Texas Council Managed Care Summit October 11, 2019 Juliet Charron, Director of Results Management Medicaid and CHIP Services, HHSC 12/7/2019

Medicaid Managed Care Programs Product Name Population Served CHIP Children in families that earn too much money to qualify for Medicaid, but cannot afford to buy private health insurance STAR Children, newborns, pregnant women, and some TANF-level families STAR+PLUS People with a disability or people who are age 65 or older; and women with breast or cervical cancer MMP People who are eligible for both Medicare and Medicaid, also known as ‘dual eligibles’ STAR Kids Children and adults 20 or younger with a disability STAR Health Serves children in the conservatorship of the Department of Family and Protective Services Dental For most children and young adults enrolled in Medicaid and CHIP. 12/7/2019

Texas MCOs by the Numbers MCOs and DMOs must provide benefits in the same amount, duration, and scope as specified in the Medicaid State Plan Current as of January 2019 – contract numbers are subject to change Current as of January 2019 – contract numbers are subject to change

Contract Oversight Tools 12/7/2019

Strengthening Oversight

Milestones and Contract Changes Network Adequacy Reminder: Dana agreed to touch on TAHP/MCOs requested details regarding Network Adequacy CAPs: Issues with the inaccurate data and HHSC process for having MCO validate inaccuracies. Issues with CAP requirements and information required to support MCO correction plan. Concerns with not acknowledging other forms of access (e.g. Telemedicine) to address shortage areas. Strategy Expand Access to Telemedicine and Telehealth Services Network Adequacy Oversight Change Reduce Administrative Burden Improve Provider Directory Accuracy Milestones and Contract Changes SB 760 and HB 1063 – expands reimbursement for telemedicine, telehealth, and telemonitoring services; cost-effectiveness research with a public university. Rider 157 - Personal Care Services measure New measures for substance use services. Increasing frequency of appointment availability studies. Automated business intelligence tool and dashboard to integrate network adequacy monitoring. Focused on improving the accuracy of provider directories, including more robust MCO validation requirements. Contract changes effective 9/1/2019.

Milestones and Contract Changes Clinical Oversight Reminder: Dana agreed to touch on TAHP/MCOs requested details regarding Network Adequacy CAPs: Issues with the inaccurate data and HHSC process for having MCO validate inaccuracies. Issues with CAP requirements and information required to support MCO correction plan. Concerns with not acknowledging other forms of access (e.g. Telemedicine) to address shortage areas. Deliverable Aggregated Prior Authorization Data Member-Level Authorization Data Milestones and Contract Changes Finalizing interim deliverable Effective FY 2020 Requirements Gathering- more complex deliverable with detailed information. Will engage with stakeholders through State Medicaid Managed Care Advisory Committee. Working to determine effective date.

Service and Care Coordination Reminder: Dana agreed to touch on TAHP/MCOs requested details regarding Network Adequacy CAPs: Issues with the inaccurate data and HHSC process for having MCO validate inaccuracies. Issues with CAP requirements and information required to support MCO correction plan. Concerns with not acknowledging other forms of access (e.g. Telemedicine) to address shortage areas. Strategy Increase Clarity of Service and Care Coordination Improve Oversight of Service and Care Coordination Enhance Continuity for Individuals in Fee-for-Service Programs Incorporate Best Practices Milestones and Contract Changes Establish consistent terminology across programs; clarify and align MCO expectations; Enhance HHSC website content related to Service Coordination expectations. Assess and enhance the current oversight framework and MCO reporting tools. Improve coordination between fee-for-service case management functions (IDD Waivers, HCBS-AMH, YES Waiver) and MCO-led service coordination functions. Conducted targeted review of managed care contract requirements in other states relating to service and care coordination.

Milestones and Contract Changes Complaints Reminder: Dana agreed to touch on TAHP/MCOs requested details regarding Network Adequacy CAPs: Issues with the inaccurate data and HHSC process for having MCO validate inaccuracies. Issues with CAP requirements and information required to support MCO correction plan. Concerns with not acknowledging other forms of access (e.g. Telemedicine) to address shortage areas. Strategy Streamline the process Standardizing data Increase data trending and transparency Milestones and Contract Changes Directing complaints to a centralized place in the agency through a “no wrong door” approach. Implementing communications plan to convey new process to clients, stakeholders, and staff. Implemented contract changes regarding relevant definitions. Clarified that complaints resolved within one business day must be reported to HHSC. Standardizing complaint data categories. Creating a data analysis plan to utilize enhanced data in contract oversight and early issue detection. Identifying opportunities to share complaints data publicly.

Administrative Simplification Strategy Claims Payments Prior Authorizations Milestones and Contract Changes Drafted MCO guidance on the directive that nursing facility daily rate claims cannot be included in claims projects. Identify how MCOs are using claims projects and how they are submitting data on the claims project deliverable. Review and begin implementation of legislation impacting prior authorization information and submissions in coordination with Clinical Oversight workgroup. Other Activities Develop provider education on core business functions such as submission of claims and prior authorizations. Continued monitoring and prompt resolution for complaints received.

Outcomes Focused Performance Management Strategy MCO Operational Review Process MCO Deliverable Review Milestones and Contract Changes Expanding scale of biennial MCO onsite reviews to include finance, quality, pharmacy, and more. Streamlining review processes to minimize administrative burden. Annual review of MCO deliverables and ad-hoc requests. Removed, or in the process of removing, 14 deliverables including one ad hoc report. Identified 15 deliverables to be streamlined.

Stakeholder Engagement Engaging stakeholders through the State Medicaid Managed Care Advisory Committee Open to public comment Subcommittees aligned with each oversight initiative Advisory committee representation Open to the public 12/7/2019

For Questions or More Information Juliet.Charron@hhsc.state.tx.us