Unless they have opted out, thousands of Texas patients who receive both Medicare and Medicaid and who reside in a target county will be automatically, or passively, enrolled in the Texas Health and Human Services Commission's (HHSC's) six-county Dual Eligibles Integrated Care Demonstration Project starting April 1.
More than 165,000 Texas patients in Bexar, Dallas, El Paso, Harris, Hidalgo, and Tarrant counties qualify for the program and may eventually be covered under the new plan.
The project is a partnership between Texas and the Centers for Medicare & Medicaid Services (CMS) to test a new model for providing coordinated care to patients enrolled in both Medicare and Medicaid. Texas and CMS will contract with Medicare and Medicaid managed care plans to coordinate patient care across both programs.
Nationally, more than 9.6 million seniors and people with significant disabilities are dually eligible for both programs, and as many as 2 million of them may be included in the demonstrations. Often, medically fragile, dual-eligible patients are typically poorer and sicker than other Medicare beneficiaries and use more health care services.
The project's objectives include:
- Making it easier for clients to get care,
- Promoting independence in the community,
- Eliminating cost shifting between Medicare and Medicaid, and
- Achieving cost savings for the state and federal government through improvements in care and coordination.
Patients will be included in the project if they:
- Are age 21 or older;
- Get Medicare Parts A, B, and D, and are receiving full Medicaid benefits; and
- Are in the Medicaid STAR+PLUS program, which serves Medicaid clients who have disabilities or get STAR+PLUS Home and Community Based Services waiver services.
In the demonstration, health plans must provide the full array of Medicaid and Medicare services. This includes any benefits that will be added to the STAR+PLUS service array by March 1, such as nursing facility services, psychosocial mental health rehabilitation, and targeted case management.
Passive enrollment begins April 1, progresses incrementally through August, and will apply to 20 percent of nonfacility patients within a county by ZIP code. For example, all dual-eligible patients eligible for passive enrollment who live in a pilot county and who are in cohort 1 ZIP codes (see list), will be passively enrolled on April 1 unless they opted out. Enrollment of dual-eligible nursing facility patients will begin Aug. 1 in Bexar and El Paso counties, followed by Harris County nursing facility patients on Sept. 1 and those in remaining counties on Oct. 1.
HHSC has developed a detailed enrollment grid by county to help practices better understand how patients will be assigned to a plan.
Patients had the choice to opt out of the project before the pilot began and may still elect to opt out after being enrolled in a plan. If they opt out, the change will take effect the first of the following month. Patients who opt out may subsequently return to the pilot. Thus, physicians should verify patient eligibility at each visit. Physicians cannot steer patients to a particular managed care plan, but can inform patients about the demonstration plan(s), if any, in which they participate.
Patients Still Have a Choice
Patients eligible for the demonstration were or will be sent introduction letters 90 days before enrollment and additional reminder letters 60 days and 30 days before passive enrollment begins. If a patient is enrolled in a plan whose network does not include their physician(s), continuity of care must be protected for the first 90 days.
Specifically, the contract between CMS, HHSC, and the plans specifies that a patient's care must not be disrupted when the patient enrolls in a plan: "The STAR+PLUS Medicare and Medicaid Plan (MMP) allows enrollees receiving any services at the time of enrollment to maintain their current providers, including with providers who are not part of the STAR+PLUS MMP's network, and service authorizations, including drugs, for at least up to ninety (90) days after the enrollee's enrollment effective date or until the Plan of Care and/or ISP are updated and agreed to by the enrollee, whichever is earlier."
The contract further states that the STAR+PLUS MMP must ensure continuity of care for new enrollees whose health or behavioral health condition has been treated by specialty care providers or whose health could be placed in jeopardy if medically necessary covered services are disrupted or interrupted.
Visit the HHSC or CMS websites for more information about the project, including the Texas proposal and memorandum of understanding.
To see how CMS will be monitor and evaluate the Texas demonstration project, read Measurement, Monitoring, and Evaluation of State Demonstrations to Integrate Care for Dual Eligible Individuals.
HHSC website resources include:
Action, April 1, 2015