Appendix A (Part 2)
TEXAS DEPARTMENT OF MENTAL HEALTH/MENTAL RETARDATION (TXMHMR)
PROGRAM: Training and Support Services [TESD term]
MEETING DATE: June 6, 2000
1. Services:Training and Support Services is a label employed to describe a group of mental health and mental retardation services designed to support natural living arrangements in community settings. This group includes:
- Mental Health:
- In-Home and Family Support
- Family Support/Respite
- Family Training
- Skills Training
- Supported Housing
- Supported Employment
- Assertive Community Treatment
- Mental Retardation:
- Supported Home Living
- Site Based Habilitation
- In-Home Respite
- Out of Home Respite
- Specialized Therapies
- In-Home and Family Support
- Goals: The goal of these services is to maintain mental health clients or clients with mental retardation in their own homes or in the homes of relatives/friends in the community and to prevent residential placement outside the home.
- Target population: Mentally ill citizens and citizens with mental retardation. Services may be delivered only to those clients in MHMR's defined priority population; with the exception of In Home and Family Support.
- Legislative authorization: State Agency
2. Current Delivery System:
- Describe: These community-based services are delivered through the local MHMR authorities or their subcontractors. For some services, local service coordinators determine need and authorize services. In In-Home and Family Support, consumers may be given a voucher for services; these vouchers are redeemed by service providers. Additionally, In-Home and Family Support has an annual dollar limit for service elements, such as $3,600 for adaptive devices and architectural modifications. Eligible clients are entered on the statewide MIS with basic identifying and service delivery information. Some services are provided in the home; some may be provided in other community-based settings such as child care centers.
- Pros:System works reliably.
- Technical infrastructure: Central agency mainframe maintains client records, which document client registration and services delivered. Case files are manual and kept locally by the Centers. Centers may operate Local Area Networks. There is a statewide e-mail system.
3. Identify Current or Planned EBT/ESD Initiatives:None planned, however, there was an ESD initiative about ten years ago within the In-Home and Family Support program, using a card-based system. (The vendor was Shearson American Express, but the card was custom designed by TXMHMR.) Service authorization was documented and a telephone dial-in accessed the client database. It also served as a billing system. The system incorporated service authorization, claims and payment. The project was not successful because local business managers did not feel there was adequate documentation and control of transactions to produce an audit trail. This system was only in use for about eight to 12 months.
4. Issues to consider related to an EBT/ESD System:
- MHMR is interested in developing systems with multiple interface features. This is partially an ADA issue - being able to accommodate access needs of a variety of levels of client and professional capabilities. The core systems must have multiple ways of accessing, such as a service verification system that could be accessed either by a card or by voice response (telephone).
- Some type of smart card technology may be possible for services involving specific dollar authorizations granted to the client if adequate controls are incorporated into the system.
- Card-based technology could potentially be used to document service delivery, such as providers that come to a client's home to deliver attendant care.
- MHMR staff suggested that the MHMR client population has a mistrust of technology, largely due to concerns about security of private information, and that significant efforts would be required for them to develop trust and the expertise to use automated systems.
- Hardware expense was cited as another issue, particularly in light of the small dollar amount of In Home and Family support grants.
- There is some concern about the home environment of some clients, and the ability to maintain hardware that might be installed there. Problems have been documented with electronic emergency monitoring devices for the elderly - roaches have invaded the devices and eaten away at them, rendering them useless.
TEXAS DEPT. MENTAL HEALTH/MENTAL RETARDATION
TEXAS COMMISSION ON ALCOHOL AND DRUG ABUSE
PROGRAM: NorthSTAR Project
MEETING DATE: June 6, 2000
- Goals:NorthSTAR is an integrated behavioral health (mental health and chemical dependency) service delivery system that combines federal, state, and local funding to provide better access to services and continuity of care than the traditional public health systems of care, which were separately managed and funded. NorthSTAR is a behavioral health managed care carve-out from the STAR physical health Medicaid managed care program.
