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CONTENTS: One TEXAS CHIP Program (Some Assembly Required) Texas CHIP Program Health and Human Services Commission February 3, 2000.

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Presentation on theme: "CONTENTS: One TEXAS CHIP Program (Some Assembly Required) Texas CHIP Program Health and Human Services Commission February 3, 2000."— Presentation transcript:

1 CONTENTS: One TEXAS CHIP Program (Some Assembly Required) Texas CHIP Program Health and Human Services Commission February 3, 2000

2 2 CONTENTS: One Texas CHIP Program, but many pieces: 4 Marketing and Volunteer Partnerships 4 Community-based Organizations (CBOs) 4 Administrative Services 4 Health Plans 4 EPO and Quality Monitoring 4 Policy and Operations

3 3 Marketing and Volunteer Partnership Overview 4 Importance of Outreach 4 Consumer Research 4 Media and Marketing Campaign 4 Volunteer Partnerships

4 4 Why Outreach is Important 4 Maximize early enrollment 4 Maximize enrollment of healthy children 4 State’s diversity, size and population necessitate a broad- based and creative outreach effort

5 5 Outreach Takes Many Forms 4 Outreach isn’t just marketing 4 Outreach is any strategy that results in coverage for uninsured children 4 Health plans, Administrative Contractor, and Management Services Contractor have outreach roles

6 6 Outreach Takes Many Forms 4 A responsive and consumer- friendly call center 4 An easy-to-understand application 4 A simple application process 4 Effective health plan marketing

7 7 Outreach Takes Many Forms 4 Highly efficient process for distributing outreach materials 4 Well-trained community-based organizations 4 Strong local support for CBOs to help them be effective

8 8 CHIP Consumer Research 4 Performed by Orchard Communications, a social marketing company 4 33 focus groups of parents of CHIP- and Medicaid-eligible children 4 June, July, and November of 1999, January and February of 2000

9 9 CHIP Consumer Research 4 Locations: McAllen, Houston, Tyler, El Paso, Waco, San Antonio, Amarillo and Dallas 4 Ethnic diversity represented 4 All participants were from CHIP- and Medicaid-eligible families

10 10 Key Findings of Focus Groups 4 Parents want the message to be clear and to the point 4 Parents want to know up-front what is being pitched to them 4 Parents are skeptical of the terms “affordable” or “low cost”

11 11 Key Findings of Focus Groups 4 Parents will have many questions they want answered before they apply 4 Parents prefer the term “children” to “kids”

12 12 Key Findings of Focus Groups 4 The perceived friendliness of the application will heavily influence whether or not parents choose to apply –The application booklet includes bright colors and as much white space as possible –Asset questions were eliminated –Questions were worded simply –Application length was shortened to single page, front and back

13 13 Key Findings of Focus Groups 4 Application booklet analysis continued... –Only questions that are absolutely necessary are included –Assurances regarding public charge are included –Boxes to check were included, where possible –Parents may call the hotline or a local representative for additional information –Application tested very well (completion time averaged 8 minutes)

14 14 Key Findings of Focus Groups 4 Parents want to know which programs are included in TexCare Partnership –The application booklet was revised to discuss the individual programs (Medicaid, CHIP, THKC) 4 Mono-lingual Spanish-speaking parents did not have a strong preference for bi- lingual materials –For better readability, English and Spanish language materials were separated

15 15 Media and Marketing Campaign 4 Create general program awareness and “buzz” 4 “Generic” outreach for all three programs, not using program names 4 Generic identity is “TexCare Partnership” and slogan is “Children’s health insurance to fit your budget” 4 Operational correspondence will come from TexCare Partnership

16 16 Media and Marketing Campaign 4 Radio and television ads 4 Posters 4 Rack brochures (tri-folds) 4 Tray liners

17 17 Media and Marketing Campaign 4 News conferences 4 Audio and video news releases 4 Telethons 4 Media tours 4 Editorial board meetings

18 18 Principal Marketing Goals 4 Prompt calls to toll-free CHIP phone number 4 Prompt requests for application booklets from local sources 4 Complement CBO outreach by creating general program awareness

19 19 Volunteer Partnerships 4 Developed and coordinated by TDH CHIP Bureau 4 Focusing on health care providers, schools, local governments, small employers, state agencies, and licensing boards 4 Covering Kids Initiative

