Overview of State Services - WellMed Charitable Foundation€¦ · Will receive a letter from the...
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Overview of State Services Cathy Stump North Central Texas Council of Governments
Transcript of Overview of State Services - WellMed Charitable Foundation€¦ · Will receive a letter from the...
Overview of State
Services Cathy Stump
North Central Texas Council of Governments
Locating Local Services
Elder Care Locator Services
National Hotline
https://eldercare.acl.gov/Public/Index.aspx
1-800-677-1116
211
Available throughout the US
Area Agency on Aging
Best resource for local information and services
Call 211 or Elder Care Locator Service
Online search
Area Agency on Aging using your County or Zip Code
Alzheimer’s Association
Alz.org
1800-272-3900
State Services
All States provide Aging and Disability Services
Some are directly funded by the State, Medicaid, City or County
Programs will depend on funding availability and is state specific
All eligibility criteria including income is state and program specific and will
vary drastically
Not all services are equal or provide the same services from state to state
Contact your local Area Agency on Aging
Call 211
Online search for Your State + Aging Services
State of Texas Services
HHS/DADS (Department of Aging and
Disability Services) Programs
Health and Human Services formerly known as DADS (Department of Aging and
Disability Services)
Medicaid and State funded programs
Long term care programs for the people in the community
Some programs are on waiting lists
HHS/DADS (Department of Aging and
Disability Services) Programs cont’d
Community Attendant Services (CAS)
Provides non-skilled, non-technical in home attendant services
Adult Foster Care
Assistance with personal care, ADL’s, transportation provided in a 24 hour living
arrangement with supervision for individuals unable to independently function on
their own
Community Living Assistance and Support Services (CLASS)
Home and community based services and supports for individuals diagnosed with
developmental disabilities
Adaptive aids, dental, minor home modifications, nursing, respite services,
attendant care
HHS/DADS (Department of Aging and
Disability Services) Programs cont’d
Consumer Managed Personal Attendant Services (CMPAS)
Personal assistance services
Must be able to supervise their attendants or delegate supervision
Day Activity and Health Services (DAHS)
Adult Day Care
Deaf Blind with Multiple Disabilities (DBMD)
Home and Community Based services for individuals diagnosed with deaf-blindness
or a condition that leads to deaf-blindness
HHS/DADS (Department of Aging and
Disability Services) Programs cont’d
Emergency Response Services (ERS)
An electronic monitoring system for emergency assistance available for adults with
functional impairments who spend significant, at least 8 hours daily, alone or live with
an incapacitated individual who could not call for help or assist in an emergency
Family Care Services
Non-skilled, non-technical attendant care services
Home Delivered Meals (HDM)
Meals on Wheels
Residential Care
Access to 24 hour assistance for persons who do not require daily nursing intervention
Alternative to Assisted Living
HHS/DADS (Department of Aging and
Disability Services) Programs cont’d
Medically Dependent Children program (MDCP)
Home and community based services and supports to families caring for a
medically dependent child who is less than 21 years
Adaptive aids, child care, respite, minor home modifications
HHS/DADS Non-Medicaid services
Limited state funding available for some programs
Waiting lists for most programs
Day Activity Health Services (DAHS)
Emergency Response Services (ERS)
Family Care Services
Home Delivered Meals (HDM)
Residential Care
CMPAS
HHS/DADS Income and Resource limits
for non-Medicaid programs
Income
Less than $2313 for an individual
Less than $4626 for a couple
Resource
Less than $5000 for an individual
Less than $6000 for an couple
HHS/DADS Medicaid services
Community Attendant Services
No waiting list
Not a full Medicaid program-only pays for attendant care
MDCP
Extensive waiting list
CLASS
Extensive waiting list
Medicaid income and resource limits
Income
Less that $2313 for an individual
Less than $4626 for a couple
Resource limit
Less than $2000 for an individual
Less than $3000 for a couple
How to access services
Contact HHS/DADS
1-888-337-6377
STAR+PLUS
WHAT IS STAR+PLUS
STAR+PLUS is a Texas
Medicaid managed
care program that
provides services to
adults who have
disabilities and/or are
at least 65 years old
It is administered by
the Health and Human
Services Commission
(HHSC), in conjunction
with managed care
organizations (MCOs)
under contract with
HHSC
MEDICARE AND STAR+PLUS
Medicare services do not change for people who have
STAR+PLUS
Medicare is primary payer for hospital/outpatient
services
WHAT RESPONSIBILITIES DO MCOs HAVE?
