Dec 31, 2020 — wheelchairs, highly configurable manual wheelchairs, adaptive seating and positioning systems, and other specialized equipment,
17 pages
128 KB – 17 Pages
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State Medicaid Managed Care Advisory Committee Annual Report to the 87 th Texas Legislature As Required by Texas Administrative Code Title 1, Part 15, Chapter 351, Subchapter B, Division 1 Rule 351.805 (d)( 2 ) State Medicaid Managed Care Advisory Committee December 2020
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1 About This Report This report was prepared by members of the State Medicaid Managed Care Advisory Committee. The opinions and recommendations expressed in this report are the Services Commission Executive Council or the Texas Health and Human Services Commission. The information c ontained in this document was discussed and voted upon at regularly scheduled meetings in accordance with the Texas Open Meetings Act. Information about these meetings is available at: https://hhs.texas.gov/about – hhs/leadership/advisory – committees/state – medicaid – managed – care – advisory – committee Report Date December 2020 Contact Information For more information on this report, pleas e contact: David A. Weden, Chair, State Medicaid Managed Care Advisory Committee Chief Administrative Officer/Chief Financial Officer, Integral Care Email: david.weden@integralcare.org
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2 Table of Contents Table of Contents .. .. . 2 1. Letter from the Chair .. .. 3 2. Committee Recommendations from 2019 .. . 5 Recommendation 1 .. .. . 5 Brief Explanation Regarding Recommendation 1 .. 5 Recommendation 2 .. .. . 6 Brief Explanation Regarding Recommendation 2 .. 7 3. Committee Recommendations from 2020 .. . 8 Recommendation 1 .. .. . 8 Recommendation 2 .. .. . 8 Recommendation 3 .. .. . 8 Recommendation 4 .. .. . 8 Recommendation 5 .. .. . 8 Recommendation 6 .. .. . 8 Brief Explanation Regarding Recommendations 1 through 6 . 9 Recommendation 7 .. .. .. 10 Brief Explanation Regarding Recommendation 7 .. . 10 Recommendation 8 .. .. .. 10 Brief Explanation Regarding Recommendation 8 .. . 10 Recommendation 9 .. .. .. 11 Recommenda tion 10 .. .. 11 Recommendation 11 .. .. 12 Brief Explanation Regarding Recommendations 10 and 11 .. 12 Recommendation 12 .. .. 12 Brief Explanation Regarding Recommendation 12 .. 12 Recommendation 13 .. .. 13 Brief Explanation Regarding Reco mmendation 13 .. 13 Recommendation 14 .. .. 14 4. Meeting Dates .. .. .. 15 5. Members as of December 2020 .. 16
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3 1. Letter from the Chair Dear Members of the Texas Legislature and Health and Human Services Executive Commissioner Cecile Young : The State Medicaid Managed Care Advisory Committee (SMMCAC) is pleased to submit our bi annual report, due by December 31, 2020 in accordance with Texas Administrative Code Title 1, Part 15, Chapter 351, Subchapter B, Division 1 Rule 351.805(d)( 2 ) On behalf of the SMMCAC, I want to begin by thanking the Texas Legislature, everyone at Health and Human Services Commission (HHSC), everyone with the Medicaid managed care plans, all of the providers throughout the state, and the individuals receiving Med icaid services along with their families and advocates. The changes that have been made over 2020 to ensure some of the most vulnerable citizens in our state were able to receive critical services while maintaining a safe environment due to COVID – 19 are s ome of the most expansive and swiftest changes we have seen in our system of care. The level of effort and cooperation shown throughout the system demonstrate why it takes all of us working together to meet the needs of our citizens. It speaks to the hea rt of this SMMCAC. The SMMCAC is comprised of representatives from individuals receiving services and their family members or advocates, representatives of Managed Care Organizations, and representatives of provider organizations. Working together, as a s ystem of care, we gain a greater understanding of challenges and collaborate to find ways to continuously improve our system of care in order to more efficiently and effectively serve Texans through Medicaid Managed Care in Texas. As per the Texas Admini strative Code Rule 351.805(b), the purpose of the SMMCAC is as follows: 1. The SMMCAC advises HHSC on the statewide operation of Medicaid managed care, including program design and benefits, systemic concerns from consumers and providers, efficiency and quali ty of services, contract requirements, provider network adequacy, trends in claims processing, and other issues as requested by the Executive Commissioner. 2. The SMMCAC assists HHSC with Medicaid managed care issues 3. The SMMCAC disseminates Medicaid managed c are best practice information as appropriate.
