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Managed Care Panel:STAR Kids Program and

Other MCO Collaboration Opportunities

June 23, 2016

Elizabeth LaMair, Healthcare Policy Director

ELaMair@tx.council.com

DISCLAIMER: EDUCATIONAL ONLY

THIS TRAINING IS PROVIDED FOR GENERAL INFORMATION AND EDUCATIONAL PURPOSES ONLY. IT DOES NOT CONSTITUTE LEGAL ADVICE OR OPINIONS. THE INFORMATION IS NOT INTENDED TO CREATE, AND THE RECEIPT DOES NOT CONSTITUTE, AN ATTORNEY-CLIENT RELATIONSHIP BETWEEN TRAINER AND PARTICIPANT. FOR LEGAL ADVICE, YOU SHOULD CONSULT AN ATTORNEY.

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OverviewSTAR Kids – history, program description, and MCO awardsCollaboration Opportunities – STAR Kids and other managed care programs

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In the Beginning…. there was STAR

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… and the STAR grew to be a big STAR…

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… and then came more and more STARs.

•STAR+PLUS•NorthSTAR•STAR Health

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STAR+PLUS grew, too….

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… and a few others…

• CHIP • Children’s Medicaid Dental Services• CHIP Dental Services•MMP Duals Demonstration

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… and finally, STAR Kids.

• First managed care program specifically tailored for children ages 20 and younger with disabilities• Starts November 1, 2016

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Why STAR Kids?Senate Bill 7, 83rd Legislature, Regular Session (2013)• Required HHSC to design a mandatory managed care program for

children with disabilities (SSI) and children enrolled in MDCP• Required HHSC to consult with STAR Kids Managed Care Advisory

Committee and Children’s Policy Council

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STAR Kids – Who’s In?Enrolled in STAR Kids Not Enrolled in STAR Kids

Children with SSI Medicaid Current STAR and STAR+PLUS members Children not previously in managed care (currently in traditional

Medicaid) Children in nursing facilities (except Truman Smith) or

community-based ICFs Children in MBI or MBIC Children in HIPP who meet STAR Kids eligibility requirements

Children enrolled in the following waivers: Medically Dependent Children Program (MDCP) Home and Community-based Services (HCS) Community Living Assistance and Support Services (CLASS) Deaf Blind with Multiple Disabilities (DBMD) Texas Home Living (TxHmL) Youth Empowerment Services (YES)

Adults 21 and over STAR Health members Children in:

Truman Smith Children’s Center State Veteran’s Homes State Supported Living Centers

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STAR Kids – Benefits STAR Kids covers:

• Basic health care services (acute care). Examples:• Prescription drugs• Hospital care• Primary and specialty care (including behavioral health)• Preventative care• Therapies• Durable medical equipment (DME) and supplies

• State Plan LTSS:• Personal Care Services (PCS)• Private Duty Nursing (PDN)• Community First Choice (CFC)• Day Activity and Health Services (DAHS)

• Long-term services and supports (for MDCP clients)

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STAR Kids – Non-Capitated Services

Examples of Medicaid benefits that are not covered by STAR Kids:• Texas Health Steps dental services/orthodontia • ECI Targeted Case Management• ECI Specialized Skills Training• IDD Targeted Case Management• Texas School Health and Related Services (SHARS) • Medicaid Medical Transportation Program (MTP) services• Waiver services – HCS, CLASS, DBMD, TxHmL, YES • Medicare-covered services (for dual eligible members)

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STAR Kids– SB 7 Features• Nurse Hotline• Health Homes• Service Coordination Teams• Comprehensive Assessment Process• Individual Service Plans (ISPs)

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STAR Kids – MCOs and Service Areas

