Medical Care Advisory Committee – November 7, 2014 Meeting

The Medical Care Advisory Committee held a meeting to act on their posted agenda.

Comments from the Associate Commissioner for Medicaid and Children's Health Insurance Program (CHIP): Gary Jesse spoke on behalf of Kay Ghahremani, Health and Human Services Commission (HHSC)

Sunset hearing is coming up- next week will be opportunity to make public comments
Session will officially begin in January and run through May 2015
Election results announced- many new members and all but three are Republicans
Pre-filing starts Nov. 10

Approval of August 2014 Meeting Minutes

Motion unanimously approved

Announcement of Proposed Slate of Candidates for Medical Care Advisory Committee Executive Committee: Michael Vaclav, DDS.

Dr. Gilbert Handal, MCAC Chair
Colleen Horton, Vice Chair
Mary Helen Tieken, member at large
Motion unanimously approved

*Presentation on the Transformation Waiver Overview: Gary Jesse first and then Lisa Kirsch, Chief Deputy Director, Medicaid and CHIP

Medicaid delivery map illustrates transition of system from FFS to MCO
Biggest managed care product is STAR
19 health plans that coordinate benefits across the state
In regards to PCP question – goal of PCP is central point of coordination
STAR+PLUS is predominately for adults
- Service coordination is key
- Recently expanded remaining counties and carved in various services
- 5 MCOs deliver
State plan amendment submitted to implement benefit
- Services for rehabilitation – Community First Choice will offer entitlement benefit
- Because it is a state plan benefit it will not apply to cost ceiling of waiver
Will also be carving in nursing services next year – nursing facilities transition
Next March will implement dual demonstration in 6 populous counties
Monitoring and oversight is important
Able to attract and hire individuals with extensive experience
Enrollment is a focus and managed closely
Complaints and appeals is an important part of management and supports its own fair hearing process
Have division that provides support for providers around complaints
- Can help to identify systemic issue

Lisa Kirsch, Chief Deputy Director, Medicaid and CHIP – DSRIP Focus

UC pool is rough replacement for UPL
DSRIP pool to support coordinated payment
Trend towards more DSRIP and a little less UC
Local and state entities through IGTs are putting up non-federal share for both of the programs
1492 active DSRIP projects across the state
- 309 DSRIP providers
Waiver expires Sept. 30, 2016
Transition plan for two pools will need to be submitted Sept. 2015
Will get broad stakeholder input on what HHSC is proposing
There is a renewal survey available currently for the public to fill out
Texas is at forefront of DSRIP renewals – HHSC expects some negotiation and there are a lot of unknowns
UC side there is significant tightening up from federal level but anticipates there will need to be a stronger case made if Texas wants to keep both pools at current level
Thinks there will be some room for new projects with money in the renewal
Had statewide summit in September but heard from stakeholders request for more time to really share what is or is not working – so in August will be building in more cross sharing of information along the regions
- Many are already doing informally

INFORMATIONAL ITEMS:
*Amendments to Title 1, Part 15, Chapter 355, Subchapter D, §355.456, concerning Reimbursement Methodology

Texas Association for Home Care & Hospice – submitted written testimony and provided oral testimony based written comments
- Was told it would be for small ICF’s and rate methodology needs to express it is small ICF (6 beds or less)
  - Actually would recommend a 4 bed facility
- Recommends focus on individual instead of project being localized for facility
Staff noted language will state it is limited to small ICF’s – maximum six beds homes

*Informal Dispute Resolution for Assisted Living Facilities

No public testimony

NOTICE OF PROPOSED RULES/ACTION ITEMS:
*Transition Assistance Services

Dr. Handal said he thought the fiscal impact is negligible
Elizabeth Tucker – Every Child – excited to see some changes in the rule, amount is small with max at $2500 but helps to get essential necessities
- Made comment that assistance could be given regardless of where they were coming from – this comment was not accepted
Texas Association for Home Care and Hospice – submitted written testimony and oral testimony
- Supports Tuckers comments
- Want to continue to work with department on rule
HHSC staff noted there is a federal limitation but willing to continue discussions
Motion was approved unanimously

*Home and Community-based Services and Texas Home Living

This is companion rules to rule just presented under 62 because they would add transition services
Allowed agency flexibility under certain corrective action situation
Majority of expenses are transition to HCS
Elizabeth Tucker – excited for rules and rules include ability for home modifications (would like to see that happen in other waivers and other assessments made)
Motion approved unanimously