20 20 Volunteer Partners: Health Care Providers 4 10 CHIP Provider Seminars to be coordinated by Texas Medical Association and involving other provider association partners. Austin Dallas Houston Fort Worth San Antonio El Paso Tyler Harlingen Amarillo Corpus Christi

21 21 Volunteer Partners: Health Care Provider Organizations 4 Texas Medical Association 4 Local County Medical Societies 4 Texas Pediatric Society 4 Texas Society Obstetrics and Gynecology 4 Texas Osteopathic Medical Association 4 Texas Academy of Family Physicians

22 22 Volunteer Partners: Health Care Provider Organizations 4 Texas Children’s Hospital Association 4 Texas Rural Health Association 4 Texas Nurses Association 4 Texas Dental Association 4 Gulf State Dental Association 4 Academy of Pediatric Dentists

23 23 Volunteer Partners: Health Care Providers 4 7 CHIP seminars to be conducted by: –Texas Hospital Association –CHARIOT –CHAT Austin San Antonio Dallas Houston Harlingen Lubbock El Paso

24 24 Volunteer Partners: Schools and Local Governments 4 Texas Association of School Boards 4 Texas Association of Counties 4 Texas Municipal League 4 Individual school districts (based on local interest) 4 Education Associations 4 Parents Teachers Association

25 25 Volunteer Partners: Employers/Employees 4 Chambers of Commerce 4 United Ways 4 Unions 4 State licensing boards 4 Small Business Association 4 Trade Associations

26 26 Volunteer Partners: State Agencies 4 Texas Department of Human Services 4 Texas Education Agency 4 Texas Workforce Commission 4 Office of the Attorney General

27 27 Volunteer Partners: State Agencies 4 Texas Department of Mental Health and Mental Retardation 4 Texas Commission on Alcohol and Drug Abuse 4 Texas Department of Protective and Regulatory Services

28 28 Community-Based Outreach Overview 4 Why community-based outreach is necessary 4 CBO Procurement 4 Region-by-region contract awards 4 Key dates

29 29 CBO Outreach Contracts 4 CBO contracts are a response to the state’s cultural, ethnic, geographic and social diversity 4 CBOs are the key to reaching special populations and overcoming wariness that can accompany new programs

30 30 CBO Outreach Contracts 4 CBOs are uniquely qualified to break down barriers and build trust with families 4 Experience in other states conclusively shows the importance of community-based outreach

31 31 CBO Contract Overview 4 Regional distribution of $5 million for two- year contracts 4 CBOs will work within public health regions (8) 4 Regional funding allocation based on proportion of uninsured children below 200% FPL in each region 4 Regional evaluation and management

32 32 Key Points in the RFP 4 Stressed collaboration and avoidance of duplication 4 Encouraged coalitions of CBOs to put together a coordinated approach 4 Encouraged culturally competent outreach strategies 4 Encouraged creative outreach strategies

33 33 CBO Contract Overview 4 CBOs that know their communities and know how to contact and work with CHIP target groups are receiving contracts 4 HHSC is funding multiple proposals within each region 4 One CBO will work in most counties

34 34 Samples of CBO Activities 4 Placing application booklets in the hands of families with uninsured children 4 Targeted distribution of CHIP brochures and posters 4 Special events or activities appealing to CHIP target groups 4 Targeted outreach to special populations such as refugees or immigrants (e.g., on the public charge issue) 4 Door-to-door canvassing

35 35 Funded CBOs 4 Subject to successful negotiations regarding funding, geographic coverage, workplans and performance measures 4 Regional negotiation process

36 36 Public Health Region counties in northwest Texas, including Lubbock and Amarillo (38,439 uninsured children below 200% FPL) 4 2 CBOs receiving awards –West Texas CHIP Coalition (University Medical Center in Lubbock, lead agency) –Coalition of Health Services, Claude

37 37 Public Health Regions 2/ counties in north and west Texas, including Abilene, Fort Worth and Dallas ( 246,492 uninsured children below 200% FPL) 4 10 CBOs receiving awards –Rolling Plains Management Corporation, Crowell

