Best Practices in Texas Medicaid
Consumer-directed care demonstrations (include number of beneficiaries served now and in any expansion plans)
Texas pioneered the concept of consumer direction in 1997 in the state’s Consumer Managed – Personal Assistance Services (CM-PAS) program, which is funded by state general revenue.The state’s Consumer Directed Services (CDS) option for delivery of program services was implemented in 2001 in three of the state’s §1915(c) Medicaid waiver programs (Community Living Assistance and Support Services for individuals with related conditions, Deaf Blind with Multiple Disabilities, and Community Based Alternatives for individuals who are aged or physically disabled), the Medicaid state plan attendant services, and in CM-PAS. In 2003, the CDS option was added to the Medicaid managed care program, State of Texas Access Reform (STAR)+PLUS, and was incorporated into the expansion of STAR+PLUS in 2007. In 2005, the CDS option was added to a fourth §1915(c) Medicaid waiver program, the Medically Dependent Children's Program. In 2007, Texas included the CDS option when it added a Medicaid state plan personal attendant service program for children. In 2008, the CDS option was added to two more §1915(c) Medicaid waiver programs, Home and Community-based Services and Texas Home Living, both of which serve individuals with intellectual disabilities. While CDS has been a service delivery option for personal assistant services and respite, in the Texas Home Living program all services can be consumer directed. Also, in 2008, Texas offered the CDS option in a new Medicaid managed care program, Integrated Care Management (ICM). Together, the §1915(c) programs provide services to individuals of all ages that meet nursing facility (NF), intermediate care facility for persons with mental retardation or related conditions (ICF/MR), and hospital levels of care.
The CDS option provides the individual receiving services, or the individual’s legally authorized representative (LAR), the opportunity to be the employer of those persons that provide attendant services and respite services to the individual. The employer hires employees to provide attendant services and in-home respite services. For out-of home respite services, the individual, or LAR, contracts with licensed facilities and other providers. Beginning in 2008, the CDS option will be available for other services such as nursing or therapies in the Community Based Alternatives program. The individual, or LAR, will retain the providers of these services directly.
Financial management services are provided by Consumer Directed Services Agencies (CDSA), which perform employer-agent responsibilities on behalf of the employer. To provide additional support for those who choose to self-direct their services, Texas began offering, in 2008, Support Consultation service in the Home and Community-based Services and Texas Home Living §1915(c) waiver programs. Support Consultation includes coaching and guidance with regard to employer-related activities beyond those provided by the CDSA. Support Consultation will be provided by Support Advisors who must pass a Department of Aging and Disabilities Services (DADS) certification training. Support Advisors can be affiliated with a CDSA or can be independent. Over the next two years, the state anticipates including Support Consultation in all programs that offer the CDS option.
With the help of a Real Choice Systems Change grant from the Centers for Medicare and Medicaid Services (CMS), Texas added the Service Responsibility Option (SRO) as another option for consumer direction. The SRO allows individuals to select, train, and supervise their workers. The provider agency remains the employer of record and retains the personnel and payroll functions. Currently, the SRO is a pilot for Medicaid state plan attendant services for adults in select areas of the state and in managed care programs. In 2008 statewide expansion is planned for state plan attendant services. In 2009, SRO will be added to select §1915(c) waiver programs. Because those who choose SRO are not employers, they do not need a CDSA. They will, however, have access to Support Consultation for management related activities. At the end of August 2007, approximately 2,600 individuals were using consumer direction in Texas.
Delivering high quality, coordinated, long term care for the disabled and/or the infirm
Texas has four important best practices in long-term care:
1. Medicaid entitlement programs that offer cost-effective services in the community to persons who might otherwise seek costly nursing facility care
2. Systematic support for individuals who wish to leave a nursing facility or other institutional setting (ICF/MR, State Mental Retardation Facility) and receive necessary relocation and transitional services and supports and care in the community
3. A broad-based quality monitoring and improvement program
4. Program of All-Inclusive Care for the Elderly (PACE)
1. Entitlement services in the community
Texas offers three Medicaid programs that are available in the community as entitlements. People who use these services must have a medical need for assistance with activities of daily living or need other health services, but are not required to meet the medical necessity criteria for nursing facility care. Because the programs are entitlements, there is no waiting list for access to services.
Texas’s entitlement community programs offer distinct advantages. Individuals who are at risk of needing nursing facility care can receive assistance before their health deteriorates to the point that nursing facility care is necessary. They can receive help in their own homes and communities, at a much lower public cost. The programs are less costly than either nursing facility or 1915(c) waiver services.
Primary Home Care (PHC)
Primary Home Care uses the Personal Care option in the Medicaid State Plan. It serves adults who are SSI-eligible (75% of the Federal Poverty Level (FPL)) and need medical practitioner-ordered assistance with one or more activities of daily living. An attendant (not a licensed professional) provides assistance with activities such as bathing and dressing, as well as light housework, shopping, escort and related services. In Fiscal Year 2008, an average of 52,117 clients will be served per month, with an average monthly cost per client served of $683.47. By comparison, the Fiscal Year 2008 estimate for nursing facility care monthly cost is $2,677.27 with an estimated 56,582 clients served per month.
Day Activity and Health Services (DAHS)
Day Activity and Health Services are also available to persons with SSI-level incomes. Participants must have a medically authorized need for regular health monitoring. Participants attend a day facility where, in addition to socialization, supervision, meals, snacks and transportation, they receive regular monitoring or therapy in an efficient setting. Participants usually live with family members who work during the day, but are available for assistance in the evening. The DAHS estimate for Fiscal Year 2008 is an average of 16,588 clients monthly, at an average monthly cost of $500.31. For persons with higher incomes, a limited number of spaces are funded by the Community Services Block Grant.
