Medicaid & Managed Care Initiatives
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Medicaid Managed Care Initiatives December 2011 Medicaid Service Delivery Models • STAR • Capitated, Health Maintenance Organization (HMO) model for non-disabled pregnant women and children. • Provides acute care services. • STAR+PLUS • Capitated HMO model for disabled Medicaid clients and dual eligibles (Medicaid and Medicare). • Provides acute and long term services and supports (LTSS). 2 Medicaid Service Delivery Models • STAR Health • Capitated HMO model for foster care children. • Provides acute care services with emphasis on behavioral health and medication management. • Primary Care Case Management (PCCM) • Non-capitated service delivery model. • Includes non-disabled pregnant women, children and disabled adults. • Acute care services only. 3 Medicaid Managed Care Initiatives • Expand STAR and STAR+PLUS to South Texas. • Expand STAR+PLUS to El Paso and Lubbock service areas. • Convert PCCM Areas to the STAR Program model. • Include In-patient Hospital Services in STAR+PLUS. • Include pharmacy benefits in managed care. • Expand Dental Managed Care Model for children in Medicaid. Page 4 STAR+PLUS Service Areas STAR+PLUS Managed Care Medicaid Rural Service Area (MRSA) Regions Service Areas Dallam Sherman Ochiltree Lipscomb Dallam Hartley Sherman Hansford Ochiltree Moore Hutchinson Roberts Lipscomb Hemphill Hutchinson Roberts Carson Gray Hemphill Wheeler Hartley Oldham Moore Potter Oldham Deaf Smith Potter Randall Hansford Carson Armstrong (effective March 1, 2012) Wheeler Gray Donley Collingsworth Tarrant Deaf Smith Randall Armstrong Donley Collingsworth Parmer Castro Swisher Briscoe Hall Childress Parmer Castro Bailey Lamb Bailey Lamb Cochran Hockley Swisher Briscoe Hall Motley Hale Floyd Hale Lubbock Floyd Crosby Motley Dickens Amerigroup, Bravo MRSA Hardeman Childress Cottle Wilbarger Foard Hardeman Wichita Cottle King Wichita Archer Foard Knox Wilbarger Baylor Amerigroup, Superior Clay Montague Cooke Grayson Fannin Clay Lubbock Lubbock Lynn Crosby Garza Montague Baylor Archer Knox Haskell Throckmorton Young Cooke Grayson Denton Collin Lamar Red River Delta Lamar Jack Wise Fannin Hunt Amerigroup, Superior El Paso Dallas Bowie Red River Titus Hopkins Franklin Morris Bowie Delta Cass Camp Titus Jack Wise Denton Collin Garza Kent Terry Lynn Stonewall Haskell Throckmorton Young Palo Yoakum Rockwall Hunt Rains Hopkins Franklin Morris Marion Wood Cass Parker Tarrant Dallas Scurry Pinto Gaines Dawson Borden Fisher Jones Shackelford Stephens Upshur Camp Dallam Sherman Hansford Ochiltree Lipscomb KaufmanVanRains Zandt Wood Palo Rockwall Harrison Marion Parker Tarrant Gregg Dallas Borden Scurry Fisher Pinto Gaines HartleyDawson Jones Shackelford Stephens Upshur Hood Hutchinson Moore Roberts Hemphill Johnson Smith Ellis Erath KaufmanVan Zandt Howard Mitchell Andrews Martin Nolan Taylor Callahan Eastland Harrison Henderson Gregg Somervell Panola Hood Oldham Potter Carson Gray Wheeler Rusk Johnson Smith Ellis Eastland Navarro Erath Andrews Martin Howard Mitchell Nolan Taylor Callahan Hill Comanche Henderson Bosque Coke Somervell Panola Ector Midland Glasscock Deaf Smith Randall Armstrong Donley Collingsworth Winkler Loving Runnels Sterling Anderson Cherokee Rusk Shelby Navarro Coleman Brown Hill Freestone ComancheHamilton Bosque Loving Coke Nacogdoches EctorParmer Midland Glasscock