presentation to the house human services · 2/12/2019 · presentation to the house human services...
TRANSCRIPT
Presentation to the House Human Services
Dr. Courtney N. Phillips Executive Commissioner
February 12, 2019
Mission & Vision
Our Mission:• Improving the health, safety,
and well-being of Texans with good stewardship of public resources
2
Our Vision:• Making a difference in the lives
of the people we serve
Agency Overview
• Total FTEs: 39,586
3
FY 2018-2019Expended/Budgeted
FY 2020-2021Requested
$77,508,766,079 $77,343,682,930
81.2%
7.6%4.6%
4.4%
0.6%0.6% 0.5%
0.4%
HHSC GR/GRD Appropriations 2018-19($28,680,165,476)
Medicaid Client Services (Goal A) - 81.2%Other Grants/Client Services - 7.6%MSS Program Administration - 4.6%State Hospitals/SSLCs - 4.4%System IT - 0.6%Regulatory/Inspector General - 0.6%CHIP - 0.5%Indirect Administration - 0.4%
5
Key Functions• Provides oversight and administrative
support for the HHS agencies• Administers the state’s Medicaid and other
client services programs• Provides a comprehensive array of long-
term services and supports for people with disabilities and people age 60 and older
• Operates the state’s mental health hospitals and state supported living centers
• Regulates healthcare providers, professions, and facilities to protect individuals’ health and safety
• Sets policies, defines covered benefits, and determines client eligibility for client services programs 5
6
HHSC Regional Map
TransformationSeptember 1, 2016
• Transferred client services to the Health and Human Services Commission’s (HHSC’s) new Medical & Social Services Division
• Consolidated most administrative services• Abolished the Department of Assistive and Rehabilitative
Services (DARS) and transferred functions to HHSC
September 1, 2017
• Created the Chief Policy Office, Health & Specialty Care System Division, and Regulatory Services Division
• Consolidated the remaining administrative services• Abolished the Department of Aging and Disability Services
(DADS) and transferred functions to HHSC• Made the Department of Family and Protective Services
(DFPS) a standalone agency, but HHSC continues to provide some administrative services
7
A Transformed HHS System
8
ProcurementVictoria Ford
Chief Policy Officer and Interim Chief Operating Officer
9
HHSC Procurement Reform
Values for Reform1. Nothing is more important than
ensuring Texans have the services they need, and we are doing everything we can to ensure that there are no interruptions in services to clients
2. We are working to ensure that there are no financial impacts to the state
3. We have to get this right, and we are 100 percent committed to improving our procurement processes and restoring accountability to the process
10
Reform: April – June 2018• HHSC replaced both the Chief Operating Officer and
Deputy Executive Commissioner of Procurement and Contracting Services (PCS)
• HHSC created a Compliance and Quality Control (CQC) division outside of PCS chain of command
• New management worked with multiple auditing entities and completed an extensive internal review of procurements in flight and existing policies and procedures
• Developed a comprehensive checklist with Department of Information Resources (DIR) and Comptroller of Public Accounts (CPA), revised high-risk operating procedures, aligned CQC expertise with high-risk activities (i.e. scoring and solicitation development)
11
External Audit Reports
HHSC Internal Audit PCS’ Procurement Processes• Issued July 8, 2018
State Auditor’s Office (1) The Scoring and Evaluation of Select HHSC Procurements (2) Select Contracts at HHSC
• Issued July 13, 2018; November 26, 2018
HHSC Office of Inspector General Reviewed HHS procurement process (2013-2018)
• Issued July 2018
12
Three external reviews published
Utilization of Best PracticesScoring Issues
Consistent compliance with the law and/or GAA
RemediationConsistent Compliance with the Law and/or GAA
• HHSC created a Compliance and Quality Control (CQC) division outside of the PCS chain of command
• HHSC, DIR, and the CPA developed a comprehensive checklist that includes all requirements from solicitation development to contract award
• The checklist is certified by the purchaser, approved by purchasing manager, and reviewed by CQC
• Complex procurement operating procedures were updated to reflect current legal and regulatory compliance requirements
• Ernst & Young’s improvement plan included projects designed to enhance governance, risk management, personnel development, and technology functions
13
RemediationScoring Issues• CQC analysts proficient in Microsoft Excel
now design score sheets to prevent unallowable scores (zeros and/or blanks) and aggregate evaluator score sheets into final score summaries using proper formulas and logic
• Each individual score sheet and all final score summaries are completed by one CQC analyst and reviewed by a separate analyst to ensure consistency and accuracy
• These measures match skill sets to job duties while long-term evaluation solutions are developed and tested 14
Remediation: Continual ImprovementBest Practices• Fully integrated operating procedures
incorporated into a redesigned HHSC Procurement and Contract Manual that is systematically updated
• PCS and Program staff regularly trained on business and system processes and applications
• Risk-based alignment of organizational resources to ensure effective and efficient workflow
• Enhanced reporting capabilities and coordinated, management-level oversight of all procurement and contract activities
• Continue building productive relationships with internal and external stakeholders 15
HHS Procurement and Contracting Improvement Plan (PCIP)
Ernst & Young Project Phases
• HHSC entered into a contract with Ernst & Young (EY) on July 16, 2018, beginning a 10-week engagement.
