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Below is a report from the House Committee on Human Services interim hearing regarding implementation of SB 7 (83R).

Please click on the link below to access the HHSC presentation:
House Committee on Human Services: Medicaid Managed Care Initiatives

Chief Deputy Commissioner Traylor, HHSC

  • SB 7, Texas 83rd Legislature, Regular Session, requires HHSC and DADS to jointly design and implement an acute care services and long-term services and supports system for individuals with intellectual and developmental disabilities through managed care
  • Implementation began in September 2013 but full redesign will not roll out until 2020 (see presentation for timeline)
  • Medicaid managed care expansion:
    • MRSA
    • Nursing facility carve in
    • IDD population
  • Background of STAR+PLUS was given
    • STAR+PLUS began in Harris County in 1998
  • Gonzalez – is there any talk about adding more than 2 providers to El Paso County?
    • There needs to be enough population to make adding another MCO viable
  • Naishtat – there have been concerns voiced to his office on what is voluntary and what is mandatory
    • Need to be as clear as you can be
    • Young adults and children are not mandatory, adults are
  • September 2014, expansion to MRSA service areas
    • Additional 80,000 members
    • 1/3 of the individuals on the CBA interest list will be moved into STAR+PLUS
    • Commissioner Weizenbaum – discussed the various waiver interest lists
      • Interest lists have decreased significantly
  • March 2015, Nursing Facility carve-in
    • Approximately 56,800 individuals will transfer into STAR+PLUS
  • Naishtat  – how many total nursing facility residents do we have now?
    • Will need to get back with an exact number, less than 100,000
  • Traylor – pushed back implementation date from September 2014 because they want to test the systems before they go live
    • Raymond – while passing the bill, the commissioner was concerned that payments were made timely
    • Gonzalez – In SB 7 there was no mention of timely payment of claims?
      • Not in the bill exactly, but HHSC has those mechanisms already
      • It is incumbent on HHSC to make payments on time to ensure providers participate in the Medicaid program
    • Requires MCOs to pay claims no later than ten calendar days after the submission of a clean claim
      • 1 year filing deadline
  • September 2014, IDD acute care carve-in
    • Zerwas – this population is unique and a number of folks are concerned about an adequate network that is knowledgeable with this population
    • Are you comfortable with this timeline that there will be enough providers?
      • Hoping there will be more exposure of the IDD population with the carve in and it will attract more providers wanting to serve them
      • We will look at this in a way to ensure that the IDD population will have the same or better services before a transition occurs
    • Raymond – when we did the South Texas expansion we had a couple informal hearings in the Valley that were very useful
      • Would like to do something similar to ensure that the September 1 date is appropriate
      • Need to engage providers to engage consumers so there is more stakeholder participation
      • Meeting will be held mid-May
    • Klick – there are a lot of moving parts – how will you measure we will be ready for the transition?
    • Gary Jessee, HHSC
      • Have reached out to significant traditional providers and an additional 40,000 providers that have previous Medicaid claims
      • MCOs must demonstrate appropriate networks
      • Single case agreements
      • MCOs are required to assist their members find providers and PCPs
        • Contracts include timeframes
      • Use network adequacy standards from TDI
      • Detailed how clients will choose their MCOs and providers based on MCO report cards, value-add services offered, etc.
      • Authorized MAXIMUS to participate in 60 local events specific to IDD to engage families, caregivers
    • Naishtat – what exactly is a clean claim?
      • All the correct information on the claim for the claim to be paid
    • Naishtat – asked about terminating contracts
      • Weizenbaum – “three strikes and you are out law” was not authorized by CMS
        • Requires the provider the opportunity to come back into compliance
    • Naishtat asked for research on what other states do regarding terminating contracts
  • Community First Choice
    • Cost effective delivery of basic attendant and habilitative services for the IDD population under STAR+PLUS
    • Increases federal match 6%
    • Have submitted a proposal to CMS
    • Tentative implementation date is March 2015
  • IDD Pilots
    • Must implement 1 or more pilots to test managed care capitated model
    • IDD Advisory Committee will be providing guidance
  • Naishtat – what are your plans to ensure that you have meaningful involvement?
    • Weizenbaum discussed the various advisory committees that are involved
  • Dual Demonstration Project
    • Implementation no sooner than January 2015
    • Fully integrated model for individuals enrolled in both Medicaid and Medicare
    • Limited to 6 Texas counties (132,608 individuals), but HHSC will continue to try and expand the integration of care for the dual eligible population
  • STAR KIDS
    • Medicaid managed care program doe SSI kids
    • RFP out
    • Naishtat – will the STAR KIDS program have any impact on STAR Health?
      • No, will not impact foster children services
  • Advisory Committees Created:
    • Intellectual and Developmental Disability System Redesign Advisory Committee
    • STAR Kids Advisory Committee
    • STAR+PLUS Quality Council
    • State Medicaid Managed Care Advisory Committee
    • Behavioral Health Advisory Committee
  • Managed care information sessions are being held throughout the state

