star+plus harris county
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Medicaid Managed Care for Elderly and Persons with Disabilities Pam Coleman Texas Health and Human Services Commission October 11, 2006. Pilot implemented in Harris County (Houston) in 1998 Risk-based, capitated managed care - PowerPoint PPT PresentationTRANSCRIPT
Medicaid Managed Care for Medicaid Managed Care for Elderly and Persons with Elderly and Persons with
DisabilitiesDisabilities
Pam ColemanPam ColemanTexas Health and Human Services CommissionTexas Health and Human Services Commission
October 11, 2006October 11, 2006
STAR+PLUSSTAR+PLUSHarris CountyHarris County
Pilot implemented in Harris County (Houston) in 1998
Risk-based, capitated managed care Integrates Medicaid funding and service delivery Integrates Medicaid funding and service delivery
of long term and acute careof long term and acute care Serves 60,000 aged and disabled not in a nursing
facility
Why STAR+PLUS?Why STAR+PLUS? Legislative direction (SCR 55, 74Legislative direction (SCR 55, 74thth session) session)
Improve coordination of physical health care needs Improve coordination of physical health care needs with personal care needswith personal care needs
Improved access to community based long-term care Improved access to community based long-term care support servicessupport services
Promote coordination of Medicaid and MedicarePromote coordination of Medicaid and Medicare
Increase cost effectivenessIncrease cost effectiveness
Texas Medicaid Texas Medicaid ExpendituresExpenditures
0%10%20%30%40%50%60%70%80%90%
100%
Clients Dollars
DisabledAgedAdultsChildrenOther
Texas Medicaid in Perspective, HHSC, April 2004Texas Medicaid in Perspective, HHSC, April 2004
Children, Adults and Other are 74% of the Medicaid population and 37% of costs. Aged and Disabled are 20% of the Medicaid population but 62% of costs (all funds). Total $18 Billion Total $18 Billion
HMOHMO PCCMPCCM FFSFFS TotalTotal
FY2006FY2006 809,418809,418(31%)(31%)
970,931970,931(35%)(35%)
932,599932,599(34%)(34%)
2,770,2682,770,268
FY2007FY2007 1,060,3581,060,358(42%)(42%)
760,071760,071(27%)(27%)
848,502848,502(30%)(30%)
2,791,4822,791,482
FY2008FY2008 1,134,8511,134,851(45%)(45%)
732,521732,521(25%)(25%)
852,094852,094(30%)(30%)
2,877,9522,877,952
Texas MedicaidTexas Medicaid Managed Managed Care GrowthCare Growth
STAR+PLUS MembersSTAR+PLUS Members
Supplemental Security Income (SSI) adults who are not in Supplemental Security Income (SSI) adults who are not in a nursing facility or other institution and who are not a nursing facility or other institution and who are not currently being served through a Home and Community currently being served through a Home and Community Based Waiver program, other than Community Based Based Waiver program, other than Community Based Alternatives (CBA), Alternatives (CBA), must enrollmust enroll in STAR+PLUS. in STAR+PLUS.
Non-SSI adults who qualify for 1915 (c) Nursing Facility Non-SSI adults who qualify for 1915 (c) Nursing Facility Waiver services Waiver services must enrollmust enroll in STAR+PLUS to receive in STAR+PLUS to receive those services.those services.
SSI children, under age 21, may SSI children, under age 21, may voluntarilyvoluntarily enroll in enroll in STAR+PLUS.STAR+PLUS.
