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The House Committee on Human Services has released its interim report to the 86th Legislature.

The report addresses multiple charges, including the impact of Hurricane Harvey, the roll out of managed care in Texas, early intervention and mental health services for children involved in CPS, the survey process for nursing facilities, and a review of legislation under the committee’s jurisdiction. For full details, including analysis and conclusions from the committee, please see the complete report.

Spotlight on Recommendations

Study the impact of Hurricane Harvey and the response to the storm on individuals living in long-term care facilities, assisted living facilities, state supported living centers, licensed community group homes, and children in the foster care system.

  • An emergency coordinator position should be established at DFPS that would manage the agency’s efforts to prepare for and react to disaster/emergency situations.
  • HHSC should establish processes to pursue waivers early on when disaster situations are expected to allow providers the resources and flexibility to meet the needs of affected individuals.
  • Providers who are highly involved with patient/beneficiary care such as long-term/post acute facilities and MCOs should be co-located with regulatory and commission staff responsible for provider coordination and more integrated into the agency disaster response process to help improve the efficiency of HHSC’s communications during disaster situations.
  • HHSC should study ways other states have streamlined the D-SNAP application process, potentially by offering a telephonic or online D-SNAP pre-registration process

Review the history and any future roll-out of Medicaid Managed Care in Texas.

Complaints and Appeals

  • HHSC should continue to improve the member complaint process by strengthening complaint tracking and analysis processes.
  • The legislature should add a definition of “complaint” to statute that encompasses all types of grievances, concerns, and inquiries as well as a definition of “appeal” that encompasses all types of protests and objections. Additionally the legislature should direct HHSC to develop a complaints and appeals system in which all beneficiary and provider complaints, appeals and denials are shared with HHSC and OIG immediately and include the member’s Medicaid identification number or provider’s Medicaid identification number. MCOs should be required to update the complaints and appeals system with the progress of the complaint or appeal including whether or not the complaint was valid and why, steps being taken to resolve the issue, and final resolution. Denials should be updated with justification and appeal information which should include current status of the appeal and resolution. The complaints system should not be limited to providers who are contracted with an MCO, particularly if they are providing services to an MCO’s beneficiary. The complaints and appeals system should be updated with complaints and appeals received by HHSC and OIG. HHSC and OIG should develop policies governing when to direct a complaint or appeal back to the MCO and when to investigate themselves, including consideration of when a beneficiary or provider wishes to remain anonymous.
  • HHSC’s expanded Chief Medical Officer should be tasked with ensuring medical necessity determinations are appropriate, consistent, and are being made according to best clinical practices.
  • The Legislature should establish a Provider Ombudsman within HHSC to serve as an advocate for providers in the same way the traditional ombudsman serves beneficiaries.
  • HHSC should engage with an Independent Review Organization (IRO.) When a claims denial based on medical necessity is upheld by an MCO after the appeals process has been initiated, the IRO would provide an external review and make a binding decision on whether to uphold or overturn the MCO’s medical necessity determination.

Office of Inspector General

  • Statute defining the role of the OIG should be amended, giving them additional authority to ensure program integrity in an evolving Medicaid landscape.
  • The OIG should investigate referrals from HHSC regarding complaints, appeals and denials when patterns of abuse and purposeful underutilization are found through analysis of complaints and appeals data.

Timely Payment

  • The legislature should establish timely payment requirements for non-clean claims. Non-clean claims should be adjudicated within 30 days of the provider submitting additional information requested by the MCO. Additionally, claims projects to fix MCO claims processing systems should be adjudicated within 60 days, and pending claims resulting from claims projects should be adjudicated no later than 30 days after the claims payment system is fixed.
  • The legislature should invest in HHSC data systems with expanded functionality helping to bring agency data technology capabilities up to date.

Care Coordination

  • HHSC should look for opportunities to re-emphasize quality and patient satisfaction as goals of managed care with the understanding that care coordination inherently helps to achieve those goals.
  • HHSC should implement requirements that health care providers be notified and given contact information for their patient’s care coordinator.
  • HHSC should implement standards to require MCOs to respond to requests for post-hospital discharge services within 72 hours at least 95% of the time and provide specific reasons for denials of post-hospital discharge services. HHSC should monitor denials to ensure services are not being denied to meet timeframe requirements.

IDD LTSS Transition to Managed Care

  • The Legislature should delay the transition of IDD LTSS into managed care indefinitely. Additionally, statute should be amended requiring HHSC to carry out a pilot program, the results of which would be reviewed by the Legislature, along with the results of the Deloitte/University of Texas study, before the Legislature ultimately decides whether and when to continue with the transition.

Value-Based Contracting

  • HHSC should produce guidance for MCOs and providers regarding best practices, proven alternative payment model structures and rules regarding what will and will not be considered a qualifying value-based payment to reduce administrative burden and ensure all parties are prepared as MCOs move toward more complex models.
  • HHSC should ensure that value-based contracts based on quality are linked to known quality measures and are based on credible data.
  • HHSC should ensure that preferred provider arrangements include a reasonable opt-out provision for any reason or no reason at all, to allow for a member’s free choice of provider. HHSC should also require that preferred provider arrangements prove an increase in quality or efficiency in order to continue.