Winkler Castro Swisher Briscoe Sterling Hall Childress Runnels Anderson Cherokee McLennan Limestone Shelby Coleman Brown Mills Ward San Augustine Culberson Hamilton Freestone Hardeman Crane Tom Green Coryell Upton Reagan Nacogdoches Sabine Concho Reeves Houston Irion Cottle Motley Wilbarger McLennan Bailey Lamb Hale Floyd Leon Ward Falls Limestone Angelina Mills Wichita Foard San Augustine McCulloch San Saba Lampasas Culberson Crane Tom Green Coryell Upton Reagan Sabine Trinity Concho Clay Montague Reeves Houston Irion Leon Lamar Bell Cooke Grayson King Baylor Red River Falls Robertson Angelina Archer Knox Cochran Hockley Lubbock Crosby Dickens Fannin McCulloch Lampasas Jasper Madison San Saba Bowie Schleicher Menard Delta Trinity Newton Bell Polk Robertson Burnet Milam Pecos Tyler Jack Titus Wise Denton Walker Garza Kent Terry Lynn Crockett Stonewall Haskell Throckmorton Young Yoakum Jeff Davis Mason Jasper Llano Collin Hunt HopkinsFranklin Morris Cass Schleicher BrazosMadison Menard Williamson Camp Newton BurnetRains Milam Pecos Grimes WalkerSan JacintoPolk Tyler Palo Rockwall Sutton Marion Crockett Burleson Jeff Davis Mason Wood Kimble Parker TarrantLlano Dallas Scurry Pinto Gaines Dawson Borden Fisher Jones Shackelford Stephens Upshur Brazos Williamson KaufmanVan Zandt San Jacinto Harrison Travis Hardin Grimes Gillespie Lee Montgomery Gregg Sutton Burleson Blanco Hood Kimble Johnson Smith Terrell Martin Howard Mitchell Nolan Ellis Erath Washington Andrews Taylor Callahan Eastland Liberty Hardin Somervell Orange Henderson Travis Bastrop Panola Lee Montgomery Kerr Gillespie Hays Rusk Blanco Navarro Terrell Presidio Hill Edwards Washington Brewster Austin Waller Comanche Kendall Liberty Bosque El Paso Jefferson Coke Orange Ector Midland GlasscockVal Loving Winkler Verde Bastrop Shelby Runnels Sterling Anderson Cherokee Kerr Coleman Brown Hays Caldwell Real Bandera Fayette Harris Chambers Comal Hamilton Freestone Presidio Edwards Brewster Austin Waller Nacogdoches Kendall Jefferson McLennan Limestone Val Verde Ward Mills Hudspeth Culberson Crane Bandera Caldwell Fayette Harris Chambers Real Tom Green San AugustineColorado Coryell Comal Upton Reagan Guadalupe Sabine Concho Reeves Houston Irion Leon Fort Bend Falls Angelina McCulloch San Saba Lampasas Gonzales Bexar Galveston Trinity Bell Lavaca Colorado Robertson Guadalupe Uvalde Medina Kinney Madison Fort Bend Jasper Schleicher Menard Gonzales Bexar Newton Wharton Polk Galveston Burnet Milam Pecos Tyler Walker Lavaca Crockett Brazoria Jeff Davis Llano Wilson Medina Kinney Mason Uvalde Brazos Williamson San Jacinto Wharton De Witt Grimes Sutton Burleson Kimble Brazoria Wilson Jackson Travis Hardin Gillespie Lee Montgomery Karnes De Witt Blanco Atascosa Terrell Frio Zavala Washington Liberty Matagorda Bastrop VictoriaOrange Jackson Kerr Hays Maverick Presidio Edwards Atascosa Austin WallerKarnes Kendall Zavala Frio Jefferson Val Verde Goliad Matagorda Caldwell Real Bandera Fayette Harris Chambers Victoria Brewster Comal Maverick Colorado Goliad Calhoun Guadalupe Bee Fort Bend Dimmit Gonzales Bexar Galveston Live Oak Lavaca La Salle McMullen Uvalde Medina Kinney Refugio Calhoun Bee Wharton Dimmit Wilson McMullenLive Oak Brazoria La Salle Refugio De Witt Aransas Jackson Karnes Atascosa Frio Zavala San Patricio Matagorda Victoria Aransas Maverick San Patricio Goliad Cochran Hockley Yoakum Terry King Dickens Kent Stonewall – Northeast Texas Molina, Superior Tarrant * El Paso Hudspeth Hudspeth El Paso Dallas * Lubbock Amerigroup, Molina El Paso Jefferson MRSA – West Texas Amerigroup, FirstCare, Superior Travis Harris Amerigroup, United Dimmit Travis Bee Webb La Salle Calhoun McMullenLive Oak Refugio Webb San Patricio Webb Bexar Bexar Amerigroup, Molina, Superior Duval Jim Wells Zapata Jim Hogg Brooks Jim Wells Nueces Jim Wells Nueces Kleberg Kleberg Nueces Kleberg Zapata Jim Hogg Brooks Zapata Jim Hogg Brooks Starr Willacy Starr Starr Cameron Hidalgo HealthSpring, Molina, Superior Kenedy Kenedy Nueces Kenedy Hidalgo Hidalgo Duval Aransas Duval Hidalgo Hidalgo Willacy Willacy Jefferson Amerigroup, Molina, United Harris Amerigroup, Molina, United MRSA – Central Texas Amerigroup, Scott & White, Superior Nueces Superior, United Cameron Cameron HHSC, Health Plan Operations September 2010 5 HHSC, HHSC, Health Health Plan Plan Operations Operations July 2011 2011 July Service Areas STAR+PLUSSTAR+PLUS Managed Care Service Areas Dallam Sherman Hartley Moore Oldham Potter Carson Deaf Smith Randall Armstrong Parmer Castro Hansford Ochiltree Lipscomb Hutchinson Roberts Hemphill Swisher Gray (effective March 1, 2012) Wheeler Donley Collingsworth Briscoe Hall Tarrant Childress Amerigroup, Bravo Hardeman Bailey Hale Lamb Motley Floyd Cottle Wilbarger Wichita Foard Clay Crosby Lubbock Cochran Hockley King Dickens Baylor Knox Montague Archer Cooke Grayson Lamar Fannin Red River Lubbock Yoakum Garza Lynn Terry Kent Stonewall Jack Haskell Throckmorton Young Amerigroup, Superior Wise Denton Collin Titus Hopkins Franklin Morris Hunt Dawson Dallam Sherman Borden Scurry Fisher Hansford Ochiltree Lipscomb Jones Palo Pinto Shackelford Stephens Parker Rains Rockwall Dallas Tarrant Wood Marion Upshur KaufmanVan Zandt Hartley Andrews Ector Winkler Loving Culberson Castro Swisher Gray Nolan Taylor Hall Runnels Upton Bailey Lamb Concho Wilbarger Wichita Irion Cottle Motley Floyd Yoakum Amerigroup, Molina Terry Lubbock Lynn Crosby Dickens King Kent Stonewall Gaines Garza Crockett Baylor Knox Dawson Borden Scurry Fisher Martin Howard Mitchell Nolan Montague Archer Cooke Wise Mason Grayson Kimble Palo Pinto Shackelford Stephens Denton Presidio El Paso Tarrant Winkler Ward Culberson Ector Crane Reeves Coke Midland GlasscockVal Verde Sterling Runnels Comanche Coleman Brown Real Reagan Tom Green Irion Schleicher Pecos Jeff Davis Menard Mason Burnet Llano Gillespie Blanco Zavala Edwards Brewster Val Verde Kerr Maverick Real Travis Fayette Uvalde Chambers San AugustineColorado Guadalupe Sabine Houston Leon Fort Bend Angelina Gonzales Bexar Galveston Trinity Bell Lavaca Robertson Medina Madison Jasper Newton Wharton Polk Milam Tyler Walker Brazoria Wilson Brazos Williamson San Jacinto De Witt Grimes Burleson Jackson Travis Hardin Lee Montgomery Karnes Atascosa Frio Washington Liberty Matagorda Bastrop VictoriaOrange Hays Austin Waller Bandera Caldwell Comal Fayette Colorado Guadalupe Gonzales Calhoun Galveston Refugio Wharton Frio Harris Brazoria San Patricio Matagorda Victoria Maverick Aransas Jackson Karnes Atascosa Bee Webb La Salle Calhoun McMullenLive Oak Refugio Duval Jim Wells Harris Amerigroup, Molina, United Goliad Dimmit Jefferson Amerigroup, Molina, United Jefferson Bee Fort Bend McMullen Live Oak Lavaca La Salle Medina Goliad Harris Chambers De Witt Zavala Travis Harris Nacogdoches Limestone Wilson Amerigroup, United