Community Assistance Services (CAS)
The Community Assistance Services program, authorized under Section 1929(b) of the Social Security Act, provides services identical to those offered under PHC, and the same functional need criteria apply. Financial eligibility is limited to those with incomes up to 300% of the SSI level, or 225% of FPL. Financial criteria are essentially the same as those for nursing home care under Medicaid. People of any age may receive CAS services.
People who qualify for CAS do not receive other Medicaid services. Those with low enough incomes may qualify for Medicare Savings Programs such as Qualified Medicare Beneficiary or Specified Low Income Beneficiary, but any such eligibility is unrelated to CAS. CAS participants who are also eligible for a Medicare Savings Program are considered partial dual eligibles for purposes of Medicare Part D. CAS participants who are Medicare beneficiaries are considered partial dual eligibles for purposes of Medicare Part D. The availability of low-cost prescription drugs to CAS participants may be important. Anecdotal evidence indicates that many persons, including CAS participants, previously sought waiver services because they had difficulty paying for prescriptions (fully covered for persons in the waiver). With Medicare Part D, CAS may now provide an adequate service package for more persons. The CAS estimate for Fiscal Year 2008 is an average of 42,219 clients monthly, at an average monthly cost of $657.58.
2. Support for People Leaving Institutional Settings
Nursing Facilities
Individuals who want their long term services and supports delivered in the community often have to be placed on an “interest” list to receive community-based waiver services. However, if an individual is residing in a Medicaid-certified nursing facility, is Medicaid-eligible, and meets all the other eligibility criteria, then the individual may relocate back into the community to receive services without having to be placed on an “interest” list. Texas allows for this expedited access to waiver services through an innovative public policy known as “Money Follows the Person” (MFP).
MFP is one of the oldest and largest programs of its kind in the United States and is the basis for the federal MFP Demonstration program. Texas’ MFP , which has helped approximately 16,000 people relocate from nursing facilities since 2001, is a part of the Promoting Independence initiative, which is Texas’ response to the Olmstead decision. In 2001, a rider to the state appropriations act authorized the Department of Human Services (DHS), then the long-term care agency for individuals in nursing facilities, to transfer money from the nursing facility budget to the waiver budget for individuals who were aging and/or with a physical disability when they left a nursing facility. The real-time result of this policy is that an individual who is a current Medicaid-certified nursing facility resident, and who meets all of the (c) waiver eligibility criteria, will receive immediate access to community waiver services without being placed on an interest list and without using a community waiver slot. An individual must make arrangements with a home health provider before leaving the facility. The 79th Texas Legislature (2005) both codified the policy through House Bill 1867 and established its own budget line strategy.
Relocation to the community for individuals with complex medical and functional needs may be difficult. Especially for individuals who have been in the facility for a long period of time, there may be a lack of community housing, household furnishings, and other community supports. In order to help facilitate the relocation and provide supports to help ensure a successful relocation, DADS has developed the following supports to assist the MFP policy:
• Transitional Assistance Funding and Transition to Life in the Community - Moving back into the community can involve significant one-time costs. Household goods, rent and utility deposits and start-up supplies of groceries can be a problem for Medicaid-certified nursing facility residents, who have very limited incomes, few or no assets, and may have lost all their community supports, including housing, due to a long nursing facility residency. Transitional Assistance Services provides up to $2,500 in start-up costs--from the community waiver cost cap--for individuals using the MFP program. Transition to Life in the Community is supported by general revenue funds that pay for wrap-around supports not funded through Medicaid.
• Relocation Services Contractors - For some individuals seeking to leave a nursing facility, the process is complex and difficult. They may lack a community home, live in a rural area, have co-occurring behavioral health issues, and, in general, have complex functional and medical needs. They may need to establish a support network. These individuals may have specific practical and financial barriers to be overcome in the process. For such individuals, Relocation Services provides service coordination, housing searches and other assistance to help the individual relocate back to the community. Texas has divided the state into six catchment areas and contracts with Centers for Independent Living and the North Texas Council of Governments to provide Relocation Services.
• Community Transition Teams (Teams) – These are public-private local workgroups who meet on a regular basis to help remove individual and systematic barriers to relocation in their communities. The Teams are based on a “community resource coordinating groups” philosophy that utilizes community private organizations/businesses and governmental agencies to respond to local problems and barriers to assistance. DADS sponsors Teams in each of the Health and Human Services regional catchment areas.
Intermediate Care Facilities for Persons with Mental Retardation
The original Promoting Independence Plan (Plan) gave a priority to individuals living in large community ICFs/MR (14 beds or more) and state mental retardation facilities (state schools) and who desire a living arrangement other than the institution. The state created separate target groups within the HCS waiver, thereby ensuring these individuals expedited access to HCS waiver slots. This is not the same as the MFP process in nursing facilities. These individuals are funded by a special legislative appropriation and through “attrition” slots. Individuals in state schools may access an HCS slot within six months of referral while those residing in a large (fourteen or more bed) community ICFs/MR may access an HCS slot within 12 months of referral.
This process is effective in meeting the demand as long as there is new funding and attrition slots. Since 1999, approximately 2000 individuals have left large community ICFs/MR and state schools for community-based waiver services.
Money Follows the Person Demonstration
As stated earlier, Texas’ MFP program was the basis of the federal MFP program included in the Deficit Reduction Act of 2005, Section 6071. Texas MFP will receive up to $18 million in enhanced Medicaid funding through 2011 for a Texas MFP Demonstration. Texas was one of the original grantees to receive funding from the $1.75 billion national demonstration program.
- The Texas Demonstration will target 2,999 additional individuals who are current residents of the following institutions:
- Nursing Facilities
- Large ICFs/MR (14 or more beds)
- State Schools
- Medium ICFs/MR (9-13 beds) whose providers want to close their facilities
In addition to those populations currently served under the initiative, four specialized projects are part of the Demonstration.
