This summary contains supplemental information from third-party sources where that information provides clarity to the issues being discussed. Not every comment or statement from the speakers in these summaries is an exact transcription. For the purpose of brevity, their statements are often paraphrased. These documents should not be viewed as a word-for-word account of every meeting or hearing, but a summary. Every effort has been made to ensure the accuracy of these summaries.
Meeting Summary
The State Medicaid Managed Care Advisory Committee provides recommendations and ongoing input to HHSC on the statewide implementation and operation of Medicaid managed care. The committee looks at a range of issues, including program design and benefits, systemic concerns from consumers and providers, efficiency and quality of services delivered by Medicaid managed care organizations, contract requirements for Medicaid managed care, provider network adequacy, and trends in claims processing.
The committee also will help HHSC with policies related to Medicaid managed care and serves as the central source for stakeholder input on the implementation and operation of Medicaid managed care.
Introduction
The meeting was called to order by the Chair, Sandy Klein. It was the 7th meeting of the advisory committee. The minutes from the meeting on March 14, 2018, were adopted as written.
Members:
| Sandy Klein, San Antonio Chair Representing: Long-term Services and Supports Providers Including Nursing Facility Provider and Direct Service WorkersDeanna Abraham, Wortham Representing: Recipients with Disabilities Including Recipients with an Intellectual or Developmental Disability or with Physical Disabilities, or Consumer Advocates Representing Those Recipients. Michael Adams, Tyler John Asbury, M.D.,Temple Chase Bearden, Austin Fabian Borrego, Edinburg Troy Carter, Sugar Land Laura Deming, Richmond
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Anne Dunkelberg, Austin Representing: Low Income Recipients or Consumer Advocates Representing Low Income RecipientsJohnny Gore, Denton Representing: Managed Care Organizations and Participating Health Care Providers Janice Fagen, San Antonio Soad Michelsen, M.D., San Antonio Paula Robinson, Houston Michelle Schaefer, Sonora David Weden, Austin
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Policy issues and Meeting Highlights
The Advisory Committee Adopted the minutes and reviewed committee by-laws then received information regarding:
- A general overview of the current state of affairs for Medicaid. This presentation was a repeat of a presentation made to the House Committee on Human Services from May 9th.
- Regarding the IDD carve-in, by September 2020 the Texas Home Living (TxHML) is to be transitioned to managed care taking into account previous transitions. HHSC can transition some or all of the services under the waiver. Then the rest of the IDD waivers are to be transitioned by September 1, 2021. Recognizing that they did not implement the pilot HHSC is contracting for a full evaluation. DeLoitte will look at the cost-effectiveness piece and UT will be focusing on qualitative analysis of programs at other states and past Texas transitions of the IDD population.
- Subcommittees gave brief reports and the timeline for the required report was presented to the members. The report will be finalized and approved at the December 12th
- Public comment verified that there are still issues related to access to care for therapies and there was a request that the Committee look at the 75-mile distance requirement for nursing facilities since that impacts families and their ability to visit their loved one.
Resolutions and Meeting Conclusion
There will be a conference call for the bylaws and subcommittee job descriptions for IDD will be sent out. The amount of denials will be provided for the next meeting. Collecting and reporting of waiting lists should be provided. HHSC stated that it will be important to be very clear about what information they want related to denials. There being no further business, the meeting was adjourned.
Re-adoption of Committee Bylaws. A question was raised by the committee about why the by-laws were being changed. Mr. Chacon, HHSC, stated that the intent is to standardize by-laws across committees. There was also the need to spell out the roles and responsibilities of subcommittees. Also, the inclusion of subject matter experts was addressed in the new by-laws. It also spells out the roles and responsibilities of the chair and vice chair. Additional changes addressed:
- Correct references to statute
- Nonsubstantive changes made for clarity
- Membership was clarified to be 23 members
- Membership term ends August 31 of each year (staggered) — applying to new members
- Interim chair allowed
- Committee elects the presiding officers
- Committee operations and meetings including quorum requirements (a majority of members)
- Expands conflict-of-interest provisions to include family member benefit
- Only requirement for a 2/3rds vote relates to by-law changes, all else is a majority
- Removal from the committee provisions are new
- Subcommittee provisions are provided
- Clarification of subject matter experts
- The Committee added HHSC staff attendance at subcommittees requirement
- Subcommittees must be recorded also
(Since 2/3rds of members — 10 — are not present, the bylaws cannot be approved.)
