AUTHOR'S / SPONSOR'S STATEMENT OF INTENT
Texas Medicaid Managed Care was first piloted in four counties in 1994. The first Medicaid Managed Care Consumer Assistance Program was created in 1995 by the 74th Legislature (S.B. 601, Section 531.023, Government Code), but not implemented until January 2001. It was operated as STARLink, an independent nonprofit based in Austin. STARLink began serving Medicaid managed care enrollees in January 2001, providing telephone assistance to Texans enrolled in Medicaid Managed Care and experiencing barriers to care.
Today, nearly all of Texas’ over four million Medicaid beneficiaries are enrolled in Medicaid Managed Care—or soon will be. However, the staffing levels to help Medicaid Managed Care enrollees who encounter barriers to care has not kept up with growth, and S.B. 1475 seeks to modernize and increase capacity in the 20-year-old consumer support system.
Medicaid Managed Care-related barriers to care may involve difficulty locating health care providers, but also can result from technology glitches with the Social Security Administration, Health and Human Services Commission (HHSC) eligibility and enrollment systems, and issues with providers of medical and community care services.
S.B. 1475 establishes an enhanced Medicaid managed care consumer support system.
•To update Texas law first adopted in 1995 to direct HHSC to ensure that Medicaid Managed Care consumer support systems can address access to care issues promptly and thereby reduce the need for appeals of managed care organization decisions and formal Medicaid fair hearings.
•To empower Medicaid Managed Care beneficiaries to advocate for themselves.
•To coordinate all existing consumer support functions at HHSC to eliminate uncoordinated “silos” and insure a “no wrong door” consumer support system.
•To add a local representative component to HHSC’s current centralized consumer supports for Medicaid Managed Care beneficiaries, so that the vulnerable populations being added to Medicaid Managed Care—nursing home residents, individuals with intellectual and developmental disabilities, seniors with dual Medicaid-Medicare coverage, and medically fragile children—will be able to access assistance in their region from staff with knowledge of the local medical and community care networks.
•To enhance coordination with community-based stakeholders who can provide additional assistance to Texas Medicaid beneficiaries.
•To fulfill commitments to provide comprehensive consumer assistance made as part of Texas Medicaid 1115 Transformation waiver, and enhance the state’s ability to extend or renew the waiver beyond 2016.
•To provide HHSC management with timely information on the performance on Medicaid Managed Care health plans that is needed to monitor contract compliance and ensure ongoing quality improvement.
As proposed, S.B. 1475 amends current law relating to establishing an enhanced Medicaid managed care consumer support system.
RULEMAKING AUTHORITY
SECTION BY SECTION ANALYSIS
SECTION 1. Amends Subchapter B, Chapter 531, Government Code, by adding Section 531.02132, as follows:
Sec. 531.02132. MEDICAID MANAGED CARE CONSUMER SUPPORT SYSTEM. (a) Defines “enhanced system.”
(b) Requires the Health and Human Services Commission (HHSC) to develop and establish an enhanced Medicaid managed care consumer support system consisting of a connected network of Medicaid managed care consumer support staff that is organized for the purpose of:
(1) educating Medicaid managed care recipients regarding the concept of managed care, their rights under the Medicaid program, including grievance and appeal procedures, and how to advocate for themselves, and ultimately reducing the need for the internal appeals process of managed care organizations under the Medicaid program and for the Medicaid fair hearing process.
(c) Requires that the enhanced system be designed to:
(1) be fully integrated with the unit of HHSC’s office of the ombudsman responsible for providing the Medicaid Managed Care Helpline and the office of the state long-term care ombudsman established under Chapter 101 (Texas Department on Aging), Human Resources Code;
(2) include specialized capacity to meet the needs of all current and future Medicaid managed care recipients, including children receiving dental benefits and other recipients receiving benefits, under the STAR Medicaid managed care program, the STAR + PLUS Medicaid managed care program, including the Texas Dual Eligibles Integrated Care Demonstration Project provided under that program, the STAR Kids managed care program established under Section 533.00253 (STAR Kids Medicaid Managed Care Program), the STAR Health program, and the child health plan established under Chapter 62 (Child Health Plan for Certain Low-Income Children), Health and Safety Code;
(3) include adequate staffing to support timely access to the enhanced system by all Medicaid managed care recipients in this state;
(4) ensure that the enhanced system staff:
(A) receives sufficient training, including training in the Medicare program for the purpose of assisting recipients who are dually eligible for Medicare and Medicaid, and has sufficient authority to resolve barriers experienced by recipients to health care and long-term services and supports;
(B) has the capacity to actively refer recipients to community-based organizations that can assist the recipients with the appeals process, including preparation for appeals and representation, as needed, whether the appeal is an internal appeal provided by a managed care organization or an appeal under the Medicaid fair hearing process;
(C) is locally accessible through satellite offices in a network of regional hub sites with at least one office in each Medicaid managed care service area, patterned after similar satellite offices operated by:
(i) the following partners in the Health Information, Counseling, and Advocacy Program:
(a) area agencies on aging; and
(b) aging and disability resource centers established under the Aging and Disability Resource Center initiative funded in part by the federal Administration on Aging and the Centers for Medicare and Medicaid Services; and
(ii) the office of the state long-term care ombudsman; and
(D) has ready access to the upper management of HHSC and managed care organizations participating in the Medicaid program that will enable staff to promptly identify and resolve both recipient-specific and systemic issues; and
(5) include an advisory interface with nonprofit, community-based organizations that routinely assist recipients in resolving Medicaid managed care issues, for purposes of timely identifying recurring, systemic issues.
(d) Authorizes enhanced system staff to include the employees of appropriate health and human services agencies and the staff of appropriate community partners under contract with the state.
(e) Requires HHSC’s office of the ombudsman, or other division of HHSC in which the enhanced system is established, to be sufficiently independent from other aspects of the Medicaid managed care system and have no financial interest in the outcome of recipient grievances and empowered to represent the best interests of recipients in problem resolution.
(f) Requires the enhanced system staff to collect and maintain statistical information on a Medicaid managed care service area basis and to publish quarterly reports that track the incidence of complaints and barriers identified by the enhanced system, identify trends and recurring barriers in delivery and access to Medicaid managed care in this state, and identify other problems occurring in the Medicaid managed care system.
SECTION 2. Requires HHSC, not later than January 1, 2016, to establish the Medicaid managed care consumer support system required under Section 531.02132, Government Code, as added by this Act.
SECTION 3. Requires a state agency, if necessary for implementation of a provision of this Act, to request a waiver or authorization from a federal agency, and authorizes a delay of implementation until such a waiver or authorization is granted.
SECTION 4. Effective date: upon passage or September 1, 2015.