Filling the need for trusted information on national health issues…

Trending on kff Medicare & Medicaid at 50 Individual Market Medicaid Expansion

Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared – Appendix – Texas – 8426-06 « » The Henry J. Kaiser Family Foundation

Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS


MOU Signed: May 23, 2014
3-way contract not yet available
Demonstration Duration: 3 years
March 1, 2015 to Dec. 31, 2018
Target Group:
Includes:  an estimated 168,000 full benefit dual eligible beneficiaries with disabilities age 21 and older who qualify for SSI benefits or Medicaid home and community-based STAR+PLUS waiver services; PACE and Independence at Home enrollees may enroll in the demonstration if they disenroll from their current program; beneficiaries enrolled in a Medicare Advantage plan not operated by the same parent organization that operates a STAR+PLUS Medicare-Medicaid Plan may enroll in the demonstration if they disenroll from their existing plan
Excludes:  dual eligible beneficiaries who are residents of an ICF/DD or receive services through the Community Living and Support Services, Deaf Blind with Multiple Disabilities Program, Home and Community-Based Services or Texas Home Living Program § 1915(c) waivers
Geographic Area: 6 counties:  Bexar, Dallas, El Paso, Harris, Hidalgo, and Tarrant; CMS and the state may change and/or add up to 2 additional counties to the demonstration if, before the scheduled start date, a situation arises that would limit beneficiary choice or the quality or availability of services would decrease in any service area – such a change is subject to ongoing stakeholder discussions and must be effectuated by Jan. 1, 2016
Initial enrollment period is voluntary, followed by passive enrollment phased-in over at least 6 months during which the remaining beneficiaries in the target population will be automatically enrolled
Voluntary enrollment will be effective March 1, 2015.  For the first 6 months of the demonstration, CMS and the state will monitor plans’ capacity to manage voluntary and passive enrollments; depending on plan capacity, beneficiaries will be passively enrolled into plans, considering the number of voluntary enrollments and the opt-out rate for each plan.  In Harris County, passive enrollment will not exceed 5,000 beneficiaries per month per plan.  In Bexar, Dallas, El Paso, Hidalgo, and Tarrant counties, passive enrollment will not exceed 3,000 beneficiaries per plan per month.  Beneficiaries subject to Medicare reassignment effective Jan. 1, 2015 will be eligible for passive enrollment no earlier than Jan. 1, 2016.  Beneficiaries will receive enrollment notices 60 days and 30 days prior to passive enrollment
Beneficiaries may opt out of the demonstration until the last day of the month prior to enrollment and thereafter on a monthly basis
Texas’s existing § 1115 Medicaid demonstration waiver requires Medicaid managed care enrollment; the waiver expires Sept. 30, 2016 and must be renewed to continue the financial alignment demonstration
Passive enrollment will be based on an “intelligent assignment” algorithm that prioritizes continuity of providers and/or services and considers beneficiaries’ previous managed care enrollment and historic provider utilization
Financing: Capitated with savings percentage (1.25% in year one(a), 2.75% in year one(b), 3.75% in year two, 5.5% in year three) applied upfront to baseline Medicare and Medicaid contributions; capitation rate qualify withhold same as in California (1% in year 1, 2% in year 2, 3% in year 3)1
Medicare baseline for capitated payments:  Same as California2
Medicare risk adjustment:  Same as California
Medicaid baseline for capitated payments:  Capitation rates in the state’s Medicaid § 1115 managed care demonstration that would otherwise apply, adjusted to add historical costs for benefits and Medicare cost-sharing not included in the Medicaid demonstration capitation rates
Medicaid risk adjustment: Rating categories consistent with the state’s § 1115 Medicaid demonstration with financial incentives for HCBS over NF care3
Risk sharing: Plans must pay an “Experience Rebate” to the state, which will be distributed back to the Medicare and Medicaid programs, if plan net income before taxes is greater than specified percentages for each demonstration year;4 beginning in year 2, the amount of administrative expenses used to determine net income before taxes will be capped
Care Delivery Model: STAR+PLUS Medicare-Medicaid Plans will provide care management of medical and behavioral health, prescription drug, and LTSS.
Participating Health Plans:
Bexar County:  Amerigroup, Molina, Superior
Dallas County:  Molina, Superior
El Paso County:  Amerigroup, Superior
Harris County:  Amerigroup, Molina, United
Hidalgo County:  Health Spring, Molina, Superior
Tarrant County:  Amerigroup, Health Spring5
Plans will provide all Medicare and Medicaid benefits, other than Medicare hospice.  Includes STAR+PLUS home and community-based waiver services
Plans have discretion to offer flexible benefits as appropriate to beneficiary needs
Continuity of Care: Beneficiaries must be able to maintain their current providers and service authorizations up to 90 days, with further details to be specified in the 3-way contract; in addition, beneficiaries receiving LTSS at the time of enrollment, including nursing facility services, will maintain service authorization up to 6 months, and beneficiaries being treated for a terminal illness at the time of enrollment shall have continued access to covered services for 9 months
Ombuds Program: The state Health and Human Services Commission Office of the Ombudsman will support individual advocacy in the demonstration, provide feedback on plan performance issues to CMS and the state, and gather and report data.
Stakeholder Engagement: Same as California
Notice:  Same as California (single integrated notice)
Timeframe to request initial appeal:  60 days to file health plan appeal for Medicare or Medicaid benefits; 90 days to request Medicaid fair hearing
Internal health plan appeal:  initial Medicare appeal is filed with health plan; initial Medicaid appeal is filed with health plan or beneficiary may directly request fair hearing; health plan appeals must be resolved within 30 calendar days for standard appeals and 72 hours for expedited appeals except that appeals related to an ongoing emergency or denial of continued hospitalization must be resolved no later than one business day
External Medicare appeals:  same as California
External Medicaid appeals:  Same as California except that Independent Medical Review not mentioned
Appeals where Medicare and Medicaid services overlap:  not mentioned in MOU
Continued benefits pending appeal:  Medicare services will be required to continue pending resolution of internal plan appeal.  Medicaid services will continue pending internal plan appeal and fair hearing if aid pending request is timely.  Payments will not be recouped based on the appeal outcome.
Medicare Part D appeals:  Same as California (existing Medicare Part D appeals process continues to apply)


South Carolina Virginia