Orange Jefferson Falls Kendall Dimmit Bexar Kinney Liberty Austin Waller Shelby Caldwell Hardin Montgomery Washington Jefferson Kimble Terrell Presidio Harrison Lee Rusk Anderson Cherokee Newton Tyler San Jacinto Bastrop Panola Hays Comal Freestone McLennan Uvalde Kinney Crockett Sutton Gregg Brazos Grimes Polk Burleson Smith Henderson Navarro Dallas * Walker Cass Marion Jasper Madison Milam Coryell Concho McCulloch San Saba Lampasas El Paso Upshur KaufmanVan Zandt Travis Blanco Bandera Hamilton Mills Upton Wood Ellis Hill Kendall Bosque Williamson Camp Rains Sabine Angelina Trinity Robertson Bowie Titus HopkinsFranklin Morris Hunt Dallas Johnson Somervell Erath Kerr Edwards Brewster Loving Hudspeth Eastland Callahan Burnet Rockwall Parker Hood Taylor San Augustine Houston Leon Bell Red River Lamar Fannin Collin Llano Shelby Nacogdoches Limestone Falls Delta Jack Gillespie Terrell Andrews Anderson Cherokee Lampasas Menard Panola Freestone McLennan Coryell McCulloch San Saba Clay Haskell Throckmorton Young Sutton Jones Rusk Navarro Hamilton Tarrant * Schleicher Pecos Henderson Bosque Hardeman Tom Green Reagan Hale Cochran Hockley Lubbock Jeff Davis Coleman Brown Childress Harrison Smith Ellis Hill Comanche Coke Sterling Johnson Erath Wheeler Foard El Paso Eastland Callahan Somervell Donley Collingsworth Briscoe Gregg Hood Hemphill Mitchell Carson Mills Crane Reeves Howard Potter Glasscock Deaf Midland Smith Randall Armstrong Parmer Ward Hutchinson Roberts Moore Martin Oldham Hudspeth Molina, Superior Cass Camp Gaines El Paso Dallas Bowie Delta Nueces Aransas San Patricio Webb Bexar Bexar Amerigroup, Molina, Superior Duval Jim Wells Kleberg Nueces Kleberg Zapata Jim Hogg Brooks Zapata Jim Hogg Brooks Starr Willacy Starr Hidalgo Hidalgo Kenedy Nueces Kenedy Willacy Nueces Superior, United Hidalgo Cameron Hidalgo HealthSpring, Molina, Superior Cameron HHSC, Health Plan Operations September 2010 6 HHSC, Health Plan Operations July 2011 Geographic Distribution of STAR Service Areas and MRSA Managed Care Delivery Models Dallam Dallam STAR and Medicaid Rural Service Areas Hartley Hartley Moore Hutchinson Roberts Moore Hutchinson Roberts Hemphill Hemphill Oldham Oldham Potter Potter Wheeler Wheeler Deaf Smith Deaf Smith (effective March 1, 2012) Sherman Hansford Ochiltree Lipscomb Sherman Hansford Ochiltree Lipscomb Parmer Parmer Carson Carson Gray Gray (effective March 1, 2012) Tarrant Randall Armstrong Donley Collingsworth Randall Armstrong Donley Collingsworth Castro Castro Swisher Briscoe Swisher Briscoe Hall Hall Aetna,Tarrant Amerigroup, Cook Children’s Childress Childress Dallas Hardeman Hardeman Bailey Bailey Lamb Lamb Hale Hale Floyd Floyd Motley Motley Cottle Cottle Dickens Dickens King King Wilbarger Wilbarger Wichita Wichita Foard Foard Amerigroup, Molina, Parkland Clay Clay Cochran Hockley Lubbock Crosby Cochran Hockley Lubbock Crosby Archer Archer Montague Cooke Montague Cooke Grayson Grayson Fannin Fannin Lamar River Lamar Red Red River Dallas Bowie Bowie Titus Titus Hopkins Hunt HopkinsFranklin Franklin Morris Hunt Morris Cass Cass Camp Camp Rains Rockwall Rains Wood Marion Dallas Rockwall Marion Wood Upshur Dallas Upshur KaufmanVan Zandt KaufmanVan Zandt Harrison Gregg Harrison Gregg Smith Ellis Smith Ellis Henderson Panola Henderson Panola Rusk Rusk Navarro Navarro Delta Delta Lubbock Lubbock Yoakum Yoakum Amerigroup, FirstCare, Superior Terry Terry Lynn Lynn