Executive Commissioner's Commitment to Improving Member and Provider Experience in Medicaid Managed Care
Executive Commissioner Chris Traylor held stakeholder meetings in 2015 to gather input on ways to improve the managed care landscape, from both the member and provider perspective. According to Executive Commissioner Traylor, the purpose was to improve provider experience in managed care and ultimately to ensure the 4.5 million people relying on the Medicaid and Children's Health Insurance Program (CHIP) programs have appropriate access to services to enable them to live strong, productive lives. He also shared thoughts that it is important as Texas evolves from fee-for-service to managed care, to project future needs to create the best system possible.
After receiving recommendations, additional meetings were held with stakeholders, on Nov. 9, 2015, and Dec. 8, 2015, to further discuss the ideas and potential next steps. Executive Commissioner Traylor explained that some recommendations the agency can handle administratively, some will require legislative action, and then there will be items on which the Health and Human Services Commission (HHSC) will not take any action. He committed to posting decisions made for each recommendation on the website along with an explanation of why action is or is not being taken, and he advised staff they should do everything possible to implement the stakeholder recommendation. Executive Commissioner Dr. Courtney Phillips is equally committed to improving member and provider experience in Medicaid managed care. Enrique Marquez, Chief Program Services Officer in coordination with Stephanie Muth, State Medicaid Director, hold responsibility for coordination and implementation of this project and monitoring its progress.
HHSC responses were shared directly with stakeholder groups in February 2016, updates were posted to the website on April 11, 2016, and July 22, 2016, and biannual updates on items in progress or under discussion will continue to be shared on the website. Items that are closed as of the last update will be provided in a separate file as there will be no further update. Items were closed either as complete, no action to be taken, or other (issue to be addressed through another existing process). In each update, changes to previous responses are noted with red strikethrough for language that is being removed in order to provide an update, and new language is provided in red.
Questions about this project can be emailed to Medicaid Managed Care.
- December 2019 Update With Changes Tracked (PDF)
- December 2019 Update with Changes Incorporated (PDF)
- December 2019 Closed Items (PDF)
Expansion of Medicaid Managed Care
Most people in Texas who have Medicaid get their services through managed care. In this system the member picks a health plan and gets Medicaid services through that health plan's network of providers. Most health plans offer Medicaid members extra services not available through traditional Medicaid.
Right now, there are three Medicaid managed care programs in Texas: STAR, STAR+PLUS, and STAR Health. The 2013 Texas Legislature approved several expansions of Medicaid managed care and directed HHSC to develop a performance-based payment system that rewards outcomes and enhances efficiencies. Managed care expansion plans include:
- Services previously provided through the Community Based Alternatives (CBA) program are provided through the STAR+PLUS Home and Community Based Services (HCBS) waiver
- Day Activity Health Services (DAHS) and Primary Home Care (PHC) services are provided through the STAR+PLUS health plans
- People with intellectual and developmental disabilities receive their basic health services (acute care) through a STAR+PLUS health plan
- People living in nursing facilities get full Medicaid coverage through a STAR+PLUS health plan
- Visit the STAR+PLUS page for more information
- Began Nov. 1, 2016
- For children and youth age 20 and younger who have Medicaid through SSI or 1915(c) waiver programs
- Provides full Medicaid services – both basic health services (acute care) and long-term services and supports – for people in Medically Dependent Children Program (MDCP)
- Provides basic health services (acute care) for children and youth in other 1915(c) waiver programs
- Includes development of a service plan for each member and service coordination
- Visit the STAR Kids page for more information
Pilot programs and other initiatives
- Basic attendant care and habilitation services to increase or maintain the skills of a member and emergency response services (also referred to as community first choice)
- Redesign of the Medical Transportation Program
- Common questions and answers about Medicaid managed care
- Map of service areas for STAR, STAR Kids and STAR+PLUS (PDF)
- Medicaid Managed Care Initiatives presentation (changes to Medicaid managed care) – for consumers and stakeholders (PDF in English)
- Medicaid Managed Care Initiatives presentation (changes to Medicaid managed care) – for consumers and stakeholders (PDF in Spanish)
- Medicaid Managed Care Initiatives presentation (changes to Medicaid managed care) – for providers (PDF)
- House Committee on Human Services: Medicaid Managed Care Initiatives
- Provider Relations Contacts for Medicaid Health Plans (PDF)
Several committees are helping HHSC in the expansion of Medicaid managed care:
- Intellectual and Developmental Disability System Redesign Advisory Committee
- STAR Kids Advisory Committee
- State Medicaid Managed Care Advisory Committee
How Managed Care Works Questions and Answers
Who will be affected by these initiatives?
