10/3/2016

1

Cook Children’s Health Plan 1

Cook Children’s Health PlanSTAR Kids Update

October 5th, 2016

UNTHCS Grand Rounds

Cook Children’s Health Plan 2

STAR Kids -- new Texas Medicaid managed care program that will provide comprehensive benefits starting November 1, 2016, to children and adults ≤ 20 years with multiple diagnosis, high-needs healthcare needs and complex care management requirements. Enrollment is mandatory for those eligible. History -- Multiple stakeholder groups advocated for a managed care solution for children with disabilities over 3 legislative cycles (6 years); STAR Kids legislation finally passed, and 3 years later, it will be implemented.

STAR Kids Program Overview

Cook Children’s Health Plan 3

To be eligible for STAR Kids, children and young adults must be currently on Medicaid or one of the following programs: • Supplemental Security Income (SSI), including Medicare duals;

• Medically Dependent Children Program (MDCP) waiver;

• Youth Empowerment Services (YES) waiver;

• Live in community-based intermediate care or nursing facility for intellectual and development disability or related conditions (IDD);

• Medicaid Buy-In program or any of these Department of Aging and Disability Services (DADS) IDD waivers:o Community Living Assistance and Support Services (CLASS)o Deaf Blind with Multiple Disabilities (DBMD)o Home and Community-based Services (HCS)o Texas Home Living (TxHmL)

STAR Kids Program (con’t)

10/3/2016

2

Cook Children’s Health Plan 4

The STAR KIDS program will provide benefits such as:

primary and specialty care

hospital care

preventive care

prescription drugs

personal care services

private duty nursing and

durable medical equipment and supplies

long term services and support (LTSS) Also, a core component of this program will be a standard screening and assessment (SAI) process used to assess member’s needs and create individual service plans (ISP).

STAR Kids Program (con’t)

Cook Children’s Health Plan 5

STAR Kids Program (con’t)

MCOs to set-up specialty networks for LTSS services Adaptive Aids (AA) - Including vehicle modifications

Flexible Family Services and Supports (FFSS)* – i.e. Personal Care Attendant (PCA)

Minor Home Modifications (MHM) – e.g. wheel chair ramps, widening doorways

Respite Services – in-home* and out-of-home

Private Duty Nursing (PDN) and Personal Care Services (PCS)

Transition Assistance Services (TAS) – for relocation from institutional care to community

Employment Services

Employment Assistance (EA)* – supports to locate employment and obtain a job

Supported Employment (SE)* – supports for individual to maintain employment

Financial Management Services (FMS) – professional services to support payroll and human resource requirements so families can exercise consumer-directed options and hire their own care attendants

Emergency Response System (ERS) – The “I’ve fallen and I can’t get up” systems

* Indicates consumer-directed options exist

Cook Children’s Health Plan 6

• Texas HHSC requires plans to develop the Patient-centered Health Home (PCHH) concept for the STAR KIDS population with all willing providers

• MCOs and PCHH providers will be held to established thresholds for EPSDT (THSteps) compliance

• Note; expect greater difficulties with EPSDT completion with the CMC population as patient mobility and transportation complexities offer little incentive for families to go to the doctor when child is not sick

• Texas HHSC requires establishment of targeted outreach programs, especially when care gaps are identified

STAR Kids Program (con’t)

10/3/2016

3

Cook Children’s Health Plan 7

Around 175,000 children are expected to beeligible statewide with between 14,000–16,000 in the Tarrant Service Delivery Area (SDA). With two MCOs in the Tarrant SDA, CCHP projects our membership at approximately 10,500 once patient enrollment begins.