 
 
Public Testimony
 
David Gonzalez, THP

  • On the legislation
  • Incredibly complex bill with complex populations
  • Working with commission on a daily basis on any issues that come up during implementation
  • Working in workgroups – focusing on provider network adequacy
  • Patients need some transparency in their plan
  • Klick – providers already providing services in the IDD community, how many have enrolled?
    • STP is a huge part and intent of the legislation

 
Bob Kafka, ADAPT

  • On the legislation
  • Supports reform of Medicaid because it is confusing with all the different wavers, programs, etc.
  • Wants an outcome of a functional system based on need
  • Concerned with waiting lists
  • Individuals in ADAPT need varying needs, not all IDD
  • Service coordinators are employees of the MCOs
    • Critical piece because they link all the services in the community
    • Great when it is done well, nightmare when it is done poorly
    • Critical piece
  • Attendant payment – $7.86
    • Crucial provider but gets the least attention
    • Will save billions in healthcare costs to keep folks out of the ER
    • Thinks Texas should lead the country and raise the payment to $10.10
  • Naishtat: Has recruitment and retention been a priority?
    • Its ramping up
    • But there is private competition that conflicts with Medicaid
  • Naishtat: Consumer delivery first service option
    • Ability for the individual to make the decisions on their own individual care
  • Gonzalez: what is the demographic of personal attendants?
    • Single mother, low income
    • Need a comprehensive demographic survey in Texas

 
Denis Borel – Coalition of Disabilities

  • Support SB 7
  • Community first Choice Option is the finest point in the bill
    • Need to educate people it is coming
    • Functional needs assessment needs progress
    • Expansion of STAR+PLUS
      • Concern with network adequacy, concern with defaults that take the choice away from the individual
  • Support the Nursing homes in STAR+PLUS
  • Enjoy the stakeholder participation
  • Potentially preventable events focus will increase the quality of care
  • Potentially preventable readmissions – need to be cognizant that there might be unintended consequences
    • Discharge planning should not be held hostage
  • No network adequacy
    • MCOS must recruit providers and be willing to provide quality of care within the rates
      • Need appropriations to raise rates
  • Naishtat: public outreach needed?
    • Do you have input on how word gets out?
    • Yes

 
ADAPT Panel

  • Increase in attendant wages because people are leaving the industry to go work at a higher paying McDonalds
  • Need strong network adequacy
  • Personal attendant demographics are getting older
  • Advocate for a $10.10 base wage
  • Need to continue the data collection on the workforce

Amanda Fredrickson, AARP

  • Supportive of the carve in because it creates shifts in opportunities
    • Rebalancing – favor more in the community rather than the institution
    • Carving nursing homes in puts all the incentives in place for the MCOs
    • Cost savings and good public policy aligning
  • MCOs will receive a larger capitation rate to carve in nursing homes, which gives them ability to pay for quality of care or increase attendant rates
  • State auditor’s report – 78 nursing home facilities that had 10 or more serious problems in a 24 month period
    • Will give the ability to focus on increasing care in these facilities or an MCO will not contract with them
  • Commissioner Weizenbaum – haven’t run that some list for that specific criteria again, but DADS will
    • Raymond – we need them to do better

