Cook Children s Health Plan STAR Kids Update

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Sharyl Cooper
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1 Cook Children s Health Plan 1 Cook Children s Health Plan STAR Kids Update October 5 th, 2016 UNTHCS Grand Rounds Cook Children s Health Plan 2 STAR Kids Program Overview STAR Kids -- new Texas Medicaid managed care program that will provide comprehensive benefits starting November 1, 2016, to children and adults 20 years with multiple diagnosis, high-needs healthcare needs and complex care management requirements. Enrollment is mandatory for those eligible. History -- Multiple stakeholder groups advocated for a managed care solution for children with disabilities over 3 legislative cycles (6 years); STAR Kids legislation finally passed, and 3 years later, it will be implemented. Cook Children s Health Plan 3 STAR Kids Program (con t) To be eligible for STAR Kids, children and young adults must be currently on Medicaid or one of the following programs: Supplemental Security Income (SSI), including Medicare duals; Medically Dependent Children Program (MDCP) waiver; Youth Empowerment Services (YES) waiver; Live in community-based intermediate care or nursing facility for intellectual and development disability or related conditions (IDD); Medicaid Buy-In program or any of these Department of Aging and Disability Services (DADS) IDD waivers: o Community Living Assistance and Support Services (CLASS) o Deaf Blind with Multiple Disabilities (DBMD) o Home and Community-based Services (HCS) o Texas Home Living (TxHmL) 1

2 Cook Children s Health Plan 4 STAR Kids Program (con t) The STAR KIDS program will provide benefits such as: primary and specialty care hospital care preventive care prescription drugs personal care services private duty nursing and durable medical equipment and supplies long term services and support (LTSS) Also, a core component of this program will be a standard screening and assessment (SAI) process used to assess member s needs and create individual service plans (ISP). Cook Children s Health Plan 5 STAR Kids Program (con t) MCOs to set-up specialty networks for LTSS services Adaptive Aids (AA) - Including vehicle modifications Flexible Family Services and Supports (FFSS)* i.e. Personal Care Attendant (PCA) Minor Home Modifications (MHM) e.g. wheel chair ramps, widening doorways Respite Services in-home* and out-of-home Private Duty Nursing (PDN) and Personal Care Services (PCS) Transition Assistance Services (TAS) for relocation from institutional care to community Employment Services Employment Assistance (EA)* supports to locate employment and obtain a job Supported Employment (SE)* supports for individual to maintain employment Financial Management Services (FMS) professional services to support payroll and human resource requirements so families can exercise consumer-directed options and hire their own care attendants Emergency Response System (ERS) The I ve fallen and I can t get up systems * Indicates consumer-directed options exist Cook Children s Health Plan 6 STAR Kids Program (con t) Texas HHSC requires plans to develop the Patientcentered Health Home (PCHH) concept for the STAR KIDS population with all willing providers MCOs and PCHH providers will be held to established thresholds for EPSDT (THSteps) compliance Note; expect greater difficulties with EPSDT completion with the CMC population as patient mobility and transportation complexities offer little incentive for families to go to the doctor when child is not sick Texas HHSC requires establishment of targeted outreach programs, especially when care gaps are identified 2

Cook Children s Health Plan 7 Around 175,000 children are expected to be eligible statewide with between 14,000 16,000 in the Tarrant Service

Cook Children s Health Plan 8 STAR Kids Program (con t) Members will stratify into 3 levels of service coordination: Level 1 MDCP Complex needs

receive PCS or RN services or who need higher levels of care based on nursing assessment Substance abuse with multiple visits, hospitalization,

3 Cook Children s Health Plan 7 Around 175,000 children are expected to be eligible statewide with between 14,000 16,000 in the Tarrant Service Delivery Area (SDA). With two MCOs in the Tarrant SDA, CCHP projects our membership at approximately 10,500 once patient enrollment begins. Cook Children s Health Plan 8 STAR Kids Program (con t) Members will stratify into 3 levels of service coordination: Level 1 MDCP Complex needs medical, developmental and/or behavioral health SED or SPMI Members at-risk for institutionalization Level 2 Not classified as Level 1 but receive PCS or RN services or who need higher levels of care based on nursing assessment Substance abuse with multiple visits, hospitalization, institutionalization Behavioral health issues significantly impairing function Level 3 All others Cook Children s Health Plan 9 * shown with parental permission 3