Cook Children’s Health Plan 8

Members will stratify into 3 levels of service coordination: Level 1

MDCP Complex needs – medical, developmental and/or behavioral health

SED or SPMI Members at-risk for institutionalization

Level 2 Not classified as Level 1 but receive PCS or RN services or who need

higher levels of care based on nursing assessment

Substance abuse with multiple visits, hospitalization, institutionalization Behavioral health issues significantly impairing function

Level 3

All others

STAR Kids Program (con’t)

Cook Children’s Health Plan 9

* shown with parental permission

10/3/2016

4

Cook Children’s Health Plan 10

Staffing Projections

High

Med

Low

7,500 9,000 10,500 12,000 15,000

I 30II 75III 6Support Staff 25

I 25II 45III 9Support Staff 25

I 20II 33III 11Support Staff 25

(50%) (60%) (70%) (80%) (100%)

136

104

89

121 136

215

115

Currently at 90%

Cook Children’s Health Plan 11

Cook Children’s Health Plan 12

Service Coordination Process Overview

• Partnering Service Coordination staff with members, parents/other caregivers to maximize health, well-being, and care independence

• Improve access to care and care coordination addressing the unique needs of members and their families

• Provide assistance to ensure timely and coordinated access to services and providers

10/3/2016

5

Cook Children’s Health Plan 13

Service Coordinators

• Service coordinators (case managers)– identify members needs via a validated

assessment tool for person-centered approach – remove barriers to meeting those needs– facilitate access and member empowerment

• Complexity will involve challenges in ≥ 1domain: physical, psychological, social and access to needed healthcare services

• RNs, SWs and LPCs all equally effective when trained in ICM (Integrated Case Management)

Cook Children’s Health Plan 14

Service Coordinators Screening

• Telephonic screening attempted for all members within 15 days of enrollment– Screening determines priority for Screening and

Assessment Interview (SAI) process completion and identifies urgent needs for immediate referral for services coordination

• SAI appointment priority: • within 7 days if urgent, unmet needs identified• within 30 days for most complex patients with

services need• all others, within 6 months

Cook Children’s Health Plan 15

Service CoordinatorAssessment, Planning and Services Delivery

• Complete SAI (Screening and Assessment Interview) process initially as per telephone screening priority, then annually and whenever significant change in life circumstances occur

• Assessments scheduled by member priority level:1. enroll after start date and request immediate services2. with most urgent unmet needs for services or care

coordination3. with few unmet needs currently receiving services

required to maintain stable 4. current MDCP recipients

10/3/2016

6

Cook Children’s Health Plan 16

Service Coordinator (con’t)Assessment, Planning and Services Delivery

• Completion of SAI informs development of individualized services plans to

address identified patient health needs development of Individualized Plan of Care (IPC)

that includes member needs, goals, objectives and planned interventions

• Coordinate care with non-covered services available through other sources

• Work closely with members, families and providers to ensure seamless coordination of needed services

Cook Children’s Health Plan 17

STAR Kids ProgramMembers stratification

Level 1 services coordination: most complex MDCP patients Patients with complex medical needs or a history of

developmental/behavioral health conditions Patients at risk for institutionalization

Named RN Services Coordinator Annual Screening and Assessment, and as needed Minimum of 4 in-person visits per year Minimum of 1 telephonic outreach contact per month

Cook Children’s Health Plan 18

Level 2: Patients who do not satisfy level 1 requirements but

receive personal care or home nursing services Patients who would benefit from higher levels of

services coordination based of needs assessments Patients with a history of substance abuse or other

behavioral health conditions that impair function

Named Services Coordinator Annual Screening and Assessment, and as needed Minimum of 2 in-person visits per year Minimum of 6 telephonic outreach contacts per year

STAR Kids Program Members stratification (con’t)

10/3/2016

7

Cook Children’s Health Plan 19

Level 3: Patients who do not qualify for levels 1 or 2 services

coordination requirements

Services Coordinator Minimum of 1 in-person assessments per year Minimum of 3 telephonic outreach contacts per year

Level three members in waiver programs will be assigned a named Services Coordinator.

Members or their LARs may also be assigned a named Services Coordinator upon request.

