Texas

State Medicaid Integration Tracker

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Managed LTSS Program

Through Medicaid §1115 authority, Texas STAR+PLUS (inception: 1998) provides primary, acute, behavioral, and LTSS (Personal Attendant, Assisted Living, PERS, nursing, Adult Foster Care, dental, respite, home-delivered meals, OT/PT/ST, consumer directed services, home mods, medical supplies) to eligible adults age 21 and older with disability (SSI), adults age 21 and older in Community-Based Alternatives HCBS waiver, adults age 65 and older, and full-benefit Medicare-Medicaid enrollees. Certain groups are excluded, such as people living in nursing facilities, ICFs-MR, and in HCBS waivers other than the community-based alternatives waiver. Enrollment is mandatory for full-benefit Medicare-Medicaid enrollees. (Source: CMS and Truven Health Analytics, The Growth of Managed Long-Term Services and Supports (MLTSS) Programs: A 2012 Update, July 2012) Program Website

Under the Healthcare Transformation and Quality Improvement Program §1115 demonstration waiver (Approved 12/12/2011), Texas is expanding STAR and STAR+PLUS (MMLTC) statewide and using savings from the expansion of managed care and the discontinuation of supplemental provider payments to finance new funding pools to assist hospitals and other providers with uncompensated care costs and to promote delivery system transformation and improvement. The Texas Health & Human Services Commission submitted a proposed amendment to the §1115 on 5/3/2012, proposing to add Day Activity Health Services to the existing STAR+PLUS waiver, effective September 1, 2012. The service targets individuals who are eligible for the STAR+PLUS waiver and exceed the financial requirements for Day Activity and Health Services under the §1915(i) authority. Services include nursing and personal care, physical rehabilitation, noon meal and snacks, social, educational and recreational activities, and transportation. (Source: Medicaid.gov)
CMS Approval Letter (12/12/2011)
Approval Document (Effective 12/12/2011)

The Texas Health and Human Services Commission (HHSC) promulgated new permanent payment rules that implement the provider eligibility requirements and payment methodologies approved by CMS under the §1115 Healthcare Transformation and Quality Improvement Program waiver. (Source: Texas Register, June 22, 2012)
State information on the adopted rules

On June 19, 2013, the state submitted a further amendment to its §1115 demonstration waiver; and CMS approved the amendment on March 6, 2014. The amendment allows the state to make several managed care changes to the §1115 waiver, including carving nursing facility services into managed care and adding additional mental health services and HCBS to managed care. The addition of cognitive rehabilitative services is effective March 6, 2014; all other amendment changes are effective September 1, 2014. (Source: CMS.gov)
Request for Amendment (Submitted 6/19/2013)
Approval Document (Effective 3/6/2014 and 9/1/2014)

In a March 2014 information session, Texas HHS verified it will expand STAR+PLUS statewide on September 1, 2014. On this date, the state will implement the Behavioral Health carve-in to managed care and I/DD acute care service carve-ins to managed care. People living in nursing facilities will move into STAR+PLUS Medicaid managed care on March 1, 2015. (Source: HMA Weekly Roundup, January 29, 2014; Texas HHS Managed Care Informational PowerPoint, March 2014, link no longer available; State Health and Human Services website)
Texas HHS Managed Care Informational PowerPoint, link no longer available (3/2014)

On June 16, 2014, the state released an update on its §1115 waiver Delivery System Reform Incentive Payment (DSRIP) project related to Behavioral Health. The five-year Medicaid demonstration waiver includes an $11.4 billion DSRIP pool to support coordinated care and quality improvements through 20 regional healthcare partnerships. (Source: HMA Weekly Roundup, 6/18/2014; Presentation to the House Appropriations Article II Subcommittee: Behavioral Healthcare Projects in the 1115 Transformation Waiver; 6/16/2014)

On March 1, 2015, the state expanded managed care to include nursing home residents.  People living in nursing facilities will now receive full Medicaid managed care coverage through a STAR+PLUS health plan.  (Source:  State HHSC website)