Behavioral Health Pilot: Individuals in Bexar County will be provided two new Demonstration services: Cognitive Adaptation Training and Adult Substance Abuse Training Services (Department of State Health Services (DSHS) has the lead on this initiative.).
Post-relocation contacts: Relocation specialists will provide intensive post-relocation contacts with individuals to provide outside support and continuity with the relocation.
Overnight Companion Support Services: Individuals in Cameron, Hidalgo, and Willacy Counties who have complex functional or medical needs will be able to hire an attendant during normal sleeping hours to be available for emergency situations and assistance with daily living activities, such as toileting.
Voluntary Closure of Nine or More Beds Community ICFs/MR: Providers of these facilities will have an opportunity to work with DADS to voluntarily close their facilities and convert to a different business model. All residents of these facilities will be given freedom of choice on where they want to live in terms of community settings or another ICF/MR.
Money Follows the Person Behavioral Health Demonstration Pilot (MFP BH)
Individuals with behavioral health conditions face particular challenges in transitioning back to the community from nursing facilities. The MFP BH Demonstration provides two specialized services in addition to regular Home and Community-based Services (HCS) waiver services to assist such individuals. Cognitive Adaptation Training assists adults with severe mental illness to re-learn the activities of daily living. Substance abuse counseling is provided to individuals with a history of substance abuse before and after transition to help support continued recovery and to prevent relapse. If successful, the pilot will result in the addition of these services to the community-based, nursing facility waiver service array throughout Texas.
3. Quality Monitoring and Improvement
Texas has developed and is continuing to expand systems to use data to monitor and improve the quality of services provided in various long-term services and supports settings.
Quality Oversight Plan
HHSC, in concert with DADS, is developing a Quality Oversight Plan and related processes to provide oversight of the 1915(c) waivers that DADS operates. The Quality Management Functions identified by CMS in their Quality Assurance Framework, discovery, remediation, and improvement, provide the underpinnings for the Quality Oversight Plan. The plan focuses on assurances that the state makes to CMS regarding administrative oversight, level of care activities, qualified providers, service plans, client health and welfare, and financial accountability.
The plan also calls for an interagency Quality Review Team to monitor detailed measures for each assurance, identify areas needing further investigation or improvement, and monitoring remediation activities. This team will also identify best practices in one or more waivers that could be applied to other waivers or programs.
DADS Quality Monitoring Program
DADS Quality Monitoring Program consists of registered nurses, nutritionists and pharmacists, who provide technical assistance and education on evidence-based best practices to all of the state’s 1,130 nursing facilities. Topics include a variety of clinical issues such as the use of psychoactive medication, management of unintended weight loss, fall risk management, pain assessment and pain management. A particularly successful measure of the program’s achievement is a dramatic reduction in the use of restraints in Texas in recent years. A related website, TexasQualityMatters.org, supplements the program by providing online access to best-practices information and links to related research. DADS is also developing a Quality Monitoring Program model for ICFs/MR and assisted living facilities.
STAR+Plus Quality
In addition to monitoring services in the long-term care setting, data-driven performance measures for contracted Medicaid managed care organizations (MCOs) in Texas provide the state with the means to review and monitor the following: access to care, use of facilities for ambulatory care sensitive conditions (ACSCs), women’s preventive and maternal health care, and care for chronic illnesses (such as asthma, diabetes, and high blood pressure). Additionally, self-reported data and special data files sent to the state from the MCOs give the state the ability to monitor provider networks, provider and member hotlines, use of nursing facilities, and various financial aspects of MCO operations and service delivery.
The state has incorporated other methods of monitoring and managing MCO service delivery and outcomes for quality. It has established at-risk premium performance measures and a quality challenge pool through value-based purchasing contracting that provide financial and non-financial incentives for MCOs to meet specific standards of performance on an annual basis.
Outcome and Experience Surveys
DADS manages two large face-to-face and clinical survey projects that measure individual outcomes and experiences in long-term care settings. The department contracts with an external third party to conduct the assessments and surveys. The results of both projects are used to benchmark quality improvement efforts in the agency. Reports are provided to the Legislature and published on the TexasQualityMatters.org web site.
The Nursing Facility Quality Review provides a structured clinical assessment of individuals’ care and treatment in Medicaid-funded nursing facilities. The process is based on first-hand nursing assessments, interviews and clinical record reviews conducted by contracted nurses. A review of the care, treatment, and satisfaction of a statistically valid sample of about 2,000 residents is conducted annually.
The second survey project, Long Term Services and Supports Quality Review, is a compilation of information from a statistically valid sample of individuals with intellectual, developmental, or physical disabilities who receive long-term services in the community and/or in an ICF/MR. Survey instruments were developed by the National Core Indicators project and by Medstat in cooperation with CMS. Survey domains include access to services, choice and control, community inclusion, and health and welfare. In 2007, 2,934 face-to-face interviews were conducted.
Texas also contracts with an External Quality Review Organization (EQRO) to assist the state in monitoring quality of care, access to care, client satisfaction with care, and health plan performance for Medicaid Managed Care Organizations contracting with the state. On a biennial basis, the EQRO administers a comprehensive Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to members enrolled in managed care acute care health plans under State of Texas Access Reform (STAR) contracts, and clients enrolled in the Primary Care Case Management (PCCM) State Plan Amendment (SPA) managed care service delivery mechanism. In addition to the biennial CAHPS surveys for STAR and PCCM, the EQRO conducts annual CAHPS surveys with members of managed care health plans contracted under the 1915(b) and (c) waivers that serve clients eligible for acute care and long-term care services and support provided by contracted MCOs participating in the STAR+PLUS program.
Fall Prevention Collaborative
DADS is sponsoring a Falls Prevention collaborative partnership between the Texas Association of Area Agencies on Aging (T4A) and Texas A&M Health Science Center School of Rural Public Health. The grant project concentrates on systematically improving fall prevention for older Texans. The A Matter of Balance (AMOB) fall prevention program is a two-pronged approach to fall prevention, focusing on changing both attitudes and behaviors that predispose older persons to falls. Sessions focus on promoting a view of falls and fear of falling as controllable and also include information to help participants change their environments to reduce fall risk factors and learn exercises that increase strength and balance.
