26 sandy-sullivan

THE RIGHT SERVICE
AT THE RIGHT TIME
What can Managed Care offer you?
Sandy Sullivan, RN CCM
VP of HealthServices
Cigna-HealthSpring STAR+PLUS

2Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2012 Cigna
• To deliver services more effectively and efficiently than traditional
Medicaid programs
• Increase the quality of services provided
• Increase positive member outcomes
• Increase member satisfaction with services
• Ensure Medicaid recipients are offered and given the services
needed to be in the least restrictive environment desired by the
person, and the opportunity to function and be part of the community
at the highest level possible and desired.
WHY MANAGED CARE?
What are expectations of these organizations?
* Footnotes here. Flush left with copyright. 8 pt. Arial narrow

Texas began implementing Medicaid Managed Care in 1993.
Clients in Medicaid Managed Care choose a Primary Care Provider
(PCP) who serves as the client’s medical home by providing
comprehensive preventive and primary care. The PCP can also make
referrals for specialty care and other services offered by the Managed
Care Organization (MCO), such as case management.
Texas Medicaid Managed Care Programs:
•STAR
•STAR+PLUS
•STAR Health
TEXAS MANAGED CARE MEDICAID PROGRAMS

In addition to the administration of the Texas Medicaid Medical Benefits
for Medicaid only Members, benefits for all Members include:
•Plans must have a Service Coordinator assess the Member within 30
days of enrolling in the program. The Coordinator must find out the
Member’s needs and develop a plan of care.
•Long-term services and supports can include:
– Day Activity and Health Services (DAHS)
– Primary Home Care (PHC)
– STAR+PLUS WAIVER Benefits for qualified members
– Specific Value add services
STAR+PLUS CURRENT BENEFITS

Other services under the STAR+PLUS Home and Community-Based
Services Waiver include:
– Personal Assistance Services
– Adaptive Aids
– Adult Foster Care Home Services
– Assisted Living
– Emergency Response Services
– Home Delivered Meals
– Medical Supplies
– Minor Home Modifications (making changes to your home so you can safely
move around)
– Nursing Services
– Respite Care (short-term care to provide a break for caregivers)
– Therapies (occupational, physical, and speech-language)
– Financial Management Services (consumer directed services)
– Transitional Assistance Services
– Support Consultation
STAR+PLUS WAIVER BENEFITS

• STAR+PLUS
– Medicaid Rural Service Areas (MRSA) Expansion
– Nursing Facility Carve-in
 Adding Nursing Facility Services to STAR+PLUS 9/1/2014
– Integration of acute care for adults with intellectual and
developmental disabilities
 Adding Acute Care Services for individuals with IDD into
Managed Care 9/1/2014
STAR+PLUS SCOPE EXPANSION
Changes for 2014

• Long-term Services and Supports
– Basic attendant and habilitation services for individuals requiring an
institutional level of care
– Carve-in of covered mental health rehabilitation and mental health
targeted case management
– Supported employment and employment assistance will be added
to the STAR+PLUS Home and Community Based Services (HCBS)
waiver service array on September 1, 2014. Cognitive rehabilitation
therapy will be added to the STAR+PLUS HCBS waiver service
array on March 1, 2014.
STAR+PLUS SCOPE EXPANSION
Changes for 2014

Service Coordination Structure within STAR+PLUS
The STAR+PLUS MCO is mandated to provide an assigned Service
Coordinator to specific Members within STAR+PLUS. These Members
must be given the name of the SC, the contact number and the number
and type of visits they will receive with 15 days of assignment.
If you are not assigned a Service Coordinator, you may always ask for
one. The STAR+PLUS MCO must furnish a Service Coordinator to all
STAR+PLUS Members who request one. They should also furnish a
Service Coordinator to a STAR+PLUS Member when they determine
one is required through an assessment of the Member’s health and
support needs.
A Service Coordinator should be your advocate and should be able to
help with all your needs.