MCO Service AreaAetna Better Health of Texas, Inc. Tarrant

Amerigroup Dallas, El Paso, Harris, Lubbock, MRSA West

Blue Cross and Blue Shield MRSA Central, Travis

Children's Medical Center Dallas

Community First Health Plans Bexar

Cook Children's Health Plan Tarrant

Driscoll Health

Hidalgo, Nueces

Superior Health Plan Bexar, El Paso, Hidalgo, Lubbock, MRSA West, Nueces, Travis

Texas Children's Health Plan Harris, Jefferson, MRSA Northeast

United Healthcare Harris, Hidalgo, Jefferson, MRSA Central, MRSA Northeast

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The Future of Managed Care

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Or… The Future of Managed Care

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The Future of Managed Care(a.k.a. Collaboration Opportunities)

Move to Value-Based/Alternative Payment Structures (for both MCOs and managed care providers)• SAMSHA Grant for CCBHCs• CMS Managed Care Rules

Align Managed Care and DSRIP Metrics• 1115 Waiver Renewal

Develop Ways to Sustain DSRIP through Managed Care

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Opportunities for Collaboration – Think About•How can you help the MCO meet its contract

requirements/metrics?

•How can you add value to the MCOs and its members while reducing costs?

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Collaboration Opportunities (STAR Kids and Other MCO Programs)• Serve as Health Homes• Conduct provider trainings • Help MCOs with their distinct Service Coordination functions• Participate in Service Coordination Teams• Help MCOs with super-utilizer initiatives• Participate in Behavioral Health Crisis Prevention and Crisis

Intervention Plans• Provide Behavioral Health Hotline services• Negotiate alternative payment models/value-based payments

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Health Home -- DefinitionWhat is a Health Home?

Texas Government Code §533.00253 -- “Health Home” means a primary care provider practice, or if appropriate, a specialty care practice, incorporating several features, including comprehensive care coordination, family-centered care, and data management, that are focused on improving outcome-based quality of care and increasing patient and provider satisfaction under Medicaid.

STAR Kids Contract, Section 8.1.4.10.2 – a team-based approach to care that is designed to enhance ease of access, coordination between providers, and quality of care. Health Home services must be part of a person-based approach and holistically address the needs of persons with multiple chronic conditions or a single serious and persistent mental or health condition.

Who gets a Health Home?Members who ask for one, and Members identified by the MCO

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Health Home – Must and May Requirements A Health Home must include:• Patient self-management education• Provider education• Patient-centered and family-centered care• Evidence-based models and minimum standards of care• Patient and family support (including authorized representatives)

A Health Home may also include:• Provider incentives for timely and quality care• Referral to community and social support services • Use of health information technology to link services, as feasible and appropriate

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Ordinary PCP vs. Health Home

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Service CoordinationService Coordination means a specialized care management service performed by a Service Coordinator that includes:

(1) identification of needs, including physical health, mental health services and long term support services,

(2) development of a Service Plan to address those identified needs;

(3) assistance to ensure timely and a coordinated access to an array of providers and Covered Services;

(4) attention to addressing unique needs of Members; and

(5) coordination of Covered Services with Non-capitated Services, as necessary and appropriate.

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STAR Kids – Service Coordination LevelsLevel STAR Kids Members Annual Minimum

Service Coordination Contacts

Named Service Coordinator?

Who can serve as a Service Coordinator? Minimum qualifications:

Level 1 – Highest

• MDCP members• Members with complex needs, or a history

of developmental or BH issues• Members with SPMI• Members at risk for institutionalization• Members with psychosocial needs that

present significant challenges to their health or wellbeing

• 4 face-to-face• Monthly

telephonic

Yes • Registered Nurse • Nurse Practitioner• Physician’s Assistant • Licensed Social Worker • Licensed Professional Counselor (if

member’s service needs are primarily BH)

Level 2 • Members who don’t meet Level 1, but receive PCS, CFC, nursing services, or HCBS waiver services

• Members the MCO believes would benefit from a higher level of Service Coordination based on STAR Kids SAI and additional MCO findings

• Members with a history of substance abuse

• Members with non-SPMI BH issues

• 2 face-to-face• 6 telephonic

Yes • Registered Nurse • Nurse Practitioner• Physician’s Assistant • Undergraduate/graduate degree in social

work or related field• Licensed Vocational Nurse with previous

service coordination experience

Level 3 – Lowest

• Members who do not qualify as Levels 1 or 2

• 1 face-to-face• 3 telephonic

No, unless requested by the member

• Minimum of a high school diploma/GED and direct experience working with children and young adults with similar conditions in the past 3-5 years

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Service Coordination TeamsWhat is a Service Coordination Team?