4. Program of All-Inclusive Care for the Elderly (PACE)
The Program of All-Inclusive Care for the Elderly (PACE) provides community-based services in a licensed adult day care to frail elderly individuals who qualify for nursing facility placement. The PACE program uses a comprehensive care approach, which includes an array of services for a capitated monthly fee that is below the cost of comparable care.
PACE programs help older people remain at home and in the community as long as medically, socially, and economically feasible. The key elements of the service delivery strategy are preventive care, maximum rehabilitation, and substitution of low-cost services for high-cost services.
The PACE model serves only adults age 55 and older who are certified as needing nursing facility level of care, are able to live safely in the community at the time of enrollment, and who reside in a defined geographic area.
A multidisciplinary team assesses needs, then plans and directly delivers all services via program staff, or under fixed-rate contracts with hospitals, skilled nursing facilities, and medical specialists. The risk-based PACE differs from the brokerage model, which depends on others to provide services.
- PACE provides all health or health-related services needed including:
- inpatient and outpatient medical care,
- specialty services including dentistry and podiatry,
- social services,
- in-home care,
- meals,
- transportation and
- rehabilitative services.
PACE combines payments from Medicare, Medicaid, and program participants. Each PACE site bears 100-percent financial risk for the complete care of its locked-in census. Medicare, Medicaid, and the individual each pay a monthly "premium" based on the individual's entitlement. The average per capita rate is lower than traditional long-term care costs. PACE integrates the long-term care financial responsibilities of Medicare, Medicaid, and the individual into a single unrestricted pool of funds. The model places cost control responsibility in the hands of the service providers without externally imposed cost constraints, such as limits on eligibility or benefit packages. It is designed to give positive incentives to these providers to use resources appropriately and efficiently.
In Fiscal Year 2008, PACE was operating in two sites: El Paso and Amarillo. The estimated monthly number of individuals served is 908, at a monthly cost of $2747.50.
Use of health information technology (electronic health records, e-prescribing, electronic billing, etc.)
Medicaid Management Information System (MMIS)
The Texas Health and Human Services Commission (HHSC) is the single state agency responsible for the State’s Medicaid Program, which serves approximately 2.9 million clients per month. HHSC has final authority for the Medicaid Management Information System (MMIS)—a distributed group of computer processing operations—in partnership with a coalition of seven collaborating vendors working under the name of the Texas Medicaid and Healthcare Partnership. The MMIS processes and adjudicates Medicaid claims, with some exceptions, and can accept electronic claims and make payments by electronic fund transfer for all provider types.
Health Passport
On April 1, 2008, HHSC implemented State of Texas Access Reform (STAR) Health, a statewide medical services delivery model for children in foster care. One important component of the STAR Health program is the Health Passport, a web-based electronic health record on each child that facilitates information sharing and medical services coordination among the child’s health care providers, the Department of Family and Protective Services staff, and caregivers. The Passport allows immediate access to a child’s basic health records so that care is less likely to be disrupted if a child moves to a new placement or location. The Passport is available to authorized users through a secure, password-protected website administered by the STAR Health managed care organization. Data available for viewing in the Passport includes:
- information from medical, dental, and behavioral health claims
- information from pharmacy claims for filled prescriptions
- immunization records from the state’s immunization registry, IMMTRAC
- allergies and vital signs if entered by an authorized health care provider
- monthly behavioral health assessments for children receiving behavioral health services
- Texas Health Steps exam forms
- laboratory test results (when available) from selected laboratories
- other relevant health care information that can be faxed to and stored in the Passport
Transformation Grant
In 2007, HHSC received a $4 million Medicaid Transformation Grant from the federal Centers for Medicare and Medicaid Services for development and post-implementation enhancements of the Health Passport. HHSC is using the grant funds to improve the Passport, such as an interoperability component to allow individual providers to share health information from their existing in-office medical record system. Texas is also studying the feasibility of developing an electronic health record and electronic prescribing for all children in Medicaid and CHIP. In support of evolving industry and federal health information technology initiatives such as electronic health records, the Medicaid and CHIP Division has formed a governance group to coordinate efforts within the Commission and external stakeholders, and to develop a strategy for encouraging the use of information technology that supports improvements in the quality of care for Medicaid clients.
Electronic Health Records in Long-term Care Facilities
DADS contracts with the Texas Tech Health Science Center on a continuing research study to identify factors that hinder and facilitate the implementation of Electronic Health Records (EHRs) in long-term care (LTC) facilities. The results of the study will provide policy makers and LTC leaders with information to develop strategies to support and promote the diffusion of EHRs in LTC with the ultimate goal of improving care. The goals of the project are to analyze the current status of Electronic Health Record (EHR) adoption and its impact on clinical outcomes in Texas Nursing Facilities (NF). Phases of the project will include: a comprehensive description of the a) experiences, challenges and benefits of EHR adoption; and b) EHR functionalities currently being used in adopter facilities in Texas, information regarding differences in organizational and resident outcomes before and after adoption of an EHR system, a comparison of organizational and resident outcomes among adopter and non-adopter facilities, and a survey of all long-term care facilities in Texas to determine their technology adoption status and intentions.
Expanding coverage through private sector initiatives
Health Care and Medicaid Reform 1115 Demonstration Waiver
In June 2007, the 80th Texas Legislature Regular Session, 2007, passed and Governor Rick Perry signed Senate Bill (SB) 10, creating a foundation to transform the Texas health care system and increase the number of Texans with access to primary and preventive care through health insurance coverage. This comprehensive legislation and the state’s pending Section 1115 Waiver proposal are based upon the principles of personal responsibility, broader flexibility, and improved purchasing strategy.
