Managed Care Long Term Care Model The Texas Experience Presentation to: San Diego County LTCIP October 26, 2001 Cindy Adams

Long Term Care - The Texas Experience October 26, STAR+PLUS l Comprehensive capitated managed healthcare model l SSI and SSI-related Aged and Disabled Population l Provides a continuum of care with a wide range of options and increased flexibility to meet individual needs

Long Term Care - The Texas Experience October 26, STAR+PLUS l Medicaid pilot project designed to integrate delivery of acute and long-term care services through a managed care system l Requires two Medicaid waivers: u 1915 (b) - to mandate participation u 1915 (c) - to provide home and community-based services

Long Term Care - The Texas Experience October 26, STAR+PLUS Program Funding l STAR+PLUS is funded by federal and state monies l The STAR+PLUS Medicaid pilot integrates funding for acute care services traditionally paid for by TDH with funding for long term care services traditionally paid for by DHS into one funding stream

Long Term Care - The Texas Experience October 26, STAR+PLUS Objectives l Provide the appropriate amount and types of services to help individuals stay as independent as possible l Serve people in the least restrictive community-based setting consistent with their safety needs l Improve care access, quality and outcomes l Increase accountability for care, and l Control costs

Long Term Care - The Texas Experience October 26, STAR+PLUS History Policy Initiatives/Enabling Legislation l August pilot for “State of Texas Access Reform” (STAR), to provide Medicaid services through a capitated HMO and PHP single health care delivery system in Travis County l Senate Bill 10 (SB10) authorizes Texas Health and Human Services Commission (HHSC) to comprehensively restructure the statewide Texas Medicaid program incorporating managed delivery systems l Senate Concurrent Resolution (SCR55) directed the Texas Medicaid Office to develop: u an integrated managed care pilot program for long-term care for the elderly and persons with disabilities; and u an integrated managed care pilot program for mental health and substance abuse services

Long Term Care - The Texas Experience October 26, STAR+PLUS History Continued l HHSC to contract with at least one HMO in each managed care service area either managed or created by a hospital district in that region l November STAR expanded into the Harris Service Area (Houston) l January STAR+PLUS pilot program was introduced in the Harris Service Area l September removed nursing facility residents from mandatory STAR+PLUS enrollment

Long Term Care - The Texas Experience October 26, Medicaid Organization in Texas

Long Term Care - The Texas Experience October 26, STAR+PLUS Program Contractors l Texas Department of Human Services (DHS) is the state STAR+PLUS contract holder l State contracts with Health Plans to provide: u Care Coordination u Acute care u Institutional and community based long term care u Behavioral health services l Two health plans operate STAR+PLUS in Harris County l Health plans contract with providers for delivery of care

Long Term Care - The Texas Experience October 26, STAR+PLUS Health Plans l Amerigroup l HMO Blue (Administered by Lifemark) l Texas Health Network (PCCM)

Long Term Care - The Texas Experience October 26, STAR+PLUS Enrollment l Maximus - state contracted enrollment broker u Mails potential enrollees STAR+PLUS enrollment kit u Individuals have 30 days to make an active choice of plan and primary care provider (PCP) l Potential enrollee u Returns enrollment form via mail u Completes an enrollment form at an enrollment event, or u Calls Maximus and enrolls via phone l Default u Individuals who do not make an active enrollment choice are assigned a plan and a PCP

Long Term Care - The Texas Experience October 26, STAR+PLUS Enrollment Continued l Community education prior to STAR+PLUS roll-out u Public hearings u State in partnership with HMOs u Maximus u Provider Associations l Maximus outreach to STAR+PLUS enrollees u Home visits on request u Targeted enrollment fairs (DAHS, Community Centers, Nursing Facilities) u Partnerships with Community Based Organizations u Follow up telephone contact u Closed caption videos, audio tapes, multi-languages

Long Term Care - The Texas Experience October 26, STAR+PLUS Enrollment Continued l Voluntary Enrollment u January, February, March 1998 l Mandatory Enrollment and Default u April 1998