38 38 Public Health Regions 2/3 –Community Health Service Agency, Greenville –People for Progress, Sweetwater –The Hmong American Planning and Development Center, Metroplex –Shackelford County Community Resources Center, Albany

39 39 Public Health Regions 2/3 –Denton County Health Department –Wichita Falls-Wichita County Public Health District –Community Council of Greater Dallas –Catholic Charities, Fort Worth –Texoma HealthCare System, Denison

40 40 Public Health Regions 4/5N 4 35 counties in northeast Texas, including Tyler and Texarkana (54,019 uninsured children below 200% FPL) 4 6 CBOs receiving awards –Community Council, Lindon –East Texas CHIP Coalition (Sabine Valley MHMR Center, Longview, lead agency)

41 41 Public Health Regions 4/5N –5N CHIP Outreach Coalition (Deep East Texas Council of Governments, lead) –Cherokee County Health Department, Rusk –Smith County Public Health District, Tyler –Northeast Texas Opportunities, Mount Vernon

42 42 Public Health Regions 6/5S 4 16 counties in east Texas, including Houston and Beaumont (250,134 uninsured children below 200% FPL) 4 9 CBOs receiving awards –Families Under Urban and Social Attack, Houston –Episcopal Health Charities, Houston

43 43 Public Health Regions 6/5S –Harris County Public Health and Environmental Services (coalition lead) –HOPE for Kids, Houston –Matagorda County Hospital District, Bay City –The Children’s Center, Galveston

44 44 Public Health Regions 6/5S –Port Arthur Health Department –Christus St. Elizabeth Family Practice Center, Beaumont –Montgomery County Hospital District, Conroe –Chambers County Health Department

45 45 Public Health Region counties in central Texas, including Austin and Waco (82,257 uninsured children below 200% FPL) 4 6 CBOs receiving awards –Brazos County United Way, Bryan –Communities in Schools, Waco

46 46 Public Health Region 7 –Austin/Travis County Health and Human Services, Travis and Williamson Counties –Hill Country Community Action Council, San Saba –Outreach Health Services, Austin –Combined Community Action, Smithville

47 47 Public Health Region counties in south Texas, including San Antonio (126,719 uninsured children below 200% FPL) 4 6 CBOs receiving awards –South Texas Rural Health Services

48 48 Public Health Region 8 –City of San Antonio and United Way Coalition, San Antonio –Community Action Committee, Victoria –Lawyers’ Committee for Civil Rights Under Law of Texas, San Antonio –Uvalde County Clinic

49 49 Public Health Regions 9/ counties in west Texas, including El Paso and Midland (98,350 uninsured children below 200% FPL) 4 3 CBOs receiving awards –West Texas CHIP Collaborative, El Paso –La Esperanza Clinic, San Angelo

50 50 Public Health Regions 9/10 –Martin County Community Fund, Stanton –West Texas Opportunities, Lamesa –Pecos County Community Action Agency, Fort Stockton

51 51 Public Health Region counties in southeast Texas, including Corpus Christi and Harlingen (149,908 uninsured children below 200% FPL) 4 5 CBOs receiving awards –City of Laredo Health Department

52 52 Public Health Region 11 –Valley Primary Care Network, Brownsville –Community Action Corporation of South Texas, Alice –AVANCE Family Support and Education Program, McAllen –San Patricio County Health Department, Sinton

53 53 Key Dates 4 Final funding decisions on January 7 4 Contracts negotiated and signed by February 8 4 CBO training: February and early March 4 CBO outreach begins mid-March

54 54 Administrative Services Overview 4 Call Center and Application Processing 4 CHIP eligibility guidelines 4 Enrollment process 4 Cost-Sharing 4 Referrals to Medicaid and THKC

55 55 Administrative Services 4 Birch & Davis Health Management Corporation (operating under the “TexCare Partnership” identity) 4 Currently providing comparable services in New Jersey 4 Broad experience directly applicable to CHIP administrative services deliverables

56 56 Application Processing 4 Begins April 3, Open enrollment for CHIP during the first full year of operation (April ) 4 Continuation of open enrollment subject to HHSC decision

57 57 Call Center 4 Customer Service number has been operational since December (voice mail only) 4 Callers may leave message requesting an application when they are available or be connected to the Medicaid or THKC hotline 4 Live operations begin April 3, There are 2 toll-free numbers: – , for application and enrollment (customer service) – , for provider inquiries (with automated look-up capability)

58 58 Customer Service Call Center 4 Staffed from 9 AM to 9 PM, M - F, and from 9 AM to 3 PM on Saturday, except for Federal holidays. 4 Voice mailbox available after hours, in English and Spanish. 4 Equipped to answer calls from persons who are deaf or hard of hearing.