Health coverage secured under the pending Section 1115 Waiver is intended to promote a culture of insurance in place of episodic, uncompensated care for the uninsured. To enhance this transition, the program leverages employer-sponsored insurance.
Consistent with the bill provisions of Senate Bill 10, Texas proposed under this Section 1115 Waiver to also strengthen and expand the existing Health Insurance Premium Payment (HIPP) Program. The bill includes significant new provisions that will assist in identifying potential HIPP enrollees and facilitate increased participation in the program. The state will also develop similar options for individuals eligible for Health Opportunity Pool (HOP) subsidies through which they can access available coverage for themselves and/or family members. The HOP is a trust fund that will include Disproportionate Share Hospital, Upper Payment Limit, and other federal funds approved through the waiver. These funds will be used to reimburse safety net hospitals, and will also be used to provide funding for subsidies and system transformation grants.
This waiver also seeks authority to develop a CHIP Premium Assistance Program. This program is designed to provide a set subsidy to allow families to purchase employer-sponsored coverage for CHIP eligible child(ren) as well as parents and other family members who are not eligible for Medicaid or CHIP.
Texas is seeking approval to use federal funds to develop insurance reforms and options for affordable products and insurance portability, including providing subsidies for targeted uninsured Texans to purchase market based insurance and other coverage options. Initially, uninsured parents with incomes up to 133% of the federal poverty level (FPL) and childless adults with incomes up to 100% FPL will be eligible for subsidies. Texas seeks flexibility to increase coverage up to 200% FPL, as funding allows. Subsidies may be used to purchase market based insurance and other coverage options. By providing subsidies to be used for private insurance and other coverage options, reform will:
- Intervene in the unsustainable trends in uncompensated care, the uninsured, and increasing pressure on Medicaid and other public programs.
- Reduce the number of uninsured.
- Create affordable insurance options, insurance innovation, and portability in the insurance system.
Lastly, S.B. 10 authorized HHSC to develop a grant program to support regional and local health-care programs (also known as multi-share or three-share programs). The grants aim to foster the initial development and operation of regional and local health care programs that seek to increase accessibility, availability, and affordability of health services or benefits to employees of small employers.
By fostering the establishment and operation of regional and local health care programs, this grant program will help to:
- Improve the health of employees of small employers and their families by increasing employee access to health care by reducing the number of those employees who are uninsured.
- Reduce the likelihood that those employees and their families will require services from publicly funded programs such as Medicaid and CHIP.
- Contribute to economic development by helping small businesses remain competitive with a healthy workforce and health care benefits that will attract employees.
- Encourage innovative solutions for providing and funding health care services and benefits.
In the spring of 2008, HHSC made available a total of $1 million for one-time grants. The contract period for these grants began April 1, 2008, and will expire on November 30, 2009. HHSC awarded grants to two separate entities; each of these entities is made up of members working on behalf of multiple communities. The grant awardees are the Brazos Valley Council of Governments (BVCOG) and the Texas Communities Healthcare Coalition.
NorthSTAR
The NorthSTAR Program is a publicly funded managed care approach to the delivery of mental health and chemical dependency services to eligible residents of Dallas, Ellis, Collin, Hunt, Navarro, Rockwall and Kaufman counties. NorthSTAR was initially implemented by the legacy agencies of the Texas Department of Mental Health and Mental Retardation and the Texas Commission on Alcohol and Drug Abuse in 1999, and is now under the direction of the Texas Department of State Health Services. Funding for the program‘s budget includes Medicaid dollars, state general revenue dollars, federal block grant dollars, other state agency funds, as well as county funding. The pooled purchasing approach of NorthSTAR transformed separately funded and disparate systems of care with different eligibility requirements into one system of care. DSHS contracts with a limited-services Health Maintenance Organization to insure a population, and through a broad network of providers, manage a comprehensive mental health/substance abuse benefit package for all eligible individuals. Individuals’ access to benefits is determined by clinical need, not funding source.
Eligibility criteria for enrollment are as follows: Most Medicaid Temporary Assistance for Needy Families (TANF) and Supplemental Security Income (SSI) recipients are automatically enrolled because of their Medicaid status. Criteria for enrollment for non-Medicaid are as follows: 1) must reside in the service area; 2) must meet clinical criteria for enrollment (Mental Health-Bipolar, Schizophrenia, or Major Depression diagnosis, Substance Abuse/Chemical Dependency-either a substance abuse or chemical dependency diagnosis); 3) must be financially eligible (less than or equal to 200% federal poverty level); and 4) have no other insurance coverage for the services needed. Medicaid recipients participate through a 1915(b) waiver that was approved in 1999. The most recent renewal date was 2007.
Transparent and publicly-accessible measurements of patient outcomes and/or quality improvements
Annual Quality of Care Report
The Health and Human Services Commission Medicaid/CHIP Managed Care Operations contracts with an External Quality Review Organization to assist in analyzing and evaluating performance measures using aggregated information on managed care programs. The Annual Quality of Care Report is a report that offers information on overall member satisfaction, use of services, access/availability, and effectiveness of care in the managed care programs of State of Texas Access Reform (STAR), STAR+PLUS and CHIP. Member Surveys provide information related to member satisfaction with health care. The Member Surveys are conducted once a year for the STAR+PLUS program and for CHIP and STAR programs, it alternates every other year. Quality of Care Reports and Member Surveys are publicized on the HHSC website.
The Long-Term Care Quality Reporting System (QRS)
QRS is a public website (http://facilityquality.dads.state.tx.us/) with information about providers of long-term services and supports. Examples of content found on the website are contact information, census, ownership, and performance based on regulatory information collected by the agency. The website includes nursing facilities, intermediate care facilities, assisted living facilities, home health and hospice agencies, and all Medicaid waiver services providers. Users can see a list of providers contracted for services by county and findings from inspections.