Provide service coordination
Arrange long term care services (LTSS) for all
members, as they qualify
Arrange acute care services for Medicaid-only
members
Dual eligible (i.e., people with both Medicare and
Medicaid) receive acute care services under their
Medicare benefit
MCO CONTACT INFORMATION
SUPERIOR
1-866-516-4501
MOLINA
1-866-449-6849
UNITED
1-888-887-9003
AMERIGROUP
1-800-600-4441
CIGNA-
HEALTHSPRING
1-877-653-0327
MAXIMUS
MAXIMUS is a third-party contracted entity
Completes initial enrollments on SSI individuals
Completes enrollment changes when an individual is already on STAR+PLUS
Can take up to 45 days to process a change depending on when the request is made
An individual can make an MCO change as many times as they want
1-800-964-2777
Service Area Medical Plans
Bexar Service Area
Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina
and Wilson counties
Amerigroup, Molina Healthcare of Texas,
Superior HealthPlan
Dallas Service Area
Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, and Rockwall
counties
Molina Healthcare of Texas, Superior HealthPlan
El Paso Service Area
El Paso and Hudspeth counties
Amerigroup, Molina Healthcare of Texas
Harris Service Area
Austin, Brazoria, Fort Bend, Galveston, Harris, Matagorda,
Montgomery, Waller, and Wharton counties
Amerigroup, Molina Healthcare of Texas,
UnitedHealthcare Community Plan
Hidalgo Service Area
Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen,
Starr, Webb, Willacy, and Zapata counties
HealthSpring, Molina Healthcare of Texas,
Superior HealthPlan
Jefferson Service Area
Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange,
Polk, San Jacinto, Tyler, and Walker counties
Amerigroup, Molina Healthcare of Texas,
UnitedHealthcare Community Plan
Lubbock Service Area
Amerigroup, Superior HealthPlan
MRSA Central Texas
Bell, Blanco, Bosque, Brazos, Burleson, Colorado, Comanche,
Coryell, DeWitt, Erath, Falls, Freestone, Gillespie, Gonzales,
Grimes, Hamilton, Hill, Jackson, Lampasas, Lavaca, Leon,
Limestone, Llano, Madison, McLennan, Milam, Mills,
Robertson, San Saba, Somervell, Washington
Superior HealthPlan, UnitedHealthcare
MRSA West Texas
Andrews, Archer, Armstrong, Bailey, Baylor, Borden, Brewster, Briscoe,
Brown, Callahan, Castro, Childress, Clay, Cochran, Coke, Coleman,
Collingsworth, Concho, Cottle, Crane, Crockett, Culberson, Dallam,
Dawson, Dickens, Dimmit, Donley, Eastland, Ector, Edwards, Fisher,
Foard, Frio, Gaines, Glasscock, Gray, Hall, Hansford, Hardeman, Hartley,
Haskell, Hemphill, Howard, Irion, Jack, Jeff Davis, Jones, Kent, Kerr,
Kimble, King, Kinney, Knox, La Salle, Lipscomb, Loving, Martin, Mason,
McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree,
Oldham, Palo Pinto, Parmer, Pecos, Presidio, Reagan,
Real, Reeves, Roberts, Runnels, Schleicher, Scurry, Shackelford, Sherman,
Stephens, Sterling, Stonewall, Sutton, Taylor, Terrell, Throckmorton, Tom
Green, Upton, Uvalde, Val Verde, Ward, Wheeler, Wichita, Wilbarger,
Winkler, Yoakum, Young, Zavala
Amerigroup, Superior HealthPlan
Nueces Service Area