• The contract includes four stages and corresponding deliverables
• The final report including Phases I through III was delivered on October 31, 2018
o Phase 1: Assessment o Phase 2: Root Cause Analysiso Phase 3: Improvement Plan o Phase 4: Post-Implementation Evaluation (start
date TBD – 4 weeks after notice to proceed)
16
Phase 1: Assessment on Maturity Model
17
Phase II: Root Cause Analysis• HHSC’s operating model and strategic direction
of our procurement and contracting functions have not evolved to meet the needs of a heavily outsourced service delivery modelo Lack of emphasis on training and systems to support
effective functionso Inefficient, inconsistent, and over-engineered contracting
and procurement processes
• The increased volume, complexity, and oversight of transactions has amplified the effects of an unfit contracting modelo Inadequate data, reports, and access to information
• The communication structure is not sufficient for an organization of our sizeo Requires significant increase in internal communication
and collaborationo Overly restrictive approach to dealing with vendor
community18
Phase III: Improvement Plan
19
Guiding Principles
EFFICIENCYProcurement and contracting objectives will bemet through optimized processes that createsignificant value for internal and externalstakeholders. Decisions related to processeswill be compliance- and risk-based whileensuring that overall time and effort fromorganizational resources are efficiently focusedon services and goods that best serve ourclients’ needs.
BALANCED & REALISTIC EXPECTATIONSImprovement of the procurement andcontracting system will proceed with a balancedand realistic approach that takes into accountexisting and emerging organizational demandsand limitations. Projects will be implementedbased on available resources, funding andcapabilities of the organization, while strivingfor movement to greater levels of maturity andexcellence.
PROGRAM-CENTRIC CUSTOMER SERVICEProcurement and contracting willfunction in a manner that recognizesan obligation to assist and serveinternal clients, which includesconsideration of the diverse needs ofprograms and divisions utilizingprocurement and contracting services,and engaging in two-waycommunication.
ACCOUNTABILITYRoles and responsibilities of all partiesthroughout the procurement andcontracting life cycle will be clearlydefined and openly communicated.Progress toward project timelines,milestones and organizational goalswill be tracked and measured.
TRANSPARENCYAll policies, processes, workflows, data,reporting and other relevant information willbe easily accessible to internal stakeholders toallow for effective and efficient procurementand contracting operations. Stakeholders willwork cooperatively and collaboratively tocontinuously improve contracting andprocurement processes.
COMPLIANCE & ETHICSThe HHS procurement and contractingsystem will be compliant with laws andregulations to maintain the integrity ofthe organization, ensure accuracy, andbuild trust with the public and businesspartners. Audit findings will beaddressed and corrected promptly, andall system stakeholders will act in anethical manner.
20
PCIP Portfolio
21
EY’s 29 project charters were prioritized and properly sequenced into a balanced, high-impact portfolio of 15 projects that addresses the most pressing short- and long-term needs of the organization
PCIP Timeline
22
Contract Oversight & Management
23
Program PCS / CQC Legal IT• Provide
subject matter expertise
• Manage and monitor the contracts
• Initiate contractual remedies (corrective action plans, liquidated damages)
• Oversight of contract management
• Oversight, support, and quality assurance for required reporting
• Fiscal monitoring
• Drafts the contract
• Counsel on legal authority, terms and conditions, and corrective action plans (including liquidated damages)
• Manages QAT process
• Provide technical assistance for all contracts with IT components
• Facilitate Steering Committees (i.e. TMHP committee required by GAA)
Ongoing relationships that require commitment to collaboration
FY 2018 Contracts
24
HHS IT Systems Used in Procurement and
Contracting
• CAPPS Financials• System of Contract
Operation and Reporting (SCOR)
• DocuSign
Contracts, TPOs, and RGCs Active at any point during FY18
Contract Count for Top 5 Departments
25
3973
3183
1859
1170 1128
MEDICAID AND CHIP SERVICES
ACCESS AND ELIGIBILITY
HEALTH AND SPECIALTY CARE SYSTEM
HEALTH, DEVELOPMENTAL AND
INDEPENDENCE SERVICES
INTELLECTUAL AND DEVELOPMENTAL
DISABILITIES AND BEHAVIORAL HEALTH
SERVICES
14,591 Total Active Contracts in Inventory as of January 31, 2019