59 59 Customer Service Call Center Staff 4 Available for translation services for non-English speaking callers 4 Are well trained, culturally competent, and meet standards of promptness and quality 4 Understand program policies and procedures

60 60 Application Booklet 4 6 pages (3 English; 3 Spanish) 4 Tear-out 2-page application form and postage-paid return envelope 4 Built on lessons learned from other states 4 Focus-tested (8 minutes average completion time)

61 61 Sources of Applications 4 Hotline (TexCare Partnership mails them) 4 CBOs 4 Download in Acrobat, WordPerfect, or Word formats from

62 62 How to Apply 4 By phone (TexCare Partnership prints completed app and mails for signature) 4 By mail (using application booklet) 4 By mail (using downloaded form) 4 By mail (using printout of website on-screen form)

63 63 Applications 4 Applications are entered into a database within 3 working days from receipt and tracked and monitored by TexCare Partnership 4 After 60 days, incomplete applications are closed

64 64 Incomplete Applications 4 Initial follow-up letter sent within 2 working days 4 Secondary follow-up letter sent 14 working days later if additional information not received 4 Assets test questions in follow-up letter (families with Medicaid- eligible incomes only)

65 65 Eligibility for CHIP 4 Age birth through 18 4 Net income at or below 200% FPL, and not otherwise eligible for Medicaid 4 Legal immigrants 4 Uninsured for at least 90 days (with some exceptions) 4 Applications of children subject to waiting period will be held, pending expiration of waiting period

66 66 Exceptions to Waiting Period 4 Parents job ended 4 Loss of Medicaid eligibility 4 Change of parents’ marital status 4 Parent’s COBRA coverage ended 4 Moving from THKC to CHIP 4 Insurance costs more than 10% of net income

67 67 Income Eligibility Guidelines 4 Based on net family income and family size 4 Deductions –standard deduction for work related expenses –child care / disabled adult care –child support / alimony

68 68 Income Eligibility: Hypothetical Example 4 Family of four (2 children), income of $38,000 (225% FPL) 4 $90 per month deduction for work- related expenses 4 $350 per month deduction for day-care expenses ($175 per child) 4 Net income after deductions is $32,720 (196% FPL) 4 Children are eligible for CHIP

69 69 Income Eligibility Guidelines 4 Definition of family tracks Medicaid 4 Adult family members are parents or step-parents of the applicant children 4 Any adult who lives and cares for a child may apply on behalf of the child (however, unless they are legally responsible for the child, their income is not included)

70 70 Income 4 Net income verified through –pay stubs; or –income tax form; or –letter from employer

71 71 Citizenship 4 Status consistent with federal guidelines 4 U.S. citizenship self-declared 4 Non-citizens provide verifications of immigration status 4 Undocumented children referred to THKC

72 72 Coverage 4 12-months continuous coverage 4 Begins the first day of the month following enrollment 4 Begins the following month if enrollment after the “cut off date” (5 business days prior to first day of the month)

73 73 Coverage 4 In some families, children will initially enroll at different times in the year 4 In these situations, the children who enroll later will have the same expiration date as their siblings 4 The initial coverage period for children who enroll later will be less than 12 months

74 74 Coverage: Hypothetical Example 4 Two children enroll in January and a younger sibling “ages out” of Medicaid and into CHIP in June 4 The initial coverage period for the younger sibling is seven months 4 All three children are eligible for re- enrollment at the same time

75 75 Pregnant Teens 4 Notification of pregnancy initiates new eligibility period 4 End date of new eligibility period depends on date of delivery 4 New expiration date is two full months after birth, or original expiration date, whichever occurs later 4 Babies automatically enrolled until mother’s expiration date 4 TexCare Partnership receives name of child from the Bureau of Vital Statistics