WHAT ARE YOUR RIGHTS IF YOU ARE DENIED WHAT YOU BELIEVE
YOU NEED?
1. The MCO should make a decision to give you the service or deny
the service within 3 business days of a completed request.
2. If you have been told a requested service is not a covered benefit ,
or you do not qualify for the covered service, the MCO must send
you a formal denial.
3. The denial should explain to you what has been denied and why it
is denied.
4. The denial should tell you how to ask for an appeal and for a fair
hearing. It also tells you how to ask for a fast appeal and fair
hearing if you feel you are in danger without the service.
5. The denial should also tell you how to get free legal services if you
feel you need them.
6. Don’t be afraid to talk to your Service Coordinator if you don’t
understand something or need help of any kind with the appeal and
fair hearing. You can even give them information you believe was
lacking when a decision was made.

1. Remember your Service Coordinator and your Managed Care
Organization are your advocates. They should be invested in your
well being and needs to reach the highest level of functioning and
the highest level of optimal health.
2. When working your Service Coordinator, be honest about why you
need something and how it will help you. This is hard sometimes
when Caregivers don’t want to admit they sometimes can’t do it all.
3. Remember the MCO wants to meet your need, but they must meet
that need in the most cost effective manner when it is a benefit. Talk
it out with your Service Coordinator. Remember the plan of care
should be built with your input.
COMMUNICATING WITH YOUR MANAGED CARE ORGANIZATION

COMMUNICATING WITH YOUR MANAGED CARE ORGANIZATION
4. Become a partner with your Managed Care Organization. We all are
owners in assuring we have a successful solvent Medicaid system
that meets the needs of all its consumers.
5. Ask questions and get answers that make sense to you from your
MCO. Ask for a Supervisor, if needed. Get the names and
telephone numbers of every person with whom you speak and
record them. Get rules, decisions, and answers in writing. Keep a
copy for your records.
6. Ask for an appeal or fair hearing when you don’t agree with what
the Managed Care Organization decides about your services. The
Managed Care Organization wants this as well, it is a check and
balance needed to ensure all guidelines of HHSC and Medicaid are
followed appropriately.

WHAT TO DO IF YOU BELIEVE YOUR MCO IS NOT LIVING UP TO
EXPECTATIONS
Make sure to communicate first with the Managed Care Organization
and file a formal complaint first with them. The MCO will have an
answer to your complaint within 30 days of the date of receipt of the
complaint. Most of the time, they can help right away. There is no time
limit for filing a complaint with your MCO. The MCOs want to know
complaints and will handle them fairly.
Medicaid Members can also complain to the Health and Human
Services Commission (HHSC) by calling toll-free at 1-800-252-8263. Or
Medicaid Members can send a letter to:
Texas Health and Human Services Commission
Health Plan Management – H-320
P.O. Box 85200
Austin, TX 78708-5200
ATTN: Resolution Services

When it comes to managing services, everyone has different needs
and preferences. In recent years, there has been a growing movement
within the aging and disability communities that is known variously as
independent living, self-determination, or consumer-direction. While
there are some differences in each of these, they have basically this
philosophy in common: that people are the best judges of what
assistance they may need and of how that assistance should be
delivered.
•STAR+PLUS gives you a choice about how your services are
managed (Three Options)
– Agency option (agency-managed)
– Service responsibility option (co-managed)
– Consumer Directed Services employer (self-managed)
STAR+PLUS AND FINANCIAL MANAGEMENT SERVICES

There are three (3) options available to STAR+PLUS Members
desiring to self-direct the delivery of:
1.Primary Home Care (PHC) (which is available to all STAR+PLUS
Members), and
2.Personal Attendant Services (PAS); in-home or out-of-home respite;
nursing; physical therapy (PT); occupational therapy (OT); and/or
speech/language therapy (SLT) (which are available to Members in
the HCBS STAR+PLUS Waivers).