Contract Count for Top 5 Departments(Excluding Enrollment Contracts)
26
1725
1018
723674
260
HEALTH AND SPECIALTY CARE
SYSTEM
INTELLECTUAL AND DEVELOPMENTAL
DISABILITIES AND BEHAVIORAL HEALTH
SERVICES
MEDICAID AND CHIP SERVICES
HEALTH, DEVELOPMENTAL AND
INDEPENDENCE SERVICES
ACCESS AND ELIGIBILITY
5622 Total Active Contracts in Inventory on January 31, 2019 (Excluding Enrollment Contracts)
MedicaidStephanie Muth, State Medicaid Director
Trey Wood, Chief Financial Officer
27
Key Budget Drivers
• HHSC projects caseloads to increase by about 1 percent each year of the biennium for Medicaid and 4.5 percent for CHIP
• Medicaid cost growth ranges between 3.2 percent and 5.5 percent each year of the biennium
• Cost growth is impacted by: Utilization trends
Benefit changes
Population acuity factors
Aging and births
Evolutionary and revolutionary advances in medicine 28
Medicaid Caseload Trends
29
2,878,126
3,005,620
3,298,099
3,543,0573,655,930 3,658,629
3,746,124
4,056,702 4,060,5644,067,380
4,021,6673,968,0494,026,358
4,094,589
4,007,4524,056,515
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
Historical and Estimated Caseloads Compared With 86th Legislature Appropriated Caseloads for Fiscal Years 2008 - 2021
House Bill 1 Caseloads
Current (Prelim December 2018) Medicaid Caseload: 3,940,000Total Disability-Related Clients: 410,000 (10%)
Total Income-Eligible Children Clients: 2,884,000 (73%)
November 2018: LAR Update 2020-2021 (in italics)
House Bill 1 Caseloads
Medicaid Caseload: Final through June 2018 Preliminary data through January 2019; Forecast data starting February 2019
Medicaid Federal FundsMedicaid is an entitlement program
There is no cap on federal funding to provide eligible services to eligible persons
• Federal Medical Assistance Percentage (FMAP) is derived from each state’s average per capita income
• CMS updates the rate annually
• For federal fiscal year (FFY) 2019, Texas’ Medicaid FMAP is 58.19 percent The FFY is on a different calendar cycle than the state
fiscal year (SFY) The SFY FMAP rate is 58.08 percent (one of month the
FFY 2018 rate of 56.88 and 11 months of FFY 2019 rate of 58.19 percent)
30
CHIP Caseload Trends
31
325,744
534,091
577,102
630,646
376,366
425,082 417,819
453,671
251,575
506,968
333,707 312,101
466,242
532,888
593,619
339,831
390,625 386,377
421,648
13,643
67,84944,214 37,027 36,535 34,458 31,442 32,023
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
450,000
500,000
550,000
600,000
650,000
700,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Total CHIP Traditional CHIP CHIP Perinatal
Traditional CHIP Excludes Perinatal
CHIP program began May 2000
CHIP Perinatal ProgramIncludes perinates not eligible for Medicaid until birth. Beginning FY 2011 children go to Medicaid upon birth.
CHIP caseload: Data for FY 2018 is estimated; FY 2019-21 is projected based on November 2018 forecasts.
CHIP Federal FundsCHIP is not an entitlement program
Federal funds are capped – when a state’s CHIP funds are spent, no more are available• Like Medicaid, the match rate is derived from each
state’s average per capita income and changes annually
• States are allotted a portion of the total federal funds based on a formula then receive federal matching funds up to that allotment
• CHIP has a more favorable match rate then Medicaid• FFY 2019 match rate is 93.73 percent• The Affordable Care Act increased the match rate for: Oct. 2015 – Sept. 2019 by 23 percent FFY 2020 by 11.5 percent CHIP resumes its standard match rate in FFY 2021
32
Caseload and Cost Growth Summary
33
$419$410
$377$388 $404 $413$451$465 $475 $477 $474 $479 $491 $477 $492
$515 $528
$-
$100.00
$200.00
$300.00
$400.00
$500.00
$600.00
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Mill
ions
Texas Medicaid Acute and Long-Term Services Costs, Fiscal Years 2002-2018:Total and Per Member Per Month Costs for Full-Benefit Clients
Total Full-Benefit Cost Full-Benefit Per Member Per Month
PMPM Total Full-Benefit
Cost
Cost Growth Trends
34
+30%
Caseload is the primary drive of cost; however, despite caseload increases, Texas Medicaid cost per person cost growth is substantially lower than the national trend
2008 to 2017
Texas Medicaid Caseload Growth
+41%
Texas Medicaid Per Capita Cost Growth
+14%
U.S. Healthcare Per Capita Spending Growth*
+30%
<1.5% avg. growth per year
*Data is for Calendar Year (CY) 2008 to CY 2016
Impact Perspective
4.5 millionTexans receiving
services
14% of Texans covered
53% of Texas births covered by Medicaid
44% of Texas children on Medicaid or CHIP
62% of nursing home residents covered by Medicaid
35
Who is Eligible for Medicaid?