TexasQualityMatters.org
DADS has created a centralized quality information website to inform stakeholders of quality initiatives and promote other public web-based applications that support quality monitoring at DADS. The website is available to anyone interested in information about quality assurance and improvement initiatives for long-term services and supports in community and institutional programs.
Efforts to combat fraud and abuse
The Office of Inspector General (OIG) is authorized by Section 531.102 of the Government Code and is responsible for preventing and investigating waste, fraud, and abuse in the health and human services system (HHS), and reducing inappropriate program expenditures. OIG provides program oversight of HHS activities, providers, and recipients with the goal of improving the integrity, efficiency, and effectiveness of the HHS system. OIG fulfills its responsibility through the following activities:
- Issuing sanctions and performing corrective actions against program providers and clients as appropriate;
- Auditing the use and effectiveness of state or federal funds including contract and grant funds administered by a person or state agency receiving the funds from an HHS agency;
- Researching, detecting, and identifying episodes of waste, abuse, and fraud to ensure accountability and responsible use of resources;
- Conducting investigations, reviews, and monitoring cases internally, with appropriate referral to outside agencies for further action;
- Recommending policies enhancing the prevention and detection of waste, abuse, or fraud and promoting economical and efficient administration of HHS funds; and
- Providing education, technical assistance, and training to improve quality of care, promote cost avoidance activities, and sustain improved relationships with providers
Executive Order on Fraud, Waste and Abuse
OIG’s efforts are enhanced by Governor’s Executive Order RP 36 (dated July 12, 2004) directing all state agencies to: (1) aggressively target waste, fraud, and abuse; (2) reduce inappropriate or unjustified program expenditures; (3) pursue fraud prevention; (4) and acquire, develop, and deploy risk assessment and data mining/analysis tools for fraud prevention and elimination programs. This order also requires agencies to:- Develop their own anti-fraud measures and report those efforts to the Governor's Office.
- Designate a staff member to implement fraud prevention and fraud elimination activities.
- Identify policy and organizational changes and provide legislative recommendations to improve fraud detection and prosecution efforts.
Office of Inspector General – Medicaid Fraud and Abuse Detection System (MFADS)
Under Section 531.106 of the Government Code, OIG has a contracted Medicaid Fraud, Abuse and Detection System (MFADS), an automated system that utilizes neural network technology to detect fraud, abuse, and waste. The MFADS expands OIG’s ability to detect, prevent, and recover funds lost to fraud, abuse, and waste by providing desktop access through the Business ObjectsTM tool to claims data and analysis, reports, suspect lists, and documents to support case development, investigation, and prosecution. Among MFADS components are:
- Targeted OIG-defined detection queries which hone in on known areas of fraud, abuse, and waste.
- Predictive neural network models which norm, profile, score, rank, and predict Medicaid claimant behavior to support detection of less obvious patterns of fraud, abuse and waste. The models help OIG identify, prioritize, and rank suspects so as to maximize the likelihood of recovery.
The desktop interface includes a robust case management component that allows OIG to track all cases and activity, which integrates in real time with BusinessObjects™ for reporting.
Technology Analysis, Development and Support (TADS) Section
As the section responsible for MFADS, TADS manages the MFADS contract and project; develops new targeted queries and models; and develops and resolves cases. The TADS Section comprises three units: Research Analysis and Detection (RAD), Business Analysis and Support Services (BASS) and Third Party Resources (TPR).
Nurse analysts and research specialists in RAD analyze MFADS model and query results and prepare and dispose of cases via overpayment recoupment, provider education, and referrals. RAD staff also oversees contract requirements and directs the Claims Administrator on the analysis and use of information generated by the Surveillance and Utilization Review Subsystem (SURS).
Program specialists and systems analysts in BASS support general OIG automation needs by specifying and developing applications, creating and maintaining databases, resolving data issues, administering servers and system security, and purchasing hardware and software.
Program specialists in TPR oversee the third-party liability (TPL) program to reduce Medicaid expenditures by shifting claims expense to third-party payers either by cost avoidance or post-payment recovery. Federal law and regulations require states to ensure that Medicaid recipients use all other resources available to them to pay for all or part of their medical care before turning to Medicaid. These resources may include:
- health insurance
- casualty and accident coverage
- payments from individuals who have voluntarily accepted or been assigned legal responsibility for the health care of one or more recipients.
Medicaid Provider Integrity (MPI) Section
The MPI Section pursues provider fraud, waste, and abuse in the Medicaid program by investigating all provider types for record alteration, inappropriate billings, upcoding, unbundling, recipient solicitation, and Medicaid policy and administrative violations.
MPI coordinates with local, state, and federal regulatory and law enforcement agencies when appropriate, and refers cases suspected of criminal activity to the Office of the Attorney General’s Medicaid Fraud Control Unit.
Criminal History Checks on Medicaid Provider Applicants
As required and authorized by section 32.0322 of the Human Resources Code and on behalf of the Health and Human Services Commission, OIG conducts statewide criminal history background checks for all potential Medicaid, Medicaid Managed Care, and Children with Special Health Care Needs (CSHCN) Services Program providers that submit an enrollment application through the Texas Medicaid and Healthcare Partnership (TMHP). Additionally, criminal background checks are performed on any person or business entity that meets the definition of "indirect ownership interest" as defined in 1 Texas Administrative Code (TAC) §371.1601 who applies to become a Medicaid provider or to obtain a new provider number or a performing provider number. OIG renders enrollment eligibility decisions based criminal history background check results, and handles administrative reviews of applications denied on the basis of criminal history.
General Investigations (GI)
The GI Section focuses on client fraud, waste, and abuse in all HHSC programs including Temporary Assistance for Needy Families (TANF), Food Stamps (FS), Medicaid and CHIP. GI establishes and pursues recovery of overpayments, disqualifies program beneficiaries when appropriate, coordinates and conducts covert operations involving retailers who illegally use Food Stamps, and works with local prosecutors.