• Member-centered support network designed to enhance services provided by a Service Coordinator. • Team members are selected based on the needs and preferences of the STAR Kids member.• Teams must have access to individuals with expertise in behavioral health, co-occurring behavioral health/IDD,

medically complex conditions, substance abuse, LTSS, local resources, pediatrics, etc.

Who gets one?The MCO or provider decide that:• Member could benefit from a multidisciplinary approach to Service Coordination.• When specific expertise is necessary to address the needs identified in a member’s ISP.

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Model Payment Approaches

Volume-based (not Value-based) FFS: rewards volume, not quality and does not support coordination across providers

Supporting Quality Improvement Pay for Reporting: Process measures and outcome measures registry participationCare Coordination Payments: Patient-centered and medical and health homes (Medical Home, Service Coordination Teams)

Paying for Higher Quality Pay for Performance: Bonus payments for quality and outcomes and penalties for PPEsShared Savings: Spending targets and up and downside risk

Paying for Value Bundled Payments: can include one setting of care or cross settings of care and pathway to full capitationFull or Partial Capitation: Generally used across settings of care (e.g. all physical or BH services), but some services can be carved outFull Risk Model: Providers at full risk

Value-based Payments to Providers

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Collaboration – What to Bring to the TableHow can you help the MCO meet its contract requirements/metrics?

• Access to care metrics (mileage, wait times for appointments, out-of-network utilization)• Health Home – many Centers already provide integrated care, or can coordinate with PCPs• Service Coordination touch requirements – established relationships with many members• Quality programs (P4Q, PIPS) – many have behavioral health components • Provider trainings – IDD, Mental Health First Aid, etc.• Behavioral Health Hotline • Behavioral Health Crisis Prevention and Crisis Intervention Plans

How can you add value to the MCOs and its members while reducing costs?• DSRIP experience• CCBHC experience• Super-utilizer programs• Experience treating high-acuity members with complex and co-occurring conditions• Provide client-centered, collaborative, culturally competent care• Can offer wellness programs as value-added service provider• In-lieu of services – crisis respite/residential• Case-by-case services

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Resources • SB 7: http://

www.capitol.state.tx.us/tlodocs/83R/billtext/pdf/SB00007F.pdf#navpanes=0 • Star Kids Website: http://

www.hhsc.state.tx.us/medicaid/managed-care/mmc/star-kids.shtml • HHSC/MCO Contracts:

http://www.hhsc.state.tx.us/medicaid/managed-care/forms.shtml • EQRO MCO Quality Reports: http

://www.hhsc.state.tx.us/medicaid/managed-care/star/reports.asp • Medicaid and CHIP Quality and Efficiency Improvement Page:

http://www.hhsc.state.tx.us/hhsc_projects/ECI/

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Managed Care Panel Discussion• Emily Zalkovsky, Deputy Medicaid Director for Policy and Program, Health and Human

Services Commission• Greg Gilmore, Associate VP of Texas Behavioral Health Provider Relations, Amerigroup• Pamela Cobb, Director of Provider Networks for Texas, Cenpatico• Cheryl Fisher, Sr. Director of Foster Care and Specialty Populations, Cenpatico• Mandie Eichenlaub, VP of Network Management and Vendor Oversight, UnitedHealthcare

Community Plan of Texas• Gregg Sherrill, Associate Director of Behavioral Health, Optum• Jon Severson, Director of Texas Network, Optum• Diane Felder, Texas Medicaid Medical Director, Magellan Health

Continuing Legal EducationThis session qualifies for 1.5 hours of CLE credit.

Course Title: 31st Annual ConferenceCourse Number: 901353698Date: June 24, 2016

Please complete the CLE attendance form before you leave. You can also request credit on the State Bar website.