STAR Kids

  • Medically fragile STAR Kids program members should choose the delivery system most appropriate for their child’s needs. Parents should be allowed to opt-out of managed care and instead receive their services through the traditional fee-for-service model.
  • Statute should be amended to ensure Medicaid beneficiaries receiving therapy services, particularly those in the STAR Kids program, are not subject to service denials or reductions based on lack of progress. Preventing regression should be the qualification for medical necessity.
  • The legislature should consider removing the statutory requirement that MCOs use the state-developed SK-SAI allowing MCOs to use nationally recognized screening tools. Additionally the legislature should consider whether there is a functional need to administer the SK-SAI every year.

Claims Portal

  • The legislature should clarify statute to ensure nursing facilities can manage all claims processes by accessing a single portal administered by HHSC.

MMP

  • HHSC should complete a study by January 1, 2020 to determine the efficacy of the MMP program. It should review costs to the state and to providers, provider and participant satisfaction, and lessons learned since implementation of the pilot. HHSC should only continue the MMP program if the study determines cost savings.

Third Party Liability

  • HHSC should follow the majority of other states and separate TPL and other cost containment initiatives from their MMIS.
  • MCOs should be given additional time to identify and recover TPL. The state allows only 120 days from adjudication yet federal law allows three years for identification and another six years to complete recovery.
  • HHSC should make efforts to identify additional data sources for TPL in order to supplement and enhance TPL recovery efforts. The State should urge TRICARE to fulfill their TPL responsibilities to state Medicaid programs by re-initiating the DEERS match process.

HHSC Transition to Managed Care

  • The Legislature should consider a requirement that all future MCO contracts include accreditation requirements to provide a cost-effective form of oversight through a proven accreditation organization.
  • HHSC should engage in an administrative simplification project. Not only should the agency make efforts to prioritize and reduce MCO deliverables, they should simultaneously ensure that MCOs are not requiring a burdensome amount of paperwork from providers when not absolutely necessary. Increased efficiency and automation of processes should be the ultimate goal. Additionally, the agency should ensure non-duplication of efforts regarding validation of quality areas that accredited health plans have already proven.
  • HHSC should remove the requirement that MCOs provide hard copy provider directories to their members which only increase administrative costs due to printing and shipping. Alternatively, HHSC should require that MCOs provide printed hard copy directories upon request.
  • The Legislature should take steps to further focus resources on preventive health care ultimately saving resources and slowing Medicaid cost growth. Additionally, HHSC should seek out opportunities to engage private sector partners with solutions that will help move the agency forward into the era of managed care.

Examine the survey process for nursing facilities to determine any duplication of government regulations.

  • HHSC should review surveyor training requirements and processes to determine where additional improvements can be made to ensure more consistent interpretation of regulations
  • HHSC should consider developing joint education opportunities for both surveyors and providers to improve communication between all parties and to help foster a consistent understanding of changing regulations
  • The Legislature should consider taking action recommended by the Texas Council on Long-Term Care Facility Surveys and Informal Dispute Resolution related to increasing retention of surveyors/investigators through a career ladder and salary restructuring in their December 2016 Report as required by SB 914 (84R)

Review the availability of prevention and early intervention programs and determine their effectiveness in reducing maltreatment of children. In addition, review services available to children emancipating out of foster care, as well as services available to families post-adoption.

  • HHSC should develop a process to streamline the Medicaid renewal process for youth formerly in foster care to prevent any disruption in services, treatment or medication they need after leaving the state’s conservatorship.
  • HHSC and DFPS should collaborate to ensure contracted MCOs serving current and former foster youth, caseworkers, and caregivers facilitate information sharing to ensure primary care and treating physicians caring for children in the child welfare system have ready access to the child’s trauma history in order to establish a baseline understanding of the child’s exposure to trauma.
  • The Legislature should invest in the creation and implementation of a strategic plan to maximize the opportunities made available through the federal Family First prevention Services Act, which provides an opportunity for states to draw down federal match for trauma-informed mental health, substance use, and in-home parenting support services for children at imminent risk of entering foster care and their families. Additionally the Legislature should fund PEI-related exceptional items requests from DFPS such as Texas Nurse Family Partnership.

Analyze the prevalence of children involved with Child Protective Services (CPS) who have a mental illness and/or a substance use disorder. In addition, analyze the prevalence of children involved with CPS due to their guardian’s substance abuse or because of an untreated mental illness.

  • The state should make efforts to expand the use of programs and techniques that sustain families through innovative treatment such as family drug courts, motivational interviewing, peer recovery coaches, parent/child residential treatment, and services to support parents’ sobriety when children are returned home.
  • DFPS should target specific regions of the state where substance use in families is most prevalent and establish specialized caseworkers with additional training in best practices for family engagement, focusing on families where substance use is present.

Monitor the HHSC’s implementation of Rider 219 in Article II of the General Appropriations Act related to prescription drug benefit administration in Medicaid. Analyze the role of pharmacy benefit managers in Texas Medicaid.

  • The legislature should amend statute to create a new, non-capitated, consolidated prescription drug benefit delivered by a single pharmacy benefit administrator that is developed and procured in a manner that: allows the state to benefit from collection of the state premium tax, achieves an administrative cost less than the existing rate paid in managed care, and allows MCOs to holistically manage care by delivering them real-time data.