HHSC Proposal Would Integrate Care for Many Dual Eligible Adults

Health Care

The Texas Health and Human Services Commission drafted a proposal to integrate care for about 214,500 adults in urban areas who receive full Medicaid and Medicare benefits in Texas (full dual eligible individuals). This Dual Eligible Integrated Care Model would serve only full dual eligible adults who are required to participate in STAR+PLUS managed care. That is about two-thirds of the 328,500 full dual eligibles in Texas. The rest, who live in the rural parts of the state, receive their Medicaid benefits through the traditional fee-for-services system.

This demonstration project would cover all Medicare benefits (including parts A, B and D) and Medicaid benefits, including wrap-around services and long-term supports and services. The proposal is for a fully integrated, capitated approach that involves a three-party agreement between a managed care organization that has both an existing STAR+PLUS contract and a Medicare Advantage Special Needs Plan contract with the federal government.

The Texas Health and Human Services Commission seeks public input on the proposal until May 11, 2012, with a proposed starting date of Jan. 1, 2014. States selected by the federal government for a dual eligible demonstration project will get a portion of the savings they achieve.

Two of the more significant ideas included in the proposal, on which the Texas Health and Human Services Commission requested input, are:

  • Passive enrollment into a Medicaid Advantage Managed Care Organization. Dual eligibles who are mandatorily enrolled in STAR+PLUS will also be enrolled into the Medicare Advantage/Special Needs Plan that corresponds to their STAR+PLUS plan. Individuals can disenroll from the MA/SNP if they choose.
  • Nursing Facility Services. HHSC proposed including a capitated rate for both the Medicare and Medicaid payments for the first four months of a nursing facility stay for STAR+PLUS enrollees. (Currently, the Medicaid portion for nursing facility services is paid through the traditional fee-for-service program.)

Visit the Texas Health and Human Services Commission website for more details and the draft application.