HHSC presented information to health care providers on the current face and operations of Medicaid, and upcoming initiatives that will begin to go into effect September 1, 2014. Please see the attached presentation. Below is an outline of the upcoming initiatives as well as some Q & A between stakeholders and HHSC after the formal presentation.
Upcoming Managed Care Initiatives
September 1, 2014:
- Expansion of STAR+PLUS into the Medicaid Rural Service Areas (MRSA) including MRSA Central, MRSA Northeast and MRSA West and is estimated to serve an additional 80,000 members in STAR+PLUS.
- Covered mental health rehabilitation and mental health targeted case management services, currently provided through fee-for-service delivery model through the Local Mental Health Authorities, will be carved into managed care, excluding North STAR. Under this initiative the state must also:
- Develop two health home pilots and a Behavioral Health Integration Advisory Committee
- Create community collaboratives for persons who are homeless, with mental illness, and/or with a substance abuse problem
- Establish and maintain a mental health and substance abuse treatment public reporting system
- Make mental health rehabilitative services and mental health targeted case management available to Medicaid recipients who are assessed and determined to have a severe and persistent mental illness such as schizophrenia, major depression, bipolar disorder or other severely disabling mental disorders or are children and adolescents ages 3 through 17 years with a diagnosis of a mental illness or exhibit a serious emotional disturbance
- Persons transition into STAR+PLUS for acute care services with Intellectual and Developmental Disabilities (IDD):
- Individuals receiving services in community-based Intermediate Care Facilities for Individuals with Intellectual Disabilities or Related Conditions (ICF-IID)
- Individuals receiving services in ICF-IID 1915 (c) waivers
- Home and Community-based Services (HCS)
- Community Living and Support Services (CLASS)
- Texas Home Living (TxHmL)
- Deaf Blind Multiple Disabilities (DBMD)
- Not included in the IDD carve-in are individuals residing in a state supported living center or dual eligibles. Children and young adults under age 21 receiving SSI or SSI-related services are voluntary.
- Nursing facility services will be rolled in to STAR+PLUS statewide
- Will serve adults (mandatory) age 21 or older who are in a nursing facility, who have been determined eligible for Medicaid, and who meet STAR+PLUS criteria
- Children and young adults under age 21 will be excluded
- Will expand LTSS managed care to 60,000 nursing facility residents
- HHSC will set the minimum reimbursement rate paid to nursing facilities under STAR+PLUS, including the staff rate enhancement
- HHSC will ensure MCOs pay clean claims no later than ten calendar days after submission
- HHSC will also establish a portal through which nursing facilities may submit claims to participating MCOs
- Hospice services will continue to be paid out of traditional Medicaid fee-for-service and Preadmission Screening and Resident Review (PASRR) services will be carved out as well
- Nursing facilities will have a one year claims filing deadline
- MCOs are required to adjudicate most claims within 30 days ( 18 days for pharmacy and 10 days for nursing facilities)
June 2014:
- Enrollment packets sent to clients by MAXIMUS including a welcome letter, provider directory, MCO comparison chart, enrollment form, and frequently asked questions
Mid-August 2014:
- Mandatory managed care clients must choose an MCO or the State will auto-assign the client to an MCO
- All members receive an MCO plan ID card, in addition to a Your Texas Benefits Medicaid card from the State
- MCOs are obligated to offer Providers who have been serving Medicaid clients historically, or Significant Traditional Providers (STPs) the opportunity to be a part of the contracted MCO network
- HHSC encouraged all providers to form a close working relationship with the MCOs
Questions and Answers:
- Hospice services are carved out, but who will hospice look to in managed care to coordinate patient care?
- MCOs must have a named coordinator for hospice to reach out to
- Who will ensure and monitor that payments are timely?
- Health plan managers at HHSC monitor on a quarterly basis, historically the MCOs do a very good job of making timely payments.
- Will MCOs be able to contract with other than traditional Medicaid providers?
- Yes. MCOs can restrict participation in the network if they have an adequate network
- There is a Traditional Medicaid Provider period that is three years long.
- If a current nursing home is not a Medicaid provider can they contract?
- Only if they are a Medicaid enrolled provider
- Will reimbursement be tied to resource utilization groups
- Yes
- Will there be any further consideration in changing the 95 day requirement for nursing homes?
- No
- With regard to pediatric home health skilled nursing and children with traditional Medicaid under 21, will they be required to pick an MCO?
- Not until the rollout of STAR KIDS in 2015
- HHSC uses TexMed Connect, and providers are told to log in regularly to make sure members are still active – if there is any confusion the provider should call the MCO directly
- If an NF approved Medicaid service has been previously approved, do services continue to be provided or will the prior authorization process be needed?
- Yes, everything should remain the same
- Will fees be used by MCOs?
- MCOs develop and negotiated their own fee schedule
- What happens to PASSAR after September 1, 2014?
- The facility will continue to do the PASSAR – PASSAR benefits will be carved out of managed care
- If an IDD person does not choose a PCP and the MCO chooses for them, what will be used for communication of that choice?
- HHSC knows that the IDD population has special concerns and HHSC will communicate with the designated responsible party for the IDD individual and inform Maximus who might be contacting them. There is going to have to be flexibility (HIPPA) for certain populations in making informed choices.
- What about EVV be included in managed care?
- EVV is only included for private duty nursing and personal attendant services – implementation begins in June
- MCOs will be required to contract with all the EVV vendors that come out of the current procurement