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STATE of TEXAS ACCESS REFORM
STATE of TEXAS ACCESS REFORM
How does HHSC design a managed care program?
STAR Health
How is Texas Medicaid Managed Care changing?
Managed Care savings are from changing client health care utilization patterns, not from reducing payments to providers.
Enrolling SSI clients in a STAR+PLUS offers the most savings since this population has significant health care expenditures and the model integrates acute and long-term care (LTC) funding.
Enrolling the TANF population in managed care offers less opportunity for cost savings due to short enrollments, limited health care use, and high administrative costs.
The HMO model and the PCCM model have roughly the same cost saving projections for the TANF population. Due to premium tax paid by HMOs, the state realizes an additional savings from the capitated model.
Key Findings from Expansion Study
RuralService AreaMarch 2012
Urban Service Areas
March 2012
Contiguous Counties
September 2011
STAR+PLUS Dallas/Tarrant
February 2010
Building a Statewide Medicaid HMO Model
2010 2013
Percent of Medicaid Recipients in Managed Care
STAR HMO40.7%
STAR+Plus5.9%
Fee for Service27.8%
STAR PCCM24.7%
STAR Heath0.8%
No Exclusive Provider Organizations (EPO) until 2012Managed Care Expansion
STAR HMO52%
Fee for Service23.5%
EPO13.6%
STAR+Plus10%
STAR Health0.9%
Primary Care Case Management (PCCM) = 0 with Managed Care Expansion
HoodHoward
Presidio
BrewsterVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
KendallComal
Gillespie
Llano
Travis
Hays
Caldwell
BurnetWilliamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
VictoriaGoliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
CampMorris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
Bexar
Lubbock
Harris
El Paso
Dallas *
HHSC, Health Plan OperationsSeptember 2010
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
Travis
Orange
Sabine
Newton
Colorado
Houston
Tarrant *
Nacogdoches
San Jacinto
Jasper
Nueces
Washington
JeffersonChambersHarris
Hidalgo
Jefferson
HHSC Managed Care Service Areas
Carved-In Services Effective March 2012
New Carved-In Services March 2012
9/1/11
•Therapists enroll independently as providers with TMHP.* MCO may require therapists to go through a credentialing process.
•PT, OT, and ST evaluations are billed to MCO.•Nutrition, audiology and counseling services are billed to MCO.•TCM services are billed to TMHP.• SST services are reported in TKIDS and billed by DARS ECI.•Ongoing PT, OT and ST services are reported in TKIDS and billed by DARS ECI.
10/1/11
•Therapists enroll independently as providers with TMHP.* MCO may require therapists to go through a credentialing process.
•PT, OT, and ST evaluations are billed to MCO.•Nutrition, audiology and counseling services are billed to MCO.•TCM services are billed to TMHP.• SST services are billed to THMP under same provider enrollment as ECI/TCM enrollment•Ongoing PT, OT and ST services are billed to THMP under same provider enrollment as ECI/TCM
enrollment
3/1/12
•March 1, 2012*NEW MCO areas and NEW MCOs•Therapists enroll independently as providers with TMHP.* MCO may require therapists to go through a
credentialing process. •PT, OT, and ST evaluations are billed to MCO.•Nutrition, audiology and counseling services are billed to MCO.•TCM services are billed to TMHP.• SST services are billed to THMP under same provider enrollment as ECI/TCM enrollment.•Ongoing PT, OT and ST services are billed to MCOs.
ECI: Children Enrolled in Managed Care
Source: DARS webinar, August 2011
9/1/11
•Therapists enroll independently as providers with TMHP.* MCO may require therapists to go through a credentialing process.
•PT, OT, and ST evaluations are billed to MCO.•Nutrition, audiology and counseling services are billed to MCO.•Psychological and counseling services are billed to the BHO (Value Options).•TCM services are billed to TMHP.• SST services are reported in TKIDS and billed by DARS ECI.•Ongoing PT, OT and ST services are reported in TKIDS and billed by DARS ECI.
10/1/11
•Therapists enroll independently as providers with TMHP.* MCO may require therapists to go through a credentialing process.
•PT, OT, and ST evaluations are billed to MCO.•Nutrition, audiology and counseling services are billed to MCO.•Psychological and counseling services are billed to the BHO (Value Options).•TCM services are billed to TMHP.• SST services are billed to THMP under same provider enrollment as ECI/TCM enrollment•Ongoing PT, OT and ST services are billed to THMP under same provider enrollment as ECI/TCM
enrollment
3/1/12
•March 1, 2012*NEW MCO areas and NEW MCOs•Therapists enroll independently as providers with TMHP.* MCO may require therapists to go through a
credentialing process. •PT, OT, and ST evaluations are billed to MCO.•Nutrition, audiology and counseling services are billed to MCO.•Psychological and counseling services are billed to the BHO (Value Options).•TCM services are billed to TMHP.• SST services are billed to THMP under same provider enrollment as ECI/TCM enrollment.•Ongoing PT, OT and ST services are billed to MCOs.