4 Cook Children s Health Plan 10 Staffing Projections High I 30 II 75 III 6 Support Staff Med I 25 II 45 III 9 Support Staff Currently at 90% Low I 20 II 33 III 11 Support Staff ,500 9,000 10,500 12,000 15,000 (50%) (60%) (70%) (80%) (100%) Cook Children s Health Plan 11 Cook Children s Health Plan 12 Service Coordination Process Overview Partnering Service Coordination staff with members, parents/other caregivers to maximize health, well-being, and care independence Improve access to care and care coordination addressing the unique needs of members and their families Provide assistance to ensure timely and coordinated access to services and providers 4

5 Cook Children s Health Plan 13 Service Coordinators Service coordinators (case managers) identify members needs via a validated assessment tool for person-centered approach remove barriers to meeting those needs facilitate access and member empowerment Complexity will involve challenges in 1domain: physical, psychological, social and access to needed healthcare services RNs, SWs and LPCs all equally effective when trained in ICM (Integrated Case Management) Cook Children s Health Plan 14 Service Coordinators Screening Telephonic screening attempted for all members within 15 days of enrollment Screening determines priority for Screening and Assessment Interview (SAI) process completion and identifies urgent needs for immediate referral for services coordination SAI appointment priority: within 7 days if urgent, unmet needs identified within 30 days for most complex patients with services need all others, within 6 months Cook Children s Health Plan 15 Service Coordinator Assessment, Planning and Services Delivery Complete SAI (Screening and Assessment Interview) process initially as per telephone screening priority, then annually and whenever significant change in life circumstances occur Assessments scheduled by member priority level: 1. enroll after start date and request immediate services 2. with most urgent unmet needs for services or care coordination 3. with few unmet needs currently receiving services required to maintain stable 4. current MDCP recipients 5

6 Cook Children s Health Plan 16 Service Coordinator (con t) Assessment, Planning and Services Delivery Completion of SAI informs development of individualized services plans to address identified patient health needs development of Individualized Plan of Care (IPC) that includes member needs, goals, objectives and planned interventions Coordinate care with non-covered services available through other sources Work closely with members, families and providers to ensure seamless coordination of needed services Cook Children s Health Plan 17 STAR Kids Program Members stratification Level 1 services coordination: most complex MDCP patients Patients with complex medical needs or a history of developmental/behavioral health conditions Patients at risk for institutionalization Named RN Services Coordinator Annual Screening and Assessment, and as needed Minimum of 4 in-person visits per year Minimum of 1 telephonic outreach contact per month Cook Children s Health Plan 18 STAR Kids Program Members stratification (con t) Level 2: Patients who do not satisfy level 1 requirements but receive personal care or home nursing services Patients who would benefit from higher levels of services coordination based of needs assessments Patients with a history of substance abuse or other behavioral health conditions that impair function Named Services Coordinator Annual Screening and Assessment, and as needed Minimum of 2 in-person visits per year Minimum of 6 telephonic outreach contacts per year 6

7 Cook Children s Health Plan 19 STAR Kids Program Members stratification (con t) Level 3: Patients who do not qualify for levels 1 or 2 services coordination requirements Services Coordinator Minimum of 1 in-person assessments per year Minimum of 3 telephonic outreach contacts per year Level three members in waiver programs will be assigned a named Services Coordinator. Members or their LARs may also be assigned a named Services Coordinator upon request. Cook Children s Health Plan 20 Service Coordination Integrated Case Management highest level of intervention Members with disease complexity that adversely impacts the stability of their condition Named Service Coordinator facilitates support for the member and LAR Emphasizes collaboration with the medical home Cook Children s Health Plan 21 STAR Kids Program (con t) Members will stratify into 3 levels of services coordination: Level 1 Named RN Service Coordinator Minimum of 4 face-to-face RN-administered assessments/year Minimum of 1 telephonic outreach per month Level 2 Named Service Coordinator Minimum of 2 face-to-face RN-administered assessments/year Minimum of 6 telephonic outreach per year Level 3 Named Service Coordinator Minimum of 1 face-to-face RN-administered assessments/year Minimum of 3 telephonic outreach per year 7

