Transcript Leadership Briefing Outline - Texas Hospital Association

Medicaid Managed Care
Introduction and Update
Medicaid Rural Service Area
What is Medicaid Managed Care?
• Establish a medical home for Medicaid clients
through a primary care provider
• Emphasize preventative care
• Improve access to care
• Ensure appropriate utilization of services
• Improve health outcomes and quality of care
• Improve client and provider satisfaction
• Improve cost effectiveness
Current Medicaid Managed Care
Delivery Models
• STAR (State of Texas Access Reform)
• Capitated, Managed Care Organization (MCO) model for people receiving
Temporary Assistance for Needed Families (TANF), non-disabled pregnant
women and low income families and children.
• Provides acute care services.
• STAR+PLUS
• Capitated MCO model for disabled Medicaid clients and dual eligibles
(Medicaid and Medicare).
• Provides acute and long-term services and supports (LTSS).
• STAR Health
• Capitated MCO model for foster care children.
• Provides acute care services with emphasis on behavioral health and
medication management.
Medicaid Rural Service Area
Dallam
Sherman
Hartley
Moore
Oldham
Potter
Carson
Deaf Smith
Randall
Armstrong
Parmer
Castro
Hansford
Hutchinson Roberts
Swisher
Medicaid Rural Service Area
Regions
Ochiltree Lipscomb
Hemphill
Wheeler
Gray
Donley Collingsworth
Briscoe
Hall
MRSA – Northeast Texas
Childress
Hardeman
Bailey
Hale
Lamb
Floyd
Motley
Cottle
Amerigroup, Superior
Wilbarger
Wichita
Foard
Clay
Cochran Hockley
Lubbock
Crosby
King
Dickens
Baylor
Knox
Montague
Archer
Cooke
Grayson
Lamar
Fannin
Red River
Bowie
Delta
Yoakum
Terry
Lynn
Garza
Kent
Stonewall
Jack
Haskell Throckmorton Young
Gaines
Dawson
Borden
Scurry
Fisher
Jones Shackelford Stephens
Andrews
Martin
Howard
Mitchell
Nolan
Taylor
Wise
Palo
Pinto
Denton
Parker
Tarrant
Collin
Dallas
Titus
Hopkins Franklin Morris
Camp
Hunt
Rains
Rockwall
Wood
Upshur
KaufmanVan Zandt
Gregg
Hood
Eastland
Callahan
Johnson
Erath
Loving
Hudspeth
Winkler
Ward
Culberson
Ector
Crane
Reeves
Midland Glasscock
Sterling
Henderson
Runnels
Coleman Brown
Bosque
Reagan
Tom Green
Irion
Schleicher
Milam
Val Verde
Lee
Bandera
Medina
Orange
Jefferson
Fayette
Guadalupe
Gonzales
Bexar
Uvalde
Liberty
Austin Waller
Caldwell
Newton
Tyler
Hardin
Montgomery
Washington
Comal
Polk
San Jacinto
Bastrop
Hays
Kendall
Real
Kinney
Travis
Blanco
Kerr
Edwards
Walker
Brazos
Grimes
Burleson
Williamson
Kimble
Gillespie
Brewster
Burnet
Llano
Terrell
Presidio
Jasper
Madison
Mason
Sutton
Trinity
Robertson
Menard
Crockett
San Augustine
Sabine
Angelina
Houston
Leon
Falls
Bell
Pecos
Nacogdoches
Limestone
Coryell
McCulloch San Saba Lampasas
Jeff Davis
Shelby
Freestone
McLennan
Concho
Panola
Anderson Cherokee
Hamilton
Mills
Upton
Rusk
Navarro
Hill
Comanche
Coke
Harrison
Smith
Ellis
Somervell
El Paso
Cass
Marion
Harris
Chambers
Colorado
Fort Bend
Galveston
Lavaca
Wharton
Brazoria
Wilson
De Witt
Zavala
Frio
Atascosa
Jackson
Karnes
Victoria
Maverick
Matagorda
Goliad
Dimmit
MRSA – West Texas
Amerigroup, FirstCare, Superior
Calhoun
Bee
La Salle
McMullenLive Oak
Refugio
Aransas
San Patricio
Webb
Duval
Jim Wells
Nueces
MRSA – Central Texas
Kleberg
Zapata Jim Hogg Brooks
Starr
Amerigroup, Scott & White, Superior
Kenedy
Willacy
Hidalgo
Cameron
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STAR Program
• Populations mandatory for STAR include:
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TANF recipients
Pregnant Women
Newborns
Children receiving Medicaid assistance only
Adult Medicaid recipients receiving Supplemental Social Security
(SSI)
• Populations excluded from STAR include:
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Medicaid recipients who reside in institutions
Medically needy
Foster children
Refugees
Dual-eligible Medicaid recipients (clients with both Medicaid and
Medicare)
• Children age 20 and younger can choose to join STAR if they
receive SSI, but do not receive Medicare.
