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Table of Contents
                            1115 Waiver MC  2017 Q2 Final
	Table of contents
	I. Introduction
		A. MANAGED CARE Plans Participating in the Waiver Program
		B. Monitoring Managed Care Plans
	II. Enrollment and Benefits Information
		A. Eligibility and Enrollment
		B. Enrollment Counts for the Quarter by Population
		C. Disenrollment
		D. ENROLLMENT OF MEMBERS WITH SPECIAL HEALTH CARE NEEDS
		E. Medicaid Eligibility Changes
		F. Anticipated Changes in Populations or Benefits
	III. Delivery Networks and Access
		A. Provider Networks
		B. GeoAccess
		C. Out-of-Network Utilization
	IV. Outreach/Innovative Activities to Assure Access
		A. Enrollment Broker and Plan Activities
		B. Medicaid Managed Care Advisory Committee
		D. Public Forum
		E. Independent Consumer Supports System Plan
		F. HHSC Managed Care Initiatives
	V. Collection and Verification of Encounter Data and Enrollment Data.
	VI. Opperational/Policy/Systems/Fiscal Developments/Issues
		A. Claims Summary
	VII. Action Plans for Addressing Any Issues Identified
	VIII. Consumer Issues
		A.  Hotline Call Volume and Performance
		B. Complaints and Appeals Received by Plans
		C. Complaints Received by the State
	IX. QUALITY Assurance/Monitoring Activity
		A. DY6Q2 Quarter 2 Update
	Enclosures/Attachments
	State Contacts
	Acronym list
Attachment A-MCOs by Service Area 2017 Q2
Attachment B-Enrollment Summary 2017 Q2
Attachment C1-Provider Network Methodology 2017 Q2
Attachment C2-Provider Network Counts 2017 Q2
Attachment C3 - Provider Termination 2017 Q2
Attachment D-Out of Network Utilization 2017 Q2
Attachment I1-STAR MCO GeoMapping 2017 Q2
Attachment I2-STAR+PLUS MCO GeoMapping 2017 Q2
Attachment I3-STAR_Kids MCO GeoMapping 2017 Q2
Attachment J-MCO Pharmacy GeoMapping 2017 Q2
Attachment K-DMO Dental GeoMapping 2017 Q2
Attachment L-Enrollment Broker 2017 Q2
Attachment M1-Member Hotline 2017 Q2
Attachment M2-Behavioral Hotline 2017 Q2
Attachment M3-Provider Hotline 2017 Q2
Attachment M4-Dental Hotline 2017 Q2
Attachment N-MCO Complaints and Appeals 2017 Q2
Attachment O_Complaints to HHSC Q2_2017
Attachment Q-MSHCN 2017 Q2
Attachment R1- MCO Provider Fraud and Abuse
Attachment R2-DMO Provider Fraud and Abuse
Attachment V1 - STAR Claims 2017Q2
Attachment V2-STAR+PLUS Claims 2017 Q2
Attachment V3-Dental Claims 2017 Q2
Attachment V4-Star Kids Claims 2017 Q2
                        
Document Text Contents
Page 1

Texas Healthcare Transformation and Quality Improvement Program


Section 1115 Quarterly Report for


Managed Care





Texas Health and Human Services Commission






Demonstration Reporting Period:


2017 State Fiscal Quarter 2, December 2016 - February 2017


Demonstration Year (DY) 6 Quarter 2, January 2017 - March 2017

Page 2

December 12, 2011 - December 31, 2017 2




TABLE OF CONTENTS



I. Introduction ................................................................................................................................. 4

A. MANAGED CARE Plans Participating in the Waiver Program ........................................... 4

B. Monitoring Managed Care Plans ......................................................................................... 4

II. Enrollment and Benefits Information ......................................................................................... 5

A. Eligibility and Enrollment.................................................................................................... 5

B. Enrollment Counts for the Quarter by Population ............................................................. 17

C. DISENROLLMENT ....................................................................................................... 17

D. ENROLLMENT OF MEMBERS WITH SPECIAL HEALTH CARE NEEDS............... 18

E. Medicaid Eligibility Changes ............................................................................................ 22

F. Anticipated Changes in Populations or Benefits ............................................................... 22

III. Delivery Networks and Access ............................................................................................... 22

A. Provider Networks ............................................................................................................. 23

B. GeoAccess.......................................................................................................................... 24

C. Out-of-Network Utilization ............................................................................................... 27

IV. Outreach/Innovative Activities to Assure Access .................................................................. 30

