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

2. 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

4. 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

5. Contract Oversight Tools
12/7/2019

6. Strengthening Oversight

7. 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 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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

14. For Questions or More Information