General managed care (PDF) – Michelle Erwin made the presentation. The Medicaid Director could not be present. The committee had requested the same information provided to the House Human Services Committee on May 9th. There is a shared goal across stakeholders with different roles in supporting the goal.
Regarding network adequacy and access to care (across all programs), there are distance and travel time standards. This tells MCOs these requirements for the referenced provider types. Distance and time doesn’t always make sense for some providers so they are thinking about including a requirement of two providers in any county, but this is not in effect yet. The requirements in the chart will have monetary damages associated with failure to meet the standards. At first, the standard will be 75% and then 90%.
Q: When do the corrective action plans that are required go into effect after an infraction is discovered? A: There is not a specific timeframe. It depends on the actions to be taken.
Long-Term Services and Supports (LTSS) and Pharmacy standards proposed to be implemented in the September 2018 managed care contracts. Metro = county with a pop. of 200,000 or greater, Micro = county with a pop. between 50,000-199,999, Rural = county with a pop. of 49,999 or less.
Oversight requirements include:
- Quarterly monitoring process using provider reconciliation files and member eligibility files. No longer using Managed Care Organization (MCO) self-reported data.
- MCOs who do not meet 75% compliance with standards will be issued a corrective action plan (CAP).
- In January 2019, this requirement will increase to 90% compliance and issuance of both CAPs and liquidated damages (LDs).
- Implemented Provider Directory requirements in the Spring of 2016.
Health plan report cards ensure quality by addressing measures important to members. Four key areas are graded:
- Overall health plan quality
- Experience with doctors and the health plan ̵
- Staying healthy
- Controlling chronic disease
Ratings by plan based on member surveys and health quality measures providing transparency for members when selecting or changing plans. HHSC is trying to improve the report calls so they will be more helpful with people making decisions.
Q: What is the strength of the system right now across the state? A: HHSC will check with the quality team to see what data is available.
Regarding STAR Kids, SB 7 (83R), 2013, directed HHSC to “establish a mandatory STAR Kids capitated managed care program tailored to provide medical assistance benefits to children with disabilities.” Other requirements include:
- Integrate with a nurse advice line
- Use an identification and stratification method to identify recipients who have greatest need for services
- Provide a holistic, comprehensive care needs assessment
- Deliver services through multidisciplinary care teams located in different geographic areas and have in-person contact
- Identify immediate interventions for transition of care
- Include monitoring and reporting outcomes
- Incorporate the Medically Dependent Children Program (MDCP) waiver program
The STAR Kids program goal is to ensure quality and cost-effectiveness through:
- Providing customized medical assistance benefits,
- Better coordinated care,
- Improving health outcomes,
- Improving access to health care services,
- Achieving cost containment and cost efficiency,
- Reducing the administrative complexity of delivery, and
- Reducing the incidence of unnecessary institutionalizations and potentially preventable events.
STAR Kids Program: Implementation Progress
MCOs voluntarily extended continuity of care for Primary Care Physicians and specialists through October 31, 2017.
We are now in the phase of continuous improvement and ongoing oversight.
Continuous improvement focuses on three core areas:
One area of discussion has been the New Service Assessment Tool.
Prior to SB 7 (83R), there was a recognized need for a tool tailored for children. HHSC contracted with Texas A&M University (TAMU) Health Science Center to determine if a proper tool existed, and if not, build and test one. Multi-phase project with 3 years dedicated to development, testing, and revisions. The testing phases included stakeholder input and review. There were two reports published related to the reliability of the tool.
Q: Do the families get a copy of the individual service plan? A: They should be receiving one from the MCOs. A requirement for providing the plan to families is being added to the MCOs’ requirements.
Q: Does the tool provide [information pertaining to] why a denial of medical necessity may occur? A: it may not be in the tool but it is part of the appeal and fair hearings process.
Q: Has HHSC looked at utilization data and denials since the tool was implemented? A: HHSC has looked at PDN, personal care services and therapies and that information can be provided to this committee.
