Transcript Texas Medicaid Program: Reimbursement Methodologies

Texas Medicaid Program:
Reimbursement Methodologies
Michelle Apodaca, J.D.
VP, Advocacy, Legal & Public Policy
Texas Hospital Association
Greater El Paso Chamber of Commerce
Healthcare Council
February 22, 2012
Texas Medicaid Overview
 Jointly funded state-federal health-care
program, and administered by the Texas
Health and Human Services Commission
(HHSC).
 Entitlement program, which means the federal
government does not, and a state cannot, limit
the number of eligible people who can enroll,
and Medicaid must pay for any services covered
under the program. Texas treats only
mandatory populations required by federal
government .
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Medicaid Expenses
Medicaid Beneficiaries and Expenditures:
2009- 65 and older/disabled = 30% caseload, 60% cost
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Health Care and Texas 2012-2013 Budget: Adopted Version
Rate Cuts
2010-2011
2012-2013
Nursing Homes
3%
0%
ICF-MR (not SSLC)
3%
2%
HCS Waiver
2%
1%
NF-related Hospice
2%
1%
Other Community Waivers
0%
$12.5 million GR
cut in in admin for
agencies
Medicaid & CHIP physician, dentist,
orthodontist
2%
0%
Medicaid Hospital
2%
8%
Medicaid DME & Labs
2%
10.5%
Other Medicaid Providers
2%
5%
Other CHIP Providers
2%
8%
Medicaid Pediatric private duty
nursing & home health
2%
0%
Medicaid Managed Care premiums
reduced to “average acuity”
n/a
$169.3 million
GR cut
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Medicaid Managed Care Expansion
 Estimated $386M GR in savings
 Medicaid lives under capitation
(MCO)
–Over 3 million, which is 77% of all
lives
–Pre-expansion, 1.8 million lives,
50% of all lives
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Medicaid - Rate Methodologies
1. Medicare-Linked (Traditional Medicaid – FFS)
– Rates based on actual Medicare rates, % of Medicare
rates, or the methodology used by Medicare.
– Physicians and other Practitioners
 Based on Medicare Relative Unit (RVU) time and
resource weighted system; CMS updates RVUs.
– Inpatient hospital: Rates based on Medicare Standard
Dollar Amount (SDA) x Diagnostic Related Group (DRG).
– Children’s and Rural Hospitals: Rates based on costs.
– Other programs: Ambulatory Surgical Centers, Ambulance
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Medicaid - Rate Methodologies
2. Actuarial Based – “Capitation Rates”
(Managed Care Programs)
- Rates established using encounter and
experience data.
- Programs: STAR, STAR+PLUS (aged and
disabled), STAR Health (foster care), CHIP, CHIP
Perinatal, CHIP dental, NorthSTAR (Behavioral
health in North Texas), and PACE.
- Rates vary by geographical area, risk group
(pregnant women, TANF adults, TANF children,
newborns, etc.), and acuity.
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Capitation Rate Methodology
 Existing Areas
– Service areas that have been in existence for 2 yrs. combine all
the MCO’s medical costs (encounter data) by risk group and
service area.
– Annual adjustments are made prospectively for benefit changes,
reimbursement changes (i.e., Frew) and cost trends.
– Allowances are made for administration, premium tax, and risk
margin.
– All MCO’s start with the same overall average ‘community’ rate
(e.g., Hildalgo).
– Thereafter, rates are adjusted from the community rate to reflect
different levels of acuity each MCO experiences.
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Capitation Rate Methodology (cont’d)
 New Areas
– Rates are determined using data from fee-for-service
(FFS) and/or primary care case management (PCCM)
programs.
– A managed care efficiency adjustment is made to
anticipate savings.
– Similar to existing MMC service areas, adjustments
are made for administration, premium tax, benefit
changes and changes in reimbursements.
– Because the acuity of the clients enrolling into each
MCO is unknown, no risk adjustment is applied.
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Medicaid Reimbursement
Fee-For-Service vs. Managed Care (MC0)
Managed Care
2
2
Fee-For-Service
3
3
1
1
1
1 : Medicare Based
2 : Capitation Rate – Actuarial based
3 : Individually Contracted
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Medicaid – Capitation Rates (effective
3/1/12)
(source:http://www.hhsc.state.tx.us/rad/managed-care/ )
El Paso
El Paso 1st.
Molina
Travis
Superior
BCBS/ SenderoTravis
Seton- Travis
Hidalgo
Superior- Travis
Hidalgo
TANF Children (over age
1)
140.56
134.75
130.00
144.34
143.66
148.28
201.77
TANF Children (<1)
311.11
297.47
285.35
360.88
360.88
354.09
365.27
TANF Adults
356.62
351.53
345.89
382.30
375.90
400.95
429.92
Pregnant Women
364.98
365.25
365.50
563.57
549.28
564.57
356.33
Newborns
490.14
480.99
472.31
687.69
687.69
691.17
643.28
Expansion Children (over
age 1)
137.83
138.84
139.61
147.85
147.74
151.95
219.38
Expansion Children (<1)
267.93
289.72
313.33
303.32
303.32
297.61
279.82
Federal Mandate Children
115.73
117.59
119.16
114.10
113.59
115.66
154.52
Delivery Supplemental
Payment
3443.04
3443.04
3443.04
3247.49
3247.49
3247.49
3409.95
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SB 1299 & SB 1053 Task Force
Recommendations
 Improve Medicaid and CHIP funding by increasing
Medicaid fee schedule to Medicare and thereafter,
update Medicaid rates each year by Medicare inflation
factor.
 Prohibit further funding reductions to the Medicaid and
CHIP programs as a result of reductions in the
Appropriations Act or cost containment strategies.
 Continue to examine potential changes in rate
methodologies - all Medicaid and CHIP rate
methodologies should promote the same outcomes in
the programs related to access, provider rates, HMOs
rates and motivation for high quality of care to members.
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Local Economic Impact
Largest El Paso county employers
Number of employees
El Paso Independent School District
8,663
Fort Bliss (civilian employees)
6,803
Ysleta Independent School District
6,500
City of El Paso
6,264
University of Texas at El Paso
4,871
Socorro Independent School District
3,995
Sierra Providence Health Network
3,761
El Paso Community College
3,728
Wal-Mart
3,706
County of El Paso
2,700
Las Palmas and Del Sol Regional
Health Care System
2,244
Echostar Satellite Corp.
2,012
Source: http://www.city-data.com/us-cities/The-South/El-Paso-Economy.html
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Local Economic Impact of Funding
 Nursing School Funding (est. FY 10
$280,000; est. FY 11 $420,000)
 Trauma Funding (FY 04- FY 10 =
$11.3 M)
 Upper Payment Limit (UPL)
Supplemental Funding: $49M (public)
+ $12M (private) = Est. FY11 $61M
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Questions?
Michelle Apodaca, J.D.
VP, Advocacy, Legal &
Public Policy
Texas Hospital Association
512/465-1506
[email protected]
www.tha.org