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Medicaid Managed Care Introduction and Update

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

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Medicaid Managed Care Introduction and Update

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  1. Medicaid Managed CareIntroduction and Update Medicaid Rural Service Area

  2. 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

  3. 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.

  4. Medicaid Rural Service Area

  5. STAR Program • Populations mandatory for STAR include: • TANF recipients • Pregnant Women • Newborns • Children receiving Medicaid assistance only • Adult Medicaid recipients receiving Supplemental Social Security (SSI) • Populations excluded from STAR include: • 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.

  6. STAR Provider Listing Includes primary care provider/specialists Unlimited Prescriptions Member Handbook 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 MCO must ensure access to providers per contract requirements (emergency, urgent, routine care) FFS Client has to locate willing provider No primary care provider Managed Care vs. Fee-For-Service

  7. 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.

  8. 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)

  9. Verify Eligibility 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. 9

  10. 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.

  11. 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. Page11

  12. Initial point of contact is MCO. May submit written complaint to HHSC at hpm_complaints@hhsc.state.tx.us. HHSC will intervene in issues when MCO is not complying with HHSC contract. Provider Complaints

  13. 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.

  14. Resources HHSC Managed Care Expansion Webpage: http://www.hhsc.state.tx.us/medicaid/MMC.shtml TMHP Website:http://www.tmhp.com/Pages/Medicaid/Medicaid_Managed_Care.aspx Vendor Drug Program website: www.txvendordrug.com Email: ManagedCare_Exp2012@hhsc.state.tx.us Email:hpm_complaints@hhsc.state.tx.us 14

  15. Questions?

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