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4 According to the Texas Medicaid and CHIP Reference Guide Twelfth Edition, 92% of individuals in Medicaid and CHIP in Te x as, approximately 4.1 million individuals, receive services through managed care. As memb ers of the SMMCAC, it is our honor and privilege to serve these Texans by working together and making recommendations for continued improvement of the managed care service delivery system. Thank you for this opportunity to serve. The following report incl udes reporting of SMMCAC activities as well as recommendations of the committee. Respectfully , David A. Weden Chair, State Medicaid Managed Care Advisory Committee
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5 2. Committee Recommendations from 2019 Recommendation 1 The SMMCAC recommends standardizing the service management and service coordination terminology in the managed care contracts to service coordination. Brief Explanation Regarding Recommendation 1 The 2018 – 19 General Appropriations Act, Senate Bill 1, 85 th Legislature, Regular Session, 2017 ( Article II, Special Provisions Relating to All Health and Human Service Agencies, Section 25) required HHSC, in collaboration with Department of Family and Protective Services (DFPS), Department of State Health Services (DSHS), and Medicaid and CHIP managed care organizations (MCOs) to review and report opportunities to streamline case management services. In May 2018, HHSC published the Health and Human Services System and Managed Care Report in response to this requirement. Recommendations stemmin g from this report include: 1. Further assess service coordination and service management in the context of managed care, taking into account different service coordination and service management structures. 2. Align the use of case management terms that are eas ily misunderstood or sound duplicative (such as service coordination and service management) to ensure greater understanding of the services. Recommendation #1 seeks to increase clarity of terminology used in managed care for care – coordination – related func tions which aligns with item 2 above. This recommendation would simplify and standardize the terminology used for similar functions. The recommendation is not intended to alter the current definitions and scope of work surrounding the existing terms. Ra ther, the implementation of this recommendation would create levels of service/stratification within the new terminology. The recommendation could be implemented with contracting cycles beginning on or after September 1, 2020. The committee believes the r ecommendation will help consumers/clients and providers by simplifying existing terminology that can be misunderstood or confusing. During discussions, some concerns were raised
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7 Brief Explanation Regarding Recommendation 2 Senate Bill 1177, 86 th Texas Legislature, Regular Session, 2019 amended Secti on 533.005, Government Code by adding Subsection (g) to read as follows: (g) In addition to the requirements specified by Subsection (a), a contract described by that subsection must contain language permitting a managed care organization to offer medicall y appropriate, cost – effective, evidence – based services from a list approved by the state Medicaid managed care advisory committee and included in the contract in lieu of mental health or substance use disorder services specified in the state Medicaid plan. A recipient is not required to use a service from the list included in the contract in lieu of another mental health or substance use disorder service specified in the state Medicaid plan. The commission shall: (1) prepare and submit an annual report to the legislature on the number of times during the preceding year a service from the list included in the contract is used; and (2) take into consideration the actual cost and use of any services from the list included in the contract that are offered by a managed care organization when setting the capitation rates for that organization under the contract. This recommendation provides an initial list approved by SMMCAC for consideration by HHSC in managed care contracts. Documentation regarding the evidence behind each service on the list is being provided by various stakeholders to appropriate HHSC staff for review, and the Clinical Oversight and Benefits Subcommittee of SMMCAC intends to discuss the recommended in lieu of services further in anticipation of helpi ng prioritize potential availability. It is hoped that some of the in lieu of services on the list can be fully vetted with Center for Medicare and Medicaid Services and made available with the contract cycle beginning September 2021 at the latest. Analysis of potential financial impact will be reviewed for each service in conjunction with HHSC staff. It is anticipated that most, if not all, of the in lieu of services on the list will show a net savings as they are available in lieu of potentially c ostlier services. Additional updated information on this item may be found under recommendation 13 in the Committee Recommendations for 2020 section of this report.