36
Federal law:• Requires coverage of certain populations and services• Gives flexibility for states to optional populations and services
Financial Criteria Non-Financial CriteriaHow the applicant’s income
compares to the definition of the federal poverty level (FPL) for
annual household incomes
• Age• Residency• Citizenship or alien status
Varies by program
Eligible Population CategoriesChildren and Youth Parents and Caretaker Relatives Women
Children and Adults with DisabilitiesPeople Age 65 and Older
Texas Medicaid Income Eligibility Levels
37More information on eligibility criteria for Medicaid and CHIP can be found in Chapter 1 of the 12th Edition of the Texas Medicaid and CHIP Reference Guide
% Caseload vs. % Spending
38
24%
61%7%
9%69%
30%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Caseload Spending
Non-DisabledChildrenNon-DisabledAdultsAge & Disability-Related
Major Category Spending
Programs and Services Available to Texans
39
Acute Care• Focus on preventive care, diagnostics, and
treatments• All clients enrolled in Medicaid programs are
eligible for acute care services• Examples of services include: Physician
Inpatient and outpatient hospital services
Pharmacy
Laboratory
Behavioral health
X-ray services
14
Long-Term Services & Supports (LTSS)
• Support an individual with ongoing, day-to-day activities, rather than treat or cure a disease or condition
• Must meet functional eligibility requirements
• Examples of services include: Community-based care Personal Assistance with activities of
daily living (cleaning, cooking) Nursing facility services
41
Behavioral Health Services• Treat mental health conditions
and substance use disorder (SUD)• These services are included in all
Medicaid programs• Services include: Psychiatric diagnostic evaluation Medication assisted therapy for SUD Psychological and neuropsychological
testing
42A full list of services offered in Texas is available in Appendix B of the 12th
Edition of the Texas Medicaid and CHIP Reference Guide
Service Delivery and Oversight
43
Two Models for Service Delivery
Fee-for-Service (FFS)• Clients go to any Medicaid provider• Providers submit claims directly to HHSC’s admin services
contractor for payment• Providers are paid per unit of service• Most FFS clients do not have access to service coordination
Managed Care• A managed care organization (MCO) is paid a capitated rate for
each member enrolled• MCOs provide a medical home through a primary care physician
(PCP) and referrals for specialty providers, when needed*• MCOs negotiate rates with providers• MCOs may offer value-added services
Examples: youth community or sports membership, pest control, respite care
*Exception: Clients who receive both Medicare and Medicaid (dual eligible) get acute care services and a PCP through Medicare
95% of clients
5% of clients
44
Goals of Managed Care• Emphasize preventive care• Improve access to care• Ensure appropriate utilization of
services• Improve client and provider satisfaction• Establish a medical home for Medicaid
clients through a primary care provider • Improve health outcomes, quality of
care, and cost effectiveness• Promote care in least restrictive, most
appropriate setting45
Managed Care Growth
46
10-year increase in managed care service delivery: +1.2 million clients
Medicaid Managed Care Programs
47
ProductName Population Served
CHIPChildren in families that earn too much money to qualify for Medicaid, but cannot afford to buy private health insurance
STARChildren, newborns, pregnant women, and some TANF-level families
STAR+PLUS People with a disability or people who are age 65 or older; and women with breast or cervical cancer
MMPPeople who are eligible for both Medicare and Medicaid, also known as ‘dual eligibles’
STAR Kids Children and adults 20 or younger with a disability
STAR HealthServes children in the conservatorship of the Department of Family and Protective Services
Dental For most children and young adults enrolled in Medicaid
Program Enrollment
48
67%
13%
10%
5% 4%
1%
STAR
STAR+PLUS*
CHIP
FFS
STAR Kids
STAR Health
*STAR+PLUS includes Dual Demonstration and CHIP includes CHIP-PerinatalFigures represent average monthly enrollment totals in SFY 2018 for full benefit clients. Data is Preliminary
3,010,872
568,943
443,111
245,454
162,647
33,751
Clients Enrolled SFY18
23
Texas MCOs by the Numbers
50Current as of January 2019 – contract numbers are subject to change
Contract Oversight Tools
Tools span a multitude of areas, administered by various expertise
Operational
Readiness reviews prior to serving members, biennial
operational reviews, targeted reviews as needed
Service delivery
Acute care utilization reviews (UR), long-term services and
supports URs, drug UR, electronic visit verification
Access to services
Network adequacy monitoring,
appointment availability studies, member
satisfaction studies
Quality measure dashboard, custom
evaluations, improvement projects, pay-for-quality,
alternative payment models, MCO report cards
Validation of financial statistical reports, administrative
expense and profit limits, independent auditing
Financial
Quality of care
51
Oversight Tool Highlight
Contract formation with
clear terms
• Set standards for reported financial data
Principles Timing Templates
• Cap administrative expenses
• Limit profits
Management by specialized expertise
• Reconcile and validate financial data
• Define scope of annual financial audit based on compliance
• Manage other additional financial audits & reviews
Non-compliance discoveries enforced as established in the contract, including liquidated damages or recovery of the Experience Rebate
(i.e. recovery of “excess profit”)
Audits annually & as needed
• Conduct annual audit by two independent contractors for additional data validation
• Conduct supplemental audits or reviews based on other identified issues
Financial
52
Contract Safeguards
Administrative Expenses
Capped by program
Profit
Net incomeMCOs keep
profit to <3%
Experience Rebate
If profit is
3% 5% 20% 5% 7% 40%7% 9% 60%9% 12% 80%12% or greater 100%
Excessive profit
Expenses in excess of admin cap At least but less than
HHSC recovers
Fiscal responsibility ensured through caps on administrative expenses, conversions to income, and rebates on excessive profit
53
Financial Oversight Timeline
HHSC recovers
54
Year start
Q2 FSR
Q3 FSR
Q4 FSR
HHSC validates data
Audit starts
Audit ends
6 – 8 months to conduct
Final Report
HHSC remedies compliance issues for that year.
