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

Medicaid Managed Care Programfor the Elderly and Persons with Disabilities

Pamela ColemanTexas Health and Human Services Commission

January 2003

WHAT IS STAR+PLUS?

A Managed Care Systemfor the SSI & SSI-RelatedPopulation

Integrates Medicaid fundingand service delivery of LongTerm and Acute Health Care

Medicare members onlyenrolled 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 - 1915(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 waiverservices as value added services

- Provides more alternatives

STAR+PLUS Eligibility

Mandatory Participation: HMO SSI-eligible (or would be except for COLA) clients age

21 and over

MAO clients who qualify for the Community Based Alternatives (CBA) waiver

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 You must enroll in a STAR+PLUS Plan for

Medicaid services

Medicare services may be obtained through the provider of choice

Enrollment Broker

New Medicaid Clients

Enrollment Broker Contacts Clients by:

Telephone, Mail, In-person

STAR+PLUS Plans

HMO Blue/Evercare

Amerigroup

STAR+PLUS Enrollment

1/1/02 54,895 Total

25,323 Dual Eligibles

29,572 Medicaid 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

Healthy Clients74%

Nursing Facility 10%

Community Care11%

CBA4%

Nursing Facility

CBA

Community Care

No LTC Service

`

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

Risk Group Medicaid Only

Capitation

Number of Enrollees

Dual Eligible Capitation

Number of Enrollees

Community Clients

$608.43 22396 $128.77 26230

CBA Waiver Clients

$2,917.06 469 $1,294.50 1505

Nursing Facility Clients

$608.43 8 $128.77 34

As of January 1, 2003

STAR+PLUS Capitation Payments

EVALUATION CRITERIA

Consumer SatisfactionIntegration of CareAccess to CareQuality of CareEmphasis of Community

Based CareImpact on BudgetImpact on Providers

Utilization Analysis

Personal Assistance Services use is 32 % higher than FFS projected.

The Community Based Alternatives program increased almost 119 percent in Harris County, but only 3.4 percent statewide.

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.

Inpatient hospital utilization decreased for this population.

Access to Care

Unique Members Receiving Personal Attendant Services

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

STAR+PLUS

Unique Members Receiving DAHS Services

0

200

400

600

800

1000

1200

Sep-

00

Oct

-00

Nov

-00

Dec

-00

Jan-

01

Feb-

01

Mar

-01

Apr-

01

May

-01

Jun-

01

Jul-0

1

Aug-

01

Sep-

01

Oct

-01

Nov

-01

Dec

-01

Jan-

02

Feb-

02

Mar

-02

Apr-

02

May

-02

Jun-

02

Jul-0

2

STAR+PLUS

Dual Eligible Members Receiving CBA Services

0

200

400

600

800

1000

1200

1400

Sep

-00

Oct

-00

Nov

-00

Dec

-00

Jan-

01

Feb-

01

Mar

-01

Apr

-01

May

-01

Jun-

01

Jul-0

1

Aug

-01

Sep

-01

Oct

-01

Nov

-01

Dec

-01

Jan-

02

Feb-

02

Mar

-02

Apr

-02

May

-02

Jun-

02

Jul-0

2

STAR+PLUS

Medicaid Only Members Receiving CBA Services

0

100

200

300

400

500

600

Sep-

00

Oct

-00

Nov

-00

Dec

-00

Jan-

01

Feb-

01

Mar

-01

Apr-

01

May

-01

Jun-

01

Jul-0

1

Aug-

01

Sep-

01

Oct

-01

Nov

-01

Dec

-01

Jan-

02

Feb-

02

Mar

-02

Apr-

02

May

-02

Jun-

02

Jul-0

2

STAR+PLUS

Nursing Home Members

0

10

20

30

40

50

60

Sep-

01

Oct

-01

Nov

-01

Dec

-01

Jan-

02

Feb-

02

Mar

-02

Apr-

02

May

-02

Jun-

02

Jul-0

2

STAR+PLUS

LTC Provider Satisfaction

Tended to be more dissatisfied than neutral or satisfied in the areas of Accuracy of claims payments Timeliness of claims payments Amount of phone work

Those with more FFS experience reported lower satisfaction than those with less

Consumer Satisfactiondisabled/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 Home visits Integration of care

Flexibility in service delivery

Lessons Learned Care Coordination is the key to integration of acute

and LTC services Challenges coordinating care for dual eligibles

when HMOs are only responsible for LTC Education of all providers and stakeholders is key Increase in administrative complexity caused

provider dissatisfaction Collaboration between competing HMOs and State

is an essential piece of successful model

STAR+PLUS Contact

Texas Health and Human Services CommissionPamela Coleman, Director, STAR+PLUS

Phone: (512) 685-3172Fax: (512) 338-6550

Email: [email protected] WEBSITE:

www.hhsc.state.tx.us/starplus/starplus.htm