Q: What [information] should be provided for a fair hearing? A: Why a person was denied under medical necessity and other reasons. MCOs will provide specific information related to denials and this requirement is spelled out in the Medicaid Managed Care Manual.
Q: We need to know the process in the event that the information was not provided to the family so they can use it for a fair hearing. A: The hearing officer is responsible for ensuring the documents were provided and the timeframes under which they were provided prior to the hearing. The hearing officer has a range of options.
Ongoing improvements for SK-SAI tool
Supported by ongoing training refinements, manual updates, policy clarifications, and public education.
Service Coordination.
| Pre-implementation
Readiness Reviews
MCOs had to show appropriate number of service coordinators were trained and ready.
20% of the service coordinators were interviewed for training and knowledge regarding program and contractual requirements. Information is shared with the MCOs
Daily, weekly, bi-weekly, and monthly calls were held with MCOs to discuss staffing and other issues. |
Post implementation
Operational Review
• On-site review of the number of service coordinators and caseloads. • 20% are interviewed for training and knowledge regarding program and contractual requirements. • Targeted reviews as needed based on any observed complaint trends
STAR Kids Stakeholder Workgroup (August 2017) • MCOs discussed service coordination structure and turnover. • Reported between 10 – 30% turnover (but was leveling out after initial implementation). • Changes to coordinators can happen due to balancing of caseloads.
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Complaints Resolution and Improvements.
Initially, there was not a complaint process for STAR Kids separate from other processes. Now there is a separate complaint process. The ombudsman will also be monitoring complaints.
SB 7 (83R): Future Implementation. There will be additional carve-in milestones for persons with Intellectual and Developmental Disabilities (IDD).
Activities underway include:
- To be completed by 2019 legislative session: Deloitte and University of Texas School of Public Health-Houston are evaluating various topics and reporting to inform IDD LTSS transition to managed care.
- To be completed by Summer 2018: HHSC and IDD System Redesign Advisory Committee developing implementation recommendations for the TxHmL carve-in.For additional STAR Kids information click on this link.
For the complete presentation, including appendices click on this link.
Q: Is the technology in place to be able to manage the oversight that is needed? A: There are opportunities for improvements still. The portal will provide more ready access to data for oversight. Until we see what the portal looks like it would be difficult to say what additional technology will be needed.
C: A member had concern that the MCOs generate good policies but fail to address where the gaps are.
Intellectual and developmental disabilities carve-in. Michelle Erwin made the presentation. HHSC has been working with the IDD Redesign Advisory committee to address next steps for IDD. There is a requirement in the Government Code that HHSC design and implement a system for people with IDD that is efficient, person-centered, effective and cost-effective. The redesign started in 2014. People with IDD were put in waivers. The statute allowed a pilot program but the pilot was not attempted due to a number of factors. There will be contracts for evaluation. The next step is to move the waiver service in an incremental approach. By September 2020, the Texas Home Living (TxHML) is to be transitioned to managed care taking into account previous transitions. HHSC can transition some or all of the services under the waiver.
The rest of the IDD waivers are to be transitioned by September 1, 2021. Recognizing that they did not implement the pilot they are doing a full evaluation. DeLoitte will look at the cost-effectiveness piece and UT will be focusing on qualitative analysis of programs at other states and past Texas transitions of the IDD population. Also, an analysis of community first choice and service coordination.
Q: Will this eliminate the HCS waitlist? A: There is not an expectation [that] that will occur. It would take more slots which would require legislative direction.
Because of the dates in the Government Code, actions and decisions are having to be made while the evaluation is still going on.
Q: Is the UT contract and scope of work available? A: HHSC will check to see if it is online.
Q: Have you thought of going to the list of people who have contacted the ombudsman to know who to interview to see what their experience has been? A: That would be a good thing to do.
HHSC has also been working out stakeholder input process and will want to work with this group in that regard. Texas Home Living has been operating under a comprehensive service provider. This is different from how managed care works and will have to be addressed in the transition. The survey and certification and other processes of TxHML have to be reviewed to see what they will look like under the transition. They are pulling together all the different advisory committees for input. HHSC said they want to designate a liaison from this committee to a subcommittee of the IDDSRAC.
