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 Improved access to community based long-term care support servicescare support 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

0

5000

10000

15000

20000

25000

30000

35000

40000

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

SterlingCoke

Runnels

Concho

Coleman

Taylor Callahan

Bell

Blanco

Kendall

Comal

Gillespie

Llano

Travis

Hays

Caldwell

Burnet

Williamson

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

Victoria

Goliad

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

Camp

Morris 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 CSA

Webb 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)