76 76 Enrollment 4 Eligibility determination notices sent to families determined eligible, based on complete application 4 Enrollment packet mailed to families (written at a 6th grade level)

77 77 Contents of Enrollment Packet 4 Explanation of CHIP benefits 4 Comparison table showing value-added services by health plan 4 A place to indicate a complex special health care needs child 4 A place to indicate whether a medical support order is applicable 4 How to select a health plan, primary care physician (PCP), and the option to choose a specialist as PCP

78 78 Contents of Enrollment Packet 4 Provider directories (provided by health plans) 4 Cost-sharing information specific to the income level of the family and payment coupon book for families with net income over 150% FPL 4 Simple form to track cost-sharing expenses relative to caps 4 Information concerning the grievances and appeals process

79 79 Enrollment Process 4 Reminder notices sent 14 days after enrollment package mailed 4 Concurrent notice sent to CBOs when there is a record of past involvement with family 4 Follow-up letter to be mailed 14 days later

80 80 Post-Enrollment Letter 4 Serves as temporary proof of coverage, pending receipt of health plan ID card 4 Member ID number and initial date of coverage 4 Health plan and PCP selections 4 Applicable co-pays

81 81 To Facilitate Choice of PCP 4 Provider data submitted electronically by the health plans to TexCare Partnership on a weekly basis 4 Monthly update of enclosure listing PCPs not currently accepting new patients

82 82 To Facilitate Choice of PCP 4 Health plans assign PCP only if no available PCP is chosen 4 Subsequent PCP changes made at health plan level 4 Health plans notify TexCare Partnership of PCP changes

83 83 Valid Enrollment Requires 4 Selection of health plan 4 Payment of enrollment fee or premium 4 Within 60 days after enrollment package mailed 4 PCP selection is not prerequisite to enrollment

84 84 Disenrollment situations 4 Aging out (turning 19) 4 Cost-sharing delinquency 4 Family moves out of state 4 Death of a child 4 Change in insurance status 4 Data match with Medicaid

85 85 Disenrollment process 4 Family notifies TexCare Partnership in the event of moving, death, or change in insurance status 4 Same cut-off date timeframes as enrollment, only in reverse 4 Premiums recouped only for the death of a child

86 86 Renewal Notices 4 Sent at the beginning of the 10 th month of coverage 4 Includes: –Return envelope –Printout of initial application data –Request to indicate changes or confirmation of original information –Request for signature 4 Response due by end of 12 th month to avoid disenrollment 4 Copies sent to health plans and CBOs (when relationship with family is known)

87 87 Changes in Health Plan Enrollment 4 Relocate to different CSA 4 Relocate to different area in CSA 4 Good cause 4 Health plan may request changes pursuant to TDI regulations

88 88 Cost-sharing Obligations 4 All CHIP-eligible families have some (except Native Americans and families below 100% FPL) 4 Monthly premiums and enrollment fees assessed per family, not per child

89 89 Cost-sharing Requirements 4 $15 annual enrollment fee for families with incomes between 100% and 150% FPL 4 $15 monthly premium for families between 150% and 185% FPL ($180 annually) 4 $18 monthly premium for families between 185% and 200% FPL ($216 annually)

90 90 Cost-sharing Caps & Exclusions 4 No cost-sharing below 100% FPL 4 Families at or below 150% FPL, co- pays do not exceed $100 annually 4 Families above 150% FPL, total cost- sharing does not exceed 5% of annual gross income 4 Reporting threshold is $90 / 4.5% 4 No co-pays on preventive services

91 91 What Happens When Cap is Reached 4 4.5% or $90 4 Family sends documentation to TexCare Partnership 4 TexCare Partnership notifies health plans to suspend co-payments 4 Health plans issue new member ID cards reflecting no copays

92 92 Premium Payments 4 Enrollment fee or initial premium due at time of enrollment 4 Cost-sharing premiums due on the 1 st day of the month 4 20 day grace period before notification 4 Coverage is cut off on the last day of the following month

93 93 Premium Payments: Hypothetical Example 4 $18 premium due on July 1 (to be sent with payment coupon to lockbox vendor) 4 Delinquent notice sent on July 20 when no payment is received 4 Delinquent notice requires payment by August 10 4 When no payment is received, children are disenrolled effective August 31