An 18-20 month audit process post-year end
Year end 1
Q1 FSR
Year end 2
12 months for claims to run out
Fin
albo
oks
clos
e
Init
ialbo
oks
clos
e
FSR = Financial Statistical Report
Oversight Tool Highlight
55
Service Delivery: Utilization Reviews (UR)
Conducted by nurses, overseen by the Office of the Medical Director
To ensure MCOs are correctly enrolling members in HCBS through assessment and justification of service need
To ensure MCOs are providing services according to their assessment of service needs
1
2
Overall purposeMCO on-site visit
UR components
Records request
Desk reviews
Client home visits
Complaint referrals
Reporting of results
Findings informNeeded policy and
contract clarifications
MCO consultation or training topics
Internal process improvements
Necessary MCO remedies
Ongoing training, consultation, and technical assistance to MCOs
HCBS = Home and Community Based Services
Addressing Non-Compliance
56
S t a g e 1
S t a g e 2
S t a g e 3
S t a g e 4
S t a g e 5
Plans of Action
Corrective Action Plan(CAP)
Liquidated Damages (LDs)
Suspensionof DefaultEnrollment
Contract Termination
$Financial Impacts
Multiple stages to address non-compliance discovered via oversight and monitoringIncreased levels of impact for MCOsRemedy issued is contingent on type of non-compliance and not necessarily sequential
Financial Impact Trends
57
$5.2M
Liquidated damages (LDs) have increased with ongoing strengthening of oversight practices
All dollars are based on SFY and are rounded
$900K
$2.9M$2.1M $2.4M
2009 2010 2011 2012 2013 2014 2015 2016 Q1-Q3 2017
LDs: $1.6M $1.1M
$4.9M
Q1-Q3 LDs: $27.3MM
Strengthening Oversight
31
Six focus areas:
Network Adequacy• Improve the accuracy of provider directories• Address the special needs of rural counties• Increase the use of telemedicine• Reduce administrative burden, including process automation• Integrate network adequacy data• Add network adequacy standards for LTSS provider type
Complaints Process and Data• Standardize definition and categorization of complaints across HHSC and
MCOs• Improve data analysis to efficiently identify patterns and resolve issues early• Streamline the member complaints process• Improve transparency by publicly sharing complaints data• Enhance education on the issue resolution process
1
2
Strengthening Oversight
59
Six focus areas, cont.:
Clinical Oversight• Expand URs to include STAR Kids and STAR Health Medically Dependent
Children Program (MDCP) recipients• Collect and analyze prior authorization data to inform oversight activities• Improve guidance on utilization management and medical necessity
determinations
Outcome Focused Performance Management• Enhance onsite operational reviews by refining the process and adding
modules for review• Review and streamline MCO deliverables when appropriate• Strengthen oversight integration across divisions
4
3
Strengthening Oversight
60
Six focus areas, cont.:
Service and Care Coordination• Examine service coordination requirements by product line
Initial focus on STAR Health• Align terminology and definitions across product lines• Enhance oversight of service coordination activities
5
Administrative Simplification• Reduce Medicaid provider burden through key areas of administrative
improvements: Claims payment Prior authorization submissions Eligibility information Enrollment process
6
Governing Framework
61
Medicaid Governing Framework• Basic principles for Medicaid were established
by the Social Security Act• The Centers for Medicare & Medicaid Services
(CMS) is the agency within the U.S. Department of Health and Human Services that oversees the Medicaid Program
• Federal regulations require each state designate a single state agency responsible for the program
• The Medicaid State Plan is a dynamic document that serves as a contract between the states and CMS
• States can apply to CMS through waivers to test new ways to deliver and pay for services
62
Fundamental Requirements
63
• Statewide Availability: All Medicaid services must be available statewide and may not be restricted to residents of particular localities
• Sufficient Coverage: States must cover each service in an amount, duration, and scope that is “reasonably sufficient”
• Service Comparability: The same level of services (amount, duration, and scope) must be available to all clients, except where federal law specifically requires a broader range of services or allows a reduced package of services
• Freedom of Choice: Clients must be allowed to go to any Medicaid health care provider who meets program standards
1
2
3
4
State Plan• Each state has a State Plan that
constitutes their agreement with the federal government on: Who will receive Medicaid services (all
mandatory and any optional populations) What services will be provided (all
mandatory and any optional services) How the program will be administered How the program will be financially
administered What the other program requirements are
• CMS must approve the State Plan to ensure the federal matching funds will be provided 64
Waivers• Waivers provide states with options to
operate their Medicaid programs• States apply for waivers with CMS for
permission to deviate from certain Medicaid requirements
• Waivers are typically sought to: Provide different kinds of services Provide Medicaid to new groups Target certain services to certain
groups Test new service delivery and
management models
65
Three Primary Waiver Types
66For additional information about waivers, see pgs. 111-112 and Appendix C of Twelfth Edition of the Texas Medicaid and CHIP Reference Guide.
