies/care plan modeling Care plans Case notes Eligibility and claims Placements Extended authorizations

MDS-HC Ability to complete and transmit member data to the State


STAR+PLUS Capitation

DHS pays health plans prospectively on a capitated, per

member per month basis by client risk group

There are six risk groups with amounts differing by

Medicare status, care setting and status at enrollment

Rates for Medicaid only members are higher than those

for dual eligibles to reflect HMO liability for acute care

Capitation rates are discounted 2% from projected fee-for-

service nursing facility costs and 5% from projected fee-

for-service acute and long term care costs


Development of STAR+PLUS Capitation Rates

Information used in rate development: Reduced fee-for-service (FFS) methodology Calendar year 1997 FFS experience data trended forward Relativity factor for Harris Co. Assumed all-plans cost increase of 6% (FY2002)

Assumptions STAR+PLUS program must be cost neutral so aggregate

claims and average costs become the balancing items with PCCM and FFS

Equitable distribution of risk among plans Costs for CBA waiver members are comparable to 1997

FFS nursing facility claims costs


STAR+PLUS Capitation

Risk Group Medicaid OnlyRates

# of Eligibles* Dual Eligible Rates # of Eligibles

Community clients 597.34 20499 96.13 26178

CBA Waiver clients 3012.60 437 1523.62 1111

Nursing facilityclients

597.34 41 96.13 68


STAR+PLUS Capitation Continued

Rate Analysis UnitTexas Medicaid Star+Plus Managed Care Program

Risk Group Medicaid-only Members Medicare/Medicaid Membersand Base Harris County Base Harris County

Type of Service Cost PR%1 CM2 Amount Cost PR%1 CM2 Amount

Other Community CareAcute Care

Basic Services 540.41 100% 1.00 540.41Physician Pass-through 0.36 100% 1.00 0.36Outpatient Pass-through 4.12 100% 1.00 4.124 months of new NFs/CBAs 1.01 100% 1.00 1.01

Acute Care Total 545.90Discount rate3 5.0%

Capitation Rate 518.83Long-term Care

Primary Home Care Services 567.22 10% 1.23 69.77 539.72 15% 1.26 102.01Day Activity Health Services 460.31 3% 1.14 15.74 453.42 2% 1.09 9.884 months of new NFs 1.83 100% 1.00 1.83 3.53 100% 1.00 3.534 months of new CBAs 0.82 100% 1.00 0.82 0.92 100% 1.00 0.92Case management services 3.32 100% 1.00 3.32 4.22 100% 1.00 4.22

Long-term Care Total 91.48 120.56Discount rate 5.0% 5.0%

Capitation Rate 86.91 114.53

OCC Capitation Rate 605.74 114.53

Proposed Capitation Rates for State Fiscal Year 2002

Texas Health and Human Services Commission


STAR+PLUS Capitation Continued

Community-based Alternatives

Acute CareBasic Services 1,413.40 100% 1.00 1,413.40Outpatient Pass-through 4.12 100% 1.00 4.12

Acute Care Total 1,417.52Discount rate3 5.0%

Capitation Rate 1,346.85Long-term Care

Basic Services 1,211.52 100% 1.00 1,211.52 1,113.30 100% 1.00 1,113.30Case management services 115.89 100% 1.00 115.89 115.89 100% 1.00 115.89

Long-term Care Total 1,327.41 1,229.19Discount rate 5.0% 5.0%

Capitation Rate 1,261.04 1,167.73

CBA Capitation Rate 2,607.89 1,167.73

1 The Star+Plus participation rate (PR%) is used to adjust the cost per utilizer to the cost per member-month. Itis the estimated number of utilizers divided by the estimated number of member-months expressed as a percentage.

2 The Star+Plus cost multiplier (CM) is used to adjust for the historically higher than average cost per utilizer in HarrisCounty and to adjust for the expected higher than average cost per utilizer arising from the shifting in emphasis fromhigh-cost services (CBA and NF) to low-cost services (PHC and DAHS).

3 No discounts are applied to pass-through amounts.


Risk Adjusters

Risk Adjusters Medicare status Waiver status Geographic relativity factor

Harris County - 14% higher medical costs that statewide average

Share of Cost Members are required to contribute toward the cost of their care

based on their income and type of placement Provider is responsible for collecting the SOC HMO payment to facility is based on total payment due facility

less the member’s SOC


Risk Sharing

HMOs retain the first 3% of any profit, but split equally with the state any profit between 3 and 7 percent

Any profit over 7 percent must be paid back to the state


STAR+PLUS Statutory and Regulatory Compliance

Compliance with federal, state and local laws Program integrity Fraud & abuse compliance plan Confidentiality Non-discrimination Notice and appeal

HMO process State appeal process


STAR+PLUS Statutory and Regulatory Compliance Continued

Quality Management

Quality improvement program (QIP) system

Written QIP plan

Summary report of member and provider complaints

Utilization reports


STAR+PLUS Quality Indicators Focus Studies

Depression Breast Cancer Screening Diabetes in Adults

Semi-annual UM Reports Behavioral Health Physical Health Long Term Care

Medical Record Audit Provider Satisfaction Member Satisfaction


Reporting/State Monitoring

Financial reports Statistical reports Arbitration/Litigation Claims report Summary Report of Provider Complaints Provider Network Reports Member Complaints Fraudulent Practices Utilization Management Reports

Behavioral, Physical and LTC Quality Improvement Reports HUB Quarterly Reports THSteps (EPSDT) Reports Encounters


STAR+PLUS Program Outcomes

November 2000 - HHSC Medicaid Managed Care Review reported the to the Texas Legislature:

STAR+PLUS has increased the number of available long-term care providers

In SFY 99, Primary Home Care utilization was higher than projected

Day Activity and Health Services utilization was lower than projected

Increased access to community-based long term care services in comparison to statewide average


STAR+PLUS Program Outcomes (Continued)

Utilization of new generation medications by individuals with serious mental illnesses increased both statewide and in Harris Co., but the Harris Co. increase did not occur until the implementation of STAR+PLUS

Inpatient hospital utilization decreased for this population From January 1998 through August 1999 total STAR+PLUS

savings was $2,171,085


Lessons Learned

Care Coordination is the key to integration of acute and LTC services

Single point of contact True integration when all services are managed by one entity

Coordination of benefits important for dual eligibles when HMOs are only responsible for LTC

Education of all providers and stakeholders is key Collaboration between competing HMOs and State is an

essential piece of successful model Program supports the Olmstead requirements


Recommendations

Structure 1915 (c) waiver to allow for cost-effective community-based services provided in the least-restrictive setting (supports Olmstead decision)

Allow for staggered phased-in enrollment Eliminate PCCM Include mechanism for upgrades of members to CBA waiver

status without decreasing waiver slots Implement and monitor the effectiveness of all HMOs using

standard forms for processes related to: Clean claims definitions and requirements Standard referral form Standard credentialing package

Case management controlled or delegated by health plan Integrate LTC and acute services into one program


Recommendations

Allow new entrants who have LTC experience into the market through a competitive bid process

Utilize 6 month lock-in or 6 month continuous eligibility to ensure continuity of care

Include nursing facility population for a full continuum of care

Utilize an HMO model that integrates acute and LTC services into one program with Care Coordination as the cornerstone


Recommendations (continued)

Mandatory vs. voluntary enrollment Member issues/outreach and education important Adverse selection - potential with voluntary enrollment Critical mass

Eligibility determination Financial Member/functioning

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