HMO Member HMO Member BenefitsBenefits
Traditional Medicaid benefit packageTraditional Medicaid benefit package Unlimited Prescription drugs (Medicaid only)Unlimited Prescription drugs (Medicaid only) Annual adult well checksAnnual adult well checks Removal of limit for length of stay for hospitalization Removal of limit for length of stay for hospitalization
(STAR only)(STAR only) PCP provider directoriesPCP provider directories PCP coordinates health care of patientPCP coordinates health care of patient 24-hour nurse helpline (through their health plan)24-hour nurse helpline (through their health plan) Member services helpline (through their health plan)Member services helpline (through their health plan) Member handbooks and health educationMember handbooks and health education Case management for members with special health Case management for members with special health
care needscare needs
STAR+PLUS LTC ServicesSTAR+PLUS LTC Services
Personal assistancePersonal assistanceDay activity and Day activity and healthhealth1915(c) waiver 1915(c) waiver servicesservicesAdaptive aidsAdaptive aidsAdult foster home Adult foster home Assisted livingAssisted living
Medical suppliesMedical suppliesHome modificationsHome modificationsRespite careRespite careTherapiesTherapiesEmergency responseEmergency response
Contracting MethodContracting Method
DADSDADS– Open EnrollmentOpen Enrollment
– LicensureLicensure
– Contract Contract
– Program specificProgram specific
STAR+PLUS HMOSTAR+PLUS HMO– Negotiated IndividuallyNegotiated Individually
– Additional providers Additional providers dependent on network dependent on network adequacyadequacy
– Contract by service, not Contract by service, not programprogram
– May add licensed providers May add licensed providers that are not contracted with that are not contracted with DADSDADS
Rates Rates
DADSDADS– Established on a Established on a
statewide basis for statewide basis for each program.each program.
– Based on cost reports Based on cost reports filed by providersfiled by providers
– Same for all providers Same for all providers
STAR+PLUS HMOSTAR+PLUS HMO– Negotiated with each Negotiated with each
providerprovider
– May establish fixed rates May establish fixed rates for each service or can for each service or can negotiate different ratesnegotiate different rates
– Provider can offer Provider can offer additional service for additional service for additional compensationadditional compensation
AccessAccess
DADSDADS– Individuals needing Individuals needing
assistance must contact assistance must contact DADS or be referred DADS or be referred by family, provider or by family, provider or community for community for assessment and assessment and authorizationauthorization
STAR+PLUSSTAR+PLUS– All members are contacted All members are contacted
within 30 days of within 30 days of enrollmentenrollment
– Informed about services Informed about services availableavailable
– Telephonic risk Telephonic risk questionnaire may lead to questionnaire may lead to assessment and assessment and authorization for servicesauthorization for services
-
500
1,000
1,500
2,000
2,500
3,000
3,500
1999 2000 2001 2002 2003 2004 2005
Enrolled Month
Distinct CBA Members
-
200
400
600
800
1,000
1,200
DistinctMembers
2000 2001 2002 2003 2004 2005 2006
SFY
DAHS Distinct Members by SFY
Medicaid Only
Dual Eligible
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
DistinctMembers
2000 2001 2002 2003 2004 2005 2006
SFY
PAS Distinct Members by SFY
Medicaid Only
Dual Eligible
Care Coordination ResultsCare Coordination Results
External quality review study completed July External quality review study completed July 20032003
SSI clients in STAR+PLUS were compared to SSI SSI clients in STAR+PLUS were compared to SSI PCCM clientsPCCM clients
Significant cost difference – particularly for the Significant cost difference – particularly for the highest acuity clients ($3,226 mo in STAR+PLUS highest acuity clients ($3,226 mo in STAR+PLUS vs. $13,160 mo in PCCM) vs. $13,160 mo in PCCM)
Lower inpatient and ER use in STAR+PLUS Lower inpatient and ER use in STAR+PLUS
STAR+PLUS vs. PCCMSTAR+PLUS vs. PCCM
Overall ExpendituresOverall Expenditures
05000
10000150002000025000300003500040000
All Healthy Significant Acute Minor Chronic Dominant/ModerateChronic
Malignancies &Chatastrophic
Ave
rage
Cha
rges
per
Mon
th
STAR+PLUS Experiment Group STAR Control Group
Cost SavingsCost Savings
Cost savings result fromCost savings result from managing care managing care by:by:
Early identification and treatment of health Early identification and treatment of health problemsproblems
Promoting wellness and healthy lifestylesPromoting wellness and healthy lifestyles Avoiding higher cost services and products Avoiding higher cost services and products
when lower-cost, clinically appropriate services when lower-cost, clinically appropriate services can be renderedcan be rendered
Coordinating care effectively and reducing Coordinating care effectively and reducing duplication of servicesduplication of services
STAR+PLUS and Special STAR+PLUS and Special Needs PlansNeeds Plans
Have 9 SNPs operating in Texas. Two have Have 9 SNPs operating in Texas. Two have STAR+PLUS plans with over 20,000 STAR+PLUS plans with over 20,000 enrolled for both programsenrolled for both programs
SNP plans would like to see expansion of SNP plans would like to see expansion of STAR+PLUSSTAR+PLUS
We pay a premium to the SNP plans to We pay a premium to the SNP plans to cover Medicaid cost share obligationcover Medicaid cost share obligation
Expansion IssuesExpansion Issues
Unable to expand the program due to potential Unable to expand the program due to potential loss of UPL to public hospitals.loss of UPL to public hospitals.