What is a managed care organization?
What is a provider network?
Provider networks are organizations of health care providers that deliver services within managed care health plans. Managed care enrollees are expected to use network providers.
In Texas, there are four types of Medicaid: STAR, STAR+PLUS, STAR Health, and traditional Medicaid. The type of Medicaid coverage a person gets depends on where the person lives and what kind of health issues the person has.
Do managed care members get to choose a health plan?
Can managed care members change their health plan?
What happens if a member does not choose a health plan by the deadline?
What if a member's provider is not in the network?
What if a member's pharmacy is not in network?
How does Medicare work with Medicaid managed care?
What is service coordination?
Service coordination is a STAR+PLUS benefit that helps members identify and coordinate service and benefit needs and develop a plan to allow them to live in the most independent setting possible. A health plan service coordinator (such as a nurse, social worker, or other health plan staff member) will work directly with plan members, family members, doctors, and community supports to make sure all health care and long-term services and supports needs are met. Service coordination will also be a benefit in the STAR Kids program. A health plan service coordinator:
- Makes home visits and assesses member needs.
- Coordinates with Medicaid and Medicare providers.
- Authorizes community long-term services and supports.
- Arranges for other services such as medical transportation.
- Coordinates other community supports, such as housing.
Will the managed care service coordinator be employed by the health plan?
How will HHSC verify individuals with complex conditions are getting the care they need in a managed care setting?
Access to Care Questions and Answers
Will managed care change the types or amounts of services a member receives?
Members will continue to receive the types and amounts of services that most appropriately meet their medical needs. Needs are determined by the results of an assessment and development of an individual service plan, where appropriate. Medicaid health plans are required to provide all covered medically necessary services to members. Medically necessary means that services are:
- Reasonably necessary to prevent illness or medical conditions, or provide early screening, interventions, and treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a handicap, cause illness or infirmity of a recipient, or endanger life.
- Provided at appropriate locations and at the appropriate levels of care for the treatment of clients' conditions.
- Consistent with health care practice guidelines and standards that are issued by professionally-recognized health care organizations or governmental agencies.
- Consistent with the diagnoses of the conditions.
- No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency.
How will HHSC provide consumer direction in a managed care model?
Medicaid managed care includes consumer-directed services that allow individuals who receive certain services to hire and manage the people who provide their services. The following services are available for self-direction:
- Personal assistance services
- Professional therapies (including, occupational, physical and speech/language therapy)
- Support consultation
- Supported employment (Sept. 1, 2014)
- Employment assistance (Sept. 1, 2014)
- Cognitive rehabilitation therapy (March 1, 2014)
Consumer-directed services will continue to be an option in the STAR+PLUS model as it is in traditional Medicaid. In addition, the STAR+PLUS health plans are required to submit quarterly consumer directed services utilization reports to HHSC for review.
Will a member be able to keep their personal attendant or nurse?
Will there be a limit on prescription drugs?
- If a member is enrolled in a Medicaid health plan and not Medicare, there is no limit on the medicines they can fill each month.
- If an individual is enrolled in Medicaid (fee-for-service or managed care) and Medicare Part D, the individual's Part D health plan will cover most medicines. Medicare Part B also covers certain medicines. Medicaid covers a limited number of medicines that are not covered by Medicare.
- If an adult (age 21 and older) is transitioning from fee-for-service Medicaid, which currently has a limit on medicines, into managed care, they will receive unlimited prescriptions once they are enrolled in managed care.