 
Trey Berndt, AARP

  • Network Adequacy issues
    • Contract needs to be clearer and well enforced and MCOs must be held accountable
    • Current HHSC standards are very outdated from TDI
      • 75 miles is too far to have to travel for s specialist
  • Recommend the Medicare Advantage Standards to the HHSC
    • Set minimum provider ratios based on provider type
    • Much more measurable
    • Reasonable exceptions process
    • Commissioner Weizenbaum – there is a tremendous amount of data, and we will go back and see what the latest numbers are

 
Melissa Machado, TAHCH

  • Impacts their members
  • Concern with population getting acute care through STAR+PLUS
    • IDD must remain continuously eligible, but there could be lapses in the paperwork that could un-enroll an individual
    • Implementation of EVV in managed care should be delayed
      • Providers are anxious to know which vendors they will work with
  • Naishtat: I want to know what you mean when you say abandon some traditional operations in waivers?
    • Not operate at all like in the FFS world we were in before
  • Wants standardizations across the program
  • Wants a single portal
  • Everything has to be done by paper to correct a claim (20%)
    • Turner – Can you do it electronically?
    • On the health plan end it isn’t set up
  • Echo everything said by Bob Kafka about network adequacy
  • Attendant rates are so low in some instances that might cause network adequacy issues

 
Raymond discussed the Sunset process, and asked members if they had any issues or suggestions that they should look at during the Sunset proceedings
 
George Linney, Leading Age Texas

  • Both their affordable housing and nursing home residents use Medicaid
  • Nursing Homes are usually the largest businesses in small towns – large economic driver
  • Is the new approach make quality of care across Texas?
  • Has the legislature been given enough oversight?
  • Nursing facilities are some of the most highly regulated entities – want to avoid duplicities
  • Applaud the transition delay
  • Working on making a standardized contract for MCOs and nursing facilities
  • The payment portal is critical, must stay within 10 days
  • Want to rollout the nursing facility carve in regionally to make sure it is working well and address glitches before it goes statewide

 
Mark Cundall, private citizen

  • Support ADAPT message
  • Personal story

 
Dr. George Handal, MCAC

  • Brewing perfect costly storm
  • Slowing productivity due to the implementation EMR
  • ICD Implementation
  • Supplemental payments from 2013 and 2014 were delayed
  • Low Medicaid rates
  • Without adjustments, we will lose even more Medicaid providers
  • Disappointed by the 1115 waiver because very few real providers got to participate
  • .2% of the 1115 money was received by El Paso
  • Lost the opportunity with the Frew, now the 1115
  • We need to be really innovative or we are going to have a real crisis on our hands

 
Clifford Gay, Representing himself

  • Medicaid is the taxpayer’s second most costly expense and a leading contributor to increasing tax costs
  • People are becoming SSBI eligible and selling the free pharmaceuticals they get from the program to supplement their income
  • SB 7 is a key to getting a handle on Medicaid expenses

 
Albert Metts, Community Now

  • There is a need for more attendants in the state

 
Cassandra Dickerson, Works with residential facilities

  • Witnesses have talked about how many providers have to be in a certain area but not how many clients they must see
  • Providers cap the number of Medicaid clients they will take and if there are 500 clients and only two providers in a thirty mile radius who cap out at 200 clients, 100 clients will not be served
  • Gary Jesse was called up and discussed that MCOs are very good about meeting network adequacy standards; MCOs are a great place to find support as well as service coordinators and the ombudsman

 
Michelle Dooley, Parent of an IDD individual

  • With “Obamacare” and SB 7 rolling out at around the same time it is becoming harder to find doctors to take new patients

 
Harrison Hyner, Texas State Employee Union

  • The results of the recent EQRO study should be looked at more closely
  • Only Amerigroup and Molina participated in the survey; other MCOs were shut out of participation
  • Many MCOs do not have a very high percentage of good phone numbers for their clients
  • Gary Jesse was called up to respond; the response being discussed is from the CAHPS survey; the agency could not compel an MCO to respond to the survey; HHSC has changed the standards of service coordination and clients must be contacted or visited multiple times based on the level of care necessary; many other standards have also been revised in response to that survey

