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
Medicaid Managed Care for Elderly and Persons with DisabilitiesPam ColemanTexas Health and Human Services CommissionOctober 11, 2006
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
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
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 in Perspective, HHSC, April 2004
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.
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
Additional providers dependent on network adequacy
Contract by service, not program
May add licensed providers that are not contracted with DADS
Established on a statewide basis for each program.
Based on cost reports filed by providers
Same for all providers
Negotiated with each provider
May establish fixed rates for each service or can negotiate different rates
Provider can offer additional service for additional compensation
Individuals needing assistance must contact DADS or be referred by family, provider or community for assessment and authorization
All members are contacted within 30 days of enrollment
Informed about services available
Telephonic risk questionnaire may lead to assessment and authorization for services
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
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
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
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.
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.