A. Enrollment Broker and Plan Activities .............................................................................. 30

B. Medicaid Managed Care Advisory Committee ................................................................. 31

D. Public Forum ........................................................................................................................ 31

E. Independent Consumer Supports System Plan .................................................................. 32

F. HHSC Managed Care Initiatives ....................................................................................... 33

V. Collection and Verification of Encounter Data and Enrollment Data. .................................... 35

VI. Opperational/Policy/Systems/Fiscal Developments/Issues .................................................... 35

A. Claims Summary ................................................................................................................ 35

VII. Action Plans for Addressing Any Issues Identified .............................................................. 36

VIII. Consumer Issues .................................................................................................................. 36

Page 56

Attachment A

Managed Care Plans by Service Area

Service

Area
STAR STAR+PLUS STAR Kids

Aetna Better Health Amerigroup Community 1st

Amerigroup Molina Healthcare of TexasSuperior

Community First Health Plans Superior HealthPlan
Superior HealthPlan
Amerigroup Molina Healthcare of TexasAmerigroup

Molina Healthcare of Texas Superior HealthPlan
Parkland Community Health Plan
El Paso First Health Plan Amerigroup Amerigroup

Molina Healthcare of Texas Molina Healthcare of TexasSuperior

Superior HealthPlan
Amerigroup Amerigroup Amerigroup

Community Health Choice Molina Healthcare of TexasTexas Children's

Molina Healthcare of Texas United

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UnitedHealthcare Community
���Œ�]�•���}�o�o�����Z�]�o���Œ���v�[�•���,�����o�š�Z���W�o���v��HealthSpring Life & Health Driscoll
Molina Healthcare of Texas Molina Healthcare of TexasSuperior

Superior HealthPlan Superior HealthPlan United

UnitedHealthcare Community
Amerigroup Amerigroup Texas Children's

Community Health Choice Molina Healthcare of TexasUnited

Molina Healthcare of Texas
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UnitedHealthcare Community
Amerigroup Amerigroup Amerigroup

FirstCare HealthPlans Superior HealthPlan Superior

Superior HealthPlan
Amerigroup Superior HealthPlan BCBS

Right Care from Scott & White United

Superior HealthPlan
Amerigroup Cigna-HealthSpring Texas Children's

Superior HealthPlan UnitedHealthcare United

Amerigroup Amerigroup Amerigroup

FirstCare HealthPlans Superior HealthPlan Superior

Superior HealthPlan
CHRISTUS Health Plan Superior HealthPlan Driscoll

���Œ�]�•���}�o�o�����Z�]�o���Œ���v�[�•���,�����o�š�Z���W�o���v�� Superior
Superior HealthPlan
Aetna Better Health Amerigroup Aetna

Amerigroup Cigna-HealthSpring Cook Children's

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Blue Cross and Blue Shield of Amerigroup BCBS

Sendero Health Plans Superior

Seton Health Plan
Superior HealthPlan

Children's Medical
Center

UnitedHealthcare

Community Plan

UnitedHealthcare

Community Plan

UnitedHealthcare

Community Plan

UnitedHealthcare

Community Plan

UnitedHealthcare

Community Plan
Travis

Tarrant

Bexar

Dallas

El Paso

Harris

Hidalgo

Jefferson

Lubbock

MRSA

Central

MRSA

Northeast

MRSA

West

Nueces

Page 57

Attachment A

Managed Care Plans by Service Area

Service ���Z�]�o���Œ���v�[�•���D�����]�����]���������v�š���o���^���Œ�À�]�����•���~�����v�š���o���W�Œ�}�P�Œ���u�•
Denta Quest USA Insurance Company, Inc.
MCNA Insurance Company

Statewide

Page 111

Attachment V4
STAR Claims Adjudication (2017 SFQ1-SFQ2)

17Q1 17Q2 17Q1 17Q2 17Q1 17Q2
Aetna Tarrant 0.00% 97.42% 0.00% 100.00% 0.00% 0.00%

Dallas  100.00% 99.90% 100.00% 100.00% 0.00% 100.00%
El Paso 100.00% 100.00% 100.00% 100.00% 0.00% 0.00%
Harris 100.00% 99.90% 100.00% 100.00% 0.00% 100.00%
Lubbock 100.00% 100.00% 100.00% 100.00% 0.00% 0.00%
MRSA West 100.00% 100.00% 100.00% 100.00% 0.00% 0.00%
MRSA Central 100.00% 96.88% 100.00% 100.00% 0.00% 0.00%