94 94 Good Cause Exceptions to Disenrollment Due to Cost-Sharing Delinquency 4 Emergencies involving responsible adults (hospitalization or death, for example) 4 Natural disaster 4 Documented postal delay 4 Processing error 4 Change in family cost-sharing obligation 4 Failure to include coupon for proper credit

95 95 Reactivation of Coverage for Delinquent Families 4 No sooner than 3 months after end of disenrollment month 4 Premiums due for delinquent months and upcoming month (total of 3 months) 4 Continuation of original 12 month coverage

96 96 Medicaid Referrals 4 Complete applications electronically transferred to DHS within 1 work day 4 Paper copy to follow to local DHS office within 2 additional work days

97 97 “Deemed” by Medicaid 4 Children who are denied Medicaid because of assets will be “deemed” eligible for CHIP 4 Children who are denied Medicaid because of income, but who have a Medicaid-eligible sibling, will be “deemed” eligible for CHIP 4 “Deeming process” is electronic

98 98 THKC Referrals 4 Electronic referrals when: –Not eligible for CHIP –Not eligible for Medicaid –Not the child of a State employee

99 99 “Deemed” by THKC 4 When CHIP rolls out, children who are receiving THKC premium assistance or are on the THKC waiting list for premium assistance will be “deemed” eligible for CHIP 4 “Deeming process” is electronic

100 100 State Employees 4 State employees not eligible for CHIP under federal law 4 Enhanced state contribution through ERS (80 percent state match rather than 50 percent) for CHIP-eligible children 4 Separate application for state employees (to include employee’s social security number)

101 101 State Employees 4 State employee children identified by social security numbers and data match with employers who offer health insurance through ERS 4 ERS publicizes availability of enhanced state contribution 4 Daily electronic referrals from TexCare Partnership to ERS during summer open enrollment period

102 102 TexCare Partnership Referral Notices 4 Sent to families who are referred to THKC, ERS, or Medicaid 4 Explains why referral was made 4 Explains the process for pursuing or appealing the referral

103 103 CBO Training 4 12 sessions throughout the State 4 Conducted throughout February and March of Focus on CHIP applications processes and basic CHIP program policies 4 2 representatives per CBO 4 Training materials subject to HHSC approval

104 104 CBO Identification 4 Unique code generated by TexCare Partnership 4 Stamped or written on each application involving CBO assistance 4 Identify CBOs that are involved with submission of applications that are consistently incomplete 4 Document relationships with specific families

105 105 Key Dates 4 Completion of business rules: mid-January 4 Complete review and approval of all materials: early March 4 Install telecom and computer equipment: late February 4 Finish facility buildout: early March (facility is located near FM 620 and Parmer) 4 Complete initial hiring of hotline staff: late March

106 106 Health Plan Overview 4 Health plan basics 4 Coverage by CSA 4 Benefits 4 Marketing 4 Members Materials

107 107 CHIP Health Plans 4 CSAs are the 11 major Texas metropolitan areas 4 Health Maintenance Organizations (HMOs) have contracted to provide CHIP services in 8 of the 11 CHIP Service Areas (CSAs) 4 Exclusive Provider Organization coverage is being negotiated for CSAs 3, 4 and 9 and the remaining rural counties

108 108 CHIP Health Plans 4 Health plans will contract with hospitals, physicians and other providers for the delivery of health care 4 Preventive and therapeutic dental care provided by dental indemnity insurer

109 109 Risk Groups 4 Ages Ages Ages Ages Premium rates vary by CSA and risk group

110 110 Vaccines 4 CHIP children do not qualify for 100% federal reimbursement under Vaccines For Children (VFC) program 4 To leverage federal purchasing power, vaccines will be purchased and distributed through VFC program (at CHIP match)

111 111 CHIP CSA counties in the panhandle including Amarillo and Lubbock 4 2 health plans awarded –Texas Universities Health Plan (9 counties; 13,512 eligible children) –FirstCare Southwest Health Alliance (9 counties; 9,575 eligible children)

112 112 CHIP CSA counties in the Dallas/Fort Worth area 4 3 health plans awarded –Americaid Community Care (8 counties; 72,522 eligible children) –Parkland Community Health Plan (7 counties; 70,479 eligible children) –Cook Children’s Health Plan (6 counties; 44,972 eligible children)

