Texas
State Access Reform - PLUS Long Term Care

Texas has recently developed an informative video about the Star+Plus Program. This video requires Real Player , if you don't have a copy of Real Player then it is available for most operating systems at www.real.com

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Project Overview

General Approach and Eligible Population: STAR+PLUS is a Texas Medicaid pilot project designed to integrate delivery of acute and long-term care services through a managed care system. The project serves approximately 58,000 SSI and SSI-related aged and disabled Medicaid recipients in Harris County (Houston). Of these, about half are dually eligible for Medicare and Medicaid services.

Participants may choose from two health maintenance organizations or a primary care case management option. An enhanced prescription drug benefit is available for Medicare-eligible participants who choose the same HMO for both Medicaid and Medicare services. When available, this option is intended to promote increased integration and coordination of care. At this time, there are no STAR+PLUS HMOs who have both Medicare and Medicaid products. One of the participating HMOs is considering developing a Medicare product in 2001.

Waivers, Implementation Date: This project requires two Medicaid waivers (1915b and 1915c) in order to mandate participation and to provide home and community-based services. The federal government approved the waivers in February 1998.

Benefit Package: Long-term care services provided by the HMOs include day activity and health services (DAHS), and personal assistance. Additional services provided to CBA waiver (nursing facility waiver) clients are adaptive aids, adult foster home services, assisted living, emergency response services, medical supplies, minor home modifications, nursing services, respite care and therapies (occupational, physical and speech-language).

Care coordination is an integral STAR+PLUS service. The Care Coordinator is responsible for coordinating the client's acute and long term care, even if the client is a dual eligible who receives Medicare from a provider who is not affiliated with the STAR+PLUS HMO's Medicare risk product. The Care Coordinator plays a central role in integration of care.

Medicaid-only clients receive traditional Medicaid acute care services plus an annual check-up. For these clients, the cost of acute care services is included in the payment to the HMO. For dual eligibles, acute care is covered by Medicare. Therefore, the HMO payment for these clients does not include the cost of acute care. However, the HMO is still required to perform care coordination between the client's Medicare services and any necessary Medicaid long-term care services.

Clients in the Texas Health Network, the PCCM model, receive traditional Medicaid acute care services plus an annual check-up. Long-term care and care coordination are not provided by Texas Health Network. Clients who need long-term care services must apply to the Texas Department of Human Services.

Prescription drugs remain outside Medicaid managed care. Clients will continue to have prescriptions filled by any pharmacist participating in the state's Vendor Drug Program. However, STAR+PLUS Medicaid-only clients receive unlimited prescriptions instead of the traditional three prescriptions per month limit. In addition to all of the traditional Medicaid and other services mentioned above, each STAR+PLUS HMO also offers its own set of additional services, known as "value added" services. These are services over and above those required and paid for by the state which the HMOs offer as incentives for Medicaid clients to join their health plan. Some value-added services are offered by both HMOs, while others may vary from plan to plan. Value-added services currently available in a STAR+PLUS plan include adult dental care, an expanded selection of eyeglass frames, pest control, and assistance with meals. All HMOs offer CBA waiver services to clients who are not in a waiver slot if the service is medically necessary. Texas Health Network does not offer any value added services.

Delivery System: The client chooses an HMO (or the primary care case management option, if applicable) and a primary care provider. All Medicaid acute and long-term care services are obtained through the HMO and its network of providers. Clients who choose the PCCM option receive primary care from a PCP within the PCCM network, but may see any specialist or hospital that accepts Medicaid and must apply to the Texas Department of Human Services for any necessary long term care services. Clients who are also on Medicare do not choose a primary care provider. These "dually eligible" clients receive all Medicaid long-term care services through the HMO but have freedom of choice regarding Medicare providers for their acute care. Dual eligibles may choose to receive Medicare services on a fee-for-service basis or may join an HMO with a Medicare risk product.