Medicaid laws prohibit hospitals from receiving Medicaid laws prohibit hospitals from receiving UPL if they are paid by a capitated HMO.UPL if they are paid by a capitated HMO.
Texas plans to implement alternative models Texas plans to implement alternative models including hospital carve-out and non-capitated including hospital carve-out and non-capitated managed care programs, but effectiveness and managed care programs, but effectiveness and efficiency will be compromised.efficiency will be compromised.
STAR+PLUS ExpansionSTAR+PLUS Expansion
STAR+PLUS is expanding to 4 new areas STAR+PLUS is expanding to 4 new areas January 2007January 2007
STAR+PLUS will carve out inpatient hospital STAR+PLUS will carve out inpatient hospital services from the HMO capitationservices from the HMO capitation
Capitates physician, ER, outpatient, and Capitates physician, ER, outpatient, and community-based long-term support services.community-based long-term support services.
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
Sterling Coke 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
Jefferson
Trinity
Brazos
Lavaca
VictoriaGoliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Washington
Robertson
Waller
Brazoria
Matagorda
Fort Bend
Harris
Galveston
Chambers
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
Harris CHIP O-SA
Bexar CSA
Lubbock SDA
Harris CSA
El Paso CSA
Medicaid & CHIPManaged Care Service Areas
with HHS Regions (in red)Dallas CSA
HHSC, Medicaid/CHIP Managed Care OperationsJanuary 2006
10
1
9
Palo Pinto
Comanche
Hamilton
2
El Paso
McMullen
Maverick
8
Travis CSA
Orange
Sabine
Newton
34
Colorado
7 5Houston
Lubbock CHIP O-SA
Tarrant CSA
Nacogdoches
San Jacinto
Jasper
6
Nueces CSAWebb CSA
NOTE:NorthSTAR
BH Carve-out Area
Core Service Area (CSA) for STAR & CHIP
Optional Addition to CSA (O-SA) for CHIP Only and STAR Rural PCCM
Non-HMO model Service Delivery Area for CHIP (EPO model) & STAR (RurealPCCM)
Bexar CHIP O-SA
11Nueces CHIP O-SA
Superior HealthPlan (CHIP OSA)
32,500 STAR / 7,500 CHIPFIRSTCARE (STAR/CHIP)
Superior Health Plan (New STAR/CHIP)
125,300 STAR / 28,200 CHIPAmerigroup (STAR/New CHIP)Aetna (NEW-STAR/CHIP)Cook Children’s (CHIP/NEW STAR)
220,000 STAR / 19,700 CHIPAmerigroup (STAR/CHIP)Parkland (STAR/CHIP)UniCare (NEW-STAR/CHIP)
80,000 STAR / 17,000 CHIPAmerigroup (STAR only)Superior (STAR/NEW CHIP)Seton (CHIP only)
356,800 STAR / 94,700 CHIPAmerigroup (STAR/CHIP/S+)Community Health Choice (STAR/CHIP)EverCare (S+//NEW STAR)Molina (NEW STAR/CHIP)Texas Children’s (STAR/CHIP)UTMB (CHIP only)
101,000 STAR / 14,000 CHIPEl Paso First (STAR & CHIP)
Superior Health Plan (STAR & CHIP)
Amerigroup (CHIP OSA, excTyler))
Texas Children’s (CHIP OSA)UTMB (CHIP OSA)
NEW STAR AREA88,000 STAR/10,500 CHIPAmerigroup (NEWSTAR/CHIP)Driscoll (CHIP/NEW STAR)Superior (NEW STAR/CHIP)
Amerigroup (CHIP OSA)Driscoll (CHIP OSA)Superior (CHIP OSA)
5,700 CHIPMercy (CHIP)
162,000 STAR / 25,500 CHIPAETNA (NEW STAR/CHIP
Community First (STAR/CHIP)Superior (STAR/CHIP)
AETNA (NEW CHIP OSA)Community First (CHIP OSA)
Superior (CHIP OSA)