113 113 CHIP CSA counties in the Waco/Temple area 4 Tentative award voided by mutual consent due to rate issues 4 This CSA will be included in the EPO service area (7 counties; 3,514 eligible children)

114 114 CHIP CSA 4 4 Tentative award voided by mutual consent due to network issues 4 This CSA will be included in the EPO service area (9 counties; 12,554 eligible children)

115 115 CHIP CSA counties in the Austin area 4 Seton Health Plan (9 counties; 20,188 eligible children)

116 116 CHIP CSA counties in the Houston area 4 3 health plans awarded –Americaid Community Care (11 counties; 119,299 eligible children) –Texas Children’s Health Plan (10 counties; 109,848 eligible children) –UTMB HealthCare System (20 counties; 124,809 eligible children)

117 117 CHIP CSA counties in the San Antonio area 4 2 health plans awarded –Community First Health Plan (9 counties; 48,911 eligible children) –Texas Universities Health Plan (8 counties; 47,866 eligible children)

118 118 CHIP CSA counties in the Corpus Christi area 4 Driscoll Children’s Health Plan (15 counties; 18,962 eligible children)

119 119 CHIP CSA counties in the Deep Valley area including Harlingen and Brownsville 4 Tentative award voided by mutual consent due to rate issues. This CSA will be included in the EPO service area.

120 120 CHIP CSA counties in the Laredo area 4 Mercy Health Plan (4 counties; 7,246 eligible children)

121 121 CSA 11 4 El Paso county 4 2 health plans awarded –Superior Health Plan (2 counties; 30,082 eligible children) –Texas Universities Health Plan (1 county; 29,816 eligible children)

122 122 CHIP Benefits 4 Comprehensive benefits package for healthy kids and CCSHCNs 4 Well-baby and well-child visits 4 Immunizations 4 Prescription drugs 4 Substance abuse and mental health 4 1 preventive dental visit annually 4 $300 cap on therapeutic dental

123 123 Status of CCSHCN Child 4 Health plans must confirm status of child tentatively identified as having complex special needs 4 Confirmed CCSHCNs receive enhanced services

124 124 Health Plan Marketing 4 Promotional giveaways may not be worth more than $10 4 Health fairs 4 Billboards 4 Written materials 4 Mass media 4 Industry Oversight Committee

125 125 Member Material Content 4 Member handbook or certificate of coverage 4 Member ID card 4 Mailed to member by fourth business day of the month

126 126 Key Dates 4 Weekly conference call: every Tuesday 1:00 - 3:30 PM (updates, discussion of key issues) 4 Readiness reviews begin March 4 Member materials submitted for approval by late February 4 Member materials printed by late March

127 127 EPO and Quality Monitoring Overview 4 EPO in a nutshell 4 Federal quality requirements 4 State quality requirements 4 Tools for measuring quality

128 128 EPO in a Nutshell 4 A form of managed care 4 EPO means “Exclusive Provider Organization” 4 Indemnity regulation 4 Available to self-insured employers in Texas commercial market 4 Option for CHIP population only under exception in SB 445

129 129 EPO in a Nutshell 4 Funding –indemnity license 4 Structure –similar to PPO –But, no coverage for out-of-network services –some medical management –no gatekeeper –UR is used

130 130 EPO in a Nutshell 4 Network provider (tentative selection): USA-MCO 4 Texas network of national PPO company 4 JCAHO accredited 4 Risk-bearing insurance carrier to be determined this week

131 131 Quality Review 4 Federal requirements 4 State requirements 4 Primary Tools

132 132 Federal Requirements 4 Annual evaluation due March 31 4 Evaluation to include –“A description and analysis of the effectiveness of elements of the State plan, including the quality of health coverage provided including the types of benefits provided”

133 133 Federal Requirements 4 States must assure “the quality and appropriateness of care provided…” particularly with respect to: –Well-baby, well-child, well-adolescent care & child and adolescent immunizations –Access to covered services 4 States must also assure that special needs children receive timely and appropriate care

134 134 State Requirements 4 Found in SB Requires the monitoring of health plans to ensure contractual performance and quality delivery of services 4 Outcome measurements