STAR Kids Program Members stratification (con’t)

Cook Children’s Health Plan 20

Service Coordination

Integrated Case Management – highest level of intervention

– Members with disease complexity that adversely impacts the stability of their condition

– Named Service Coordinator facilitates support for the member and LAR

– Emphasizes collaboration with the medical home

Cook Children’s Health Plan 21

STAR Kids Program (con’t)Members will stratify into 3 levels of services coordination:Level 1

Named RN Service Coordinator

Minimum of 4 face-to-face RN-administered assessments/year

Minimum of 1 telephonic outreach per month

Level 2

Named Service Coordinator

Minimum of 2 face-to-face RN-administered assessments/year

Minimum of 6 telephonic outreach per year

Level 3

Named Service Coordinator

Minimum of 1 face-to-face RN-administered assessments/year

Minimum of 3 telephonic outreach per year

10/3/2016

8

Cook Children’s Health Plan 22

Service CoordinationPod Unit Team Approach

• Service Coordinators work as members of a 5-person team, within the structure of a Pod

• Pod team members include nurses, social workers, and support staff

• The SAI determines member’s Level of Care (1, 2 or 3) which then determines their Pod assignment

• Pod structure designed to facilitate team communication and to allow for quick team huddles

• Seating space for 6 allows for easy access to additional team members who support the team

Cook Children’s Health Plan 23

Skill Set• Registered Nurse

• Licensed Master Social Worker

• Licensed Baccalaureate Social Worker

• Support Staff

RNLMSW/LCSW

CCHP Pod Model

LBSWLBSW

Support Staff

Cook Children’s Health Plan 24

Skill Set• Registered Nurse• Licensed Master Social Worker• Licensed Baccalaureate Social Worker• Support Staff

RNLMSW/LCSW

LBSWLBSW

Support Staff

RNLMSW/LCSW

LBSWLBSW

Support Staff

RNLMSW/LCSW

LBSWLBSW

Support Staff

CCHP Pod Model

10/3/2016

9

Cook Children’s Health Plan 25

RN LMSW/LCSW

LBSW LBSW

Support Staff

RNLMSW/LCSW

LBSW

Support Staff

LTSS

CCHP Pod Model

LBSW

BeaconBeacon

Skill Set• Registered Nurse• Licensed Master Social Worker• Licensed Baccalaureate Social Worker• Support Staff• Beacon• Long Term Support Services• Transition Specialist

Transition Specialist

CCHP Specialists Therapy Durable Medical Equipment PharmD Parent Coordinator

Community Based Orgs: ECI ISDs MHMR

Cook Children’s Health Plan 26

Transition Specialist

• Transition Specialist, along with Services Coordinator and POD team, works directly with complex members, their families and other individuals in their support systems, from age 15 through 20 years to help prepare for transition to adulthood

– Adult transition planning addresses a member’s health care and non-health care related needs

– Discussion with member and families begins at 10

Cook Children’s Health Plan 27

Transition Specialists

• Non-health care related services – Transition to adult STAR+PLUS benefits without

break in service

– Independent living

– Supported decision-making

– Guardianship

– Personal care (habilitation services)

– Education and vocational training

– Employment

– Social and recreational supports

10/3/2016

10

Cook Children’s Health Plan 28

Evolution & Implementation of ICM Model

STAR

CHIP

120,000 members

STAR Kids

C O M P L E X I T Y

+ ++ +++ ++++

Cook Children’s Health Plan 29

Evolution & Implementation of ICM Model

STAR

CHIP

120,000 members

STAR Kids

C O M P L E X I T Y

+ ++ +++ ++++

RNLMSW/LCSW

LBSW

Support Staff

LBSW

Cook Children’s Health Plan 30

Service CoordinationOrganizational Structure

10/3/2016

11

Cook Children’s Health Plan 31

Service CoordinationContinuity of Care

• Primary and Acute Services– Authorizations will be honored for 6 months, until authorization

expires or until a new assessment and ISP is completed

• Long Term Services and Support– Authorizations will be honored for 6 months or until a new

assessment and ISP is completed.

• CCHP ensures members’ continuity of care for services from out of network providers– CCHP uses best efforts to contract with or provide

single case agreements for these service providers

Cook Children’s Health Plan 32

STAR Kids Program

Cook Children’s Health Plan 33

Service CoordinationConversion Planning

• Newly identified medically necessary services will be authorized and will remain in place until a new or updated IPC is completed with the member and parents or LAR (Legally Authorized Representative)– If the members’ preferred providers are not in network,

a STAR KIDS Provider contract or SCA (single case agreement) will be offered to the provider

– Service Coordinators will work with members and their LAR to arrange for any necessary transition of services

10/3/2016

12

Cook Children’s Health Plan 34

Utilization Management• Unplanned hospital admissions are

reviewed by CCHP or Beacon Inpatient UM specialists– Significant communication occurs to assure

LTSS services are paused and appropriately resumed at discharge.