1
2
3
Research and Demonstration 1115 WaiversProvide flexibility to test new ideas for operating Medicaid programs.Texas: Also called the 1115 Transformation Waiver. Allows the state to expand managed care including pharmacy and dental services while preserving federal hospital funding (historically received as UPL payments). Participating providers implement programs, strategies, and investments to improve care.
Freedom of Choice Waivers 1915(b)Provide states with the flexibility to modify their service delivery systems.
Texas: The authority under which the state implements the managed care model
Home and Community-Based Services 1915(c) WaiversAllow states to provide community-based services as an alternative for people who meet eligibility criteria for care in an institution.
Texas: Medically Dependent Children Program (MDCP), Home and Community-Based Services (HCBS), Texas Home Living (TxHml), Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Youth Empowerment Services (YES)
Intellectual and Developmental Disability Services
Sonja GainesDeputy Executive Commissioner
67
Types of IDD Services and Supports
Intellectual and developmental disability (IDD) services and supports are delivered through: • Medicaid Waivers
Medicaid Community First Choice (CFC)ICF/IID Waiver ProgramsHome and Community-based Services (HCS)Texas Home Living (TxHmL)Community Living Assistance and Support Services (CLASS)Deaf Blind with Multiple Disabilities (DBMD)
• Local IDD Authorities (LIDDAs)
• Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID)
• Community-based ICF/IID
• State Supported Living Centers (SSLCs)
68
Single Points of Access
The IDD Services unit contracts with thirty-nine local intellectual and developmental disabilities authorities (LIDDAs)LIDDAs conduct the following activities that help individuals access services:
• Provide information about services and supports• Help individuals identify community-based services and supports or residential placement
• Conduct psychological testing to determine eligibility• Assist with enrollment into community based services and supports or residential placements
69
LIDDA Local Service Areas
70
Service Coordination
LIDDAs provide service coordination (Targeted Case Management) for individuals in:• Nursing facilities• SSLCs• HCS and TxHML waivers• Non-Waiver services• Community First Choice (CFC) (Adults only)
71
Non-Waiver Services
LIDDAs receive General Revenue (GR) funding to support individuals in the community awaiting services in a waiver programGR Services may include but are not limited to:
• Respite• Service Coordination (Targeted Case
Management)• Employment Assistance/Supported Employment• Day Habilitation Services• Community Support Services• Behavioral Support Services
72
Transition Support Teams
Transition Support Teams (TST) in eight regions provide support to other LIDDAs and community waiver providers in designated service areas• Money Follows the Person Demonstration (MFPD)
Program funds are used• Opportunities include:
educational activities technical assistance case review for LIDDAs and community IDD
waiver providers
73
Enhanced Community Coordination
• MFPD funds also support Enhanced Community Coordination (ECC) for all individuals diverting or transitioning from a nursing facility or SSLC
• ECC provides the following services: Intensive and flexible support to achieve success
in a community setting, including arranging for support needed to prevent and manage a crisis
Flexible funding for one-time assistance with items such as rental deposits, home modifications, educational tuition, and any other service or support to enhance transition
74
Crisis Intervention Services
The 84th Legislature funded support for individuals with IDD with significant behavioral and psychiatric challenges• Crisis Intervention Specialists enhance current Mobile Crisis
Outreach Teams (MCOTs) to provide: Real time response to crisis situations Training and educating MCOT workers on IDD supports and
services• Crisis respite provides short-term respite for individuals with
IDD: Out-of-home crisis respite provides on-site therapeutic
support and 24-hour supervision In-home crisis respite provides therapeutic support in a less
restrictive setting for crises that can be resolved within a 72-hour period
75
Other IDD Resources
• Wellness Training – Web-based training modules about individuals with co-occurring IDD/Mental Health
• Employment First Training – In-person training to increase job opportunities for people with intellectual and developmental disabilities
• Host Annual Pre-Admission Screening and Resident Review (PASRR) Conference and training PASRR is a federally mandated program that
is applied to all individuals seeking admission to a Medicaid-certified nursing facility, regardless of funding source
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Health & Specialty Care System
Mike MaplesDeputy Executive Commissioner
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Health & Specialty Care System (HSCS)
Campuses:• 13 state supported living
centers (SSLCs)• 9 psychiatric hospitals• 1 youth residential treatment
center• 1 primary care outpatient
clinic
System Overview:• 22,000+ positions• 1,400 buildings• 2,500+ contracts• ~5,000 served each day
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A Direct Services Provider
State Hospitals
Primary Functions:• Provides adult psychiatric inpatient treatment; forensic services; child,
adolescent, and geropsychiatric treatment• Serves 7,800 individuals per year, each with an individualized recovery