135 135 Tools 4 Patient-level encounter data 4 Surveys 4 Health plan QIP reports 4 HEDIS 4 Other

136 136 Encounter Data 4 Quarterly submission from plans 4 Subset of information from HCFA 1500 & UB-92 forms 4 Data will be case-mix adjusted 4 Analysis by health plan coverage area

137 137 Case-mix Adjustment 4 Assigns ICD-9-CM codes to diagnosis groups based on –duration –severity –diagnostic certainty –etiology –specialty care

138 138 Case-mix Adjustment 4 Patients within a particular group have similar patterns of morbidity and resource use 4 Allows for comparisons of expected versus actual utilization for plan’s CHIP members 4 Provides framework for analyzing appropriateness of care given a specific child’s health status, age and gender

139 139 Surveys 4 CAHPS: variety of instruments, including –children’s care –complex special needs children –adolescent survey –behavioral health 4 FAACT/NCQA (CAHMI) in development

140 140 Health Plan QIP 4 Due to State March 31 of each year 4 Must include: –executive summary of QIP –description of activities re: QIP standards (see Appendix E4 of RFP) –data collection methodologies –tracking and monitoring quality –role of providers in QIP –action plan

141 141 HEDIS 4 Pediatric measures, including: –childhood immunizations –diabetes care –well-child visits to 15 months –well-child visits at 3, 4, 5, & 6 years-of-age 4 No reporting until State will coordinate with plans & Health Care Information Council

142 142 Other 4 Focused studies –one selected by plan, one by State –annually reported –topics of particular interest to State include: diabetes asthma treatment of complex special needs children

143 143 Other 4 Medical records reviews –will be coordinated with Bureau of Managed Care –encounter data collection vendor will perform spot checks –abstraction planned for on-site

144 144 Other 4 State reserves the option to use additional tools or benchmarks as suggested by HCFA, e.g., –RAND Quality Care Measurement System for Children and Adolescents –Bright Futures

145 145 CHIP Policy and Operations Overview 4 Staffing 4 THKC Role 4 TDH CHIP Bureau Role 4 HHSC Role 4 Project Plan 4 General Principles

146 146 Staffing 4 Full-time State staff at HHSC and TDH –5 permanent staff at HHSC –10 permanent staff at TDH –Technical support from HHSC, TDH, DHS, TCADA, MHMR, TDI 4 Management contractor (THKC) –40+ permanent staff

147 147 THKC Role 4 Contract oversight and monitoring 4 Day-to-day management of contractual requirements 4 Conduct readiness reviews 4 CBO technical assistance, support, and monitoring

148 148 THKC Role (Cont’d) 4 Coordination of contractors 4 Provide community feedback to HHSC 4 Regional Advisory Committees (RACs) admin support

149 149 TDH CHIP Bureau Role 4 Approval of business rules 4 Approval of materials (outreach, health plan, TexCare Partnership) 4 Approval of advertising and PR strategies 4 Conflict resolution between contractors

150 150 TDH CHIP Bureau Role (Cont’d) 4 Resolution of medical policy issues 4 Oversight of non-THKC contracts 4 Resolution of operational issues 4 Respond to press inquiries 4 Solicitation of corporate involvement

151 151 HHSC Role 4 Single state agency for federal purposes 4 Management of THKC contract 4 Final authority for policy issues and rule-making 4 Final authority for conflict resolution 4 Contract authority, amendments, and auditing

152 152 HHSC Role (Cont’d) 4 Approve readiness review plans 4 Pay vendor invoices or claims 4 Impose remedies, liquidated damages 4 Manage program budget

153 153 HHSC Role (Cont’d) 4 Liaison with provider associations 4 Communication with Governor’s Office, Legislature, Federal agencies 4 Liaison with national organizations or national CHIP-related initiatives 4 Respond to press inquiries 4 Solicitation of corporate involvement

154 154 Project Plan 4 Resides with HHSC 4 Timeline 4 Dependencies

155 155 General Principles 4 Transition to team approach to implementation, operations management (THKC/TDH CHIP Bureau collaboration) 4 THKC CHIP staff: primary vendor point of contact 4 Program and vendors: public/private partnership


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