1. Managed Medicaid:
Our New Paradigm
Patsy Tschudy, RN, CCM, Director of Managed Care
Cantex Continuing Care Network
Paul Gerharter, RN, C, Director, Post-Acute Services
Touchstone Communities
…

2. Industry History
• Medicare 1965
• Medicare HMO’s 1980s
• Hospice 1982
• DRGs 1983
• TILEs 1989
• PPS 1998
• Harris County Star Plus Demonstration

3. • Medicare PDP Programs – 2006
• Affordable Care Act - 2010
• Medicaid RUG transition - 2008-2010
Industry History

4. • When???
– March 2015
• Why???
– Increasing Lifespan
– Increasing Beneficiaries
– Workforce Decreasing
Managed Medicaid

5. • Passed – 83rd Session
• Medicaid HMO
• Impacts 60K+ Facility Residents
• 19 States Preceded Texas
• HHSC – Standards & Regulations
Senate Bill -7

6. • Goal – Quality Improvement
• ↑ Access
• ↑ Outcomes
• ↓ Cost
• ↓ Readmissions
• ↓ Preventable Events
Senate Bill -7

7. • Eligibility
– State Determines
• 5 MCOs – Texas
– UHC
– Amerigroup
– HealthSpring
– Molina
– Superior
Senate Bill -7

8. • MCOs - Distribute Enrollment Packets
• Plans - Provide Care Coordinator
• No Admission Pre-Certification
• 100% Medicaid RUGs Reimbursement
• Pay For Performance
Senate Bill -7

9. What Does This Mean
To Referral Sources??
• Education:
– Marketing
– Discharge Planners
– Physicians

10. What Does This
Mean To Me?
• Understanding
– Change
– Appropriate Placement
– Pre-Certification Requirements

11. • Prepare List – Facility Providers
• Be Available - MCO Site Visits
• Coordinate MCO Facility Orientation
• Host Resident Council
• Host Open House – Families
• Review Admission Process
• Review Documentation
What Do I Need
To Do Now?

12. • Collaboration With Payors
• Care Coordinator Involvement
– Care Planning & Family Meetings
– Discharge Planning
• Higher Acuity
– Beds To Fill
The Future?

13. • Current Clinical Skills
• Needed Resources
– IV Certification
– TPN
– 24/7 RNs
– Complex Wounds
– Resp. Therapy
– Pulmonary Unit - Vents
The Future?

14. Dual Demonstration Project
• Targets Traditional Medicare Beneficiaries and
Medicaid Recipients
• Effective 3-1-15
• Passive Enrollment to Medicare HMO over 6
Months
• Goal: ↑ Care Coordination

15. We Shall Overcome!!