ECI: Children Enrolled in Managed Care in Dallas SA
Source: DARS webinar, August 2011
Carved-Out Services Impacting Community Centers
Mental Health Rehabilitation Skills Training
Mental Health Case Management
IDD Case Management
Persons in IDD Waivers
This is not a change. Centers bill the State, through TMHP, for carved-out services.
Who are the Managed Care plans?
Statewide Marketshare
Andrews, ACCESS and Community Health Core have all counties in the NorthEast Medicaid Rural Service Area.
Northeast MRSA
STAR
AmerigroupSuperior
CHIP
MolinaSuperior
STAR HealthSuperior (Cenpatico)
There are no changesin plans operating in STARHealth statewide.
What is HHSC’s financing strategy?
$5.6 Billion Revenue(SFY 2010, including CHIP Dental)
Health Plan Medical Expenditures
Trends in Growth and Medical Inflation
Administrative Fee
Risk Margin
Community Rate
Acuity Factor
Health Plan
Specific Rate
Medical Loss Ratio
John Smith pays $100 for insurance.
His medical bills total $70.
The insurance company keeps $30.
Medical Loss Ratio = 70%
HHSC does not require a minimum Medical Loss Ratio.
HHSC does require an Experience Rebate.
Pre-Tax Incomes as a % of Revenue
HMO Share
HHSC Share
< 3% 100% 0%
> 3% and < 7% 75% 25%
> 7% and < 10% 50% 50%
> 10% and < 15% 25% 75%
> 15% 0% 100%
STAR Formula, Contract Period 1-3
SFY 2010 HMO Net Income $ 150,135,000Experience Rebates $ (62,143,000)Final Profit $ 87,992,000
Finances are reported and monitored through the HMO Financial Statistical Report
Summary Reports are available on-line
Detailed Reports, including a line-item for behavioral health expenditures, are available upon request
--------------------------------------------------------------------------------------------------------------------------------------Slide 15. Read the quote
See Handout on Medicaid Health Plan FSR
How does HHSC define quality?
Quality Monitoring
Quarterly Performance
BH Crisis Hotline Provider Hotline Member Complaints Provider Complaints BH Claims Timeliness
External Quality Reports
Quality of Care Measures Enrollee Surveys Select Topics Legislative Studies
See Handouts on Annual Chart Book and Quarterly Measures
Does HHSC think about behavioral health?
See Handout on Managed Care RFP
How can Centers be successful in a Managed Care environment?
Get SmartCreate RelationshipsQuantify ChallengesPropose Solutions
Letters of Intent
1911821657/
Which company holds the contract with the State?
Who do you need to contract with for provider services?
What’s the plan’s financial performance?
How is the quality of care and outcome data for the plan?
What did the plan propose in the RFP response?
What is required in the HHSC RFP and contract?
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Get SmartCreate RelationshipsQuantify ChallengesPropose Solutions
It takes a lot to get paid.
Contract NegotiationCredentialingAuthorizationBillingAppealsPayment
HMOs don’t understand us.
Specialized ServicesAdministrative CapabilityCommunity RelationshipsPurpose of General Revenue
Contract Negotiation = 30-90 days• HMO sends template for review• Provider reviews contract language and rates and proposes changes• HMO review of changes and sends revised template• Provider signs contract, with Board approval if required• HMO conducts a facility site review• HMO signs contract once credentialing thresholds are met• HMO loads fee schedule into system
Credentialing and Loading = 45-120 days• HMO sends credentialing information, requirements vary by HMO• Provider complies with requirements and sends in necessary information• HMO reviews and sends to credentialing committee if required• Agency or individual provider is credentialed• HMO loads agency or provider into system, or Center loads agency or provider into
system
Billing and Payment = 30-180 days• Provider requests and receives preauthorization, if required• Provider provides service, documents and bills• HMO adjudicates clean claim as paid, denied or pended within 30 days• HMO rejects unclean claim within 30 days• Provider appeals denials, pends or rejections to HMO• HMO reviews appeals and makes a determination to pay or deny• Provider appeals to HHSC if necessary
It takes a lot to get paid.
Get SmartCreate RelationshipsQuantify ChallengesPropose Solutions
Texas Council Managed Care Webpagehttp://www.txcouncil-intranet.com/texas-council-initiatives/managed-care-page/
HHSC Managed Care Proposals Websitehttp://www.hhsc.state.tx.us/medicaid/MMC-Proposals.shtml
Client Education Events Calendar www.txmedicaidevents.com
Provider Training and Informationhttp://www.tmhp.com/Pages/PCCM/PCCM_Home.aspx
RESOURCES
Melissa RowanHealthcare Policy DirectorTexas Council of Community [email protected] ext 109
Texas Council Managed Care Webpagehttp://www.txcouncil-intranet.com/texas-council-initiatives/managed-care-page/For a user name and password contact: [email protected]