Sanctions Section
The Sanctions Section receives administrative enforcement case referrals from Medicaid Provider Integrity (MPI), Research and Analysis (RADS), Surveillance and Utilization Review (SURs), the Office of Attorney General’s Medicaid Fraud Control Unit, and state licensing boards and determines the administrative sanctions/actions that are appropriate, based on the evidence obtained. Administrative sanctions and actions that are pursued include pre-payment review, payment holds, funds recovery, closed-end contracts, contract cancellation, and program suspension/exclusion, as appropriate.
Sanctions provides formal notice to Medicaid providers and persons of administrative enforcement actions, conducts informal reviews, and negotiates settlements involving overpayments and penalties. For administrative enforcement cases that are not resolved informally, Sanctions prepares the case for administrative and legal proceedings, coordinates subject matter and expert testimony and evidence, and represents HHSC and OIG in resulting contested case hearings. Sanctions also monitors and reports on overpayment recoupment, collection of penalties, and costs avoided as a result of administrative sanction actions.
Internal Affairs Unit (IA)
The Internal Affairs investigates and responds to referrals involving HHS contractor, employee, and vendor fraud. The unit conducts independent, fact-based administrative and/or criminal investigations, reviews, and analyses in accordance with applicable federal and state laws. Internal Affairs’ Computer Forensics Unit Conducts forensic analysis of reported allegations of misuse of state computer systems and other electronic peripherals. The Vital Statistics Unit coordinates with the Department of State Health Services’ Vital Statistics Unit to process all law enforcement, and other state and federal agencies’, requests for verification of birth, death, marriage, and divorce records. The team also coordinates with the Department of State Health Services and Texas Department of Public Safety to flag and track birth records for reported missing and/or exploited children, and to prevent the misuse of birth records to further the commission of fraud or other illegal activity. Internal Affairs-Vital Statistics staff, in conjunction with the Department of State Health Services, also conducts a death and birth certificate cross-match review as an identity theft prevention program.
Audit Section
The OIG Audit Section is comprised of five individual units – Subrecipient Financial Review Unit (SFRU), Contract Audit Unit (CAU), Medicaid/CHIP Audit Unit (MCAU), Outpatient/MCO Audit Unit (OMAU), and Cost Report Review Unit (CRRU). The audit units perform independent, risk-based, financial and programmatic contract and grant compliance audits across the HHS enterprise.
Medicaid/Chip Audit Unit (MCAU)
The MCAU perform audits of Medicaid/CHIP contractors to ensure the integrity of the Medicaid and CHIP programs. These audits focus on identifying potential waste, fraud and abuse to ensure that program resources are used effectively and efficiently and comply with applicable laws, regulations and contractual requirements. The Unit’s information systems audit team ensures that Medicaid and CHIP information systems operate properly.
Contract Audit Unit (CAU)
The CAU is audits contract compliance to ensure program funds are properly used to provide contracted services, to ensure recipient funds are well managed, and to serve as a deterrent to abuse and fraud within programs. The CAU performs audits of HHS contracts other than the Texas Medicaid Administrative Services (TMAS) and sub-recipient contracts, pharmacies participating in the Vendor Drug Program (VDP), and Intermediate Care Facilities (ICF) providers as mandated in 40 Texas Administrative Code §§, 9.219 through 9.269 (TAC) related to provider reimbursement and client trust funds.
Cost Report Review Unit (CRRU)
The CRRU conducts field audits and desk reviews of provider cost reports and provides other requested non-audit services. The field audits and desk reviews are designed to meet the OIG’s goal to identify and correct waste, abuse, and fraud in the Medicaid and non-Medicaid programs. Field audits and desk reviews are performed in accordance with applicable sections of the TAC, including Title 1, Part 15, Chapter 355, Subchapter A, Rule 355.106. The results of field audits, desk reviews, and modified reviews are used by the HHSC Rate Analysis Division (RAD) in its rate setting responsibilities.
Subrecipient Financial Review Unit (SFRU)
The SFRU work involves desk reviews of single audit reports (financial statements and federal/state requirements) submitted by sub-recipients, quality control reviews of Certified Public Accountant (CPA) firms who conduct single audits of subrecipients, and limited-scope audits of subrecipients. The reviews are designed to evaluate the subrecipient’s compliance with requirements of the state and/or federal program, applicable laws and regulations, the provisions of the contract agreement and achievement of performance goals. The audits are also conducted in accordance with the Single Audit Act of 1984, and related amendments of 1996 [Office of Management and Budget (OMB) Circular A-133], including the State of Texas Single Audit Circular.
Outpatient/MCO Audit Unit (OMAU)
The OMAU performs audits of cost reports to ensure they include reasonable, necessary, and allowable costs incurred in providing outpatient services under the Texas Medicaid program and that the costs are reported in a format required by the Texas Health and Human Services Commission. Audit reports issued may result in recovery of previously reimbursed costs by the Medicaid program. In addition, the OMAU also conducts reviews of Managed Care Organization’s Special Investigations Unit Fraud, Waste, and Abuse Plans.
Utilization Review
The Utilization Review unit (UR) conducts post-payment reviews of inpatient hospital and nursing facility activities. Hospital reviews comprise determining medical necessity, validating diagnosis related groups (DRGs), and examining quality of care. UR adds high-volume, error-prone DRGs to the claim sample for hospitals reimbursed through the DRG prospective payment system. On-site nursing facility reviews assess the accuracy of level-of-care assessments submitted by providers for Medicaid reimbursement. Both reviews include education at the exit conference. Nursing facility providers receive mandatory training prior to submitting their first claim.
Limited Program
The Limited Program prevents medical services abuse and promotes quality of care. The Limited Program assigns or restricts selected recipients to designated primary care providers and/or pharmacies when recipient activity indicates receipt of duplicative, excessive, contraindicated, or conflicting health care services or drugs or when review indicates abuse, misuse, or suspected fraud.