On March 3, 2015, the North Texas Behavioral Health Authority (NTBHA) submitted to HHSC/DSHS a proposed plan to phase out the NorthSTAR behavioral health managed care program and replace it with an administration services organization (ASO) contract to continue the provision of managed behavioral health services in Dallas, Ellis, Rockwall, Navarro, Hunt, and Kaufman Counties.  The proposed plan is in line with the Sunset Advisory Commission’s recommendation to transition from NorthSTAR to an updated behavioral health services model.  (Source:  NTBHA website)
Sunset Issue 9:  NorthSTAR PowerPoint Presentation, link no longer available (1/13/2015)
NTBHA Preliminary Plan for Indigent BH Services, link no longer available (3/3/2015)

The Texas Health and Human Services Commission (HHSC) circulated a Request for Information (RFI) for MCOs that are interested in establishing a managed LTSS program for individuals with intellectual and developmental disabilities, or the IDD population, in Texas. Responses were due to HHSC by August 20, 2015. (Source: Texas HHSC, 7/20/2015; HMA Roundup, 7/29/2015)

On October 1, 2015, the Texas Health and Human Services Commission (HHSC) announced awards regarding a request for proposal (RFP) that integrates children eligible for Supplemental Security Income (SSI) and other SSI-related home and community-based service (HCBS) programs into the state’s STAR Kids managed care program. The program goes into effect in the fall of 2016. (Source: RFP Announcement 10/1/2015)

The Texas Health and Human Services Commission (HHSC) has requested CMS approval, through a section 1115 amendment, of the addition of STAR+PLUS HCBS Program slots that were newly appropriated by the 84th Texas Legislature, as well as a new electronic process for assessing the STAR+PLUS HCBS Program individual service plans. (Source: Medicaid.gov 11/30/2015)

The Texas Health and Human Services Commission (HHSC) announced on November 15, 2016, that it will reprocure contracts for the entire state under STAR+PLUS, which is the state’s MLTSS program. Initially HHSC intended on only reprocuring the Dallas and Tarrant areas. The anticipated implementation date is January 1, 2019. (Source: HHSC 11/15/2016) 

On December 22, 2016, the Texas Health & Human Services Commission (HHSC) released a request for information (RFI) regarding the provision of acute care and LTSS through the state’s STAR+PLUS managed care program. Responses were due January 30, 2017. HHSC is seeking information on strategies to provide quality, comprehensive acute and LTSS care in a manner that improves beneficiary health; intervention strategies to avoid disparities in health care delivery to diverse populations and; choice of health plans for STAR+PLUS members. Additionally, respondents were asked to respond with innovative, cost-effective, and evidence-based practices and strategies on the following elements:

  • Improvements to current service coordination requirements;
  • New approaches in care coordination for persons with physical, mental, emotion, intellectual, or developmental disabilities;
  • New approaches to the LTSS assessment process;
  • New approaches to person-centered service planning as well as measuring impactful outcomes for individuals;
  • Innovative approaches for improving independence, community involvement, and employment for individuals with disabilities;
  • Innovative methods of providing behavioral health services to individuals with disabilities;
  • Improvements that can be made to  facilitate better access to care; and
  • Innovative methods of delivery system reform, such as value-based payments or patient-centered medical homes. (Source: RFI 12/22/2016)

On June 29, 2017, HealthPayer Intelligence reported that the Texas Health & Human Services Commission has submitted an extension request to CMS for the state’s section 1115 waiver, which includes three key programs: Medicaid managed care, including MLTSS; the state’s uncompensated care (UC) funding; and the Delivery System Reform Incentive Payment (DSRIP) program. If approved, the 1115 waiver would be extended through September 30, 2019 (Source: HealthPayer Intelligence 6/29/2017)

On June 19, 2017, the Texas Health & Human Services Commission selected Molina Healthcare of Texas, and United Healthcare Community Plan of Texas, as the two MCOs for the state’s Intellectual and Developmental Disability (IDD) Pilot Program. The program will pilot a fully capitated Medicaid managed care arrangement that includes both LTSS and acute care services for the I/DD population.