plan
Key Issues:• Changing population and
associated revenuecollection issues 600 beds to the inpatient
psychiatric care network in our communities
• Aging infrastructure• Workforce recruitment
and retention
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72%
35%28%
65%
0%
25%
50%
75%
100%
FY 2006 FY 2008 FY 2010 FY 2012 FY 2014 FY 2016 FY 2018
Percentage of Average Census by Commitment Type
% Civil %Forensic
State Hospital Admissions
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16,415
4,380
1,7752,592
18,190
6,972
0
5,000
10,000
15,000
20,000
FY 2006 FY 2008 FY 2010 FY 2012 FY 2014 FY 2016 FY 2018
Civil Forensic Total
State Supported Living Centers (SSLCs)
Primary Functions:• Serves approximately 3,000 individuals with intellectual disabilities
in a 24 hour residential setting
• Services include comprehensive behavioral treatment and health care; skills training; occupational, physical, and speech therapies; and vocational programs; among others
Key Issues: • Changing admissions and
transitions trends• Department of Justice
Settlement Agreement• Aging infrastructure• Workforce recruitment and
retention81
166 187 177 160 139 149
421 380 362
253229 204
0
250
500
750
FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018
Admissions Separations
Improve access to services• Capacity evaluation and changes to increase efficiency• Infrastructure improvements, including renovation &
construction
Provide high-quality services• Academic partnerships and expansion of telemedicine• Standardized best practices and processes to ensure
consistency
Enhance our workforce• Aggressive recruitment campaign, with new website and
recruiting activities• Comprehensive evaluation of contract and overtime, with
reduction strategies
HSCS Initiatives
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Access and Eligibility Services
Wayne SalterDeputy Executive Commissioner
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Temporary Assistance for Needy Families (TANF) Overview
• The U.S. Department of Health and Human Services, Administration for Children and Families (ACF) regulates the program
• Program Administration is shared between HHSC and the Texas Workforce Commission (TWC) HHSC is responsible for eligibility
determinations, program policy, and benefit issuance.
TWC is responsible for work-related policies and delivering employment services through local workforce development boards
55,800 TANF recipients in State Fiscal Year (SFY) 2018
Federal and State governments have a role in the design and funding of the TANF program:
TANF Eligibility
The most common form of TANF assistance is a monthly cash grant. The amount of the grant is based on family size and income. Eligibility requirements include:• Texas residency• U.S. citizen or eligible documented immigrant• Having a child under age 18 living in the home• Cooperating with Personal Responsibility
Agreement, including work requirements• Income limit of approximately $188 per
month/$2,256 per year for a parent with two children
• Asset limit of $1,000• Benefits are time-limited
TANF Funding and Benefits• TANF is funded by state and federal funds:
$527.2 million was appropriated for FFY 2018* $33.8 million or 6.4% was allocated for TANF
cash assistance Other uses of the TANF block grant include child
protective services staff, child care, and employment assistance for TANF recipients
• The maximum monthly benefit for a household with one parent and two children is $295
• In November 2018: The average monthly benefit amount for each
recipient was $77 The average monthly benefit amount for each
case was $190
*This includes appropriations to HHSC, TWC, Texas Education Agency, and Department of Family and Protective Services
Supplemental Nutrition Assistance Program (SNAP) Overview• U.S. Department of Agriculture, Food and
Nutrition Services (FNS) regulates the program
• HHSC is responsible for eligibility determinations, program policy, and benefit issuance
• TWC is contracted to provide employment services
• Benefits can be used to purchase eligible food items from participating retailers
• SNAP benefits are provided through the Lone Star Card, an electronic benefit transfer card that is similar to a debit card
• 3.8 million SNAP recipients in SFY 2018
SNAP Eligibility• Texas residency• U.S. citizen or eligible documented
immigrant• Households must meet gross and net
monthly income tests. The maximum gross monthly
income for a family of three is $2,858
• Most households may have up to $5,000 in countable resources (e.g., checking/savings account, cash)
• Able-bodied, childless, and unemployed adults ages 18-49 are limited to three months of SNAP benefits
SNAP Funding and Benefits• HHSC issued over $6.0 billion in SNAP
in SFY 2018• Household benefit allotments are
established at the federal level For example, the maximum monthly
SNAP allotment for a family of three is $505
• Administrative costs are: 50 percent federally funded 50 percent state funded
Eligibility Accomplishments• Awarded $11.3 million performance bonus for
FFY 2017 for application payment accuracy• Awarded $4.7 million performance bonus for
FFY 2017 for most improved program access• Application processing timeliness was 96.84
percent for SFY 2018• Days from application to decision averaged
between 6.9 to 11.9 days in SFY 2018• Successfully ensured the early issuance of over
$338 million in SNAP benefits to over 1.3 million families during the government shutdown.
