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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
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 facilitySTAR+PLUSHarris County
Texas Medicaid in Perspective, HHSC, April 2004
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
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 needsHMO Member Benefits
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 compensationRates
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 servicesAccess
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 servicesCost Savings
SNP plans would like to see expansion of STAR+PLUS
We pay a premium to the SNP plans to cover Medicaid cost share obligationSTAR+PLUS and Special Needs Plans
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 will carve out inpatient hospital services from the HMO capitation
Capitates physician, ER, outpatient, and community-based long-term support services.