- Target population: The project operates in the seven county Dallas service area. It serves Medicaid recipients and medically indigent people based on their need for behavioral health services. A federal waiver enables the State to require that most of the non-institutionalized Medicaid population enroll in this pilot for behavioral health services. This includes people with disabilities receiving SSI; certain Medicaid clients who also have Medicare coverage; Temporary Assistance to Needy Families (TANF) clients; and Medicaid eligible women and children.
- Some non-Medicaid individuals who are clinically eligible are also served, including persons meeting the TXMHMR mental health priority population definition, persons meeting the criteria for services from TCADA including persons with substance abuse diagnoses, and persons with HIV who also have substance abuse diagnoses.
- Legislative authorization: NorthSTAR is a pilot program implemented under the direction of HHSC as a carve-out from the STAR program in an effort to increase access and utilization of behavioral health care by Medicaid recipients. The partnering agencies, TXMHMR and TCADA, are authorized to carry out this program under the Texas Government Code. The Texas Health and Human Services Commission is the single state Medicaid agency. The federal Health Care Financing Administration has approved Texas' request for a Medicaid managed care waiver for this project.
2. Current Delivery System:
All behavioral health services are delivered through two behavioral health organizations (BHOs). The BHOs are also obligated to provide medical transportation for enrollees and to conduct outreach. Client Medicaid eligibility is determined based on information obtained by a DHS eligibility worker, using the SAVERR system, just as in the regular STAR program, which provides the physical health Medicaid managed care for the same service delivery area as NorthSTAR and serves the rest of the state.
For non-Medicaid persons needing to access NorthSTAR services, clinical need establishes eligibility, after a financial assessment determines they are below 200% of the current FPL.
The BHOs receive a per member per month (PMPM) premium each month for enrolled members in their plans. The PMPM is a combination of the funding streams. However, Medicaid dollars cannot be spent on non-Medicaid clients. The BHOs process and pay claims received from providers and in turn send encounters of paid and denied claims to the TXMHMR NorthSTAR operational system.
- Increased access to care for consumers of services.
- Increased coordination of care
- Improvement in the quality of care
- Providers are very resistant to managed care in general - too much control, high admin costs, low reimbursement rates, difficulties in getting claims paid.
- Perception of admin dollars moved to the BHO
- Providers do not particularly like the NorthSTAR project and the changes they have experienced as a result of implementation.
- There are some issues around eligibility determination. DHS controls the SAVERR system, and they are the only ones who can update the system.
- It sometimes takes as much as 7 months to accurately get eligibility changes into the system.
- Technical infrastructure:
- Uses existing DHS, TDH (NHIC), automated systems for eligibility determination, claims, and payments.
- The BHO's must maintain records in a fashion that can link electronically to these systems.
3. Identify Current or Planned EBT/ESD Initiatives:None planned.
4. Issues to consider related to an EBT/ESD System:Staff suggest that the NorthSTAR system could be improved by use of card technology which contained specific mental health care information on the client, including prescriptions, diagnosis, number of visits, and other relevant data. The project could link cards to the project's database. Staff believe clients would like such a system, and that providers would also approve of this technology if assurances for a smooth claims payments process through better eligibility determination were provided.
5. Other Comments:NorthSTAR managers would like to see a more direct linkage to the eligibility information system to make faster updates when information changes. They would like to have the ability for clients to access the database via kiosks for updates such as address changes.
TEXAS DEPARTMENT OF HEALTH
PROGRAM: Vendor Drug Program
MEETING DATE: June 2, 2000
1. Current Service Delivery System:
- Describe: The Vendor Drug Program uses an on-line system to pay pharmacies for authorized prescriptions. A file is first sent to DHS (for refugee information) and then to Comptroller's office for electronic payment.
- The current paper form guarantees payment to the vendor. An ESD system would have to do the same, and provides notices to the client.
- There are four primary ways for a client to defraud the current system (call in amount of pills, forged prescriptions, loaning Med ID to someone not eligible, stealing prescription pads from doctor's office).
