medicaid managed care initiatives december 2011. 2 star capitated, health maintenance organization...
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Medicaid Managed Care Initiatives
December 2011
2
• STAR• Capitated, Health Maintenance Organization (HMO)
model for non-disabled pregnant women and children.• Provides acute care services.
• STAR+PLUS• Capitated HMO model for disabled Medicaid clients and
dual eligibles (Medicaid and Medicare).• Provides acute and long term services and supports
(LTSS).
Medicaid Service Delivery Models
3
• STAR Health• Capitated HMO model for foster care children.• Provides acute care services with emphasis on behavioral
health and medication management.• Primary Care Case Management (PCCM)
• Non-capitated service delivery model.• Includes non-disabled pregnant women, children and
disabled adults.• Acute care services only.
Medicaid Service Delivery Models
Page 4
Medicaid Managed CareInitiatives
• Expand STAR and STAR+PLUS to South Texas.• Expand STAR+PLUS to El Paso and Lubbock
service areas.• Convert PCCM Areas to the STAR Program
model. • Include In-patient Hospital Services in
STAR+PLUS.• Include pharmacy benefits in managed care.• Expand Dental Managed Care Model for children
in Medicaid.
5
STAR+PLUS Managed Care Service Areas
HoodHoward
Presidio
BrewsterVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
Kendall
Comal
Gillespie
Llano
Travis
Hays
Caldwell
Burnet
Williamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
Victoria
Goliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
Camp
Morris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
Bexar
Lubbock
Harris
El Paso
Dallas *
HHSC, Health Plan OperationsSeptember 2010
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
Travis
Orange
Sabine
Newton
Colorado
Houston
Tarrant *
Nacogdoches
San Jacinto
Jasper
Nueces
Washington
JeffersonChambersHarris
Hidalgo
Jefferson
HoodHoward
PresidioVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
Kendall
Comal
Gillespie
Llano
Travis
Hays
Caldwell
Burnet
Williamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
Victoria
Goliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
Camp
Morris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
BexarAmerigroup, Molina, Superior
LubbockAmerigroup, Superior
HarrisAmerigroup, Molina, United
El PasoAmerigroup, Molina
STAR+PLUS Service Areas(effective March 1, 2012)
DallasMolina, Superior
HHSC, Health Plan OperationsJuly 2011
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
TravisAmerigroup, United
Orange
Sabine
Newton
Colorado
Houston
TarrantAmerigroup, Bravo
Nacogdoches
San Jacinto
Jasper
NuecesSuperior, United
Washington
JeffersonChambersHarris
HidalgoHealthSpring, Molina, Superior
JeffersonAmerigroup, Molina, United
Brewster
Hood
Howard
PresidioVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
Kendall
Comal
Gillespie
Llano
Travis
Hays
Caldwell
Burnet
Williamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
Victoria
Goliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
Rains Wood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
Camp
Morris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
Medicaid Rural Service Area (MRSA) Regions
HHSC, Health Plan OperationsJuly 2011
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
Orange
Sabine
Newton
Colorado
Houston
Nacogdoches
San Jacinto
Jasper
Washington
JeffersonChambersHarris
MRSA – West TexasAmerigroup, FirstCare, Superior
Brewster
MRSA – Central TexasAmerigroup, Scott & White, Superior
MRSA – Northeast TexasAmerigroup, Superior
6
STAR+PLUS Managed Care Service Areas
HoodHoward
Presidio
BrewsterVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
Kendall
Comal
Gillespie
Llano
Travis
Hays
Caldwell
Burnet
Williamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
Victoria
Goliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
Camp
Morris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
Bexar
Lubbock
Harris
El Paso
Dallas *
HHSC, Health Plan OperationsSeptember 2010
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
Travis
Orange
Sabine
Newton
Colorado
Houston
Tarrant *
Nacogdoches
San Jacinto
Jasper
Nueces
Washington
JeffersonChambersHarris
Hidalgo
Jefferson
HoodHoward
PresidioVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