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8 3. Committee Recommendations from 2020 Recommendation 1 HHSC should develop a list of excepti ons to telehealth/telemedicine and ensure fee for service align with the intent of Senate Bill 670 (86 th Texas Legislature, Regular Session). Recommendation 2 HHSC should ensure all telehealth and telemedicine is included in the medical portion of the Medi cal Loss Ratio. Recommendation 3 HHSC is encouraged to conduct an environmental scan regarding any barriers administratively that may limit or discourage utilization of telehealth and telemedicine. Recommendation 4 HHSC should review potential means for in cluding telehealth and telemedicine in network adequacy standards. Recommendation 5 Recommend HHSC consider covering audio only, telehealth/telemedicine services and extending indefinitely the modalities to have increased access to care, and more services be covered by telehealth/telemedicine in line with national coverage standards (e.g. Medicare). Recommendation 6 Recommend that HHSC permanently allow service coordination assessments and face – to – face visits to occur by way of a telehealth modality if medi cally appropriate, member; in order to reduce costs, improve access to service coordination, and improve efficiency.
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9 Brief Explanation Regarding Recommendations 1 through 6 Reco mmendations 1 through 6 deal with availability of telemedicine and telehealth for various services throughout the Medicaid managed care system. As allowances have been made during the public health emergency related to COVID – 19, the managed care system ha s pivoted to have available virtual and telephonic services , help ing ensure the safety and care of Texans with Medicaid coverage. As we move forward, the committee believes it is imperative that we retain appropriate flexibility in service delivery models to help ensure individuals receive appropriate services in a manner that is clinically appropriate as well as convenient to the individual receiving services . Video as well as telephonic contacts are being encouraged to be considered for continuation as i ndividuals at high risk for COVID – 19 need to maintain as much isolation as possible and not all individuals have direct access to video technology or appropriate broadband for video services. In addition, maintaining the various modalities can help addres s availability of services within Health Professional Shortage Areas. In reviewing the interactive maps of Health Professional Shortage Areas (HPSA) at https://dshs.texas.gov/tpco/HPSADesignati on/ , the following HPSAs are noted: Primary Care HPSA Designations 199 Full Counties and 14 partial counties Mental Health HPSA Designations 206 Full Counties and 4 partial counties Dental HPSA Designations 80 Full Counties and 3 partial counties Maintaining telehealth and telephonic services as clinically appropriate would help make services more readily available for individuals with Medicaid coverage. The service delivery options would help remove some challenges with transportation or time need ed to travel for services, thereby encouraging individuals to reach out for more appropriate access to routine services instead of waiting until a more critical need arose before reaching out for service. In addition, the Centers for Medicare & Medicaid Services (CMS) recently passed new rules that encourage the utilization of telehealth as well as flexibility within Medicare to count telehealth providers in certain specialty areas toward meeting CMS network adequacy standards. With the number of HPSAs a cross the state, the committee also believes consideration of similar means to include telehealth and telemedicine in Medicaid Managed Care network adequacy standards should be considered.
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10 Recommendation 7 Recommend review for relief from the duplicative a nd burdensome (provider) enrollment and credentialing process, request a more streamlined and tighter sequencing of processes, review federal requirements and best practices to streamline the process so that providers can start providing services more quic kly , and to allow retro date for service reimbursement to date of enrollment and allow one enrollment to be completed for approval by all MCOs and TMHP. Brief Explanation Regarding Recommendation 7 Positive changes in the provider enrollment process have been accomplished in the recent past, such as the credentialing verification for MCO applications. There continues, however, to be a burdensome and delayed enrollment with TMHP and then a provider m ust credential with MCOs. Providers are asking for consideration of steps or progress that can be taken toward a single application for enrollment and credentialing that is required for reimbursement . In addition, a review should be completed regarding t he possibility for reimbursement back to the application or enrollment date of the provider who provided treatment to Medicaid Managed Care patients. Recommendation 8 Recommend HHSC consider and explore any potential access and quality issues due to issue s resulting from reimbursement rates set for Durable Medical Equipment (DME) and if there is a need for establishing a separate recognition and coverage for Complex Rehab Technology products and the services that incorporate the customized nature of the te chnology and the broad range of services necessary to meet the unique medical and functional needs of people with significant disabilities and complex medical conditions . Brief Explanation Regarding Recommendation 8 The Durable Medical Equipment (DME) bene fit was created over forty years ago to address the medical equipment needs of older individuals. Over the years, available technology has advanced and now includes complex rehab power wheelchairs, highly configurable manual wheelchairs, adaptive seating and positioning systems, and other specialized equipment, such as standing frames and gait trainers.
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