2000 STAR+PLUS

Star+PLUS Managed Care

If you have questions regarding Star+Plus Managed Care payment rates, please call (512) 491-1347.

Purpose

The Star+Plus Managed Care Program (Star+Plus) intends to demonstrate that managed care can provide an improved Medicaid health care delivery system for aged and disabled eligibles for both acute care and long-term care at a cost that does not exceed the cost of providing care under the traditional fee-for-service system.

Description

Managed care services are delivered using two basic models - Health Maintenance Organizations (HMOs) and Primary Care Case Management (PCCM).  The demonstration phase of Star+Plus started in February 1998 in Harris County.

Services

All services routinely provided to Medicaid eligibles in the fee-for-service system are provided in Star+Plus. The predominate services are acute care including physician, hospital, and other services; long-term care including Primary Home Care (PHC), Day Activity and Health Services (DAHS), Community-based Alternatives (CBA), and Nursing Facility (NF) care; and, prescription drugs. In this latter category the basic coverage for Medicaid eligibles in the fee-for-service system is three (3) prescriptions each month, except that unlimited prescriptions are provided to NF clients, CBA clients, and all Medicaid eligibles under 21 years of age. Star+Plus provides in addition to the basic coverage unlimited prescriptions to all Medicaid eligibles in managed care who are Medicaid-only, i.e., are not covered by Medicare.

Participation

Enrollment in a HMO is required for most Medicaid eligibles including Supplemental Security Income (SSI) eligibles 21 years of age and over; CBA clients; and, clients entering a NF. SSI eligibles under 21 years of age must enroll either in an HMO or in PCCM. Most of the remaining Medicaid eligibles are not required to enroll, but may do so voluntarily.

Payment for Services

HMOs participating in Star+Plus are paid a monthly amount (capitation rate) per member to provide all needed acute care and long-term care services. Providers of acute care and long-term care services for non-HMO Medicaid eligibles are paid on a fee-for-service basis. Pharmacists providing prescription drug services to both HMO and non-HMO Medicaid eligibles are paid on a fee-for-service basis.

Eligibility Categories

There are two (2) eligibility categories - persons eligible only for Medicaid (Medicaid-only) and persons eligible for both Medicare and Medicaid (Medicare/Medicaid). These two eligibility categories were created for two reasons. First, Medicaid pays for the acute care of Medicaid-only eligibles while Medicare pays for the acute care of Medicare/Medicaid eligibles.  Second, Medicare/Medicaid eligibles generally have more financial resources available to offset the cost of their CBA and NF care.

Rate Components

There are two rate components - acute care and long-term care. Within the long-term care component there are four (4) sub-components - CBA, PHC , DAHS, and NF.

Risk Groups

There are three (3) classes of eligibles (risk groups) - Other Community Care (OCC), CBA, and NF - within each eligibility category. This yields six (6) risk groups. The three (3) Medicaid-only risk groups consist of an acute care component and a long-term care component. The three (3) Medicare/Medicaid risk groups consist of a long-term care component only.

Rate Determination

The capitation rates paid to HMOs are determined in a two-step process called cost-finding and rate-setting. Cost refers to historical cost as well as projected cost.

Cost-finding Methodology

Step one consists of gathering the number of members in each risk group; the acute care costs for the three (3) Medicaid-only risk groups; and, the long-term care costs for the three (3) Medicaid-only risk groups and the three (3) Medicare/Medicaid risk groups. After these items are gathered the weighted mean cost for each rate component and sub-component is calculated. The required information for Star+Plus cost-finding is detailed below.

Members for each of the Six (6) Risk Groups

Acute care weighted mean cost for the Medicaid-only OCC risk group

Acute care weighted mean cost for the Medicaid-only CBA risk group

Acute care weighted mean cost for the Medicaid-only NF risk group

Long-term care weighted mean cost for the Medicaid-only OCC risk group composed of:

Community Care for Aged and Disabled (CCAD) weighted mean cost composed of:

Primary Home Care (PHC) weighted mean cost

Day Activity and Health Services (DAHS) weighted mean cost

NF Care - 120 days (modeled) weighted mean cost

Long-term care weighted mean cost for the Medicaid-only CBA risk group (CBA cost)

Long-term care weighted mean cost for the Medicaid-only NF risk group (NF cost)

Long-term care weighted mean cost for the Medicare/Medicaid OCC risk group composed of:

Community Care for Aged and Disabled (CCAD) weighted mean cost composed of:

Primary Home Care (PHC) weighted mean cost

Day Activity and Health Services (DAHS) weighted mean cost

NF Care - 120 days (modeled) weighted mean cost

Long-term care weighted mean cost for the Medicare/Medicaid CBA risk group (CBA cost)

Long-term care weighted mean cost the Medicare/Medicaid NF risk group (NF cost)

Rate-setting Methodology

Step two consists of applying the rate-setting methodology to the various cost components produced in the cost-finding process. The rate-setting methodology is shown below.

  1. Multiply acute care weighted mean cost components by 0.95;
  2. Multiply CCAD weighted mean cost sub-components by 0.95;
  3. Multiply NF care weighted mean cost components and sub-components by 0.98; and,
  4. Sum the resultant discounted cost components and sub-components within each risk group.

Capitation Rates

The application of the cost-finding and rate-setting methodologies produces capitation rates for the six (6) risk groups as shown below.

  1. Medicaid-only OCC (Acute Care and Long-term Care - PHC, DAHS, and NF)
  2. Medicaid-only CBA (Acute Care and Long-term Care - CBA)
  3. Medicaid-only NF (Acute Care and Long-term Care - NF)
  4. Medicare/Medicaid OCC (Long-term Care only - PHC, DAHS, and NF)
  5. Medicare/Medicaid CBA (Long-term Care only - CBA)
  6. Medicare/Medicaid NF (Long-term Care only - NF)
Star+Plus Managed Care Program
Capitation Rate History
Eligibility Categories Medicaid-only Members Medicare/Medicaid Members
Period
Rate Component
OCC
Risk
Group
CBA
Risk
Group
NF
Risk
Group
OCC
Risk
Group
CBA
Risk
Group
NF
Risk
Group
Feb-1998 thru Oct-1998
Acute Care $ 586.25 $1,210.22 $1,206.47 $00.00 $00.00 $00.00
Long-term Care 30.06 1,720.88 1,976.35 77.06 1,427.72 1,533.74
Total $ 616.31 $2,931.10 $3,182.82 $77.06 $1,427.72 $1,533.74
Nov-1998 thru Aug-1999
Acute Care $ 513.74 $1,057.12 $1,060.43 $00.00 $ 00.00 $00.00
Long-term Care 39.67 1,787.32 2,100.26 96.36 1,479.15 1,766.10
Total $ 553.41 $2,844.44 $3,160.69 $96.36 $1,479.15 $1,766.10
Sep-1999 thru Aug-2000
Acute Care $ 555.92 $1,163.49 $1,163.46 $00.00 $00.00 $00.00
Long-term Care 41.42 1,849.11 2,164.32 96.13 1,523.62 1,819.89
Total $597.34 $3,012.60 $3,327.78 $96.13 $1,523.62 $1,819.89