8 Cook Children s Health Plan 22 Service Coordination Pod Unit Team Approach Service Coordinators work as members of a 5-person team, within the structure of a Pod Pod team members include nurses, social workers, and support staff The SAI determines member s Level of Care (1, 2 or 3) which then determines their Pod assignment Pod structure designed to facilitate team communication and to allow for quick team huddles Seating space for 6 allows for easy access to additional team members who support the team Cook Children s Health Plan 23 Skill Set Registered Nurse Licensed Master Social Worker Licensed Baccalaureate Social Worker Support Staff CCHP Pod Model LMSW/LCSW RN Support Staff Cook Children s Health Plan 24 CCHP Pod Model LMSW/LCSW RN LMSW/LCSW RN Skill Set Registered Nurse Licensed Master Social Worker Licensed Baccalaureate Social Worker Support Staff Support Staff Support Staff 8

9 Cook Children s Health Plan 25 CCHP Pod Model LMSW/LCSW RN RN LMSW/LCSW Beacon Beacon LTSS Support Staff Transition Specialist Support Staff Skill Set CCHP Specialists Therapy Durable Medical Equipment PharmD Parent Coordinator Registered Nurse Licensed Master Social Worker Community Based Orgs: ECI ISDs MHMR Licensed Baccalaureate Social Worker Support Staff Beacon Long Term Support Services Transition Specialist Cook Children s Health Plan 26 Transition Specialist Transition Specialist, along with Services Coordinator and POD team, works directly with complex members, their families and other individuals in their support systems, from age 15 through 20 years to help prepare for transition to adulthood Adult transition planning addresses a member s health care and non-health care related needs Discussion with member and families begins at 10 Cook Children s Health Plan 27 Transition Specialists Non-health care related services Transition to adult STAR+PLUS benefits without break in service Independent living Supported decision-making Guardianship Personal care (habilitation services) Education and vocational training Employment Social and recreational supports 9

10 LMSW/LCSW Support Staff RN 10/3/2016 Cook Children s Health Plan 28 Evolution & Implementation of ICM Model STAR STAR Kids 120,000 members CHIP C O M P L E X I T Y Cook Children s Health Plan 29 Evolution & Implementation of ICM Model STAR STAR Kids 120,000 members CHIP C O M P L E X I T Y Cook Children s Health Plan 30 Service Coordination Organizational Structure 10

Cook Children s Health Plan 31 Service Coordination Continuity of Care Primary and Acute Services Authorizations will be honored for 6 months, until authorization expires or until a new assessment

11 Cook Children s Health Plan 31 Service Coordination Continuity of Care Primary and Acute Services Authorizations will be honored for 6 months, until authorization expires or until a new assessment and ISP is completed Long Term Services and Support Authorizations will be honored for 6 months or until a new assessment and ISP is completed. CCHP ensures members continuity of care for services from out of network providers CCHP uses best efforts to contract with or provide single case agreements for these service providers Cook Children s Health Plan 32 STAR Kids Program Cook Children s Health Plan 33 Service Coordination Conversion Planning Newly identified medically necessary services will be authorized and will remain in place until a new or updated IPC is completed with the member and parents or LAR (Legally Authorized Representative) If the members preferred providers are not in network, a STAR KIDS Provider contract or SCA (single case agreement) will be offered to the provider Service Coordinators will work with members and their LAR to arrange for any necessary transition of services 11