Travis 100.00% 98.72% 100.00% 100.00% 0.00% 0.00%

Children's 
Medical Center

Dallas  0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Community 1st
Bexar 83.31% 78.56% 100.00% 99.76% 100.00% 45.80%

Cook Children's Tarrant 100.00% 98.24% 100.00% 99.98% 0.00% 0.00%
Hidalgo 100.00% 98.71% 100.00% 100.00% 0.00% 100.00%
Nueces 100.00% 98.61% 100.00% 100.00% 0.00% 100.00%
Bexar 0.00% 92.89% 0.00% 99.96% 0.00% 0.00%
El Paso 0.00% 96.07% 0.00% 99.90% 0.00% 0.00%
Hidalgo 100.00% 98.73% 100.00% 99.95% 0.00% 0.00%
Lubbock 100.00% 96.89% 100.00% 100.00% 0.00% 0.00%
MRSA West 100.00% 94.27% 100.00% 100.00% 0.00% 0.00%
Nueces 100.00% 96.84% 100.00% 100.00% 0.00% 0.00%
Travis 0.00% 90.75% 0.00% 100.00% 0.00% 0.00%
Harris 100.00% 99.45% 100.00% 100.00% 0.00% 100.00%
Jefferson 100.00% 99.45% 100.00% 100.00% 0.00% 100.00%
MRSA NE 0.00% 99.73% 0.00% 100.00% 0.00% 100.00%
Harris 100.00% 99.55% 100.00% 100.00% 0.00% 0.00%
Hidalgo 100.00% 99.65% 100.00% 100.00% 0.00% 0.00%
Jefferson 100.00% 99.90% 100.00% 100.00% 0.00% 0.00%
MRSA Central 100.00% 99.46% 100.00% 100.00% 0.00% 0.00%
MRSA NE 100.00% 99.59% 100.00% 100.00% 0.00% 0.00%

United

Amerigroup

BCBS

Driscoll

Superior

Texas Children's

(98% Std.)

MCO
% Clean Adj. w/in

30 Days Service Area

Long Term Care Organization's Claims

(99% Std.) (98% Std.)

% Clean Adj. w/in
90 Days

% Appealed Adj. w/in 30
Days

Page 112

Attachment V4
STAR Claims Adjudication (2017 SFQ1-SFQ2)

17Q1 17Q2 17Q1 17Q2
Aetna Tarrant 100.00% 100.00% 0.00% 0.00%

Dallas  100.00% 100.00% 0.00% 100.00%
El Paso 100.00% 100.00% 0.00% 0.00%
Harris 100.00% 100.00% 0.00% 0.00%
Lubbock 100.00% 100.00% 0.00% 0.00%
MRSA West 100.00% 100.00% 0.00% 0.00%
MRSA Central 100.00% 100.00% 0.00% 100.00%

Travis 100.00% 100.00% 0.00% 0.00%

Children's 
Medical Center

Dallas  100.00% 100.00% 0.00% 0.00%

Community 1st
Bexar 100.00% 100.00% 0.00% 0.00%

Cook Children's Tarrant 100.00% 100.00% 0.00% 0.00%
Hidalgo 100.00% 100.00% 0.00% 0.00%
Nueces 100.00% 100.00% 0.00% 0.00%
Bexar 0.00% 100.00% 0.00% 0.00%
El Paso 0.00% 100.00% 0.00% 0.00%
Hidalgo 100.00% 100.00% 0.00% 0.00%
Lubbock 100.00% 100.00% 0.00% 0.00%
MRSA West 100.00% 100.00% 0.00% 0.00%
Nueces 100.00% 100.00% 0.00% 0.00%
Travis 100.00% 100.00% 0.00% 0.00%
Harris 100.00% 100.00% 0.00% 0.00%
Jefferson 100.00% 100.00% 0.00% 0.00%
MRSA NE 100.00% 100.00% 0.00% 0.00%
Harris 100.00% 100.00% 0.00% 0.00%
Hidalgo 100.00% 100.00% 0.00% 0.00%
Jefferson 100.00% 100.00% 0.00% 0.00%
MRSA Central 100.00% 100.00% 0.00% 0.00%
MRSA NE 100.00% 100.00% 0.00% 0.00%

MCO Service Area

Amerigroup

BCBS

Driscoll

Superior

Texas Children's

United

% Non-Electronic Claims Adj. w/in
21 Days 2

% Clean Electronic Claims Adj. w/in
18 Days

Pharmacy Benefit Manager's Claims

(98% Std.)2

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