WIC (Women, Infants, and Children)
WIC is a federally-funded program providing food instruments for redemption by over 846,000 Texans at any of some 2,500 statewide WIC-authorized grocery stores. The OIG WIC Vendor Monitoring unit conducts covert in-store investigations and routine site visits to ensure compliance with applicable rules and gather evidence of potential fraud, waste, or abuse.
Quality Assurance Office (QA)
The QA Office ensures that OIG activities comply with applicable laws, rules, regulations, policies, procedures, and professional standards. QA supports OIG cases and investigations by developing, testing, deploying, refining, monitoring the use of, and training OIG staff on quantitative analysis methods and automated tools in such areas as data integrity testing, statistical sampling, normative testing, prediction, and extrapolation. QA also develops and administers the agency-wide performance reporting system and participates in numerous State-Federal projects, workgroups, and initiatives in fraud, abuse, and waste detection, monitoring, and control.
What changes would you make to the federal Title XIX so that you could provide better services to individuals and families on Medicaid in your state?
- Simplify the overall administration of the program. Align administrative structure and requirements along the lines of more streamlined commercial insurance programs with necessary protections for the Medicaid population.
- Provide states with additional flexibility to manage the programs, as long as states assure quality of care and appropriate access to services.
- Reimburse states at the Federal Matching Assistance Program (FMAP) rate for case management services provided by state employees managing 1915 (c) waiver clients if it is shown to be cost saving. (A compromise could be a rate that is higher than the administrative match but lower than the FMAP rate.)
- Allow states the authority to provide required services with a preference for community-based care. The current structure preferences institutional care as an entitlement program.
- Research, pursue, and provide support and assistance to states for bold program innovation, development and implementation, and communicate best practices broadly. The Centers for Medicare and Medicaid Services (CMS) should integrate research-based approaches into program design and management for longer-term successes and partnerships with states in managing this joint state/federal program. A longer view of program investment might produce short-term increased costs in some programs but are highly likely to result in longer-term program savings.
- Support logical, consistent approaches to program management and incentives.
- Revise the current approach to calculating Medicaid savings: Look at Medicaid costs and savings in the context of the bigger federal budget picture. For example, states should be able to claim savings to Supplemental Security Income (SSI), Supplemental Security Disability Income (SSDI), Medicare, block grant and other sources in their demonstration waiver cost effectiveness calculations if they can empirically demonstrate the savings to CMS. CMS should also encourage blending of federal, state and local funding streams into more efficient delivery systems. Current 1915(b) managed care waiver rate policies are based on the assumption that Medicaid is not related to other federal and state systems of care. Cross-system efficiencies are not rewarded in this siloed and categorical approach. One example would be to separate Medicaid eligibility from SSI eligibility, enabling states to fund health and substance abuse treatment services for individuals before they become physically disabled as a result of substance dependence (and, therefore, become more expensive to care for in the long term).
- Continue in the direction of the Deficit Reduction Act (DRA) for community-based services, but clarify the language and approach so it is simpler and better meets needs and allows states to achieve the identified goal. For example, simplify Home and Community-Based Services for Elderly and Disabled Individuals under Sec 1915(i) of the Social Security Act to:
- allow state plan amendment consumers to qualify at the same income level as 1915(c) waiver clients (300% of SSI);
- enable states to have multiple state plan amendments just as they are allowed to implement multiple 1915(c) waivers customized to the needs of various populations; and enable states to propose innovative community-based services in addition to those statutorily defined, as they are allowed to do under 1915(c) waivers.
What are your future plans?
Texas policymakers are considering several types of Medicaid reforms including:
Texas is pursuing a Section 1115 waiver designed to improve the efficiency of health care investments in Texas, reduce the number of uninsured, focus on keeping Texans healthy, optimize the use of funds and seek federal funding flexibility to create efficient health care investments. Additional objectives include supporting healthy lifestyles, consumer choice and responsibility, and pursuing public-private partnerships. Texas’ plan will transform state investments in health care by more directly supporting broader access to primary and preventive care through value-based competitive insurance and coverage models. Texas will more effectively drive quality and efficiency while improving access to health coverage, leading to better health outcomes for Texans. The programs will include deployment of a range of consumer options for health insurance and coverage, including health savings accounts (if feasible). Texas’ reform website is: http://www.hhs.state.tx.us/Medicaid/Reform.shtml
Proposed reform efforts also include:
- Development of tailored benefit packages for children with special health care needs;
- Development of more extensive care management programs for populations with chronic conditions;
- Further development of health care technology, including e-prescribing, health passports, and integration with electronic health records.
Also, during calendar year 2009 the Texas Health and Human Services Commission (HHSC) will begin statewide implementation of the Medicaid Eligibility and Health Information Project (MEHIP). The project has several major objectives.
First, the plastic magnetic stripe card will replace the current paper forms used by the Medicaid program as a vehicle for communication of eligibility identification. Rather than mailing monthly paper cards with client eligibility information to millions of people, clients will receive a plastic card at the time of Medicaid enrollment.
Second, the magnetic stripe card will allow clients and providers to access health care information about the card holder. This health care information is associated with Medicaid/CHIP claims, encounters, as well as vendor drug data and immunization history and is accessed through a secure, HIPAA compliant portal via the Internet.
HHSC will issue a request for proposals in September 2008 to select a contractor for the project, and the system will likely be in place by the second half of 2009.
Finally, the OIG plans to seek authority through the rulemaking process for Medicaid and CHIP cases with suspected fraud to be pursued through a process of administrative hearings. Currently suspected fraud cases are referred for prosecution only. Specific authority to utilize an administrative process to establish an intentional program violation in Medicaid and CHIP when prosecution is not appropriate will enhance the ability of the state to recover overpaid benefits.