The authorizing legislation behind the program is S.B. 7, which was passed in 2013, and requires HHSC and the Department of Aging and Disability Services (DADS) to establish a program to serve Medicaid enrollees with I/DD through a coordinated system of managed care for their acute and LTSS benefits. Initial implementation commenced in 2014, when certain individuals receiving care in ICF/IDD facilities and enrollees in I/DD waivers were enrolled in STAR+PLUS for their acute care services. Ultimately, the state intends to gradually implement full integration of all ICFs/IDD and IDD waivers into managed care by 2021.

The pilot will be voluntary, and is allowed to operate for up to two years. Individuals enrolled in the following waivers may opt-in to the program:

  • Home and community-based Services (HCS)
  • Deaf Blind with Multiple Disabilities (DBMD)
  • Community Living Assistance and Supports Services (CLASS) (Source: Award Notice, link no longer available 6/19/2017; Pilot RFP)

The Texas Health and Human Services Commission announced that it will align the procurement cycles and operational start dates for the following programs: STAR+PLUS, STAR, and CHIP. The revised operational start date for all three programs will now be September 1, 2019. (Source: Texas.gov 7/28/2017)

On September 15, 2017, the Texas Health and Human Services Commission (HHSC) released a draft request for proposals (RFP) for the STAR+PLUS Medicaid managed care program that includes LTSS. HHSC is seeking to re-procure two MCOs for each service area, which are: Bexar; Central Texas, Dallas, El Paso; Harris; Hidalgo; Jefferson; Lubbock; Northeast Texas; Nueces; Tarrant; Travis; and West Texas. The draft RFP was open through October 14, 2017, and HHSC was seeking input and ideas to improve and expand support services for STAR+PLUS. The final RFP is expected in November 2017, with services commencing in September 2019. (Source: Draft RFP 9/15/2017)

Texas has cancelled a planned I/DD Medicaid managed care pilot, which was discussed at a Health and Human Services Commission (HHSC) I/DD System Redesign Advisory Committee meeting on October 3, 2017. Instead, HHSC will include parameters in the upcoming STAR+PLUS request for proposals (RFP) for MCOs to be prepared for the addition of this population into Medicaid managed care and MLTSS. (Source: HHSC Website 10/3/2017)

On December 4, 2017, the Texas HHSC released its RFP to re-procure the STAR+PLUS Medicaid managed care program, which provides acute and LTSS services to approximately 529,966 adults 65 and older, and those that are blind or have a disability. The procurement is statewide, and includes the following service areas (SAs): Bexar; Central Texas; Dallas; El Paso; Harris; Hidalgo; Jefferson; Lubbock; Northeast Texas; Nueces; Tarrant; Travis; and West Texas. HHSC will award contracts to a minimum of two MCOs per each SA.

HHSC notes that service coordination will be a key component of the re-procured program, including adequate levels of personnel to manage the everyday service needs of beneficiaries, including those with I/DD and dual eligibles. MCOs must demonstrate readiness to serve the I/DD population and provide LTSS in the event that HHSC adds this population to STAR+PLUS.

Populations included in the STAR+PLUS program where participation is mandatory include:

  • Supplemental Security Income (SSA) eligibles age 21 and above;
  • Individuals 21 and older who are eligible for Medicaid due to being in a Social Security Exclusion Program;
  • Beneficiaries who quality for the STAR+PLUS HCBS program;
  • Medicaid residents of licensed nursing facilities (NFs);
  • Dual eligibles who are 21 and older;
  • Beneficiaries eligible for the Medicaid for Breast and Cervical Cancer program;
  • Individuals enrolled in certain 1915(c) waiver programs will receive acute care services from an MCO:
    • Community Living Assistance and Support Services (CLASS);
    • Home and Community-based Services (HCS);
    • Deaf-Blind Multiple Disability waiver (DBMD); and
    • Texas Home Living (TxHml).
  • Residents of community-based intermediate care facilities for individuals with I/DD or related conditions (ICF/IIDs) will receive acute services from an MCO.

Populations excluded from STAR+PLUS are:

  • Residents of state supported living centers (SSLCs), institutions of mental disease, individuals residing in a pediatric care facility class of NFs, or any State Veterans Home;
  • Participants in the states’ dual eligible demonstration, PACE program, or dual eligibles not eligible for full Medicaid benefits.

