The Health and Human Services Commission (HHSC) is proposing expanding the STAR+PLUS HMO model to all existing Medicaid managed care service delivery areas. Under the proposal, there will not be a PCCM option.
What is the HHSC Proposal?
The existing Medicaid managed care service delivery areas impacted by the HHSC STAR+PLUS proposal include:
- Dallas (Dallas, Ellis, Kaufman, Rockwall, Hunt, Collin and Navarro counties)
- El Paso (El Paso, Hudspeth, and Culberson counties)
- Houston (Harris, Fort Bend, Colorado, Austin, Montgomery, Waller, Brazoria, Galveston, Wharton, Washington, Matagorda counties)
- Lubbock (Lubbock, Lamb, Hale, Floyd, Crosby, Garza, Lynn, Terry, Hockley counties)
- San Antonio (Bexar, Kendall, Comal, Medina, Atascosa, Wilson, Guadalupe)
Additionally, HHSC is proposing the addition of the Nueces County service delivery to the STAR+PLUS HMO model (Nueces SDA also will be added to the STAR HMO model, which serves Medicaid pregnant women, parents, and children)
- Nueces (Nueces, Aransas, Bee, Calhoun, Jim Wells, Kleberg, Refugio, San Patricio, Victoria) *
What is STAR+PLUS?
The STAR+PLUS program is a managed care demonstration project currently operating in Harris and surrounding counties. The goal of the model is to integrate acute and long term care services into a managed care delivery system. Populations included in the program include Medicaid recipients eligible for Supplemental Security Income (SSI), Medical Assistance Only (MAO), and elderly or disabled individuals, including children, who require long-term care, including short-term nursing facility care. Patients who are eligible for Medicaid and Medicare ( aka dual- eligibles ) must participate in the program.
STAR+PLUS Medicaid only clients are required to choose an HMO and a Primary Care Provider in the HMO's network. Like other forms of Medicaid managed care, patients who do not choose a primary care physician will be assigned to one. Medicaid-only clients receive all services - both acute and long term care - from the HMO. Dual eligible clients choose an HMO but do not choose a PCP. This is because dual eligibles receive acute care from their Medicare providers. The STAR+PLUS HMO only provides Medicaid long term care services to dual eligible clients.
In Harris County, all STAR+PLUS patients must enroll in an HMO, except children and some classes of mentally ill patients, who may choose the PCCM option.
While physicians support elements of STAR+PLUS, such as better integration and management of the continuum of care for eligible patients, TMA and local medical societies do not believe that another Medicaid managed care model can be integrated into the system without causing it to collapse. In areas with Medicaid managed care already, physicians and health care providers are already at their breaking points. The expansion of STAR+PLUS or other Medicaid managed care pilots will exacerbate existing Medicaid provider shortages.
For example, if expanded, physicians in Dallas would have to contend with STAR, the physical health Medicaid managed care program; NorthSTAR , the Medicaid behavioral health pilot; CHIP; and STAR+PLUS. Each of the programs has different administrative and claims payment requirements, adding complexity to a system few physicians are willing to navigate today.