 
Carol Smith, Executive Director, Private Providers Association of Texas

  • The system in Texas is not ready for the changes made by SB 7
  • When network adequacy is tested, it should be tested for doctors and specialists who will see new IDD patients

 
Peter Heming, Executive Director, Special Texas Homes

  • It was hard for ICFs to get ready for implementation of SB 7
  • Network adequacy does not look like it should; there are not enough specialists
  • Special Texas Homes patients will not have access to a neurologist among other specialties
  •  

Linda Litsinger, Representing herself

  • Would like to know what the process will be when people are told no for medical transportation requests
    • Gary Jesse noted the agency is in a procurement to restructure the medical transportation services; there is always a process for finding transportation including MCOs who often provide a value-add transportation service
  • Attendant care wages are not commensurate with the services they provide; raising wages is the only way to keep attendants in the industry

 
Colleen Horton, Hogg Foundation for Mental Health

  • People with IDD rarely get good mental health care; when they show signs of certain behaviors they are attributed to their disability instead of a separate mental health disorder
  • Many behavior management techniques currently used can easily exacerbate past traumas or trigger new traumas; underlying mental health needs must be addressed for other systems to be effective
  • Offering more training and developing crisis intervention teams are a few possible ways to begin the solution
  • MCOs, SSLCs and ICFs should be required to have a certain level of training regarding what services are available

 
Carol Maxwell, ARC of Texas

  • The IDD redesign committee within HHSC has only met once and there is concern that there has not been enough opportunity to give input
    • Chairman Raymond noted that he has been told that members of the committee have been communicating with the agency about concerns outside of the committee setting, so things are being done
  • The committee should consider establishing subcommittees to tackle specific issues more effectively

 
Ruth Mason, ARC of Texas

  • When social workers administering assessments are not trained properly there can be devastating effects

 
Jeff Miller, ARC of Texas

  • Network adequacy will be an issue for IDD clients
  • Increased coordination of care will be great for everyone it just needs to be done in the best way possible

 
Susan Murphrey, Disability Rights Texas

  • Would like to see the promise of addressing the waiting list come to fruition in the STAR Kids program
  • Glad there is the potential to create hospital level care systems for medically fragile people in SB 7
  • There need to be more than just 5 people in the HHSC ombudsman office
  • There are gaps with the different computer systems that determine eligibility regarding whether people qualify for services; with IDD in managed care that could be a bigger problem

 
Jessica Ramos, Texas Council for Developmental Disabilities

  • Glad that the STAR Kids rollout was delayed
  • New physicians need to be recruited into the Medicaid system
  • People need to be sure that the system they are entering into is equal to or better than the system they are in now
  • It takes a sophisticated consumer to navigate the managed care arena successfully so more consumer education is needed
  • Network improvements that need to happen to ensure a smooth rollout cannot happen in the next five months

 
Judy Telge, Coastal Bend Center for Independent Living

  • Concerned about how the nursing facility carve-in will work; who is going to ensure that people who don’t want to be in a nursing center are able to get out
  • There are often tensions between relocation staffs and MCO staffs

 
Susan Milam, National Association of Social Workers Texas

  • Access to care is a huge problem
  • There has been a huge drop in the number of social workers participating in Medicaid in the past few years
  • There are 44 counties in Texas with no social workers; many are moving out of rural areas where they cannot afford to work
  • Being paid 70% of the allowable rate for social worker wages is far too low

 
Sheryl Standefer, Representing herself

  • Families of clients and clients themselves are confused about the IDD carve-in; they are not getting enough information from the agency and are relying on providers to inform them
  • The rollout may need to be pushed back
  •  

Ellen Bowman, Grandparent of an IDD individual

  • Concerned about generalizing when it comes to IDD individuals and providing services; a cookie cutter approach cannot be used to provide effective care
  • There will always be outliers in any program, particularly, those who require more attendant hours than average