Dallam Gaines Gaines Garza Garza Sherman Moore Kent Kent Stonewall Haskell Throckmorton Young Stonewall Haskell Throckmorton Young Hansford Ochiltree Lipscomb Dawson Borden Dawson Borden Hartley Scurry Scurry Hutchinson Roberts Fisher Fisher Jones Shackelford Stephens Jones Shackelford Stephens Jack Jack Palo Palo Pinto Pinto Wise Wise Parker Parker Denton Denton Tarrant Tarrant Hemphill Collin Collin Hood Hood Johnson Erath Johnson Erath Somervell Somervell Deaf Smith Randall Armstrong Donley Collingsworth Hill Comanche Hill Bosque Comanche Coke Ector Midland Glasscock Sterling Loving Winkler Bosque Coke Runnels Ector Midland Glasscock Sterling Anderson Cherokee Loving Winkler Shelby Runnels Coleman Brown Anderson Cherokee Shelby Parmer Castro Swisher Briscoe Hall Childress Coleman Brown Hamilton Freestone Hamilton Freestone Nacogdoches Hardeman Nacogdoches McLennan Limestone Ward McLennan Limestone Mills San Augustine Ward Culberson Cottle Mills Motley Wilbarger Hale Floyd Crane Bailey Lamb San Augustine Tom Green Culberson Coryell Wichita Foard Crane Upton Reagan Tom Green Sabine Coryell Concho Reeves Houston Upton Reagan Irion Leon Sabine Concho Reeves Houston Angelina Clay Falls Irion Leon McCulloch Montague Cooke Lampasas Angelina Lamar Red RiverFalls Grayson Saba King Baylor Archer Knox McCullochSan Cochran Hockley Lubbock Crosby Dickens San Saba Lampasas Fannin Trinity Bell Bowie Trinity Robertson Delta Bell Robertson Madison Jasper Jack Schleicher Jasper Titus Menard Young Wise Denton Madison Collin Garza KentSchleicher Terry Lynn Stonewall Haskell Throckmorton Yoakum HopkinsFranklin Morris Menard Newton Burnet Hunt Polk Milam Cass Pecos Tyler Newton Walker Burnet Polk Camp Milam Pecos Crockett Mason Tyler Jeff Davis Llano Walker Crockett Rains Mason Brazos Jeff Davis Palo Rockwall Williamson Llano Marion Wood Parker Brazos Tarrant Dallas Williamson Upshur Scurry Pinto Gaines Dawson Borden Fisher Jones Shackelford Stephens San Jacinto Grimes San Jacinto Sutton KaufmanVan Zandt Burleson Kimble Grimes Harrison Sutton Burleson Kimble Gregg Hood Smith Ellis Travis Hardin GillespieJohnson Erath Lee Howard Mitchell Andrews Martin Nolan Montgomery Taylor Callahan Eastland Travis Hardin Gillespie Somervell Blanco Lee Panola Montgomery Henderson Terrell Blanco Washington Rusk Terrell Liberty Navarro Orange Washington Bastrop Hill Liberty Orange Comanche Kerr Hays Bastrop Bosque El Paso Coke Ector Midland Glasscock Sterling Loving Winkler Waller Kerr Hays Presidio Runnels Anderson Cherokee Edwards Shelby Brewster Austin Coleman Brown Waller Presidio Edwards Jefferson Brewster Austin Hamilton Kendall Freestone Kendall Val Verde Jefferson Nacogdoches Caldwell Val Verde Real Bandera Fayette Harris Chambers McLennan Limestone Comal Ward Mills Bandera Caldwell Fayette Harris Chambers Real Hudspeth Comal Culberson Crane Tom Green San Augustine Coryell Upton Reagan Sabine Concho Reeves Houston Irion Leon Falls AngelinaColorado McCulloch San Saba Lampasas Guadalupe Colorado Fort Bend Guadalupe Trinity Bell Fort Bend Gonzales Bexar Robertson Madison Jasper Galveston Gonzales Schleicher Bexar Menard Lavaca Galveston Uvalde Medina Kinney Newton Polk Lavaca Milam Pecos Tyler UvaldeLlano Burnet Medina Kinney Walker Crockett Jeff Davis Mason Wharton Brazos Williamson Wharton San Jacinto Brazoria Wilson Grimes Sutton Burleson Brazoria Kimble Wilson De Witt Travis Hardin De Witt