- If the current system is down on weekends, some clients are denied purchases until system is back up for authorization.
- Technical Infrastructure:
- Electronic Claims Management System (ECM) includes seven months' data (including current month). The ECM is up twenty two hours/day, with a two hour maintenance window. It includes a prescriber file with license number, name, location, specialty, and status of the license.
- The system maintains contract beginning and ending dates for each pharmacy, detailed payment history, and fiscal year payment totals. If a pharmacy is placed on hold, a reason is included.
- There are 39,000 drugs in the National Drug Code. The system maintains pricing information on each to determine level of reimbursement to pharmacies.
2. Current EBT/ESD InitiativesNone planned.
3. Issues to consider related to an EBT/ESD System:
- Currently, pharmacies are responsible for identifying potential drug interactions among prescriptions for an individual. TDH plans to use an automated system to check for those. The system will be able to detect a potential interaction within two seconds and kill a transaction within 15 seconds.
- The length of time required from eligibility determination to issuance of a card to a client should be considered.
- Med ID cannot stop theft or forgery of prescriptions.
- How will messages and required notification get to the client if the current Med ID card is replaced?
TEXAS DEPARTMENT OF HEALTH
Program: Supplemental Nutrition Program for Women, Infants, and Children (WIC )
MEETING Date: May 24, 2000
- Goal: The WIC Program is to improve the health and nutritional status of a high risk population by providing nutrition education, supplemental foods, and referrals for health services to eligible applicants.
- Target Population:The program serves women who are pregnant, postpartum (up to six months), breastfeeding (up to twelve months after delivery), infants from birth through the first birthday, and children up to their fifth birthday.
- Legislative Authority: WIC is legislatively mandated by Congress as an amendment to Chapter 17 of the Child Nutrition Act of 1972. It is a categorical grant program, with funding levels for each state determined by a formula based on a combination of eligible population and program participation. Funding is one hundred percent federal, with no State matching requirement.
2. Current Service Delivery System:
- The Texas Department of Health contracts with independent local agencies to conduct WIC clinics in approximately seven hundred locations each month in each county.;
- Some clinics are full time, permanent locations, while others are part-time sites open only a few days a month in shared locations. By federal statute, local agencies must be governmental or not-for-profit organizations;
- Eligibility determinations, health and nutrition assessments, and referrals for other health and social services are provided in these clinics;
- Also at the clinics, participants receive one to three vouchers per month for their food prescription. The vouchers must be redeemed in their entirely at a participating grocery store within thirty days from the date of issue or the vouchers expire.;
- The program contracts with approximately 2,400 grocery stores across the state. These stores bundle the redeemed vouchers in batches and submit them to the WIC office within TDH for payment; and
- After editing, payment is made electronically by direct deposit through the Comptroller's office.
- Some monitoring tools are available to spot suspect individual transactions or patterns of suspicious behavior. These tools range from statistical analysis to on-site compliance activity;
- Since both the WIC Program and Food Stamps contract with some of the same retailers, there are some opportunities for cooperation between TDH and the United States Department of Agriculture; and
- The paper food vouchers allow the Program to specify exactly what foods (including specific brands in some instances) and what quantities may be purchased.
- However, compliance depends largely on the integrity of the retailer and participant involved in the transaction;
- Client must purchase all items on voucher during a single store transaction. ESD could eliminate that requirement; and
- Retailers must properly train staff. The manual effort required with the vouchers results in errors by check-out clerks, which result in settlement reductions. ESD could improve this situation.
- Technical infrastructure:
- TDH operates an off-line, distributed computer system to support delivery of WIC services;
- Clinic software maintains a database of participant records for that local agency;
- At the end of each clinic day, new or modified records are uploaded to a central database maintained at TDH. Issuance records for food vouchers are included.;
- As batches of redeemed vouchers are presented for payment by retailers, the vouchers are matched against the database of issued records to verify authenticity before payment; and
- The Department has the ability to adjust the total amount of payment back to a retailer for any errors or questioned costs.