*Community Living Assistance and Support Services (CLASS)

Dr. Handal asked how are outcomes measured – rule is very processed oriented without focus on outcomes he stated
Colleen Horton was very concerned about restraint rules
Horton said allowing restrain rules to be put into behavior plans will put the clock back
Other board members indicated there was no therapeutic value to restraint and possibly contraindicative
Horton said she did not think restrains had any place in the plans
Texas Association for Home Care and Hospice – high level of concern on language regarding restraints
- Person can be over-restrained and traumatized
- Rule is refocused on process and not on quality of life issues
MCAC members discussed if individuals had tools they needed to work with if having to use restraints and if individuals were being rushed out of facilities
In regards to a question on what precipitated the rules, staff noted surveys were sent out and had questions regarding restraint
- Comment from MCAC members again revolved around if maybe families are doing care without proper equipment/training
MCAC members discussed several motions from sending the whole rule back to removing the complete section on restraints to removing restraints references
The item was postponed until after agenda item 17 with the caveat that staff would re-work language
The item was brought back up after agenda item 17
Starting on page 10 of 132 restraint language was removed
- Protective devices language was kept in
Motion approved unanimously

*Reimbursement Methodology for School Health and Related Services (SHARS)

Motion approved unanimously

*Community First Choice Services

March 1 implementation
State Plan amendment was submitted on October 10
This plan will get services to those who were on interest list much sooner
Motion approved unanimously

*Reimbursement Methodology for CFC Services

Staff noted there is just approval for the methodology of setting rates, rates will not be proposed until further down the road
The language is still a work in progress
MCAC members did request language clean up before submitting to the Texas Register to address things such as typos, etc.
Texas Association for Home Care and Hospice suggested that one blended rate is where the agency should ultimately go
Gary Jessee with HHSC noted that they are not taking about blended rates at this time but looking at equalized rates
Staff noted they will be looking at the possibility of blended rates later and will continue to work with stakeholders
Motion approved unanimously

*Prescribed Pediatric Extended Care Centers

Texas Association for Home Care and Hospice noted the bill language had a provision which clarified PPECC could be in addition to private-duty nursing (PDN) and would like it added to the rule so intention is clearer
Motion approved unanimously

*Reimbursement Methodology for PPECC

David Rimer testified that part of the reimbursement should include transportation and dietary services
Staff said the rate will be limited to a reimbursement rate to no more than 70 percent of the average hourly PDN rate and there is no intention at this time to cover transportation and dietary costs
In regards to members questions regarding why HHSC is not reimbursing for a service it is mandating (transportation and food) staff noted the rule is not effective until July so there is “ample time for the legislature to redirect” their intention
Motion approved unanimously

*Presumptive Medicaid Program

Discussion ensued on determining eligibility
The standard of 95% is strict noted several board members
Based on rule language hospitals have one business day to submit – staff noted that based on the automated system it should be possible
Staff hopes that since it will take up to 11 months for the disqualification process they can work on the corrective action plan with the hospitals
Motion approved unanimously

*Texas Dual Eligibles Integrated Care Demonstration Project

There is no final savings estimate available at this point
Members asked if the project was too ambitious
Mary Tieken, MCAC member asked if they should just start out and test the waters
There is a very aggressive timeline in place but there are several events scheduled across the state to help inform providers stated staff
Texas Association for Home Care and Hospice had two witnesses testify
- There are rumors that MCOs are dropping all dual eligibles
- Also recommended that rule language be add specificity that speaks to passive enrollment
- Concerned agency is biting off too much and would recommend they scale back the demonstration
- Providers need to be made aware of this project
- Concern on implementation timeline and again recommends delay rollout or reduce size of rollout
- Letters need to go to nursing facilities as well as SSI individual addresses
- SB 7 protections should be included in the rules
Discussion ensued on high rates of those participating out of network because rates are low
Network adequacy discussion then ensued
All 5 MCOs are participating
Jessica Cassidy – Attorney Texas Legal Services Center
- Recommended to note member have access to acute care
- Was concerned how counties were selected
- In appeal rules need to clarify 60 days and 90 days as those two dates seem contradictive
Staff noted the counties were selected based on those that had the most dual eligible in them
Staff will look at enrollment and disenrollment to see if clarity is needed
It was noted a legislative session is coming up in hopes that some of these things could be addressed before motion to approve was made
Motion approved unanimously

Proposed Next Meeting: Thursday, February 20, 2015 at 9 a.m.