Newly-certified Medicaid eligibles will be contacted by the enrollment broker with enrollment information and will have 30 days to make a selection before being assigned a health plan and provider. The process of assigning clients is called the "default" process. However, clients who are defaulted may still make a choice about their health plan and PCP. If after 30 days they still have not made a selection, they must receive their Medicaid services through that health plan until they contact the enrollment broker and make a selection. Clients may change plans or PCP as often as monthly if they are unsatisfied with their care.

Quality Assurance: The HMO contract requires each plan to develop a detailed Quality Improvement Plan and to ensure compliance with a number of quality standards. In addition, the Health and Human Services Commission and the Texas Department of Human Services work with the Texas Health Quality Alliance (THQA), which is the state's quality monitor, to ensure that clients receive a high quality of services. THQA activities include conducting consumer and provider satisfaction surveys, a baseline care coordination study, and performing a detailed review of HMO compliance with contract requirements. In 2001-2002, a multidisciplinary task force, with technical assistance from RWJF will be developing and initiating a self-assessment tool for HMOs to measure the quality of their care coordination activities.

Current Status

Enrollment: STAR+PLUS enrollment started in November 1997. Clients were encouraged to voluntarily enroll in STAR+PLUS for services beginning January 1, 1998. This gave the STAR+PLUS HMOs an opportunity to start out with a small population and test their systems. Mandatory participation for eligible clients began April 1, 1998. Many efforts were made to contact clients and get them to enroll before the default process started. According to Maximus, the State's enrollment broker, 82% of clients selected their own plan and 18% were assigned to a plan.

September 2002

AMERICAID	HMO BLUE	PCCM	TOTAL
20,767	28,709	8,438	57,911

Recent Accomplishments: The state has been working to develop a data warehouse system for capturing all STAR+PLUS data that will enhance program analysis and reporting capability. The system will include eligibility files, the premium payment system, client enrollment files, network provider files and HMO encounter data files. The State is also planning to include Medicare data, MDS assessment data for nursing facility clients and MDS-HC assessment data for clients in the community.

Next Steps

Evercare Medicare+Choice - In September, Evercare, a subsidiary of United Health Care, began offering a Medicare product to dual eligibles in Harris County. Evercare is a partner with HMO Blue STAR+PLUS. This partnership provides dual eligible members with the opportunity to have the same HMO provide Medicare and Medicaid services.

When STAR+PLUS began operation in January 1998, one of the contracting HMOs, Memorial Sister's of Charity, had a Medicare HMO. Soon after implementation, HMO Blue started a Medicare product called Senior Blue, which was available to dual eligible members. The number of clients enrolled in the same HMO for Medicaid/Medicare only reached about 600 before both the Medicare HMOs announced they were dropping the product. There was never an opportunity to analyze and evaluate the impact of this dual enrollment and evaluate whether or not this model resulted in improved quality, coordination and cost-effectiveness.

With this agreement, the STAR+PLUS project will be able to integrate Medicare encounter data obtained directly from the health plan with the Medicaid encounters in the data warehouse. The next step will be to obtain the Medicare claims data on the dual members prior to enrollment in Evercare M+C for comparative analysis.

Also with the Evercare M+C members, there will be trackingof pharmacy utilization. Although the pharmacy benefit is not capitated, the state Medicaid program provides an additional benefit. As an incentive for dual eligible members to enroll in Evercare M+C, the state offers unlimited prescription drugs versus the regular 3-prescription limit. There will be analysis of the trends in pharmacy use for these members and possibly some case studies to determine if the increased prescription benefit results in greater or less over all costs for members.

MDS-HC analysis - There are negotiations ocurring with Dr. Brant Fries at the University of Michigan and Drs. Catherine Hawes/Charles Phillips from Texas A&M University on a technical assistance contract to analyze and evaluate the Minimum Data Set - Home Care assessment data completed for STAR+PLUS members. There are currently over 14,000 MDS-HC assessments in the data warehouse.

Contact Information

Pamela Coleman, Director
Department of Human Services, Managed Care Division
701 W. 51st Street
Austin, Texas 78751
Phone: (512) 438-5067
Fax: (512) 438-2845
E-mail: pamela.coleman@ursa.dhs.state.tx.us
Website: http://www.hhsc.state.tx.us/starplus/starplus.htm