Long Term Care - The Texas Experience October 26, STAR+PLUS Default Methodology l Maximus administers the default process l Follows the STAR default methodology l Percentage of default is driven by plan performance on elective enrollments l Order for assigning a recipient to a plan and PCP is determined by: u Prior enrollment history with a plan and PCP u Claims history u Proximity

Long Term Care - The Texas Experience October 26, STAR+PLUS Eligibility Criteria l Resident of Harris County (Houston)Texas l Elderly or have a physical or mental disability and qualify for Supplemental Security Income (SSI) benefits or for Medicaid due to low income l Financial eligibility established by the Social Security Administration (SSA) for SSI, or by DHS for Medical Assistance Only (MAO)

Long Term Care - The Texas Experience October 26, STAR+PLUS Eligibility Criteria l Mandatory Participation: HMO u SSI-eligible (or would be except for COLA) clients age 21 and over u MAO clients who qualify for the Community Based Alternatives (CBA) waiver u Clients who are Medicaid-eligible because they are in a Social Security exclusion program

Long Term Care - The Texas Experience October 26, STAR+PLUS Eligibility Criteria l Mandatory Participation: HMO or PCCM* u SSI clients under age 21 u MHMR clients diagnosed with Serious and Persistent Mental Illness (SPMI) * PCCM is only available to non-Medicare clients

Long Term Care - The Texas Experience October 26, STAR+PLUS Eligibility Criteria l Voluntary participation: HMO u Dual eligible clients under age 21

Long Term Care - The Texas Experience October 26, STAR+PLUS Eligibility Criteria l Excluded u STAR+PLUS HMO members who have been in a nursing facility for more than 120 days u Individuals already residing in a nursing facility at the time they become otherwise eligible for STAR+PLUS u Clients in several small limited waiver programs u Residents of Intermediate Care Facilities for the Mentally Retarded (ICF-MR) u Clients not eligible for full Medicaid benefits (1929(b) program, QMB, SLMB, QDWI, undocumented aliens) u Individuals not eligible for Medicaid u Children in state foster care

Long Term Care - The Texas Experience October 26, STAR+PLUS CBA Eligibility l MAO Applicants for CBA Waiver Services u TDHS informs applicant that services are provided through an HMO and allows applicant to select HMO u TDHS informs selected HMO and requests pre-enrollment assessment be completed* u HMO completes: n Medical necessity form n CBA eligibility assessment u HMO provides results of assessment activities to TDHS * HMO is authorized payment for assessment regardless of final eligibility determination

Long Term Care - The Texas Experience October 26, STAR+PLUS CBA Eligibility u THDS notifies applicant and HMO of their eligibility determination n Applicant eligible: è HMO notified of applicant eligibility and effective date è Applicant will be enrolled in HMO è HMO will initiate ISP on date of enrollment n Applicant ineligible: è Applicant notified and provided information on their right to appeal the adverse determination è HMO not notified if applicant is ineligible

Long Term Care - The Texas Experience October 26, STAR+PLUS CBA Eligibility l SSI Member CBA Upgrades u Currently enrolled members who meet screening criteria based on TDHS Risk Assessment Indicator (RAI) u Care Coordinator completes: n Medical Necessity Form n MDS-HC n Complete Personal Attendant Services (PAS) tool n Assesses current equipment and supplies n Completes cover sheet u Submits to TDHS Regional Nurses for review and eligibility determination

Long Term Care - The Texas Experience October 26, STAR+PLUS CBA Eligibility u Denial of CBA Upgrade n Regional nurse notifies HMO n HMO authorizes identified medically necessary services n No increase in capitation u Approval of CBA Upgrade n Regional nurse notifies HMO n HMO authorizes identified medically necessary services n Member enters 120-day wait n At end of 120-days capitation increases to CBA payment amount

Long Term Care - The Texas Experience October 26, STAR+PLUS CBA Eligibility l CBA Annual Reassessments u Completed on all enrolled CBA waiver members n Up to 120-days prior to expiration of ISP u Care Coordinator completes: n PAS Tool and MDS-HC n Assesses member for equipment and supplies n Completes Medical Necessity Form n Completes CBA cover sheet u Assessments completed and forwarded to TDHS Regional Nurses