Responses to the RFP are due March 5, 2018. HHSC expects contracts to begin October 2018, with an operational start date of January 1, 2020. HHSC expects enrollment to reach 530,000. (Source: RFP 12/4/2017) 

On December 21, 2017, the Texas Health and Human Services Commissions (HHSC) announced it has received approval for a five-year renewal of the state’s 1115 waiver, which enables the continued use of Medicaid managed care, and also funds the state’s Uncompensated Care (UC) pool and the Delivery System Reform Incentive Payment (DSRIP) program. Regarding DSRIP, CMS will provide two years of level funding, two years of reduced funding, and then on the fifth year DSRIP funding will cease for the state. (Texas HHSC 12/21/2017)

On July 23, 2018, Texas STAR+PLUS reposted the cancelled Request for Proposals (RFP) for Medicaid managed care services in its statewide procurement. The original RFP was cancelled on July 5, 2018.  STAR+PLUS, a MLTSS program for older adults and people with disabilities, serves 529,966 members (2016) statewide with five plans—Amerigroup/Anthem, Cigna, Centene, Molina, and UnitedHealthcare. The proposals are solicited to expand the program and to ensure that at least two MCOs exist for each service area. (Sources: Texas Comptroller, 07-05-2019, Texas Comptroller, 7-31-2018 and HMA Weekly Roundup, 07-11-2018)
 

Recently, a Dallas Morning News investigation reported that the Medicaid MCO system is failing the state’s most vulnerable Texans. Subsequently, on June 27, 2018, the Texas House General Investigating and Ethics Committee convened a hearing where patients, advocates, and executives of five health plans reported on the status of the state’s Medicaid managed care program. (Texas Tribune, 06-27-2018, Dallas Morning News, 06-03-2018, and HMA Weekly Roundup, 07-11-2018)

Texas released a comprehensive report, known as the “Rider 61 Report,” that assesses the state’s managed care system. The report includes information about the state’s STAR+PLUS program, which includes MLTSS. Notably, the report included an audit examining ways to reduce costs through administrative efficiencies. The report cited the STAR+PLUS program as having high aggregate administrative expenses. Sources: State of Reform (10-11-2018); Texas HHSC (8-17-2018).

On October 2, 2018, the Dallas Morning News reported that the Texas Health and Human Services Commission cancelled its procurement for Medicaid managed care, including MLTSS, and would re-issue the RFP after finding flaws in the procurement process specifically related to rules around minority owned businesses. Texas reopened the procurement for STAR+PLUS and required all bidders to resubmit as if no previous procurement had taken place. The new deadline was November 15, 2018.

Sources: Dallas Morning News (10-2-2018); Texas Online Procurement System (10-1-2018)

STAR Kids

Beginning September 1, 2015, most children and young adults under the age of 21 who get SSI Medicaid or HCBS will receive some or all of their Medicaid services through a new program known as STAR Kids. This program is a Medicaid managed care model designed specifically for children and young adults with special needs. Enrollees will receive comprehensive service coordination. Children and youth enrolled in the Medically Dependent Children Program and children enrolled in the Youth Empowerment Services mental health and substance abuse waiver will receive all of their services (LTSS and acute care) through STAR Kids. Individuals who receive services through other home and community-based programs administered by DADS will continue to receive LTSS through that program, but will receive acute care through STAR Kids. (Source: Texas HHS Managed Care Informational PowerPoint, March 2014; HMA Weekly Roundup, January 29, 2014)

State Demonstration to Integrate Care for Dual Eligible Individuals

In May 2012, the state submitted to CMS a proposal for the Texas Dual Eligibles Integrated Care Demonstration Project. (Source: NASDDDS Managed Care Tracking Report, October 2012)
Demonstration Proposal (5/2012)

On May 23, 2014, CMS and the state signed an MOU for the Texas Dual Eligibles Integrated Care Demonstration Project. The demonstration will be open to all duals in six counties (Bexar, Dallas, El Paso, Harris, Hidalgo, and Tarrant) aged 21 and older, with exception of following: 1) Duals residing in ICF/IIDs; and 2) Duals receiving services through the following §1915(c) waivers: Community Living Assistance and Support Services; Deaf Blind with Multiple Disabilities Program; Home and Community-Based Services; and Texas Home Living Program. Additionally, duals currently enrolled in a Medicare Advantage plan operated by a parent organization that is not participating in the demonstration must disenroll from their current MA plan. Existing STAR+PLUS Medicaid managed care plans in the six counties will serve the duals demonstration population as STAR+PLUS Medicare-Medicaid Plans (MMPs).