12 Cook Children s Health Plan 34 Utilization Management Unplanned hospital admissions are reviewed by CCHP or Beacon Inpatient UM specialists Significant communication occurs to assure LTSS services are paused and appropriately resumed at discharge. Level 1 and 2 named Service Coordinators facilitate and oversee discharge planning. New services are arranged prior to discharge. Cook Children s Health Plan 35 Denials and Appeals Dedicated Staff Denial and Appeals Coordinators Registered Nurses Bilingual Support Staff Medical Director review Additional Support Pharm D Member Advocates Management Team Cook Children s Health Plan 36 Denials and Appeals (con t) When requested services are determined not to be medically or functionally necessary Always determined by CCHP Medical Director or contracted specialist physician. Peer-to-Peer discussion is available to prescribing provider. Assigned Service Coordinator is involved in decision. Member advocate available to assist. Service Coordinator works with member and LAR to find alternative to meet member s need 12

13 Cook Children s Health Plan 37 Denials and Appeals (con t) Reconsideration prior to requesting appeal, new information submitted is reviewed by original Medical Director. If overturned, services are immediately authorized and communicated to the requesting services provider Expedited Appeal provided when emergency situation (within 24 hours of receipt) ongoing hospitalization (within 24 hours of receipt) decision impacts continuation of previously authorized services (within 72 hours of receipt) Cook Children s Health Plan 38 Denials and Appeals (con t) Appeals requested by the member, LAR or other authorized representative Appeals are reviewed by Medical Director not involved in original decision to deny Overturned -- services authorized immediately Upheld/partially upheld -- decision communicated to member and prescribing provider Thirty days to respond, unless request expedited Cook Children s Health Plan 39 Notice of Action - Appeal Rights Any notice of action must list members appeal rights, including right to a fair hearing. Member/LAR additional resources regarding appeal rights Member Handbook CCHP Website CCHP Service Coordinator Member Advocate 13

Cook Children s Health Plan 40 STAR Kids Program Reasons to Implement Most members are currently being served by CCHCS CCHP s participation in STAR Kids will maintain current CCHCS relationships for

14 Cook Children s Health Plan 40 STAR Kids Program Reasons to Implement Most members are currently being served by CCHCS CCHP s participation in STAR Kids will maintain current CCHCS relationships for patients and between-providers HHSC and MCOs have identified significant gaps in robust case management and services coordination for this population Promotes healthcare services delivery via patientcentered health home model Adding this segment of the care continuum to our existing general population will enhance our population health management capabilities Cook Children s Health Plan 41 CCHP Challenges Environmental Factors: Ongoing changes and repeated delays by HHSC Maintaining current operations while developing new product Developing a Health Plan within a Health Plan Unfamiliar Long Term Services and Support (LTSS) environment Contingency plan for CCHP in the event that Aetna does not pass readiness Cook Children s Health Plan 42 Important Dates August HHSC IT Readiness Review September HHSC on-site Operational Readiness Review End of October Preparatory review for go live November 1 STAR Kids launch Mid November Post go-live review and update Ongoing evaluation and stabilization of systems. 14

Cook Children s Health Plan 43 STAR Kids Resources

cookchp.org/english/providers/pages/ Manuals.

15 Cook Children s Health Plan 43 STAR Kids Resources CCHP STAR Kids Provider Manual - Manuals.aspx STAR Kids Advisory Committee - HHSC STAR Kids Information Cook Children s Health Plan 44 THANK STAR KIDS YOU!! Jose.Gonzalez@cookchildrens.org Kimberly.Aaron@cookchildrens.org QUESTIONS? 15

STAR Kids Update. Medicaid and CHIP Division Texas Health and Human Services Commission. August 2016

STAR Kids Update. Medicaid and CHIP Division Texas Health and Human Services Commission. August 2016 STAR Kids Update Medicaid and CHIP Division Texas Health and Human Services Commission August 2016 STAR Kids Background Senate Bill (S.B.) 7, 83rd Legislature, Regular Session, 2013, directs HHSC to establish