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Medicaid Managed Care Programfor the Elderly and Persons with Disabilities
Pamela ColemanTexas Health and Human Services Commission
January 2003
WHAT IS STAR+PLUS?
A Managed Care Systemfor the SSI & SSI-RelatedPopulation
Integrates Medicaid fundingand service delivery of LongTerm and Acute Health Care
Medicare members onlyenrolled for LTC services
STAR+PLUS Objectives
Integrate Acute & Long Term Care into Managed Care System
Provide the Right Amount & Type of Service to Help People Stay as Independent as Possible
Serve People in the Most Community-based Setting Consistent with their Personal Safety
Improve Access and Quality of Care
Increase Accountability for Care
Improve Outcomes of Care
Control Costs
STAR+PLUS - 1915(b) and (c)
1915(b) - Waives freedom of choice to allow mandatory participation
1915(c) - Allows additional services for 1915© waiver eligibles
- Encourages HMOs to add waiverservices as value added services
- Provides more alternatives
STAR+PLUS Eligibility
Mandatory Participation: HMO SSI-eligible (or would be except for COLA) clients age
21 and over
MAO clients who qualify for the Community Based Alternatives (CBA) waiver
Clients who are Medicaid-eligible because they are in a Social Security exclusion program
Is STAR+PLUS Mandatory?
If you are in a required group You must enroll in a STAR+PLUS Plan for
Medicaid services
Medicare services may be obtained through the provider of choice
Enrollment Broker
New Medicaid Clients
Enrollment Broker Contacts Clients by:
Telephone, Mail, In-person
STAR+PLUS Services
Primary, Preventive and Acute Care (Doctor, Hospital, Lab, X-ray)
Mental Health & Substance Abuse Services
Personal Care Services
Adult Day Health Services
Nursing Facility Services
Care Coordination Waiver Services (therapy, respite, adult foster care, assisted living, adaptive
equipment, in-home modifications)
Value-added Services (adult dental services, waiver services for non-waiver clients)
HARRIS COUNTY Estimated STAR+PLUS Clients FY’01
Healthy Clients74%
Nursing Facility 10%
Community Care11%
CBA4%
Nursing Facility
CBA
Community Care
No LTC Service
`
CARE COORDINATION
HMO have care coordinators, nurses and social workers, available to all members
Care coordinators makes home visit and assesses members needs
Care coordinators authorize community based LTC services. Arrange for other
services
Risk Group Medicaid Only
Capitation
Number of Enrollees
Dual Eligible Capitation
Number of Enrollees
Community Clients
$608.43 22396 $128.77 26230
CBA Waiver Clients
$2,917.06 469 $1,294.50 1505
Nursing Facility Clients
$608.43 8 $128.77 34
As of January 1, 2003
STAR+PLUS Capitation Payments
EVALUATION CRITERIA
Consumer SatisfactionIntegration of CareAccess to CareQuality of CareEmphasis of Community
Based CareImpact on BudgetImpact on Providers
Utilization Analysis
Personal Assistance Services use is 32 % higher than FFS projected.
The Community Based Alternatives program increased almost 119 percent in Harris County, but only 3.4 percent statewide.
Utilization of new generation medications by people with serious mental illnesses increased both statewide and in Harris County, but the Harris County increase did not occur until the implementation of STAR+PLUS.
Inpatient hospital utilization decreased for this population.
Unique Members Receiving Personal Attendant Services
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
STAR+PLUS
Unique Members Receiving DAHS Services
0
200
400
600
800
1000
1200
Sep-
00
Oct
-00
Nov
-00
Dec
-00
Jan-
01
Feb-
01
Mar
-01
Apr-
01
May
-01
Jun-
01
Jul-0
1
Aug-
01
Sep-
01
Oct
-01
Nov
-01
Dec
-01
Jan-
02
Feb-
02
Mar
-02
Apr-
02
May
-02
Jun-
02
Jul-0
2
STAR+PLUS
Dual Eligible Members Receiving CBA Services
0
200
400
600
800
1000
1200
1400
Sep
-00
Oct
-00
Nov
-00
Dec
-00
Jan-
01
Feb-
01
Mar
-01
Apr
-01
May
-01
Jun-
01
Jul-0
1
Aug
-01
Sep
-01
Oct
-01
Nov
-01
Dec
-01
Jan-
02
Feb-
02
Mar
-02
Apr
-02
May
-02
Jun-
02
Jul-0
2
STAR+PLUS
Medicaid Only Members Receiving CBA Services
0
100
200
300
400
500
600
Sep-
00
Oct
-00
Nov
-00
Dec
-00
Jan-
01
Feb-
01
Mar
-01
Apr-
01
May
-01
Jun-
01
Jul-0
1
Aug-
01
Sep-
01
Oct
-01
Nov
-01
Dec
-01
Jan-
02
Feb-
02
Mar
-02
Apr-
02
May
-02
Jun-
02
Jul-0
2
STAR+PLUS
Nursing Home Members
0
10
20
30
40
50
60
Sep-
01
Oct
-01
Nov
-01
Dec
-01
Jan-
02
Feb-
02
Mar
-02
Apr-
02
May
-02
Jun-
02
Jul-0
2
STAR+PLUS
LTC Provider Satisfaction
Tended to be more dissatisfied than neutral or satisfied in the areas of Accuracy of claims payments Timeliness of claims payments Amount of phone work
Those with more FFS experience reported lower satisfaction than those with less
Consumer Satisfactiondisabled/under 65/ n= 238
88% of respondents reporting knowing how to reach someone in their health plan
76% reported that it was easy to get help from their care coordinator
75% of respondents experienced no problem getting the home health or attendant care they needed
80% reported being satisfied or very satisfied with how the care coordinator explained information.
53% reported being included in the decision making about their services.
Consumer Satisfaction*aged/over 65/ n=109
86% of respondents reporting knowing how to reach someone in their health plan
93% reported that it was easy to get help from their care coordinator
85% of respondents experienced no problem getting the home health or attendant care they needed
89% reported being satisfied or very satisfied with how the care coordinator explained information.
77% reported being included in the decision making about their services.
*separate survey results
CASE HISTORY
STAR+PLUS CLIENT
58 Year Old Male with past history of
Congestive heart failure
Atrial Fibrillation
Morbid Obesity
Childhood Polio
CLIENT’S HEALTH ISSUES
Multiple Disease Process
Patient’s Limitations to move within
his environment due to his weight
Living Environment
Inability of Family to Provide Care
Possibility of Placement in a Nursing Home
CARE COORDINATION INTERVENTIONS
Caregiver Provider in Home
Home Visits by Primary Care Physician
Hostel Bed and Trapeze
Skilled Nursing
CLIENT OUTCOME
Member’s Ability to Maintain his Independence
Loss of Almost 200 lbs.
Improvement in Quality of Life
Opportunities
Early Intervention
Disease Management
Care Coordination Home visits Integration of care
Flexibility in service delivery
Lessons Learned Care Coordination is the key to integration of acute
and LTC services Challenges coordinating care for dual eligibles
when HMOs are only responsible for LTC Education of all providers and stakeholders is key Increase in administrative complexity caused
provider dissatisfaction Collaboration between competing HMOs and State
is an essential piece of successful model
Recommended