Texas Medicaid Managed Care Basics

Michelle Apodaca John Berta

November 2011

Topics

 Key Features  Managed Care Operations  Managed Care Contracting  Resources  Reimbursement and Out-of-Network Issues

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STAR Service Areas – March 1, 2012 3

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Rural Service Areas – March 1, 2012 5

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STAR+PLUS Service Areas – March 1, 2012 7

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CHIP Service Areas March 1, 2012

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What is Managed Care?

 Term used to describe a variety of techniques designed to ensure better access to health care services; improve quality; promote more appropriate utilization of services.

 Risk-based, Capitated payments to MCO.

 Contains costs for the State and brings in $$ from Premium Tax paid by Medicaid MCOs.

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Managed Care Features

 Medical home  Defined network of providers  Utilization review and utilization management  Quality assessment and performance improvement

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Managed Care Features (cont’d)

 Each client may choose a PCP who is responsible for ensuring the continuity and quality of care. The PCP is also responsible for administering preventive and primary care, including medical screens and immunizations.  When specialized or acute care is necessary, the PCP serves as the manager of care by referring the client to other health care providers for those services.

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Forms of Managed Care in Texas

 STAR - primarily serves non-disabled children, low income families, and pregnant women.

 STAR Health - statewide program designed to provide coordinated health services to children and youth in foster care and kinship care.

 Primary Care Case Management (PCCM) is a non capitated network of PCPs and hospitals under contract with HHSC. (

3/1/12 THIS PROGRAM WILL NO LONGER BE VALID

).

 STAR+PLUS.

 Childern’s Health Insurance Program (“CHIP”).

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STAR Program- Excluded populations Populations excluded from STAR include: • Supplemental security income (SSI) recipients.

• Medicaid recipients in institutions.

• Dual-eligible Medicaid recipients (clients with both Medicaid and Medicare).

• Medically needy.

• Foster children.

• Refugees.

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What is STAR+PLUS?

• • • • • A managed care system for persons on SSI.

Integrates acute care and LTSS.

Dual eligibles enrolled for long-term care “insurance policy”.

Improved access to community based LTSS.

MCOs are responsible for coordinating acute and LTSS through the use of a service coordinator.

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STAR+PLUS Members  Medicaid recipients who must participate in STAR+PLUS: • SSI adults who are not:  Residing in a Nursing Facility or other institution.

 Being served through a Home and Community Based Waiver program other than Community Based Alternatives (CBA).

• Non-SSI adults who qualify for 1915(c) Nursing Facility Waiver services must enroll in STAR+PLUS to receive those services.

 Medicaid recipients who can choose to participate in STAR+PLUS: • SSI children, under age 21, may voluntarily enroll in STAR+PLUS. SSI children that do not volunteer will be in traditional Medicaid effective 09/01/2011.

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STAR+PLUS Program Information • Service coordinator is responsible for:  Formulating an individualized plan covering acute and LTSS.

 Overseeing smooth transition from acute care to LTSS.

 Making home visits and assessing members’ needs: – Authorize community LTSS.

– Arrange acute care services.

• STAR+PLUS Medicaid only members can choose or be assigned a PCP. • Service coordinators are required to assist with Medicare physician and service coordination.

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Maximus – Enrollment Broker

 Eligibility Support Services and Enrollment Contractor for Medicaid, food stamps, TANF programs and for Children’s Health Insurance Program (CHIP);  Assists in educating clients who are enrolling in Medicaid managed care (STAR) and CHIP about health plan and PCP choices;  Enrolls clients in STAR and CHIP.

 1-800-964-2777, Monday through Friday, 8 a.m. to 8 p.m. Central Time.

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Maximus – STAR Expansion

 Introduction letters and FAQs sent to potential members beginning 10/17.

 Enrollment packets will be sent between November 28th and January 15th.  Recipients can enroll any time after they receive the enrollment packets, but services in the expansion service areas will not begin until March 1st. If recipients return enrollment forms after cut-off in February (2/15/12), they cannot begin receiving services until April 1st.

