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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)
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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)
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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)
In October, Texas Health and Human Services Commission (HHSC) announced the contract award winners for the STAR+ PLUS MLTSS program for thirteen service areas throughout the state. Contracts have been awarded to Aetna, Amerigroup, Molina, United Health Care, Superior, and El Paso Health. STAR+PLUS serves approximately 526,000 older adults, blind individuals, and individuals with disabilities.
(Source: Medicaid STAR+PLUS Procurement Announcement; 10-29-2019)
The Texas Health and Human Services Commission, Office of Inspector General released an audit report of STAR+PLUS on August 22, 2019. The audit focused on Cigna’s compliance with contractual requirements for service coordination for STAR+PLUS enrollees with home and community-based services. Auditors tested if members receiving HCBS had individual service plans (ISPs) created for them, if service coordinators followed up with members to ensure they received their ISPs, and if members had two annual face-to-face visits from service coordinators. Auditors found that 38 percent of members receiving HCBS did not receive one or more of the activities required of service coordinators. The report includes recommendations for Cigna to improve service coordination for STAR+PLUS members.
(Source: Audit of STAR+PLUS Service Coordination: Cigna-HealthSpring; 8-22-2019)
On January 20, 2021 Texas submitted an amendment to the Texas Healthcare Transformation and Quality Improvement Program (THTQIP) 1115 demonstration waiver. This amendment would include non-emergency medical transportation (NEMT) for Medicaid managed care and MLTSS members, including older adults in the STAR+PLUS waiver, as a required covered service. This amendment stems from a state law (H.B. 1576) that requires all Medicaid managed care organizations to provide NEMT for trips requested less than 48 hours’ notice.
(Source: Texas Healthcare Transformation and Quality Improvement Program Waiver Amendment Request; 1-20-2021)
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On June 8, 2021, the Centers for Medicare & Medicaid Services (CMS) approved Texas’ request to amend the Texas Healthcare Transformation and Quality Improvement Program (THTQIP) 1115 demonstration waiver. This amendment approves non-emergency medical transportation (NEMT) for Medicaid managed care and MLTSS members, including older adults in the STAR+PLUS waiver, as a required covered service for managed care organizations (MCOs) in the state. The change in the transportation delivery system will extend through September 30, 2022.
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(Source: Texas Healthcare Transformation and Quality Improvement Program Waiver Amendment Approval; 6-8-2021)
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)
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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)
CMS released the first evaluation report for the Texas Dual Eligible Integrated Care Demonstration Project on May 24, 2019. The report explains the implementation and provides an early analysis of the demonstration project using data from key informant interviews, focus groups, Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results, and other data. Results from the evaluation include findings from the project’s inception in March 2015 to December 2017. The demonstration is implemented in six Texas counties with the highest number of Medicare and Medicaid beneficiaries. Highlights from the report include:
• Of the more than 155,000 Medicare-Medicaid enrollees eligible for the demonstration, approximately 43,000, or 28 percent, were enrolled as of November 2017. The enrollment rate has remained between 25 and 30 percent in most months.
• Most focus group participants in 2016 and 2017 indicated that their health or quality of life had improved in the previous 2 years, due to factors such as access to providers or new health benefits, weight loss achieved through Medicare-Medicaid Plan (MMP) programs, reduced out-of-pocket costs, and diminished financial stress. Most enrollees who participated in in depth interviews indicated that MMPs had little or no impact on their lives.
• Sixty-four percent of MMP enrollees responding to the CAHPS survey in 2017 rated their health plan a 9 or 10 on a scale of 0 to 10. This result is consistent with the national MMP average and the national average for Medicare Advantage plans.
(Source: TX Demonstration Project: First Evaluation Report; 5-24-2019)
CMS released a summary of quality withhold analyses of Texas’ Medicare-Medicaid Plans (MMPs) for the second demonstration year (CY 2017) of the Financial Alignment Initiative (FAI), called Texas Dual Eligible Integrated Care Project. A percentage of both state Medicaid and federal Medicare capitation rates are withheld from the MMPs to ensure quality for dually eligible individuals. MMPs can earn the withheld funds back if Federal, CMS Core, and state-specific quality withhold performance measures were met. MMPs in Texas met 71 percent of the overall quality withhold measures, 73 percent of the federal measures, and 67 percent of the state’s specific measures.
(Source: Texas Medicare-Medicaid Plan Quality Withhold Analysis Results; 8-14-2019)
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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)
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