The MCO must provide information concerning the three (3)
options to all Members:
1.Who meet the functional requirements for PHC Services and the
requirements for PAS (the functional criteria for these services are
described in the Form 2060)
2.Who are eligible for in-home or out-of-home respite services in the
SPW
3.Who are eligible for nursing, PT, OT and/or SLT in the SPW.

In addition to providing information concerning the three (3) options, the
MCO must provide Member orientation in the option selected by the
Member. The MCO must provide the information to any STAR+PLUS
Member receiving PHC/PAS and/or in-home or out-of-home respite:
1. At initial assessment
2. At annual reassessment or annual contact with the STAR+PLUS
Member
3. At any time when a STAR+PLUS Member receiving
PHC/PAS/Respite/Nursing/PT/TO/SLT requests the information
4. In the Member Handbook.

The STAR+PLUS MCO must contract with Providers who are able to
offer PHC/PAS in-home or out-of-home respite, nursing, PT, TO, and/or
SLT and must also educate/train the MCO Network Providers regarding
the three (3) PAS options. Network Providers must meet
licensure/certification requirements as indicated in Attachment B-1,
Sections 8.3.11 and 8.3.1.2 of the Uniform Managed Care Contract.
In all three (3) options, the Service Coordinator and the Member work
together in developing the Individual Service Plan.

The STAR+PLUS Managed Care Organizations work with State
contracted Relocation Specialists to design and implement a plan of
care allowing people in nursing homes to relocate back to the
community with housing, needed household support and LTSS
services including STAR+PLUS WAIVER services.
For residents in a STAR+PLUS service area who wish to receive
services in the community through the HCBS Waiver, the selected
STAR+PLUS MCO performs the functional assessment and service
planning. Once the assessment process is completed and the resident
is determined eligible for HCBS services, the MCO must initiate the
individual service plan (ISP) upon notification. The MCO is not
responsible for obtaining independent housing for the resident, but is
responsible for identifying Assisted Living or Adult Foster Care
alternatives available in the network.
STAR+PLUS AND MONEY FOLLOWS THE PERSON

IMPORTANT CONTACT NUMBERS
Cigna-HealthSpring Member Services 1-877-966-9272
(Your Managed Care Organization)
Maximus 1-800-964-2777 (TTY 1-800-267-5008).
Medicaid Managed Care Helpline 1-866-566-8989
Medicaid Managed Care Helpline TDD 1-866-222-4306
STAR+PLUS Help Line 1-800-964-2777
2-1-1 Help in Texas 211 or www.211texas.org

“Cigna,” “HealthSpring” and “GO YOU” are registered service marks, and the “Cigna HealthSpring” logo is a service mark, of Cigna Intellectual
Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such
operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company (CHLIC),
Cigna HealthCare of South Carolina, Inc. (CHCSC,) Cigna HealthCare of North Carolina, Inc. (CHCNC), Cigna HealthCare of Georgia, Inc.
(CHCGA), Cigna HealthCare of Arizona, Inc. (CHCAZ), HealthSpring Life & Health Insurance Company, Inc. (HSLH), HealthSpring of
Tennessee, Inc. (HSTN), HealthSpring of Alabama, Inc. (HSAL), HealthSpring of Florida, Inc. (HSFL), Bravo Health Mid-Atlantic, Inc. (BHMA),
and Bravo Health Pennsylvania, Inc. (BHPA). CHLIC, CHCSC, CHCNC, CHCGA, CHCAZ, HSLH, HSTN, HSAL, HSFL, BHMA and BHPA are
Medicare approved Medicare Advantage Organizations.
XX/13 © 2013 Cigna. Some content provided under license.

26 sandy-sullivan

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to 26 sandy-sullivan

Similar to 26 sandy-sullivan (20)

More from txsilc

More from txsilc (14)

Recently uploaded

Recently uploaded (20)

26 sandy-sullivan