Gillespie Lee Montgomery Blanco Terrell Jackson Washington Liberty Karnes Orange Jackson Atascosa Bastrop Frio Zavala Kerr Hays Karnes Atascosa Presidio Frio Edwards ZavalaKendall Austin Waller Victoria Jefferson Matagorda Matagorda Val Verde Maverick Victoria Caldwell Real Bandera Fayette Harris Chambers Brewster Comal Maverick Goliad Goliad Colorado Guadalupe Fort Bend Gonzales Calhoun Bexar Bee Galveston Lavaca Dimmit Calhoun Bee Uvalde Medina Kinney Dimmit Wharton La Salle McMullenLive Oak Refugio Brazoria LaWilson Salle McMullen Live Oak Refugio De Witt Andrews Andrews El Paso El Paso Baylor Baylor Knox Knox Martin Oldham Martin HowardCarsonMitchell Potter Gray Howard Mitchell Nolan Wheeler Nolan Taylor Callahan Eastland Taylor Callahan Eastland Tarrant * Hudspeth Hudspeth Dallas * Lubbock ElPaso Paso El El Paso First, Molina, Superior Medicaid Rural El Paso Service Area (MRSA) Medicaid Rural Service Area (MRSA) Jefferson Jefferson Harris Jefferson Amerigroup, Community Health Choice, Harris Molina, Texas Children’s, United Travis Travis Zavala Frio Travis Blue Cross and Blue Shield of Texas, Sendero, Seton, Superior Bexar Bexar Aetna, Amerigroup, Community First, Superior Jackson Karnes Aransas San Patricio Aransas San Patricio Matagorda Victoria Goliad Dimmit La Salle McMullen WebbLive Oak Calhoun Bee Refugio Jim Wells Nueces Duval Jim Wells Nueces Duval Aransas Webb Harris San Patricio Webb Bexar Atascosa Maverick Duval Jim Wells Kleberg Kleberg Nueces Kleberg Hogg Brooks Zapata Jim Zapata Jim Hogg Brooks Zapata Jim Hogg Brooks Starr Kenedy Hidalgo Starr Starr Cameron Hidalgo Kenedy Kenedy Nueces Willacy Amerigroup, Community Health Choice, NuecesMolina, Texas Children’s, United Willacy Willacy Hidalgo Hidalgo Hidalgo Hidalgo Cameron Cameron Nueces HHSC, HealthDriscoll Plan OperationsChildren’s, Superior Christus, Driscoll Children’s, Molina, Superior, UnitedHealthCare Page 7 September 2010 HHSC, Health Plan HHSC, Managed CareOperations Operations June 2011 September 2011 HMO Member Benefits • Traditional Medicaid benefit package. • Provider directories – physicians, specialists, and LTSS. • PCP to coordinate health care of patient (Medicaid only). • Member services helpline (through their health plan). • Member handbooks and health education. • Service Coordination. • Value Added Services – vary by health plan. STAR Members • Populations mandatory for STAR include: Temporary Assistance to Needy Families (TANF) recipients Pregnant Women Children receiving Medicaid assistance only • Populations excluded from STAR include: Medicaid recipients who reside in institutions Medicaid recipients receiving Supplemental Social Security (SSI) Dual-eligible Medicaid recipients (clients with both Medicaid and Medicare) Medically needy Foster children Refugees • Medicaid Rural Service Area: Children age 20 and younger can choose to join STAR if they receive SSI but do not receive Medicare. Page 9 STAR+PLUS Members • Medicaid recipients who must participate in STAR+PLUS: SSI adults who are not: • Residing in a Nursing Facility or other institution. • Being served through a Home and Community Based Waiver program other than Community Based Alternatives (CBA). Non-SSI adults who qualify for 1915(c) Nursing Facility Waiver services must enroll in STAR+PLUS to receive those services. • Medicaid recipients who can choose to participate in STAR+PLUS: SSI children, under age 21, may voluntarily enroll in STAR+PLUS. SSI children that do not volunteer will be in traditional Medicaid effective March 1, 2012. 