Kendall
Comal
Gillespie
Llano
Travis
Hays
Caldwell
Burnet
Williamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
Victoria
Goliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
Camp
Morris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
BexarAmerigroup, Molina, Superior
LubbockAmerigroup, Superior
HarrisAmerigroup, Molina, United
El PasoAmerigroup, Molina
STAR+PLUS Service Areas(effective March 1, 2012)
DallasMolina, Superior
HHSC, Health Plan OperationsJuly 2011
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
TravisAmerigroup, United
Orange
Sabine
Newton
Colorado
Houston
TarrantAmerigroup, Bravo
Nacogdoches
San Jacinto
Jasper
NuecesSuperior, United
Washington
JeffersonChambersHarris
HidalgoHealthSpring, Molina, Superior
JeffersonAmerigroup, Molina, United
Brewster
Page 7
Geographic Distribution of Managed Care Delivery Models
HoodHoward
Presidio
BrewsterVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
Kendall
Comal
Gillespie
Llano
Travis
Hays
Caldwell
Burnet
Williamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
Victoria
Goliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
Camp
Morris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
Bexar
Lubbock
Harris
El Paso
Dallas *
HHSC, Health Plan OperationsSeptember 2010
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
Travis
Orange
Sabine
Newton
Colorado
Houston
Tarrant *
Nacogdoches
San Jacinto
Jasper
Nueces
Washington
JeffersonChambersHarris
Hidalgo
Jefferson
HoodHoward
PresidioVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
Guadalupe
Gonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
Kendall
Comal
Gillespie
Llano
Travis
Hays
Caldwell
Burnet
Williamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
Victoria
Goliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
Camp
Morris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
Bexar
Lubbock
Harris
El Paso
STAR and Medicaid Rural Service Areas
(effective March 1, 2012)
Dallas
HHSC, Health Plan OperationsJune 2011
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
Travis
Orange
Sabine
Newton
Colorado
Houston
Tarrant
Nacogdoches
San Jacinto
Jasper
Nueces
Washington
JeffersonChambersHarris
Hidalgo
Jefferson
Medicaid Rural Service Area (MRSA)
Brewster
HoodHoward
PresidioVal Verde
CulbersonHudspeth
Jeff Davis
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
Zavala
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
Kendall
Comal
Gillespie
Llano
Travis
Hays
Caldwell
Burnet
Williamson
Mills
San Saba
Brown
Eastland
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
Parker
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collingsworth
Hemphill
OchiltreeHansford Lipscomb
Trinity
Brazos
Lavaca
Victoria
Goliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Burleson
Robertson
Waller
Brazoria
Matagorda
Fort BendGalveston
Montgomery
Walker
Grimes
Madison
Liberty
Hardin
Polk Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
KaufmanVan Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
Camp
Morris Cass
San Augustine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
BexarAetna, Amerigroup, Community First, Superior
LubbockAmerigroup, FirstCare, Superior
HarrisAmerigroup, Community Health Choice,
Molina, Texas Children’s, United
El PasoEl Paso First, Molina, Superior
STAR Service Areas and MRSA(effective March 1, 2012)
DallasAmerigroup, Molina, Parkland
HHSC, Managed Care OperationsSeptember 2011
Palo Pinto
Comanche
Hamilton
El Paso
McMullen
Maverick
TravisBlue Cross and Blue Shield of Texas, Sendero, Seton, Superior
Orange
Sabine
Newton
Colorado
Houston
TarrantAetna, Amerigroup, Cook Children’s
Nacogdoches
San Jacinto
Jasper
NuecesChristus, Driscoll Children’s, Superior
Washington
JeffersonChambersHarris
HidalgoDriscoll Children’s, Molina, Superior, UnitedHealthCare
JeffersonAmerigroup, Community Health Choice,
Molina, Texas Children’s, United
Medicaid Rural Service Area (MRSA)
Brewster
HMO Member Benefits
• Traditional Medicaid benefit package.
• Provider directories – physicians, specialists, and LTSS.
• PCP to coordinate health care of patient (Medicaid only).
• Member services helpline (through their health plan).
• Member handbooks and health education.
• Service Coordination.
• Value Added Services – vary by health plan.