Long Term Care - The Texas Experience October 26, STAR+PLUS Population l STAR+PLUS is the largest population enrolled in an integrated, acute and LTC managed care model in the country l 47% of the STAR+PLUS population are dual eligibles l Approximately 18% of the STAR+PLUS population are members under the age of 21 l 2.7% of the STAR+PLUS population are CBA waiver members l 7% of the STAR+PLUS population have the diagnosis of SPMI l 85% of the total mandatory enrollees selected the HMO model

Long Term Care - The Texas Experience October 26, STAR+PLUS Current Enrollment as of 10/01/2001 l HMO Blue STAR+PLUS28,092 l Amerigroup STAR+PLUS20,242 l Texas Health Network (PCCM) 8,235 STAR+PLUS Totals56,569

Long Term Care - The Texas Experience October 26, STAR+PLUS Services l Acute care services (Medicaid only members) l Long term care services l Behavioral Health l Care coordination l Value added services

Long Term Care - The Texas Experience October 26, STAR+PLUS Acute Care Services l Hospital u Inpatient u Outpatient l Professional u Physician or physician extenders u Certified Nurse Midwife (CNM) u Lab and X-ray u Podiatric services u Vision u Ambulance services u Home health services/limited DME

Long Term Care - The Texas Experience October 26, STAR+PLUS Acute Care Services l Hearing Aid Services l Chiropractic l Ambulatory Surgical Center Services l Certified Nurse Midwife Services l Birthing Center l Maternity Clinic Services l Transplant Services l Adult Well Check l Family Planning

Long Term Care - The Texas Experience October 26, STAR+PLUS Acute Care Services l Genetics l EPSDT Medical Screens l EPSDT Comprehensive Care Program (CCP) l Non-emergent Screening and stabilization fees l Renal Dialysis l Total Parenteral Hyperalimentation (TPN) l PT/OT/Speech Therapies l Behavioral Health

Long Term Care - The Texas Experience October 26, STAR+PLUS Carve Out Services l EPSDT Dental (including Orthodontia) l Early Childhood Intervention (ECI) l MHMR Targeted Case Management l Mental Retardation Diagnostic Assessment (MRDA) l Mental Health Rehabilitation l Pregnant Women and Infants Case Management (PWI) l Texas School Health and Related Services (SHARS) l Texas Commission for the Blind (TCB) l Tuberculosis (TB) Clinic Services

Long Term Care - The Texas Experience October 26, Excluded STAR+PLUS l Pharmacy u Unlimited prescription for: n Medicaid only n Less than 21 n CBA n Duals who join same HMO for Medicaid and Medicare u 3 prescriptions per month: n Duals enrolled for Medicaid LTC services only

Long Term Care - The Texas Experience October 26, STAR+PLUS Long Term Care Services l Day Activity and Health Services (DAHS) l In Home Respiratory Care Services l Nursing Facility Care (first 120 days after admission) l Personal Assistance Services

Long Term Care - The Texas Experience October 26, STAR+PLUS CBA Waiver Services l Adaptive aids l Adult foster home services l Assisted living/residential care services l Emergency response services l Medical supplies l Minor home modifications l Nursing services l Occupational therapy l Personal assistance services

Long Term Care - The Texas Experience October 26, STAR+PLUS CBA Waiver Services l Physical therapy l Respite care l Speech language therapy services l Home delivered meals l Durable medical equipment

Long Term Care - The Texas Experience October 26, STAR+PLUS HCBS Alternative Residential Settings l Assisted Living/Residential Care Facilities l Adult Foster Care l Personal Care Homes l Nursing Facilities u First 120 days of long-term placement u Subacute short-term stays

Long Term Care - The Texas Experience October 26, STAR+PLUS Behavioral Health Services l Under age 21 u Early screening, diagnosis and treatment of behavioral disorders u Psychiatric hospital/facility (freestanding) u Hospital - inpatient services - mental health and chemical dependency treatment u Licensed master social workers - advanced clinical practitioners (LMSW - ACPs) u Licensed professional counselors (LPCs) u Psychology u Psychiatry u Chemical dependency treatment