Subcommittee reports:
Subcommittee on Goal 1 (Provide Health and Human Services Commission (HHSC) leadership with an accurate and balanced view of both challenges and opportunities identified in the Medicaid managed care delivery system, and offer innovative and operationally practical solutions). The subcommittee has met three times since the last full committee meeting. HHSC is now doing the network adequacy and they have used the data to review the status of network adequacy. They reviewed the recent telehealth and telemedicine rules. There was discussion about the centralized credentialing process and whether there was a way to use it to verify the networks that are in place as opposed to self-reporting. The looked at the MCO report card and the new portal. The reviewed the behavioral health issues and the external quality review process. They discussed the possibility of Aperture (vendor doing centralized credentialing) feeding some of the information directly because there have been issues in verifying the information.
Q: What surveys were reviewed? A: There are about ten different reviews and the surveys are very extensive.
There have been issues identified that parallel the issues raised by the Dallas Morning News. We will be looking at the coordination between managed care and private insurance. They will also look at processes for resolving problems and coordination of benefits when MCOs use a carve-out behavioral health organization. They are looking at clinician time spent doing non-patient direct care, especially because we have a shortage of some clinicians
Subcommittee on Goal 2 (Develop sound recommendations that directly affect Medicaid managed care clients by prioritizing quality health outcomes, patient safety, and fiscal responsibility in the delivery of programs and services). The subcommittee started with a broad range of topics that included service coordination, and the development of recommendations.
Subcommittee on Goal 3 (Advise HHSC on activities related to ensuring clients or members are receiving timely care coordination for medically and functionally necessary services across all Medicaid managed care programs. This will include recommendations for continuous collaborative communication between HHSC, managed care organizations, members, and providers, as well as for the rapid resolution of eligibility and enrollment issues). The Committee Chair had resigned and they are still in the process of getting the committee working.
Committee structure, committee and subcommittee priorities (PDF). The committee talked about the timelines for the committee report.
Mr. Bredwell stated that he would like to have – by August 1 – the schedule for the subcommittees since staff are required to attend.
There was open discussion about the direction the Committee is moving. This was to be the overarching committee looking at managed care in Texas. Comments from the Committee follow:
- When you look at what we were designed for and the issues we were to engage, some other advisory committees are also looking at the same things.
- This committee has stepped down a level and is not performing efficiently. There is, indeed, overlapping with work of other committees.
- We can get a list of the issues of other committees.
- HHSC stated that the minutes can be shared from other committees. There are numerous advisory committees.
- Is the current structure working? The structure is broad and if it should change, how should that occur?
The liaison to the IDD committee will be decided after the meeting when the subcommittee information is sent out to members.
Public comment.
Vicki Gilani, Speech language therapist stated that the average wait time is 5 months and for PT it is 9 months. The MCOs have been tasked with tracking waitlists but they have never been contacted by an MCO. Denials have tripled. It is an MCO financial conflict of interest when denials or delays are experienced. On May 1, HHSC released guidance related to delays. MCOs are still continuing with their current practices and using their own prior authorization process. Children are also not receiving denial letters though the services have been denied. There should be procedures and fines when MCOs act poorly.
David Reimer, Avianne Health Care Systems commented about the STAR Kids program and letters of denial requirements. The assessment is designed to provide data for medical necessity and it is HHSC that makes the determination. It is a tool to see if the family can benefit from the services. Denial of services has impacted them by 126,000 hours of care under STAR Kids. There are some problems that are still having to be addressed.
Dorothy Crawford, Texas Health Care Association thanked the Committee for their work. She stated that 75 miles requirement is used for nursing facilities. She asked the committee to revisit the distance for nursing facilities. That distance will impact the ability for families to visit their loved ones. Ms. Erwin asked what the Medicare mileage was and it was believed to be the same (75 miles).
Adjournment. There will be a conference call for the bylaws and subcommittee job descriptions for IDD will be sent out. The amount of denials will be provided for the next meeting. Collecting and reporting of waiting lists should be provided.
HHSC stated that it will be important to be very clear about what information they want related to denials.
There being no further business, the meeting was adjourned.
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