Texas STAR+PLUS ProgramManaging Integrated Acute & Long Term

Services and Supports

Erica Stick, Texas Health & Human Services CommissionOctober 5, 2012

Topics• History of STAR+PLUS• What is STAR+PLUS?• Who does STAR+PLUS Serve?• What are STAR+PLUS Services?• How are Services Delivered?• Member Benefits• Complaints & Appeals• MCO Responsibilities

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History• In 1995, the Texas Legislature implemented the State of

Texas Access Reform Plus (STAR+PLUS) program to create a cost-neutral managed care system which would combine acute care as well as long-term services and supports.

• The first STAR+PLUS pilot began operation in 1998 in Harris County.

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History• Today, Texas operates Medicaid managed care

programs in 13 Service Delivery Areas (SDAs) across the state.

• STAR+PLUS exists in 10 of the 13 SDAsJust over half of our total Aged and Disability-Related Medicaid Clients will receive their services through STAR+Plus in FY 2013

This is up from around one-quarter in FY 2009.Currently in urban areasPlans to expand to rural areas

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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

Sterling Coke Runnels

Concho

Coleman

Taylor Callahan

Bell

Blanco

KendallComal

Gillespie

Llano

Travis

Hays

Caldwell

BurnetWilliamson

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

VictoriaGoliad

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

CampMorris Cass

San Augustine

FanninCooke Grayson

Delta

Lamar Red River

Bowie

BexarAmerigorup, Molina,

Superior

LubbockAmerigroup, Superior

HarrisAmerigroup,

Molina, United

El PasoAmerigroup, Molina

DallasMolina, Superior

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

HidalgoHealtlhSpring, Molina,

Superior

JeffersonAmerigroup, MoliUnited

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What is STAR+PLUS?• STAR+PLUS is a capitated health maintenance

organization (HMO) model for Medicaid clients with disabilities and dual eligible clients (have Medicaid and Medicare):

Integrates acute and long term services and supports (LTSS).Operates under authority of a federal waiver.

• Goal: Achieve a seamless continuum of care by integrating acute and long-term services and supports (LTSS) in a managed care environment.

Promotes delivery of home and community-based services.

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Who Does STAR+PLUS Serve?• SSI adults participate in STAR+PLUS, if they are:

Not in a nursing facility or other institution. Not currently being served through a Home and Community Based Waiver program, EXCEPT for Community Based Alternatives (CBA).

SSI adults who are in CBA participate in STAR+PLUS.

• Non-SSI adults who qualify for 1915 (c) Nursing Facility Waiver services participate in STAR+PLUS in order to receive those services.

• SSI children, under age 21, may voluntarily enroll in STAR+PLUS.

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What Services DoesSTAR+PLUS Provide?

• Clients who are Medicaid-only receive all acute and LTSS services through STAR+PLUS

• Clients with Medicaid and Medicare receive acute care services, including prescription drugs, from Medicare. These clients are called “dual eligible” clients.

Dual eligible clients can see any Medicare providers they choose.

Medicaid provides some services to help cover treatment if Medicare does not cover it completely; these are called “wrap-around services”.

Medicaid provides LTSS to dual eligible clients who need them.

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What Services Does STAR+PLUS Provide?• Personal Attendant Services (PAS) – both Primary Home Care

(PHC) and Community Based Alternatives (CBA) Personal Assistance Services.

• Day Activity and Health Services (DAHS).

• STAR+PLUS Waiver – those services provided through CBA in traditional Medicaid:

Home delivered meals Nursing servicesMedical SuppliesAdult Foster CareDentalTherapiesConsumer directed

services option

Assisted livingAdaptive aidsMinor home modificationsPersonal assistance servicesRespite CareEmergency responseTransition assistance services Page 9

How are Services Delivered?

• The State contracts with five Managed Care Organizations (MCOs)- also known as HMOs- to coordinate and deliver services in 10 areas of the state

State pays a monthly capitated per member per month premium for each enrolled member.HMOs are at risk for service levels that exceed capitated premium.There must be at least two MCOs in a service area to give members a choice.

• MCOs are responsible for coordinating acute and LTSS through the use of a service coordinator.

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How are Services Delivered?

• Service Coordinators are responsible for:Formulating an individualized plan covering acute and LTSS.Overseeing smooth transition from acute care to LTSS.Making home visits and assessing members’ needs:

Authorizing community LTSS.Arranging acute care services.

• STAR+PLUS Medicaid-only members can choose or be assigned a primary care provider (PCP).

• Service Coordinators are required to coordinate as needed with the Medicare physician, member and other service providers.

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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.

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Complaints & AppealsMembers • MCOs must have a grievance and appeals process in which members can

make inquiries or file complaints. • Members may also file for a Fair Hearing with the State of Texas.

Providers• MCOs serve as initial points of contact for provider complaints.

Appeals, grievances or dispute resolution is the responsibility of each MCO. Providers must exhaust the complaints or grievance process with their managed care HMO before filing a complaint with the State.

• Medicaid managed care providers may file complaints with the State if they find they did not receive full due process from the respective managed care health plan.

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MCO ResponsibilitiesThe MCOs contracted to deliver STAR+PLUSservices are responsible for:• Recruiting and maintaining an adequate network of providers• Adjudicating and paying provider claims

Contract requires 98% of all clean claims to be paid in 30 days or less (average is 14 days for existing HMOs)

• Serving as point of contact for any member assistance.All members must be contacted after enrollment and at least twice annually, and informed of available services

• Service Coordinators who assess need for LTSS services and help coordinate all care

Responsible for all functional assessments• Authorizing (when appropriate)and coordinating delivery of

services Page 14