Long Term Care - The Texas Experience October 26, STAR+PLUS Behavioral Health Services l Age 21and over u Screening for behavioral health disorders u Hospital - inpatient services - mental health and chemical dependency treatment u Licensed master social workers - advanced clinical practitioners (LMSW -ACPs) u Licensed professional counselors (LPCs) u Psychology u Psychiatry u Chemical dependency treatment

Long Term Care - The Texas Experience October 26, STAR+PLUS Value Added Services l In addition to all traditional Medicaid and other mandatory services, each STAR+PLUS HMO offers its own set of “value added” services. u Over and above services paid for by the state u Incentives for members to join l All HMOs offer CBA waiver services to members not in a waiver slot if service is medically necessary l PCCM model does not offer value added services

Long Term Care - The Texas Experience October 26, STAR+PLUS Value Added Services l Examples: u Transportation assistance u Adult dental u Eyeglasses u Medication dispensers u Smoke detectors u Pest control u Medical alert ID u Nightlights u Bathmats

Long Term Care - The Texas Experience October 26, STAR+PLUS Value Added Services l Examples behavioral health: u Partial hospitalization/extended day treatment u Intensive outpatient/day treatment u Off-site services u Forensic services u Freestanding psychiatric facility u Residential services u Crisis clinics u Team interventions

Long Term Care - The Texas Experience October 26, STAR+PLUS Healthplan Structure l Member services l Care coordination l Utilization management l Quality management l Network management l Claims and encounters l Finance

Long Term Care - The Texas Experience October 26, STAR+PLUS Network l Significant Traditional Providers (STPs) l Template contracts require state approval u Language for mandatory provisions supplied by state l Texas Medicaid certification l Credentialing/recredentialing l Network adequacy/geographic accessibility l PCPs 24/7 access

Long Term Care - The Texas Experience October 26, STAR+PLUS Network l Long Term Care Providers u Network built through contracts with STP providers contracted with TDHS u State Licensed u Enrolled as Medicaid providers u Credentialing and oversight policies and procedures developed by HMO

Long Term Care - The Texas Experience October 26, STAR+PLUS Care Coordination l Qualified and trained personnel to serve as contact for members u Telephonic team in office u Field team set up with the technology to work from home u Care Coordinator Associates assist field team telephonically acting as liaisons between the member, Care Coordinator and physician and/or provider(s)

Long Term Care - The Texas Experience October 26, Care Coordinator l Texas licensed registered nurse (RN) or licensed vocational nurse (LVN) l Master level social worker (LMSW) l Unlicensed (telephonic staff) l Coordinate, facilitate, investigate, advocate l Foster a person-centered approach l Liaison with member, family, caregiver, PCP

Long Term Care - The Texas Experience October 26, Care Coordination Responsibilities l Assess members for service needs l Facilitate/coordinate services with the member’s PCP l Intervene to assure appropriate care is provided u Placement options u Cost effectiveness u Ensure member’s health needs are met l Act as plan resource l Member/patient advocate l Coordination of benefits with other payers

Long Term Care - The Texas Experience October 26, Care Coordination Responsibilities - Assessments l New enrollees - health status/orientation within 30 days of enrollment l Transitioning members - within 30 days of enrollment l All members over 21 years of age receiving long term care services - Minimum Data Set (MDS-HC) l Initial assessment l Pediatric assessment l Maternal/child assessment l Personal Attendant Services scoring tool l Risk Assessment Indicator (RAI) l Medical necessity determination

Long Term Care - The Texas Experience October 26, Care Coordination Model Care Coordinator Family or Representative PCP Member Summary: Care Coordinators are the key to establishing a comprehensive, individualized Plan of Care to serve the member in the least restrictive environment, with the most quality oriented, cost effective care/services. l Who u RN or licensed Master’s level social worker (with specific cultural and linguistic expertise) l Responsibilities u Coordinator, facilitator, investigator, liaison, advocate, empowered to authorize services u Leads team of service providers u Close collaboration with medical providers, patient, and family u Knowledge of TPL/Medicaid/Medicare resources

Long Term Care - The Texas Experience October 26, Care Coordination Model Overview l All plan members are assigned to a care coordinator u Promotes member/care coordinator relationship l “Across the board” integration of member education l Incorporates a disease management approach l Integration of acute and long term care into a unique individual care plan l Plan transitions l Coordination with community resources l Discharge planning l Post-hospitalization follow up

Long Term Care - The Texas Experience October 26, Care Coordination Assignment l Service - driven based on: u Risk group placement u Acute episodic events u Health Status Screen/review u Disease management u Transition from: n DHS care plan n Individual Service Plans (CBA) n Other program contractors

Long Term Care - The Texas Experience October 26, Level I Average caseload 1:1800 l Telephone care coordination l Stable population with episodic support l Authorizations done by licensed staff u Staffing includes non-licensed, LVN, LMSW and RN l Orientation/Health Status Screen u Initial and annual HSS u “Unable to Locate” - attempt to reach member every 6 months l Assignment criteria: Authorizations for short term needs, I.E. Respite, 1x only DME

Long Term Care - The Texas Experience October 26, Level 2 Average caseload 1:150 l Field and Telephonic Care Coordination l Members receiving LTC services l Adult Day Care (DAHS) l All Licensed staff l Care Coordinator Associates l Reassessments every days l Field Assessments u CBA/SSI upgrade u MDS-HC completion l Assignment criteria u Adult Day Care (DAHS), u PAS <120 hrs per month, u ER/Hosp visits = 2 within 6 months

Long Term Care - The Texas Experience October 26, Level 3 Average caseload 1:200 l Field care coordination l Members receiving CBA services l All licensed staff l Care coordinator associates l Reassessments <90 days l Field assessments u CBA/SSI upgrade u MDS-HC l Assignment criteria u CBA Members

Long Term Care - The Texas Experience October 26, Continuum of LTC Placement Options Most Restrictive Home or Apartment DAHS Assisted Living/ Residential Care Personal Care Home Adult Foster Care Home Adult Care Home Skilled Nursing Facility Specialty Unit within a nursing facility Least Restrictive

Long Term Care - The Texas Experience October 26, Care Coordinator Associate Support l Member/care coordinator liaison l Direct member contact l Assigned to care coordinators u Ratio 1:4 l Assist care coordinators with: u Post E.R. Follow up u Fax/mail authorizations u Transitional notifications u Provider/PCP contact with service DS. u Care coordination caseload reports u Produces monthly reports

Long Term Care - The Texas Experience October 26, Care Coordination Integration with Concurrent Review Authorization Tech and/or Nurse Member Care Coordination Hospital Case Manager/ Discharge Planner Physician PCP Concurrent Review

Long Term Care - The Texas Experience October 26, Case Management Information Systems l Care Management u Assessments u Cost effectiveness studies/care plan modeling u Care plans u Case notes u Eligibility and claims u Placements u Extended authorizations l MDS-HC u Ability to complete and transmit member data to the State

Long Term Care - The Texas Experience October 26, STAR+PLUS Capitation l DHS pays health plans prospectively on a capitated, per member per month basis by client risk group l There are six risk groups with amounts differing by Medicare status, care setting and status at enrollment l Rates for Medicaid only members are higher than those for dual eligibles to reflect HMO liability for acute care l Capitation rates are discounted 2% from projected fee-for- service nursing facility costs and 5% from projected fee- for-service acute and long term care costs

Long Term Care - The Texas Experience October 26, Development of STAR+PLUS Capitation Rates l Information used in rate development: u Reduced fee-for-service (FFS) methodology u Calendar year 1997 FFS experience data trended forward u Relativity factor for Harris Co. u Assumed all-plans cost increase of 6% (FY2002) l Assumptions u STAR+PLUS program must be cost neutral so aggregate claims and average costs become the balancing items with PCCM and FFS u Equitable distribution of risk among plans u Costs for CBA waiver members are comparable to 1997 FFS nursing facility claims costs