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Managed Care Operations

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Contracting Method STAR and STAR+PLUS MCOs  Contract Individually.

 Additional providers dependent on network.

 May limit network.

 MCOs are encouraged to contract with Significant Traditional Providers (STP).

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Verify Eligibility  Health Plan ID Card.

 State Medicaid 3087 Form.

 Health Plan Website.

 Contact the plan directly.

 Automated Inquiry System (AIS).

 Medicaid Eligibility SAVERR Authorization Verification System (MESAV).  For after hour eligibility verification, call the health plan.

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Authorizations STAR and STAR+PLUS • Members are offered a choice of HMO network providers.

• Authorization for services may be limited. • Authorizations are service specific.

• HHSC will require the MCOs to honor TMHP prior authorizations for at least 3 months during initial transition.

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Claims

STAR and STAR+PLUS • Claims are paid by the MCO.

• Providers must file claims within 95 days of Date of Service (DOS). • MCOs required to adjudicate within 30 days.

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Appeals and Fair Hearings

STAR and STAR+PLUS  Members may still appeal to HMO and/or file Fair Hearing request if services are denied, reduced, or terminated.

 Applicants are still notified by the State if determined not eligible.

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Provider Complaints • Initial point of contact is MCO • May submit written complaint to HHSC at [email protected].

us • HHSC will deal with issues when MCO is not complying with HHSC contract

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HHSC Monitors MCOs

 HHSC monitors the HMO performance quarterly for these key indicators: • Network Adequacy • Claims Processing time • Hotline Performance • Complaint processing  Additional contract requirements and performance is also monitored on ongoing basis.

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HHSC Uniform contract with Plans

http://www.hhsc.state.tx.us/medicaid/UniformManagedCareContract.pdf

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Managed Care Contract Provisions Between HHSC and MCOs 

HHSC Uniform Managed Care Contract



http://www.hhsc.state.tx.us/me dicaid/UniformManagedCareC ontract.pdf

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Managed Care Contract Provisions

 Definitions  Clean Claims  Underpayments, Overpayments and Recoupment  Covered Services  Enrollee or Member  Medically Necessary or Medical Necessity  Participating Provider  Policies & Procedures

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Managed Care Contract Provisions

 Credentialing  Utilization Review Obligations  Quality Assurance Program  Audit, Retroactive Review, Concurrent Review, etc.  Provider Insurance & Tail Coverage  Dispute Resolution  Never Events

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Resources

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Rules : Texas Administrative Code

 TITLE 1ADMINISTRATION  15 TEXAS HEALTH AND HUMAN SERVICES COMMISSION  CHAPTER 353 MEDICAID MANAGED CARE  SUBCHAPTER ESTANDARDS FOR THE STATE OF TEXAS ACCESS REFORM (STAR)

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Rules – cont’d       

§30.21

General Provisions §30.22

Definitions §30.23

Enrollment §30.24

Marketing §30.25

Selection of Managed Care Organizations (MCO) §30.26

Scope of Services §30.27

Accessibility of Services

   

30.28

Managed Care Benefits and Services for Children Under 21 Years of Age §30.29

Member Complaint Procedures §30.30

Quality Improvement §30.32

Financial Standards 35

Reimbursement

 Check your contracts with health plans  Medicaid Manual and bulletins (http://www.tmhp.com/default.aspx)