– Level 1 and 2 named Service Coordinators facilitate and oversee discharge planning. New services are arranged prior to discharge.

Cook Children’s Health Plan 35

Denials and Appeals• Dedicated Staff

– Denial and Appeals Coordinators• Registered Nurses

– Bilingual Support Staff

– Medical Director review

• Additional Support– Pharm D

– Member Advocates

– Management Team

Cook Children’s Health Plan 36

Denials and Appeals (con’t)

When requested services are determined not to be medically or functionally necessary

– Always determined by CCHP Medical Director or contracted specialist physician. Peer-to-Peer discussion is available to prescribing provider.

– Assigned Service Coordinator is involved in decision. Member advocate available to assist.

– Service Coordinator works with member and LAR to find alternative to meet member’s need

10/3/2016

13

Cook Children’s Health Plan 37

Denials and Appeals (con’t)

• Reconsideration – prior to requesting appeal, new information submitted is reviewed by original Medical Director. If overturned, services are immediately authorized and communicated to the requesting services provider

• Expedited Appeal – provided when– emergency situation (within 24 hours of receipt)

– ongoing hospitalization (within 24 hours of receipt)

– decision impacts continuation of previously authorized services (within 72 hours of receipt)

Cook Children’s Health Plan 38

Denials and Appeals (con’t)

• Appeals requested by the member, LAR or other authorized representative

• Appeals are reviewed by Medical Director not involved in original decision to deny– Overturned -- services authorized immediately

– Upheld/partially upheld -- decision communicated to member and prescribing provider

– Thirty days to respond, unless request expedited

Cook Children’s Health Plan 39

Notice of Action - Appeal Rights

• Any notice of action must list members appeal rights, including right to a fair hearing.

• Member/LAR additional resources regarding appeal rights

– Member Handbook– CCHP Website – CCHP Service Coordinator – Member Advocate

10/3/2016

14

Cook Children’s Health Plan 40

STAR Kids ProgramReasons to Implement

• Most members are currently being served by CCHCS • CCHP’s participation in STAR Kids will maintain current

CCHCS relationships for patients and between-providers• HHSC and MCOs have identified significant gaps in

robust case management and services coordination for this population

• Promotes healthcare services delivery via patient-centered health home model

• Adding this segment of the care continuum to our existing general population will enhance our population health management capabilities

Cook Children’s Health Plan 41

CCHP Challenges

Environmental Factors:– Ongoing changes and repeated delays by HHSC

– Maintaining current operations while developing new product

– Developing “a Health Plan within a Health Plan”

– Unfamiliar Long Term Services and Support (LTSS) environment

– Contingency plan for CCHP in the event that Aetna does not pass readiness

Cook Children’s Health Plan 42

Important Dates

• August 10-12 – HHSC IT Readiness Review

• September 26-28 – HHSC on-site Operational Readiness Review

• End of October –

– Preparatory review for go live

• November 1 – STAR Kids launch

• Mid November –

– Post go-live review and update

• 2017-2018 – Ongoing evaluation and

stabilization of systems.

10/3/2016

15

Cook Children’s Health Plan 43

STAR Kids Resources• CCHP STAR Kids Provider Manual

- https://www.cookchp.org/English/Providers/Pages/Manuals.aspx

• STAR Kids Advisory Committee- https://hhs.texas.gov/about-

hhs/leadership/advisory-committes/star-kids-managed-care-advisory-committee

• HHSC STAR Kids Information– https://hhs.texas.gov/services/health/medicaid-

and-chip/programs/star-kids

Cook Children’s Health Plan 44

THANK YOU !!Jose.Gonzalez@cookchildrens.orgKimberly.Aaron@cookchildrens.org

STAR KIDSQUESTIONS ?