Long Term Care - The Texas Experience October 26, STAR+PLUS Capitation

Long Term Care - The Texas Experience October 26, STAR+PLUS Capitation Continued

Long Term Care - The Texas Experience October 26, STAR+PLUS Capitation Continued

Long Term Care - The Texas Experience October 26, Risk Adjusters l Risk Adjusters u Medicare status u Waiver status u Geographic relativity factor n Harris County - 14% higher medical costs that statewide average u Share of Cost n Members are required to contribute toward the cost of their care based on their income and type of placement n Provider is responsible for collecting the SOC n HMO payment to facility is based on total payment due facility less the member’s SOC

Long Term Care - The Texas Experience October 26, Risk Sharing l HMOs retain the first 3% of any profit, but split equally with the state any profit between 3 and 7 percent l Any profit over 7 percent must be paid back to the state

Long Term Care - The Texas Experience October 26, STAR+PLUS Statutory and Regulatory Compliance l Compliance with federal, state and local laws l Program integrity l Fraud & abuse compliance plan l Confidentiality l Non-discrimination l Notice and appeal u HMO process u State appeal process

Long Term Care - The Texas Experience October 26, STAR+PLUS Statutory and Regulatory Compliance Continued l Quality Management u Quality improvement program (QIP) system u Written QIP plan u Summary report of member and provider complaints u Utilization reports

Long Term Care - The Texas Experience October 26, STAR+PLUS Quality Indicators l Focus Studies u Depression u Breast Cancer Screening u Diabetes in Adults l Semi-annual UM Reports u Behavioral Health u Physical Health u Long Term Care l Medical Record Audit l Provider Satisfaction l Member Satisfaction

Long Term Care - The Texas Experience October 26, Reporting/State Monitoring l Financial reports l Statistical reports l Arbitration/Litigation Claims report l Summary Report of Provider Complaints l Provider Network Reports l Member Complaints l Fraudulent Practices l Utilization Management Reports u Behavioral, Physical and LTC l Quality Improvement Reports l HUB Quarterly Reports l THSteps (EPSDT) Reports l Encounters

Long Term Care - The Texas Experience October 26, STAR+PLUS Program Outcomes l November HHSC Medicaid Managed Care Review reported the to the Texas Legislature: u STAR+PLUS has increased the number of available long- term care providers u In SFY 99, Primary Home Care utilization was higher than projected u Day Activity and Health Services utilization was lower than projected u Increased access to community-based long term care services in comparison to statewide average

Long Term Care - The Texas Experience October 26, STAR+PLUS Program Outcomes (Continued) u Utilization of new generation medications by individuals with serious mental illnesses increased both statewide and in Harris Co., but the Harris Co. increase did not occur until the implementation of STAR+PLUS u Inpatient hospital utilization decreased for this population u From January 1998 through August 1999 total STAR+PLUS savings was $2,171,085

Long Term Care - The Texas Experience October 26, Lessons Learned l Care Coordination is the key to integration of acute and LTC services u Single point of contact u True integration when all services are managed by one entity l Coordination of benefits important for dual eligibles when HMOs are only responsible for LTC l Education of all providers and stakeholders is key l Collaboration between competing HMOs and State is an essential piece of successful model l Program supports the Olmstead requirements

Long Term Care - The Texas Experience October 26, Recommendations l Structure 1915 (c) waiver to allow for cost-effective community-based services provided in the least-restrictive setting (supports Olmstead decision) l Allow for staggered phased-in enrollment l Eliminate PCCM l Include mechanism for upgrades of members to CBA waiver status without decreasing waiver slots l Implement and monitor the effectiveness of all HMOs using standard forms for processes related to: u Clean claims definitions and requirements u Standard referral form u Standard credentialing package l Case management controlled or delegated by health plan l Integrate LTC and acute services into one program

Long Term Care - The Texas Experience October 26, Recommendations l Allow new entrants who have LTC experience into the market through a competitive bid process l Utilize 6 month lock-in or 6 month continuous eligibility to ensure continuity of care l Include nursing facility population for a full continuum of care l Utilize an HMO model that integrates acute and LTC services into one program with Care Coordination as the cornerstone

Long Term Care - The Texas Experience October 26, Recommendations (continued) l Mandatory vs. voluntary enrollment u Member issues/outreach and education important u Adverse selection - potential with voluntary enrollment u Critical mass l Eligibility determination u Financial u Member/functioning