Medicaid Managed Care Program for the Elderly and Persons with Disabilities Pamela Coleman Texas Health and Human Services Commission January 2003

WHAT IS STAR+PLUS? * A Managed Care System for the SSI & SSI-Related Population * Integrates Medicaid funding and service delivery of Long Term and Acute Health Care * Medicare members only enrolled for LTC services

STAR+PLUS Objectives * Integrate Acute & Long Term Care into Managed Care System * Provide the Right Amount & Type of Service to Help People Stay as Independent as Possible * Serve People in the Most Community-based Setting Consistent with their Personal Safety * Improve Access and Quality of Care * Increase Accountability for Care * Improve Outcomes of Care  Control Costs

STAR+PLUS (b) and (c) 1915(b) -Waives freedom of choice to allow mandatory participation 1915(c) -Allows additional services for 1915© waiver eligibles -Encourages HMOs to add waiver services as value added services -Provides more alternatives

STAR+PLUS Eligibility 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

Is STAR+PLUS Mandatory? If you are in a required group l You must enroll in a STAR+PLUS Plan for Medicaid services l Medicare services may be obtained through the provider of choice

Enrollment Broker l New Med i caid Clients l Enrollment Broker Contacts Clients by: l Telephone, Mail, In-person

STAR+PLUS Plans n HMO Blue/Evercare Amerigroup

STAR+PLUS Enrollment 1/1/0254,895Total 25,323Dual Eligibles 29,572Medicaid Only

HMO Services

STAR+PLUS Services * Primary, Preventive and Acute Care (Doctor, Hospital, Lab, X- ray) * Mental Health & Substance Abuse Services * Personal Care Services * Adult Day Health Services * Nursing Facility Services * Care Coordination * Waiver Services (therapy, respite, adult foster care, assisted living, adaptive equipment, in-home modifications) * Value-added Services (adult dental services, waiver services for non-waiver clients)

HARRIS COUNTY Estimated STAR+PLUS Clients FY’01

CARE COORDINATION * HMO have care coordinators, nurses and social workers, available to all members * Care coordinators makes home visit and assesses members needs * Care coordinators authorize community based LTC services. Arrange for other services

STAR+PLUS Capitation Payments

EVALUATION CRITERIA * Consumer Satisfaction * Integration of Care * Access to Care * Quality of Care * Emphasis of Community Based Care * Impact on Budget * Impact on Providers

Utilization Analysis l Personal Assistance Services use is 32 % higher than FFS projected. l The Community Based Alternatives program increased almost 119 percent in Harris County, but only 3.4 percent statewide. l Utilization of new generation medications by people with serious mental illnesses increased both statewide and in Harris County, but the Harris County increase did not occur until the implementation of STAR+PLUS. l Inpatient hospital utilization decreased for this population.

Access to Care

LTC Provider Satisfaction l Tended to be more dissatisfied than neutral or satisfied in the areas of u Accuracy of claims payments u Timeliness of claims payments u Amount of phone work l Those with more FFS experience reported lower satisfaction than those with less

Consumer Satisfaction disabled/under 65/ n= 238 * 88% of respondents reporting knowing how to reach someone in their health plan * 76% reported that it was easy to get help from their care coordinator * 75% of respondents experienced no problem getting the home health or attendant care they needed * 80% reported being satisfied or very satisfied with how the care coordinator explained information. * 53% reported being included in the decision making about their services.

Consumer Satisfaction* aged/over 65/ n=109 * 86% of respondents reporting knowing how to reach someone in their health plan * 93% reported that it was easy to get help from their care coordinator * 85% of respondents experienced no problem getting the home health or attendant care they needed * 89% reported being satisfied or very satisfied with how the care coordinator explained information. * 77% reported being included in the decision making about their services. *separate survey results

CASE HISTORY STAR+PLUS CLIENT 58 Year Old Male with past history of * Congestive heart failure * Atrial Fibrillation * Morbid Obesity * Childhood Polio

CLIENT’S HEALTH ISSUES * Multiple Disease Process * Patient’s Limitations to move within his environment due to his weight * Living Environment * Inability of Family to Provide Care * Possibility of Placement in a Nursing Home

CARE COORDINATION INTERVENTIONS * Caregiver Provider in Home * Home Visits by Primary Care Physician * Hostel Bed and Trapeze * Skilled Nursing

CLIENT OUTCOME * Member’s Ability to Maintain his Independence * Loss of Almost 200 lbs. * Improvement in Quality of Life

Challenges * Enrollment * Medicaid Population * LTC Providers Transition * Computer Systems * Dual Eligibles

Opportunities * Early Intervention * Disease Management * Care Coordination l Home visits l Integration of care * Flexibility in service delivery

Lessons Learned l Care Coordination is the key to integration of acute and LTC services l Challenges coordinating care for dual eligibles when HMOs are only responsible for LTC l Education of all providers and stakeholders is key l Increase in administrative complexity caused provider dissatisfaction l Collaboration between competing HMOs and State is an essential piece of successful model

STAR+PLUS Contact Texas Health and Human Services Commission Pamela Coleman, Director, STAR+PLUS Phone: (512) Fax: (512) WEBSITE: