Read Overview_of_Managed_Care_in_Texas_2011-2012_updated_0920.pdf text version

August 2011

TEXAS ASSOCIATION OF COMMUNITY HEALTH CENTERS, INC. 5900 SOUTHWEST PARKWAY, BUILDING 3 AUSTIN, TX 78735 PH (512) 329-5959 FAX (512) 329-9189

Overview of Managed Care in Texas Several important changes have recently taken place that will affect your center in the delivery of Medicaid and CHIP services statewide. First, beginning in September 2011, the STAR and STAR+PLUS managed care programs will begin a first wave of expansions as current service areas encompass new counties. By March 2012, STAR+PLUS will expand to all Medicaid managed care areas except the Medicaid Rural Service Areas ("MRSAs"), and STAR will roll out to all remaining counties in the state. PCCM will be phased out completely as of March 2012. If your center does not have a contract with Managed Care Organizations ("MCOs") for Medicaid, CHIP, Dental, and STAR+PLUS (where applicable), you will not be able to provide medical or dental services to Medicaid or CHIP patients. Second, the state recently underwent a renegotiation of most of its managed care contracts.1 Most service areas will see changes in MCOs under the new contracts and will have new health plans operating in their areas. Charts listing all MCOs contracted for each product in each service area, both effective September 2011 and March 2012, are included below for your reference. These changes will mean new contracts for many centers. Even if your center does not see a change in MCOs you are contracted with, you will at least receive contract amendments regarding changes in managed care regulations, primarily that the MCOs are now responsible for paying the center encounter rate.2 More details on changes in the Medicaid/CHIP managed care programs and resources for additional information are included at the end of this document. Centers should note that some MCOs subcontract out portions of their services (for example behavioral health or vision care) to subcontractors. Centers may have to contract separately with these subcontractors and should determine this from the MCOs operating in your area. Note that the charts below do not include any subcontractors.

1

See http://www.hhsc.state.tx.us/contract/529120002/RFP/Section-1.pdf for the RFP that was the backdrop for these new negotiations. Each component of the expansion is also explained here. 2 The MCO used to pay the prevailing rate and the state would make a wraparound payment to the center to reimburse it for 100% of its costs as reflected in its PPS rate.

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August 2011

Medicaid and CHIP Products and MCOs as of SEPTEMBER 1, 2011 Service Area (Red indicates a new county/new service area) Bexar: Atascosa,

Bandera, Bexar, Comal, Guadalupe, Kendall, Medina, Wilson Dallas*: Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, Rockwall STAR Medicaid STAR+PLUS Medicaid CHIP STAR Health Medicaid

Aetna, Community First, Superior Amerigroup, Parkland, UniCare El Paso First, Superior Amerigroup, Community Health Choice, Molina, Texas Children's, United Amerigroup, Community Health Choice, Molina, Texas Children's, United FirstCare, Superior

Amerigroup, Molina, Superior Molina, Superior (effective 02/11)

Aetna, Community First, Superior Amerigroup, Parkland, UniCare El Paso First, Superior Amerigroup, Community Health Choice, Molina, Texas Children's, United Amerigroup, Community Health Choice, Molina, Texas Children's United FirstCare, Superior

Superior

Superior

El Paso: El Paso,

Hudspeth Harris: Austin, Brazoria, Fort Bend, Galveston, Harris, Matagorda, Montgomery, Waller, Wharton

Superior Superior

Amerigroup, Evercare, Molina

Jefferson: Chambers,

Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler, Walker

Amerigroup, Evercare, Molina

Superior

Lubbock: Carson,

Crosby, Deaf Smith, Floyd, Garza, Hale, Hockley, Hutchinson, Lamb, Lubbock, Lynn, Potter, Randall, Swisher, Terry Nueces: Aransas, Bee, Brooks, Calhoun, Goliad, Jim Wells, Karnes, Kenedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio, Victoria Tarrant: Denton, Hood, Johnson, Parker, Tarrant, Wise

Superior

Amerigroup, Driscoll, Superior

Evercare, Superior

Amerigroup, Driscoll, Superior

Superior

Travis: Bastrop, Burnet,

Caldwell, Fayette, Hays, Lee, Travis, Williamson

Aetna, Amerigroup, Cook Children's Amerigroup, Superior,

Amerigroup, Bravo (effective 02/11) Amerigroup, Evercare

Aetna, Amerigroup, Cook Children's Seton, Superior

Superior

Superior

2

August 2011 *The NorthSTAR behavioral health program operates in this service area. Centers should contract with ValueOptions, the behavioral health organization that manages NorthSTAR. Note that all counties not listed above will continue under PCCM for Medicaid beneficiaries (through TMHP) and CHIP RSA for CHIP beneficiaries (with Superior and Molina) until March 2012. Medicaid and CHIP Products and MCOs as of MARCH 1, 2012 Service Area (Red indicates a new service area) Bexar: Atascosa,

Bandera, Bexar, Comal, Guadalupe, Kendall, Medina, Wilson STAR Medicaid STAR+PLUS Medicaid CHIP Medicaid and CHIP DENTAL STAR Health Medicaid

Dallas: Collin, Dallas,

Ellis, Hunt, Kaufman, Navarro, Rockwall

Aetna, Community First, Superior, Amerigroup Amerigroup, Parkland, Molina El Paso First, Molina, Superior Amerigroup, Community Health Choice, Molina, Texas Children's, United Driscoll, Molina, Superior, United Amerigroup, Community Health Choice, Molina, Texas Children's, United Amerigroup, FirstCare, Superior

Amerigroup, Aetna, Molina, Superior Community First, Superior, Amerigroup Molina, Superior Amerigroup, Molina, Parkland Amerigroup, Molina Amerigroup, Molina, United El Paso First, Superior

Delta Dental, DentaQuest, MCNA Delta Dental, DentaQuest, MCNA Delta Dental, DentaQuest, MCNA Delta Dental, DentaQuest, MCNA

Superior

Superior

El Paso: El Paso,

Hudspeth

Superior Superior

Harris: Austin,

Brazoria, Fort Bend, Galveston, Harris, Matagorda, Montgomery, Waller, Wharton

Hidalgo: Cameron,

Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy, Zapata Jefferson: Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler, Walker

Amerigroup, Community Health Choice, Molina, Texas Children's, United Health Spring, Molina, Molina, Superior Superior

Delta Dental, DentaQuest, MCNA Delta Dental, DentaQuest, MCNA

Superior

Amerigroup, Molina, United

Lubbock: Carson,

Crosby, Deaf Smith, Floyd, Garza, Hale, Hockley, Hutchinson, Lamb, Lubbock, Lynn, Potter, Randall, Swisher, Terry Nueces: Aransas, Bee, Brooks, Calhoun, Goliad, Jim Wells,

Amerigroup, Superior

Amerigroup, Community Health Choice, Molina, Texas Children's United FirstCare, Superior

Superior

Delta Dental, DentaQuest, MCNA

Superior

Christus, Driscoll,

Superior, United

Christus, Driscoll,

Delta Dental, DentaQuest,

Superior

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August 2011

Karnes, Kenedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio, Victoria Tarrant: Denton, Hood, Johnson, Parker, Tarrant, Wise

Superior

Superior

MCNA

Travis: Bastrop,

Burnet, Caldwell, Fayette, Hays, Lee, Travis, Williamson MRSA* Central: Bell, Blanco, Bosque, Brazos, Burleson, Colorado, Comanche, Coryell, DeWitt, Erath, Falls, Freestone, Gillespie, Gonzales, Grimes, Hamilton, Hill, Jackson, Lampasas, Lavaca, Leon, Limestone, Llano, Madison, McLennan, Milam, Mills, Robertson, San Saba, Somervell, Washington

Aetna, Amerigroup, Cook Children's Superior, Seton, BCBS, Sendero Amerigroup, Scott & White, Superior

Amerigroup, Bravo Amerigroup, United

Aetna, Amerigroup, Cook Children's Superior, Seton, BCBS, Sendero Molina, Superior

Delta Dental, DentaQuest, MCNA Delta Dental, DentaQuest, MCNA Delta Dental, DentaQuest, MCNA

Superior

Superior

Superior

MRSA* Northeast:

Anderson, Angelina, Bowie, Camp, Cass, Cherokee, Cooke, Delta, Fannin, Franklin, Grayson, Gregg, Harrison, Henderson, Hopkins, Houston, Lamar, Marion, Montague, Morris, Nacogdoches, Panola, Rains, Red River, Rusk, Sabine, San Augustine, Shelby, Smith, Titus, Trinity, Upshur, Van Zandt, Wood

Amerigroup, Superior

Molina, Superior

Delta Dental, DentaQuest, MCNA

Superior

MRSA* West:

Andrews, Archer, Armstrong, Bailey, Baylor, Borden, Brewster, Briscoe, Brown, Callahan, Castro, Childress, Clay, Cochran, Coke, Coleman, Collingsworth, Concho, Cottle, Crane, Crockett,

Amerigroup, FirstCare, Superior

Molina, Superior

Delta Dental, DentaQuest, MCNA

Superior

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August 2011

Culberson, Dallam, Dawson, Dickens, Dimmit, Donley, Eastland, Ector, Edwards, Fisher, Foard, Frio, Gaines, Glasscock, Gray, Hall, Hansford, Hardeman, Hartley, Haskell, Hemphill, Howard, Irion, Jack, Jeff Davis, Jones, Kent, Kerr, Kimble, King, Kinney, Knox, La Salle, Lipscomb, Loving, Martin, Mason, McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Palo Pinto, Parmer, Pecos, Presidio, Reagan, Real, Reeves, Roberts, Runnels, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sterling, Stonewall, Sutton, Taylor, Terrell, Throckmorton, Tom Green, Upton, Uvalde, Val Verde, Ward, Wheeler, Wichita, Wilbarger, Winkler, Yoakum, Young, Zavala

*Medicaid Rural Service Area TEXAS MEDICAID AND CHIP PRODUCTS Medicaid Acute Care Management PCCM Primary Care Case Management ("PCCM") is a Medicaid managed care system in Texas for acute care run under contract with the Texas Health and Human Services Commission ("HHSC") by the Texas Medicaid and Healthcare Partnership ("TMHP"). Effective September 2011, the number of counties under PCCM will be reduced as STAR is expanded. PCCM will remain operational only until March 2012, when it will be completely phased out and replaced with the STAR program statewide. STAR State of Texas Access Reform ("STAR") is a Medicaid managed care system in Texas for acute care run under contract with various MCOs. An MCO receives a monthly `capitated' payment from HHSC for each 5

August 2011 person enrolled. The STAR program primarily serves non-disabled children, low-income families, and pregnant women. Medicaid beneficiaries must choose an MCO (or the state will choose among available health plans if the beneficiary fails to do so) if they reside in a STAR service area and receive Medicaid. On September 1, 2011, the following changes in the STAR program will take effect: STAR Service Areas will be expanded to include certain new counties contiguous to current STAR Service Areas. The Harris Expansion Service Area will be combined with the Harris Service Area. The STAR program will roll out in a new 11-county Jefferson Service Area.

Current state MCO contracts were modified to include these expansions, so STAR Service Areas will not see a change in health plans until March 2012, when the statewide renegotiations go into effect. For a map of STAR counties as of September 1, 2011, see http://www.hhsc.state.tx.us/medicaid/mc/STARdocs/STAR_Service_Areas.pdf. In March 2012, the following changes to STAR will occur: The STAR program will roll out in a new 10-county Hidalgo Service Area. The remaining PCCM counties will become a subdivided Medicaid Rural Service Area ("MRSA") the MRSA West Texas, MRSA Central Texas, and MSRA Northeast Texas.

For a map of managed care service delivery areas beginning March 2012, see http://www.hhsc.state.tx.us/contract/529120002/Attachment/Attachment-B5.pdf. For a map of the subdivided MRSA, see http://www.hhsc.state.tx.us/contract/529120002/Attachment/Attachment-B5-3.pdf. [In 1999 a behavioral health managed care program, NorthSTAR, was implemented in the Dallas Service Area and continues to be utilized. ValueOptions is the behavioral health organization that manages the provider network for the NorthSTAR program.] STAR Health Foster Care Program HHSC's STAR Health program began enrolling Texas foster children into Medicaid managed care in April 2008. Superior HealthPlan is the only MCO that manages the STAR Health program. All centers should be contracted with Superior in order to file claims for providing services to foster children. [NoteSuperior uses a subcontractor, Cenpatico (formerly IMHS), for all behavioral health claims. Therefore, any centers who contract with Superior and provide behavioral health service also need to be contracted with Cenpatico and file behavioral health claims for Superior members directly to them.] Medicaid Long Term Care Management STAR+PLUS

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August 2011 In the STAR Plus model, MCOs integrate and manage acute and long term care services in the Medicaid program. Enrollment in STAR+PLUS is required for Medicaid recipients who live in a STAR+PLUS service area and qualify for supplemental security income ("SSI") or related benefits. Enrollment in STAR+PLUS is also voluntary for children under age 21 receiving SSI. On February 1, 2011, STAR+PLUS expanded to the Tarrant and Dallas Service Areas. As of September 1, 2011, the following changes will take effect: STAR+PLUS will expand to certain new counties contiguous to current STAR+PLUS service areas. STAR+PLUS will expand to the new Jefferson Service Area.

For a map of the STAR+PLUS Service Areas effective September 2011, see http://www.hhsc.state.tx.us/starplus/Map.pdf. As with the STAR program, state contracts with current MCOs in these areas were modified to include the new counties, so health plans serving these areas will not change until March 2012. Beginning in March 2012, the following changes will take effect: STAR+PLUS will expand to the El Paso and Lubbock Service Areas. STAR+PLUS will roll out in the new 10-county Hidalgo Service Area.

At this time, there are no plans for STAR+PLUS to expand into the MRSA counties. For a map of the STAR+PLUS Service Areas as of March 2012, see http://www.hhsc.state.tx.us/contract/529120002/Attachment/Attachment-B5-2.pdf. Information on the HHSC managed care initiatives will be updated periodically on their website here:

http://www.hhsc.state.tx.us/medicaid/MMC-Proposals.shtml.

CHIP Managed Care CHIP The Texas Children's Health Insurance Program ("CHIP") operates under a managed care system statewide. Counties not included in current CHIP Service Areas comprise a Rural Service Area ("RSA") in which both Superior and Molina hold the managed care contracts. As of March 2012, boundaries for CHIP, STAR, and STAR+PLUS Service Areas will be consistent for all programs. However, CHIP RSA state contracts were not included in this state reprocurement and therefore the CHIP RSA MCOs will remain the same (this is true even in the new Hidalgo Service Area). For a map of the CHIP Service Areas as of March 2012, see http://www.hhsc.state.tx.us/contract/529120002/Attachment/Attachment-B5-1.pdf.

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August 2011 [Note, in 2007 the CHIP Perinatal Program began to provide prenatal care for the unborn children of low-income women who do not qualify for Medicaid. All MCOs contracted under the CHIP program must also serve CHIP Perinatal members.] Medicaid and CHIP Dental The Texas Medicaid and CHIP Dental Program covers certain preventative and restorative dental services. Beginning in March 2012, the following dental contractors will administer the dental program statewide: Delta Dental Insurance Company DentaQuest USA Insurance Company, Inc. MCNA Insurance Company

All CHIP members and all Medicaid members under 20 years of age will be eligible for the Texas Dental Program. Centers that provide dental services should contract will all three dental organizations in order to ensure proper reimbursement. However, dental claims for STAR Health foster children will continue to be processed through Superior, the MCO that manages that program. Also, Medicaid recipients living in Medicaid-paid facilities (like nursing homes) and all adult Medicaid beneficiaries over 21 are excluded from the dental program and will continue to receive dental services through their existing service delivery models (i.e. the MCOs operating in their service delivery area). Since some MCOs offer dental benefits to adults as value-added services, MCOs may include dental components in their FQHC contracts. For more information, see the dental program RFP at http://www.hhsc.state.tx.us/contract/529120003/rfp.shtml. Subcontractors Various MCOs subcontract out portions of care to separate entities. Often, this results in centers having to also negotiate contracts with the subcontracting organization and file claims directly to them. For example, as mentioned in the STAR Health section of this document, Superior is the only MCO contracted to manage the STAR Health program. However, a subcontractor Cenpatico (formerly IMHS) manages the behavioral health portion of care for all Superior products. Therefore, all centers that provide behavioral health services for Superior members will need to contract Cenpatico as well. Centers should inquire with MCOs in your service area whether or not there are subcontractors with which you need to contract separately. Contracts for All Health Centers As managed care expands to new service areas and the MCOs for current service areas change, centers must be contracted with each appropriate MCO for all products in your service area to ensure reimbursement for services. All centers, regardless of location, should be contracted with Superior HealthPlan (and their subcontractors), which handles the STAR Health foster care program statewide. Also, all centers that provide dental services should be contracted with all three of the dental managed care organizations, Delta Dental, DentaQuest, and MCNA. 8

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