Medicaid Managed Care for Elderly and Persons with Disabilities
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Medicaid Managed Care for Elderly and Persons with Disabilities Pam Coleman Texas Health and Human Services Commission October 11, 2006. Pilot implemented in Harris County (Houston) in 1998 Risk-based, capitated managed care

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STAR+PLUS Harris County

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Star plus harris county

Medicaid Managed Care for Elderly and Persons with DisabilitiesPam ColemanTexas Health and Human Services CommissionOctober 11, 2006


Star plus harris county

Pilot implemented in Harris County (Houston) in 1998

Risk-based, capitated managed care

Integrates Medicaid funding and service delivery of long term and acute care

Serves 60,000 aged and disabled not in a nursing facility

STAR+PLUSHarris County


Why star plus

Legislative direction (SCR 55, 74th session)

Improve coordination of physical health care needs with personal care needs

Improved access to community based long-term care support services

Promote coordination of Medicaid and Medicare

Increase cost effectiveness

Why STAR+PLUS?


Texas medicaid expenditures

Children, Adults and Other are 74% of the Medicaid population and 37% of costs. Aged and Disabled are 20% of the Medicaid population but 62% of costs (all funds). Total $18 Billion

Texas Medicaid Expenditures

Texas Medicaid in Perspective, HHSC, April 2004


Texas medicaid managed care growth

Texas MedicaidManaged Care Growth


Star plus members

Supplemental Security Income (SSI) adults who are not in a nursing facility or other institution and who are not currently being served through a Home and Community Based Waiver program, other than Community Based Alternatives (CBA), must enroll in STAR+PLUS.

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

SSI children, under age 21, may voluntarily enroll in STAR+PLUS.

STAR+PLUS Members


Hmo member benefits

Traditional Medicaid benefit package

Unlimited Prescription drugs (Medicaid only)

Annual adult well checks

Removal of limit for length of stay for hospitalization (STAR only)

PCP provider directories

PCP coordinates health care of patient

24-hour nurse helpline (through their health plan)

Member services helpline (through their health plan)

Member handbooks and health education

Case management for members with special health care needs

HMO Member Benefits


Star plus ltc services

STAR+PLUS LTC Services

  • Medical supplies

  • Home modifications

  • Respite care

  • Therapies

  • Emergency response

  • Personal assistance

  • Day activity and health

  • 1915(c) waiver services

  • Adaptive aids

  • Adult foster home

  • Assisted living


Contracting method

DADS

Open Enrollment

Licensure

Contract

Program specific

STAR+PLUS HMO

Negotiated Individually

Additional providers dependent on network adequacy

Contract by service, not program

May add licensed providers that are not contracted with DADS

Contracting Method


Rates

DADS

Established on a statewide basis for each program.

Based on cost reports filed by providers

Same for all providers

STAR+PLUS HMO

Negotiated with each provider

May establish fixed rates for each service or can negotiate different rates

Provider can offer additional service for additional compensation

Rates


Access

DADS

Individuals needing assistance must contact DADS or be referred by family, provider or community for assessment and authorization

STAR+PLUS

All members are contacted within 30 days of enrollment

Informed about services available

Telephonic risk questionnaire may lead to assessment and authorization for services

Access


Care coordination results

External quality review study completed July 2003

SSI clients in STAR+PLUS were compared to SSI PCCM clients

Significant cost difference – particularly for the highest acuity clients ($3,226 mo in STAR+PLUS vs. $13,160 mo in PCCM)

Lower inpatient and ER use in STAR+PLUS

Care Coordination Results


Star plus vs pccm

Overall Expenditures

STAR+PLUS vs. PCCM


Cost savings

Cost savings result frommanaging care by:

Early identification and treatment of health problems

Promoting wellness and healthy lifestyles

Avoiding higher cost services and products when lower-cost, clinically appropriate services can be rendered

Coordinating care effectively and reducing duplication of services

Cost Savings


Star plus and special needs plans

Have 9 SNPs operating in Texas. Two have STAR+PLUS plans with over 20,000 enrolled for both programs

SNP plans would like to see expansion of STAR+PLUS

We pay a premium to the SNP plans to cover Medicaid cost share obligation

STAR+PLUS and Special Needs Plans


Expansion issues

Unable to expand the program due to potential loss of UPL to public hospitals.

Medicaid laws prohibit hospitals from receiving UPL if they are paid by a capitated HMO.

Texas plans to implement alternative models including hospital carve-out and non-capitated managed care programs, but effectiveness and efficiency will be compromised.

Expansion Issues


Star plus harris county

STAR+PLUS is expanding to 4 new areas January 2007

STAR+PLUS will carve out inpatient hospital services from the HMO capitation

Capitates physician, ER, outpatient, and community-based long-term support services.

STAR+PLUS Expansion


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