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Rural Hospitals – Rider 40



40. Payments to Hospital Providers.

Until the Health and Human Services Commission (HHSC) implements a new inpatient reimbursement system for Fee-for Service (FFS) and Primary Care Case Management (PCCM) or managed care, including but not limited to health maintenance organizations (HMO) inpatient services, hospitals that meet one of the following criteria: 1) located in a county with 50,000 or fewer persons according to the U.S. Census, or 2) is a Medicare designated Rural Referral Center (RRC) or Sole Community Hospital (SCH), that is not located in a metropolitan statistical area (MSA) as defined by the U.S. Office of Management and Budget, or 3) is a Medicare-designated Critical Access Hospital (CAH), shall be reimbursed based on the cost-reimbursement methodology authorized by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) using the most recent data. Hospitals that meet the above criteria, based on the 2000 decennial census, will be eligible for TEFRA reimbursement without the imposition of the TEFRA cap for patients enrolled in FFS and PCCM. For patients enrolled in managed care other than PCCM, including but not limited to health maintenance organizations (HMO),

inpatient services provided at hospitals meeting the above criteria will be reimbursed at the Medicaid reimbursement calculated using each hospital's most recent FFS rebased full cost Standard Dollar Amount for the biennium.

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Rider 40 Considerations

 Rates are

Negotiated

 Contract Terms are

Negotiated

 Hospitals that do not contract are considered out-of-network  Contracted hospitals need to follow contract terms

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Uniform Managed Care Contract Manual : http://www.hhsc.state.tx.us/medicaid/UMCM/default.html

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Uniform Managed Care Manual : http://www.hhsc.state.tx.us/medicaid/UMCM/default.html

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Reports http://www.hhsc.state.tx.us/medicaid/mc/about/reports/confirmed_eligibl es_report.html

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MCOs provider relation staff http://www.hhsc.state.tx.us/medicaid/mc/ProviderInformation.html42

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Rate Analysis http://www.hhsc.state.tx.us/medicaid/programs/rad/ManagedCare/Mng Care.html

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Sanctions http://www.hhsc.state.tx.us/medicaid/ContractorSanctions/index.html

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Medicaid Managed Care Enrollment http://www.hhsc.state.tx.us/research/index.html

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Managed Care Resources • HHSC Managed Care Proposals Website: http://www.hhsc.state.tx.us/medicaid/MMC-Proposals.shtml

• HHSC STAR Website: http://www.hhsc.state.tx.us/medicaid/mc/about/faq.html

• HHSC STAR+PLUS Website: http://www.hhsc.state.tx.us/starplus/Overview.htm

• TMHP Website: http://www.tmhp.com/Pages/PCCM/STAR_Expansion.aspx

• Email: [email protected]

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Out of Network Providers

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Out of Network - Considerations

 Rates are

Negotiated

 Contract Terms are

Negotiated

 Hospitals that do not contract are considered out-of-network  Contracted hospitals are obligated to follow contract terms – (preauthorization, other)  Rules apply to out-of-network providers  MCO Adequate Network Requirements are in place

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Out of Network Providers – HHSC Rules

 Texas Administrative Code  Title 1  Part 15    Chapter 353 Subchapter A RULE § 353.4

 Applies to MCO contracts executed after 8/31/2006

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Out of Network – Patient Referrals

 MCO shall allow referral to an out-of-network provider when: – Medicaid covered services are

medically necessary

and these services are

not available

through an in-network provider; –

A provider

currently providing authorized services to the member

requests authorization

for such services to be provided to the member by an out-of-network provider;

and

– The authorized services are provided within the time period specified in the MCO's authorization.

And

 The MCO shall: – Timely issue the proper authorization for such referral; and – Timely reimburse the out-of-network provider for authorized services provided.

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Out of Network - Reimbursement General Rules

 A MCO shall reimburse an

out-of-network, in area service

provider the Medicaid Fee-For-Service (FFS) rate in effect on the date of service

less five percent (5%),

unless the parties agree to a different reimbursement amount.

 The MCO shall reimburse an

out-of-network, out-of-area service provider at 100 percent

of the Medicaid Fee-For-Service rate in effect on the date of service, unless the parties agree to a different reimbursement amount.