Aransas, Bee, Brooks, Calhoun, Goliad, Jim Wells, Karnes, Kenedy,
Kleberg, Live Oak, Nueces, Refugio, San Patricio and Victoria counties
Superior HealthPlan, UnitedHealthcare Community Plan
Tarrant Service Area
Denton, Hood, Johnson, Parker, Tarrant, and Wise counties
Amerigroup, HealthSpring
Travis Service Area
Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis and Williamson
counties
Amerigroup, UnitedHealthcare Community Plan
MRS Northeast Texas
Anderson, Angelina, Bowie, Camp, Cass, Cherokee, Cooke,
Delta, Fannin, Franklin, Grayson, Gregg, Harrison, Henderson,
Hopkins, Houston, Lamar, Marion, Montague,
Morris, Nacogdoches, Panola, Rains, Red River, Rusk, Sabine,
San Augustine, Shelby, Smith, Titus, Trinity, Upshur, Van Zandt,
Wood
Cigna-HealthSpring, UnitedHealthcare
WHO CAN BE ON STAR+PLUS?
To get services through STAR+PLUS you must:
Be approved for full Medicaid benefits
Be at least 21 years old and receiving
Supplemental Security Income (SSI)
Be approved for Waiver Medicaid and meet
medical necessity for nursing home care
WHO CAN’T BE ON STAR+PLUS
Anyone not on Full Medicaid
Benefits such as:
QMB (Qualified Medicare
Beneficiary)
SLMB
QI-1
CAS (Community Attendant
Services)
Illegal Immigrants
Anyone receiving any Department
of Aging and Disability Services
Waiver programs:
CLASS
TxHML (Texas Home Living)
HCS (Home and Community
Services)
DBMD (Deaf Blind Multiple
Disabilities)
WHAT DOES STAR+PLUS PROVIDE?
Long-term services and
supports
Range of services
varies on the basis of
medical condition—
particularly need for
skilled care
Service Coordination
through the MCO
STAR+PLUS and STAR+PLUS WAIVER
STAR+PLUS provides
traditional Medicaid
services, long term
services and supports and
“value-added” services
from the MCOs.
In order to qualify for
STAR+PLUS Waiver (SPW),
an individual must meet
medical necessity (MN) for
nursing home care. The
STAR+PLUS waiver offers a
much broader and more
flexible array of benefits.
WHAT SERVICES ARE OFFERED UNDER
STAR+PLUS?
LONG TERM SERVICES AND SUPPORTS:
Primary Home Care (PHC)
Provides an attendant to assist with activities of
daily living
Day Activity Health Services (DAHS)
Adult Day Care that provides social activities
WHAT SERVICES ARE OFFERED UNDER
STAR+PLUS WAIVER?
Attendant Services
Nursing Services
Adaptive Aids
Medical Supplies
Assisted Living/Adult Foster Care
DAHS
Emergency Response Service
Home Delivered Meals
Minor Home Modifications
Respite Care
Dental Services
Prescription Benefits
Speech Therapy
Occupational Therapy
Physical Therapy
Financial Management Services
Cognitive Rehabilitation Therapy
Supported Employment and Employment Assistance
HOW TO GET ON STAR+PLUS WAIVER
For those who already receive full Medicaid benefits and are enrolled in STAR+PLUS, contact MCO service coordinator.
MCO will conduct assessment. If member qualifies for “upgrade,” waiver services will be authorized on the first day of a subsequent month.
For those who don’t receive Medicaid benefits, contact the Texas Department of Aging and Disability Services.