• Cost per eligibility determination decreased from $35.88 in SFY 2017 to $34.18 in SFY 2018
Regulatory ServicesDavid Kostroun
Deputy Executive Commissioner
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Regulatory Services Division
The Regulatory Services Division, which came together as a division on September 1, 2017, regulates:• Long-term care (LTC) providers, such as nursing facilities
and assisted living facilities• Health care facilities, including hospitals and dialysis
centers• Child care providers• Licensed professionals, such as social workers,
professional counselors, and nursing facility administratorsThe division also investigates allegations of abuse, neglect, and exploitation in certain provider settings and triages complaints about providers.
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Long-term Care Regulatory
The Long-term Care Regulatory (LTCR) department regulates the following facilities and programs:• Nursing Facilities• Intermediate Care Facilities• Assisted Living Facilities• Day Activity and Health Services• Home and Community Support Services Agencies
(including home health, hospice, and personal assistance services)
• Home and Community-based Services waiver providers
• Texas Home Living waiver providers • Prescribed Pediatric Extended Care Centers
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Long-term Care Regulatory
LTCR also licenses or permits the following professionals who work in long-term care settings:
• Nursing facility administrators• Medication aides• Certified nurse aides
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Health Care Quality
The Health Care Quality (HCQ) department licenses, surveys, and investigates these facilities:• Hospitals – General and
Specialty• Psychiatric hospitals• Ambulatory surgical
centers• End-Stage Renal Disease
(dialysis) facilities • Freestanding emergency
medical care facilities• Birthing centers• Abortion facilities• Special care facilities• Crisis stabilization units
• Substance abuse treatment facilities
• Narcotic treatment programs
• Rural health clinics• Outpatient Physical
Therapy/Speech Therapy• Comprehensive
Outpatient Rehabilitation Facilities
• Community Mental Health Centers
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Health Care Quality: Professional Licensing
HCQ’s Professional Licensing and Certification Unit licenses and regulates the following behavioral health occupations:
• Social Workers• Licensed Professional Counselors • Marriage and Family Therapists• Licensed Chemical Dependency Counselors• Sex Offender Treatment Providers
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Health Care Quality: Professional Licensing
When the Professional Licensing and Certification Unit transferred to HHSC on September 1, 2017, there were significant backlogs in processing license applications and complaint investigations
• HHSC has worked closely with the independent boards to streamline processes and update rules
• As a result of these improvements, it takes ten business days to process a complete license application
• Once new rules are in effect this spring, the complaint resolution process will be modified, and the investigation backlog will see a steady decrease
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Provider Investigations
The Provider Investigations (PI) department investigates allegations of abuse, neglect, or exploitation of individuals receiving services from:• State hospitals• State supported living centers• Intermediate care facilities for individuals with
intellectual disabilities• HHSC-operated community services• Persons contracting with an HHS agency to provide
inpatient mental health servicesPI also investigates allegations involving individuals residing in a Home and Community-based Services (HCS) group home or children receiving services from a Home and Community Support Services Agency (HCSSA)
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Child Care Licensing
The Child Care Licensing department has two major functional areas to carry out its regulatory role in child care:
• Daycare Licensing – Protects the health, safety, and well-being of children from birth through age 13 who attend daycare centers and daycare homes
• Residential Child Care Licensing – Protects the health, safety, and well-being of children birth through age 17 who reside in residential child care operations
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Complaint and Incident Intake
The Complaint and Incident Intake department processes contacts from the public, clients, and providers who have complaints related to long-term care and acute health facilities and agencies. The department:
• Receives, screens, documents, and prioritizes complaints and incidents for investigation
• Provides information regarding rules, regulations, and policies related to long-term care and acute health care providers
• Refers complaints to internal and external agencies as appropriate
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Key Issues for Regulatory Services
• Supports for protection of vulnerable Texans
• Enhancing background checks
• Continued transformation
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