STAR+PLUS MMPs will begin receiving opt-in enrollments in January 2015, with passive enrollment set to begin on March 1, 2015. Enrollees will be able to opt-out of enrollment at any time, effective on the first day of the following month. (Source: HMA Weekly Roundup, 5/28/2014; CMS.gov, 7/2014; State Duals Demonstration website, 7/2/2014) 
Memorandum of Understanding (5/23/2014)
MOU Addendum (6/6/2014)
Three-Way Contract for Demonstration (11/18/2014)

The state has delayed its duals demonstration implementation until March 1, 2015. The state will begin opt-in enrollment in March 2015 and passive enrollment in April 2015. (Source: Texas HHS website)
Texas HHS Commission Presentation, link no longer avialble (9/3/2014)
Texas Readiness Review Tool (9/29/2014)

On March 1, 2015, the state began rolling out its dual eligible demonstration program.  The program will be limited to dual eligible clients in the state’s six most populated counties:  Bexar, Dallas, El Paso; Harris, Hidalgo, and Tarrant.  Full implementation is expected by Summer 2015.  (Source:  State HHSC website; HMA Weekly Roundup, 3/11/2015)

On May 28, 2015, Atlantic Information Services, Inc. reported that enrollment in Texas’ duals demonstration has reached 27,616 participants, primarily as a result of the state’s passive enrollment program. (Source: AIS Health, 5/28/2015)

 

Texas’ Demonstration Year 1 (Calendar Years 2015-2016) for the Texas Dual Eligible Integrated Care Project included five plans.  All Financial Alignment Demonstrations include a provision to ‘withhold’ a portion of the Medicare-Medicaid Plans’ capitation rate that can be recaptured if the MMPs meet quality measures.  The average percent of performance measures meeting criteria ranged from 75% (2015) to 61% (2016). In 2016, none of the plans met 100% of the performance measures—with the plans ranging from 50%-83%. The average percent of quality withholds recaptured for the five plans was 65% in 2016—with three plans receiving only 50% of the withheld funds and one plan receiving 100%. This is a decline from earlier in the demonstration (2015) when the plans received an average of 75% of withheld funds. (Source: TX Medicare-Medicaid Plan Demo Year 1, 6-19-2018)
 

Balancing Incentive Program

On September 4, 2012, CMS approved the state's BIP application, awarding $301.5 million of enhanced Medicaid funds. Texas must implement the required structural changes and achieve a 50 percent benchmark of Medicaid community-based LTSS expenditures by October 2015. HHSC has delegated coordination of BIP activities to DADS. (Source: State website)
BIP Application (6/29/2012)
BIP Structural Change Work Plan (link no longer available) 

Section 1915(i) HCBS State Plan Option (Withdrawn)

Texas submitted a proposed §1915(i) HCBS State Plan Amendment to CMS; however, the state later withdrew its proposed SPA. (Source: Kaiser HCBS State Plan Option website, 5/2014)

Section 1915(k) Community First Choice Option

Senate Bill 7 from the 2013 Texas Legislature required the state to put in place a cost-effective option for attendant and habilitation services for people with disabilities who have STAR+PLUS Medicaid coverage. The Community First Choice Option will provide a 6 percent increase in federal matching funds for Medicaid for these services. Texas is planning to begin a Community First Choice program on March 1, 2015. This means: individuals on a 1915(c) waiver interest list who meet eligibility and coverage requirements will be eligible on March 1, 2015 to get Community First Choice services; and individuals already getting services through a 1915(c) waiver will continue to get those services exactly as they do today from their existing providers. (Source: State CFC website, 6/2014)

As of November 2014, the state has officially submitted a Section 1915(k) Community First Choice Option SPA to CMS for approval.  (Source:  Kaiser Community First Choice website, 10/2014)

Texas received approval of its Community First Choice Option SPA on April 2, 2015. (Source: SPA Summary 6/2/2015)