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Managed Medicaid:
Our New Paradigm
Patsy Tschudy, RN, CCM, Directorof ManagedCare
Cantex Continuing Care Network
Paul Gerharter, RN, C, Director, Post-Acute Services
Touchstone Communities
…
IndustryHistory
• Medicare 1965
• Medicare HMO’s 1980s
• Hospice 1982
• DRGs 1983
• TILEs 1989
• PPS 1998
• Harris County StarPlus Demonstration
• Medicare PDP Programs – 2006
• Affordable Care Act - 2010
• Medicaid RUG transition - 2008-2010
IndustryHistory

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• When???
– March2015
• Why???
– Increasing Lifespan
– Increasing Beneficiaries
– Workforce Decreasing
ManagedMedicaid
• Passed – 83rd
Session
• Medicaid HMO
• Impacts 60K+ Facility Residents
• 19 States Preceded Texas
• HHSC – Standards & Regulations
SenateBill -7
• Goal – Quality Improvement
• ↑ Access
• ↑ Outcomes
• ↓ Cost
• ↓ Readmissions
• ↓ PreventableEvents
SenateBill -7

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• Eligibility
– StateDetermines
• 5 MCOs – Texas
– UHC
– Amerigroup
– HealthSpring
– Molina
– Superior
SenateBill -7
• MCOs - Distribute Enrollment Packets
• Plans - Provide Care Coordinator
• No Admission Pre-Certification
• 100% Medicaid RUGs Reimbursement
• Pay For Performance
SenateBill -7
What Does This Mean
To Referral Sources??
• Education:
– Marketing
– DischargePlanners
– Physicians

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What Does This
Mean To Me?
• Understanding
– Change
– AppropriatePlacement
– Pre-CertificationRequirements
• 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?
• Collaboration With Payors
• Care Coordinator Involvement
– CarePlanning & Family Meetings
– DischargePlanning
• HigherAcuity
– Beds ToFill
The Future?

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• Current ClinicalSkills
• Needed Resources
– IVCertification
– TPN
– 24/7 RNs
– Complex Wounds
– Resp. Therapy
– Pulmonary Unit - Vents
The Future?
Dual DemonstrationProject
• Targets Traditional Medicare Beneficiaries and
Medicaid Recipients
• Effective 3-1-15
• Passive Enrollment to Medicare HMO over 6
Months
• Goal: ↑ Care Coordination
We Shall Overcome!!

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