The SMMCAC met on June 24, 2019, to take up a number of items, including complaints process and data improvements, Texas Healthcare Transformation and Quality Improvement Program, and an update on HHSC legislative items. A full report on the meeting is below.
This report is intended to give you an overview and highlight of the discussions on the various topics the committee took up. It is not a verbatim transcript of the hearing but is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.
Chair election
- Election will be delayed until next meeting, which is scheduled for August.
Establishment of new subcommittees
- Administrative simplification.
- Complaints and appeals.
- Monitoring strategy.
- Carter – Concerns that rules created by subcommittees could be misinterpreted by the MCOs.
- Subcommittees will have five members each.
Complaints Process and Data Improvements
- Claire Middleton, Medicaid and CHIP Services Department – Aggregating data to identify early warning signs and increasing transparency around that data.
- Middleton – All MCO complaints will be funneled to the ombudsman’s office regardless of where they were originally filed.
- Dunkelberg – How hard is it to tell what is encompassed in the complaint and are “informal complaints” captured at all?
- Middleton – A complaint is any expression of dissatisfaction.
- Dunkelberg – There could be more done in complaint training.
- Stephanie Muth, State Medicaid Director – If there is a “first call resolution” then that does not qualify as a complaint for TDI purposes. There are some nuances in the difference between an inquiry and a complaint.
- Ashbury – Is independent data used to verify Medicaid utilization? Certain data shows that it is not going down, but HMOs will often claim their utilization is decreasing. Providers could be cherry-picking the data. Need to ensure truthful and unbiased data.
- Muth – Can share more insight around the data quality program in Medicaid.
- Middleton – Looking to use data to promote early issue resolution.
- Janice Fagan, Blue Cross Blue Shield – Will HHSC vendors such as Maximus send issues discovered through their call centers to the ombudsman?
- Middleton – Primarily focused on member managed care complaints. Not looking at eligibility complaints within the scope of this group.
- Fagan – As long as everyone understands what is within scope. Otherwise there will be some disappointment.
- Weedon – Is this only the various STAR plans or the STAR plans and CHIP?
- Middleton – That is an open question, working with legal to get a final determination on that.
- Klein – There is a subcommittee that will be established to deal with this issue, how will that subcommittee deal with this process?
- Muth – Started with consumer complaints, have not yet addressed the process around provider complaints.
HHSC Legislative Update
- HB 4533 – Bill originally dealt with disability service, had some MCO legislation amended onto it near the end of the session.
- Requires HHSC to publicize data related to outcomes.
- Requires HHSC to study the 30 day “spell of illness” limitation.
- Expand consumer directed services delivery option to all services provided by medically dependent children program.
- SB 1096 – Requires prior authorization determination to be issued by MCOs within shorter timeframes.
- HB 3041 – Requires MCO websites to include timelines for PA requests and to include a guide for how to communicate with the MCO.
- SB 1207 has several provisions around STAR kids.
- Requires STAR Kids MCOs to ensure legally authorized representatives to receive an assessment.
- Requires HHSC to streamline the assessment process.
- Requires HHSC to determine if a child ahs certain conditions. Prioritization of certain conditions on the waitlist.
- Requires an annual review process of prior authorization requirements.
- HB 72 – Applies specifically to kids adopted through DFPS. Allows certain children to remain in STAR Kids until they are enrolled in a different program.
- Ashbury – Certain news report said the Legislature cut Medicaid’s budget by $900m. That may not be a totally accurate number, but with these new requirements and budget cuts some things will have to be cut. Is that $900m accurate and what is the plan to deal with that?
- Bearden – This is a bit of a “smoke and mirrors” way for the state to achieve a balanced budget.
- Dunkelberg – This will be the 6th or 7th budget written with a budget rider called “cost containment”, the one this session is one of the more modest ones.
- Weedon – Legislature put in the rider “efficiencies without reduction in access to services”.
Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver
- Gary Young, Advisor to State Medicaid Director – Have completed nearly all terms and conditions in the waiver related to the uncompensated care pool. Only condition remaining relates to the size of the pool. Should be completed by August.
- Ashbury – What does uncompensated care reimburse for? What amount of money per $10,000 do they get back?
- Young – Pool payments are made on a hospital-specific basis. Hospitals have different charity care policies, that will drive how much they can justifiably report for purposes of the pool.
- Dunkelberg – Which calendar year is demonstration year 9?
- Andy Vasquez, HHSC – October 2019 – September 2020.
- Vasquez – DSRIPP has been in place since 2012.
- 40% of spending on DSRIPP has been for the uninsured.
- Trying to take lessons from DSRIPP and move those into more mainstream Medicaid.
- DSRIPP will run out of funding by demonstration year 9.
- Klein – When the plan is announced will it have to have specific dollar amounts attached to it?
- Vasquez – As of now there are not specific dollar amounts attached to that plan.