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Managed Care vs. Fee-For-Service
FFS
STAR
•
Provider Listing
•
Unlimited Prescriptions
•
Member Handbook
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Includes phone numbers for assistance,
descriptions of benefits, complaints and
appeal information
Value-added services (varies by MCO)
•
Such as 24 hour nurse lines, additional
transportation help, cell phones for high risk
clients, weight loss programs
Member chooses primary care
provider or is assigned one – can
change through the MCO
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Client has to locate willing
provider
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No primary care provider
Includes primary care provider/specialists
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MCO must ensure access to providers per
contract requirements (emergency, urgent,
routine care)
Medicaid Managed Care
• MCO model offers improved utilization management:
• Improved utilization achieved through internal MCO
processes.
• Premium tax:
• Premiums paid to Medicaid MCOs are subject to state
premium tax.
• As part of HHSC’s check and balance on the MCOs,
HHSC caps the amount of profit that may be earned.
Health Plan Identification Cards
• All members receive a Health plan ID card, in addition to
an Your Texas Benefits Medicaid card from the State.
• The card contains the following information:
• Member’s name and Medicaid ID number
• Identification of health care program (STAR)
• MCO name
• Primary care provider name and telephone number
• Toll-free telephone numbers for member services and behavioral
health services hotline
• Additional information may be provided (e.g., date of birth,
service area, primary care provider address)
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Verify Eligibility
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Your Texas Benefits Medicaid card.
Health plan ID card.
Health plan website.
Contact the plan directly.
For after hour eligibility verification, call the health plan.
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STAR Program
• Providers must contract and be credentialed with the
managed care organization (MCO) to provide STAR
services.
• Rates are negotiated between the provider and the
MCO.
• Authorization requirements may be different and must
be obtained from the MCO.
• Providers must follow MCO 95 day billing
requirements.
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Claims
• STAR Medicaid Managed Care
 Acute care 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.
• Long-term services and supports will continue to be
provided through the current process.
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Provider Complaints
• Initial point of contact is MCO.
• May submit written complaint to HHSC at
[email protected].
• HHSC will intervene in issues when MCO is
not complying with HHSC contract.
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Challenges and New Opportunities
• Access Concerns
• In Network / Out of Network
• Keeping Up with Growth
• Reimbursement Concerns
• TEFRA and Rider 40
• Transition to APR-DRG
• STAR+PLUS in the Medicaid Rural Services
Areas.
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Resources
• HHSC Managed Care Expansion Webpage:
http://www.hhsc.state.tx.us/medicaid/MMC.shtml
• TMHP Website:
http://www.tmhp.com/Pages/Medicaid/Medicaid_Man
aged_Care.aspx
• Vendor Drug Program website:
www.txvendordrug.com
• Email: [email protected]
• Email: [email protected]
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Questions?