3. Current or Planned EBT/ESD InitiativesThe WIC Program is actively planning to implement an EBT system to replace the paper food vouchers. Because WIC issues a food prescription, rather than a dollar allocation that is restricted to the purchase of foods (like the Food Stamp Program), TDH has concluded that use of an integrated circuit card, or "smart card," is the best alternative.
As envisioned by the agency, the food prescription would be loaded on the smart card at the clinic. Retailers would be equipped with smart card readers (point of sale or "POS" devices) at the checkout stands. The readers would work in an off-line mode. They would compare the types and quantities of foods being purchased with the prescription available on the card. Authorized items purchased would be debited from the balance on the card. The cost of the transaction would be stored on the store's front-end system, or in a separate file within the store. At the end of the day, there would be one single financial settlement with the State's host system.
TDH has completed an Advanced Planning Document containing a programmatic and financial feasibility study, and has received conditional approval from USDA. A Request for Proposals (RFP) was released in 1999 with the State of New Mexico to hire a contractor to develop a system and conduct a pilot project. There were no responses to this RFP. After working with the vendor community, Texas and New Mexico have issued a joint RFO for a card integrator. The revised proposal was released in June, 2000.
TDH believes EBT will significantly improve delivery of services (food benefits). TDH also plans to include other non-food information, such as immunization records, on the card so this information can be shared with other providers.
4. Issues to consider related to an EBT/ESD System (not prioritized):
- Retail grocers have expressed a preference for a single system for WIC and Food Stamps. Large chains also prefer an integrated system, rather than stand-alone or stand-beside. TDH believes an integrated system would make it easier to break even on costs.
- The imperative in implementing WIC EBT is to not do anything to interfere with Food Stamps and TANF.
- There appears to be little communication within USDA between the WIC and Food Stamp offices. (TDH believes this communication may be better at the USDA Regional level).
- Privacy may continue to be an issue (for example, the concern that grocers may access sensitive client immunization data). This must be addressed with proper card security design, but it may take time for cardholders to feel comfortable.
- The replacement rate and cost of replacement for cards will be studied during pilot.
- The current paper based system is difficult for many potential participants to use. Some may feel it's not worth the effort. TDH believes card based EBT will improve the quality of service delivery.
- About 20% of the people on WIC are also on Food Stamps. Virtually all WIC retailers also deliver Food Stamps, but many Food Stamps retailers do not deliver WIC.
- WIC will provide hybrid cards for WIC recipients already receiving Food Stamps. These cards will carry both WIC and Food Stamps authorization.
- WIC does not have the "cost neutrality" provision that Food Stamp does, but has a finite amount of NSA funds. TDH believes WIC EBT may require some investment by retailers for some part of the equipment, software, or training. WIC will pick up part of the cost for the transition from the voucher system to EBT. TDH believes the current system is expensive for retailers (e.g., the cost of the "float" on outstanding voucher reimbursements) and warrants an investment on the part of TDH.
- With Food Stamps, stores seldom incur a loss on a transaction. This does, however, sometimes occur with WIC. EBT will reduce or eliminate the incidence of that.
- WIC does not have specific regulatory language governing EBT, other than a general policy that it is allowed.
- The cost of replacing hybrid WIC cards will be higher than that of the current Lone Star card.
- Converting to EBT is not seen as a way to increase the number of retailers participating in WIC. WIC sees value in limiting the number of stores and feels it does not pose a barrier to participation. Retailer eligibility criteria are more strict than for Food Stamps.
5. General Comments:
- Within TDH, WIC is considered a "done deal" for EBT. It is TDH's first step in ESD planning, with nothing else definite beyond it. However, the agency is working on a Service Delivery Initiative (SDI), and if the WIC EBT/ESD pilot is successful, then the groundwork will have been laid to add more service programs to the card.
- TDH has worked with the EBT task force to develop a coordination plan with Food Stamps with an emphasis on insuring that clients on both programs can use one card.