Special Rule

 All post stabilization services provided to a member by an out-of-network provider must be reimbursed by the MCO at

100 percent of the Medicaid Fee-For-Service rate

in effect on the date of service until the MCO arranges for the timely transfer of the member, as determined by the member's attending physician, to a provider in the MCO's network.

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Out of Network - Reporting Requirements

  Each MCO must submit quarterly Out-of-Network reports to HHSC; Each report must contain information about members, including: – The types of services provided by out-of-network providers; – The scope of services provided by out-of-network providers; – The total number of hospital admissions, as well as number of admissions that occur at each out-of-network hospital. Each out-of network hospital must be identified; – The total number of emergency room visits, as well as total number of emergency room visits that occur at each out-of-network hospital. Each out-of-network hospital must be identified; – The total dollars billed for other outpatient services, as well as total dollars billed by out-of-network providers for other outpatient services; and – Any additional information required by HHSC.

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Out of Network - Usage Standards

 No more than 15 percent of an MCO's total hospital admissions may occur in out-of-network facilities;  No more than 20 percent of an MCO's total emergency room visits, by service delivery area, may occur in out-of-network facilities;

and

 No more than 20 percent of total dollars billed to an MCO for "other outpatient services" may be billed by out-of-network providers.

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Out of Network - Usage Standards Exception

 If a MCO exceeds the maximum Out-of-Network standard for Inpatient Admissions or Emergency Room Visits, HHSC may modify the calculation if: – The admissions or visits to a single out-of-network facility account for 25% or more of the MCO's admissions or visits in a reporting period;

and

– HHSC determines that the MCO has made all reasonable efforts to contract with that out-of-network facility as a network provider without success.  HHSC may modify the calculation by excluding the Inpatient Admissions or Emergency Room Visits to the single, large out-of network facility.

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Out of Network – Reasonable Effort to Contract

 In determining whether the MCO has made all reasonable efforts to contract with a large out-of-network facility HHSC will consider: – How long the MCO has been trying to negotiate a contract; – The in-network payment rates the MCO has offered; – The other, non-financial contractual terms the MCO has offered, particularly those relating to prior authorization and other utilization management policies and procedures; – The MCO's history with respect to claims payment timeliness, overturned claims denials, and provider complaints; – The MCO's solvency status; and – The out-of-network facility's reasons for not contracting with the MCO.

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Out of Network - Provider Complaints

 HHSC investigates provider complaints regarding payment for out-of-network providers;  If a provider files a complaint regarding out-of network payment, HHSC requires the MCO to submit data to support its position on the adequacy of the payment to the provider.

 Within 60 days of the complaint, HHSC notifies the provider of its conclusion, including any corrective action and the disposition of any payment owed to an out-of-network provider.

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Out of Network – Complaint Upheld

 If HHSC determines that a MCO did not reimburse the out-of network provider a reasonable payment, HHSC initiates a corrective action plan and requires the MCO to:  Pay the out-of-network provider within 90 days from the date the complaint was received by HHSC or 30 days from the date the clean claim, whichever comes first; or  Submit a reimbursement payment plan to the out-of-network provider within 90 days from the date the complaint was received by HHSC.

 If the MCO does not pay the entire amount of the additional reimbursement within 90 days from the date the complaint was received by HHSC, HHSC may require the MCO to pay interest at a rate of 18 percent per year on the unpaid amount from the 90th day

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Out of Network - Corrective Action Plan & Remedies

 A Corrective Action Plan is required by HHSC if:  The MCO exceeds a maximum standard established by HHSC for out-of-network access to health care services;  The MCO does not reimburse an out-of-network provider based on a reasonable reimbursement methodology;  Corrective Action Plan requirements may include:  The MCO begin paying allowed rates;  New members are not allowed into the plan;  The MCO provide education to its members on the use of networked providers; or  Other actions mandated by HHSC

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Questions

Thank You!

Michelle Apodaca 512-465-1506 [email protected]

John Berta 512-465-1556 [email protected]

Don McBeath 512-873-0045 [email protected]

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