Must have low income (i.e., no more than $2,313 for single individual)
Must have limited resources (i.e., no more than $2,000 for single individual)
Must meet medical necessity for nursing home care
Currently on a waiting list (8-12 months)
STAR+PLUS WAIVER ELIGIBILITY
FULL MEDICAID BENEFITS
SSI
MEDICAL ASSISTANCE ONLY (MAO)
IF CERTIFIED FOR STAR+PLUS
WAIVER AND NOT ON SSI
MEDICAL NECESSITY
THE INABILITY TO SAFELY SELF
MEDICATE
INABILITY TO RECOGNIZE CHANGES
IN YOUR CONDITION AND BE ABLE
TO CALL FOR HELP
HOW TO BYPASS THE STAR+PLUS WAIVER
INTEREST LIST
MONEY FOLLOWS THE PERSON (MFP)
IF AN INDIVIDUAL IS IN THE NURSING FACILITY AND WANTS TO DISCHARGE TO THE
COMMUNITY
ALL SERVICES WILL BE IN PLACE BY THE TIME AN INDIVIDUAL DISCHARGES
SERVICES ARE COORDINATED WITH MCO, NURSING FACILITY, RELOCATION
SPECIALISTS
INDIVIDUAL MUST BE RESIDING IN A NURSING FACILITY UNDER FULL MEDICAID
AND MEET MEDICAL NECESSITY
IF AN INDIVIDUAL LEAVES PRIOR TO BEING APPROVED, HE/SHE BECOMES
INELIGIBLE
REASONS FOR DENIAL OF STAR+PLUS
WAIVER
MEDICAID DENIAL
IF MEDICAID IS DENIED SO ARE
STAR+PLUS WAIVER SERVICES
MOST COMMON REASONS FOR
MEDICAID BEING DENIED
FAILURE TO RETURN ANNUAL
REVIEW PACKET
FAILURE TO PROVIDE INFORMATION
SUCH AS BANK STATEMENTS OR
VERIFICATION OF RESOURCES
DENIAL OF MEDICAL NECESSITY
MEDICAL NECESSITY DENIAL
ANNUAL REASSESSMENT
COMPLETED BY MCO NURSE
TEXAS MEDICAID HEALTH
PARTNERSHIP (TMHP) DETERMINES
MEDICAL NECESSITY
IF DENIED WILL LOSE ALL
STAR+PLUS SERVICES INCLUDING
MEDICAID IF NOT ON SSI
IF DENIED, WHAT HAPPENS
If denied Medicaid
Will receive a letter from MEPD
and/or SSA
Will receive a letter from the
program support unit (HHSC)
Letter will provide information:
Reason for denial
Appeals
Who to contact
If denied Medical Necessity
Will receive a letter from TMHP
Additional information can be
submitted to support Medical
Necessity within 14 days of letter
Will receive a letter from program
support unit
Reason for denial
Appeals
Who to contact
IF DENIED MEDICAID
If denied Medicaid an individual has 13 days to appeal from the date of
denial.
If an individual does not appeal within the 13 days he/she is not eligible for
continued benefits
An individual has 6 months from the denial date to get reinstated without having to
go back on the interest list
An individual must contact the Program Support Unit to have the necessary
paperwork sent to MEPD
Tarrant SDA 972-337-6334
Dallas SDA 972-337-6221
IF DENIED MEDICAL NECESSITY
An individual has until the denial date on the letter to appeal and receive
continued benefits
An individual has 90 days to appeal
An individual must call the Program Support Unit to Appeal a Medical Necessity
Tarrant SDA 972-337-6334
Dallas SDA 972-337-6221
If an individual does not appeal he/she must go on the interest list if he/she
still wants services
If an individual is denied Medical Necessity and is on Waiver Medicaid he/she’s
Medicaid will be denied
COMPLAINTS OR ISSUES WITH MCO
Call the HHSC Ombudsman
1-866-566-8989 (Issues with MCO)
1-877-787-8999 (Issues with Medicaid)
HEALTH PLAN MANAGEMENT
COMPLAINTS
The Health Plan Management is the overseer of the MCO’s
QUESTIONS?