Page 9
STAR Members• Populations mandatory for STAR include:
Temporary Assistance to Needy Families (TANF) recipients Pregnant Women Children receiving Medicaid assistance only
• Populations excluded from STAR include: Medicaid recipients who reside in institutions Medicaid recipients receiving Supplemental Social Security (SSI) Dual-eligible Medicaid recipients (clients with both Medicaid and
Medicare) Medically needy Foster children Refugees
• Medicaid Rural Service Area: Children age 20 and younger can choose to join STAR if they receive SSI
but do not receive Medicare.
10
STAR+PLUS MembersSTAR+PLUS Members
• Medicaid recipients who must participate in STAR+PLUS: SSI adults who are not:
• Residing in a Nursing Facility or other institution.• Being served through a Home and Community Based Waiver
program other than Community Based Alternatives (CBA). Non-SSI adults who qualify for 1915(c) Nursing Facility Waiver
services must enroll in STAR+PLUS to receive those services.
• Medicaid recipients who can choose to participate in STAR+PLUS: SSI children, under age 21, may voluntarily enroll in
STAR+PLUS. SSI children that do not volunteer will be in traditional Medicaid effective March 1, 2012.
Page 11
Managed Care vs. FFS
FFS State operated plan.Providers are contracted directly with state.Providers paid fee-for-service (FFS) rates.
Managed careProviders must contract and be credentialed with the
health plan to provide services.Rates are negotiated between the provider and the MCO
or DMO.
Page 12
PCCM vs. Managed Care Organizations
Primary Care Case Management (PCCM)State operated plan.Providers are contracted directly with state.Members assigned PCP, but can see any Medicaid specialist.Providers paid fee-for-service (FFS) rates.
Medicaid Managed Care Organizations Providers must contract and be credentialed with the
MCO to provide STAR services.Rates are negotiated between the provider and the MCO.
Significant Traditional Providers
• Significant Traditional Provider (STP) requirements relate to providers that have been providing services to Medicaid clients in some service areas.
• MCOs are obligated to offer STP contractors the opportunity to be a part of the contracted MCO provider network.
• MCOs will reach out to contact STPs; however, STPs may initiate the contact.
• STP providers must accept MCO conditions for contracting and pass credentialing.
Public Health Coordination
• The MCO must make good faith effort to enter into a subcontract for covered services with public health entities.
• Services covered by public health entities may include: Sexually transmitted diseases Confidential HIV testing Immunizations Tuberculosis care
MCO Contract Requirements: Immunizations
• MCOs must educate providers on the following: Standard requirements in
• Chapter 161 of the Health and Safety Code• ACIP Immunization Schedule• AAP Periodicity schedule for CHIP members• Texas Health Steps Periodicity schedule for Medicaid members.
The screening provider is responsible for administration of immunizations and should not refer children to local health departments for immunizations.
Compliance with ImmTrac requirements, including parental consent on
the Vaccine Information Statement.
Page 16
Enrollment Broker
• Client Welcome letters/FAQs:
• Dental – September 2011• Medical – November 2011
• Client Enrollment packets:• Dental – November 2011• Medical – December 2011 through January 2012
• Clients must enroll by February 10, 2012 or the state will assign a plan and main doctor.
Page 17
Enrollment Broker
• Enrollment Options• Fill out the forms and mail them back.• Call the Help Line and sign up by phone.
1-800-964-2777• Attend a client outreach and enrollment event.
• Client outreach and enrollment events – November 2011 through February 2012
• www.txmedicaidevents.com
Page 18
Managed Care Operations
HHSC Managed Care Operations monitors the HMO performance quarterly for these key indicators:
Network Adequacy Claims Processing timeHotline PerformanceComplaint processing
Additional contract requirements and performance isalso monitored on ongoing basis.
Page 19
Provider Complaints
• Initial point of contact is MCO or dental plan
• May submit written complaint to HHSC at [email protected]
• HHSC will intervene in issues when MCO is not complying with HHSC contract
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Resources Resources
• HHSC Managed Care Proposals Webpage:http://www.hhsc.state.tx.us/medicaid/mmc.shtml
• TMHP Website:http://www.tmhp/Pages/PCCM/PCCM_Home.aspx
• Email:[email protected] [email protected]
Questions?