10 Managed Care vs. FFS FFS State operated plan. Providers are contracted directly with state. Providers paid fee-for-service (FFS) rates. Managed care Providers must contract and be credentialed with the health plan to provide services. Rates are negotiated between the provider and the MCO or DMO. Page 11 PCCM vs. Managed Care Organizations Primary Care Case Management (PCCM) State operated plan. Providers are contracted directly with state. Members assigned PCP, but can see any Medicaid specialist. Providers paid fee-for-service (FFS) rates. Medicaid Managed Care Organizations Providers must contract and be credentialed with the MCO to provide STAR services. Rates are negotiated between the provider and the MCO. Page 12 Significant Traditional Providers • Significant Traditional Provider (STP) requirements relate to providers that have been providing services to Medicaid clients in some service areas. • MCOs are obligated to offer STP contractors the opportunity to be a part of the contracted MCO provider network. • MCOs will reach out to contact STPs; however, STPs may initiate the contact. • STP providers must accept MCO conditions for contracting and pass credentialing. Public Health Coordination • The MCO must make good faith effort to enter into a subcontract for covered services with public health entities. • Services covered by public health entities may include: Sexually transmitted diseases Confidential HIV testing Immunizations Tuberculosis care MCO Contract Requirements: Immunizations • MCOs must educate providers on the following: Standard requirements in • • • • Chapter 161 of the Health and Safety Code ACIP Immunization Schedule AAP Periodicity schedule for CHIP members Texas Health Steps Periodicity schedule for Medicaid members. The screening provider is responsible for administration of immunizations and should not refer children to local health departments for immunizations. Compliance with ImmTrac requirements, including parental consent on the Vaccine Information Statement. Enrollment Broker • Client Welcome letters/FAQs: • Dental – September 2011 • Medical – November 2011 • Client Enrollment packets: • Dental – November 2011 • Medical – December 2011 through January 2012 • Clients must enroll by February 10, 2012 or the state will assign a plan and main doctor. Page 16 Enrollment Broker • Enrollment Options • Fill out the forms and mail them back. • Call the Help Line and sign up by phone. 1-800-964-2777 • Attend a client outreach and enrollment event. • Client outreach and enrollment events – November 2011 through February 2012 • www.txmedicaidevents.com Page 17 Managed Care Operations HHSC Managed Care Operations monitors the HMO performance quarterly for these key indicators: Network Adequacy Claims Processing time Hotline Performance Complaint processing Additional contract requirements and performance is also monitored on ongoing basis. Page 18 Provider Complaints • Initial point of contact is MCO or dental plan • 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 Page 19 Resources • HHSC Managed Care Proposals Webpage: http://www.hhsc.state.tx.us/medicaid/mmc.shtml • TMHP Website: http://www.tmhp/Pages/PCCM/PCCM_Home.aspx • Email: managedcare_exp2012@hhsc.state.tx.us managedcaredental@hhsc.state.tx.us 20 Questions?
