Submitted by email to the Medicaid and CHIP Division of the Texas Health and Human Services Commission on behalf of Disability Rights Texas and the Texas Council for Developmental Disabilities
May 11, 2012
Thank you for the opportunity to comment on the Draft Application for the Dual Eligibles Integrated Care Demonstration Project. These comments are offered on behalf of Disability Rights Texas and the Texas Council for Developmental Disabilities.
These comments reflect our concern that the approach outlined in the Draft Application will limit patient access to their existing healthcare providers and forcibly disenroll at-risk patients from the plan of their choice and re-enroll them in a Star+Plus plan. In many instances, patients will be disenrolled from a higher CMS rated health plan into a lower rating plan or from fee for service which allows them a greater choice of and access to providers. As HHSC continues its review and development of this proposal, we respectfully request that the Draft Application be amended to preserve the continuity of care for this vulnerable population as much as possible.
We seek to join HHSC and other stakeholders in efforts to minimize disruption to Dual Eligibles and provide all Dual Eligibles with patient choice of the highest quality of care, preserve patient protections and maintain a robust and diverse provider base. Individuals must be educated and provided time to make selections based on informed choice.
We recommend the following:
Minimize any negative outcomes and increase meaningful learning opportunities by the State by implementing a small scale demonstration initially including only individuals who are in Star Plus and also enrolled in a Medicare Advantage health plan who actively choose to enroll in the demonstration.
Provide advanced notice that is accessible to individuals with disabilities and individuals with Limited English Proficiency (LEP), an assertive and meaningful education and outreach process, and a voluntary opt-in enrollment process consistent with Sect. 19932 of the Social Security Act that requires informed and affirmative choice by the beneficiary to participate in a dual eligible integration demonstration (i.e. opt-in) instead of the proposed passive enrollment process. We do not support passive enrollment with an opt-out that may not be timely or well understood and that violates Medicare Freedom of Choice regulations.
- Allow at least 90 days to choose an HMO.
- Create a user friendly guide for individuals to use to ask questions when choosing an HMO.
- Work with stakeholders to create a Texas Managed Care Bill of Rights.
- Allow long term single case agreements, without arbitrary limits, to maintain continuity of care.
- Continue to exclude the voluntary child population.
- Continue to exclude 1915 (c) Medicaid waiver participants not enrolled in Star Plus.
- Permit change of health plans and opting out without limits at any time
- Ensure that managed care organizations are not the only or primary source of beneficiary information and assistance.
Prevent crowding out HMOs in good standing with the standards of Texas managed care. Disallow poor performing HMOs from participation. Find a mechanism to be more inclusive of additional HMOs to ensure choice, continuity of care and quality.
Allow for continuous enrollment of qualified, willing providers. Contract with experienced community providers of long term supports and services.
Do not cut benefits, eligibility or provider rates.
Specific guidance should be provided to MCO’s that chronic care teams should be part of a physician led medical home that is comprehensive, accessible, continuous, consumer-centered, coordinated, compassionate, and culturally effective.
Access functional status, social and vocational needs, socioeconomic factors, personal preferences and the ability to obtain accessible services.
Improve access to long term rehabilitative services for physical and mental well being. Provide enriched services to support members and their caregivers, including but not limited to: mental health services, respite, transportation, nutritional dietary support, over the counter medication, podiatry, cognitive adaptive behavior supports, supported employment, etc. Ensure access to medical and environmental technology that promotes health and independent living.
Provide Medicaid services as a wrap around when Medicare does not cover acute or long term community-based supports in the type or amount sufficient to prevent hospitalization or institutionalization in a long term care facility.
Ensure and expand self-direction. Ensure that service plans reflect individual needs through use of a person-centered planning process. Allow purchase of Individual Goods and Services that are services, equipment or supplies not otherwise provided through the Star Plus waiver or State Plan that address an identified need in the service plan (including improving and maintaining the participant’s opportunities for full membership in the community) and that would decrease the need for other Medicaid services, such as attendant services.
Use savings from prevention of re-admissions to nursing facilities and hospitals to increase the availability and scope/amount/duration of community based services to promote independence and home-based services over institutional care.
Consider PACE as a service delivery option within the demonstration project.
Include consumer protections related to choice, dignity, autonomy, privacy and due process complaints and appeals rights at the highest level. Star Plus requires that an appeal be filed within 30 days, but Medicare allows 60 days to appeal. We support 60 days. Also, individuals should continue to receive services at the current level and breadth until a comprehensive assessment is conducted and pending an appeal decision when requested in a timely manner.
Add an “independent advocacy” option so that individuals can seek and receive some level of conflict free assistance. This can be added to the Star Plus waiver and is an option offered by the Centers for Medicare and Medicaid services (CMS). Independent advocacy is a separate advocacy function performed by individuals or entities that do not provide other direct services perform assessments or have monitoring, oversight or fiscal responsibilities. It is person specific rather than advocacy that is performed on behalf of a group of individuals collectively. It provides participants with a source of disinterested assistance available to them to address problems that may arise with respect to any aspect of their waiver services, including participant direction. Based on our experience with the individuals we serve, we do not believe that the service coordination function within the current Star Plus program is accessible in a timely manner, effective or conflict free.
Quality and cost measurement should include quality of life measures identified by stakeholders as important , obtained with significant individual member input and analyzed by health plan and contract area, including:
- Preventing enrollees from entering institutional settings by providing appropriate levels of community-based care,
- Transitioning enrollees back to the community and monitor to ensure a successful transition,
- Providing Timely access to effective service coordination, and
- Providing access to a independent advocate.