Quick recap

The meeting focused on billing and financial challenges faced by behavioral health providers, particularly regarding Medicaid Managed Care Organization (MCO) rate reductions and service delivery issues. The group discussed Superior 100's decision to reduce targeted case management (TCM) rates by 40% for most providers, with only three "super providers" in the entire state able to maintain existing rates, affecting approximately 178 clients. Providers shared experiences about the difficulty of predicting service needs and moving funds between service types under current contract structures, with the state expressing concerns about unanticipated shifts from residential to outpatient services. The discussion also covered challenges with billing for patient medications and medical visits, with providers typically absorbing these costs or partnering with pharmacies like Juvenile to help indigent clients. The group explored potential solutions including implementing wraparound rates to make providers whole and allowing payment of patient deductibles, co-payments, and admission fees, while noting these would need to be tracked in headcount numbers for state reporting.

Next steps

Carrie

• Contact licensure to inquire about the process for extending a facility license to a new location (site extension) for providing services in a nearby county.

Luci.Silva

• Continue monitoring Superior's website for updates and application cycles for "super provider" status and share relevant information with staff for future applications.

Noelle

• Research the possibility of billing for medical visits through county hospital district and ask the question to Carmen with Permia Care.

• Collect ideas and feedback from providers on how to better report and predict service needs to HHSC to support retention of the 25% fund movement flexibility in contracts.

• Share with the group any information on upcoming managed care meetings, especially if they become public, and include interested providers in advocacy efforts regarding MCO rate changes.

• Bring up the "wraparound rate" and payment for unfunded client needs (e.g., medications, admission fees) in discussions with HHSC and report back to the group.

• Update the group on any developments regarding potential Medicaid rate increases.

Collaboration

• All providers: Report significant shifts in service delivery or funding allocations to their HHSC grants manager as soon as possible to help the state track community needs and maintain flexibility in contracts.

• All providers: Track and, if possible, categorize expenses related to unfunded mandates (e.g., medications, diapers, transportation) to strengthen advocacy for rate adjustments or wraparound funding.

• All providers: Proactively request prior authorizations and monitor client service units, especially towards year-end, to minimize claim denials due to exceeded annual limits.

  
  

Summary

Superior 100 TCM Rate Reduction

The group discussed Superior 100's plan to reduce Targeted Case Management (TCM) rates by 40% for most providers, with only three "super providers" in Texas able to maintain existing rates. Luci Silva explained that while many providers received letters about the reduction, information about the super provider application process was difficult to find on Superior's website and the application period has closed until the next cycle opens. The discussion revealed that 178 of their clients would be impacted by this change, and participants expressed concern that other MCOs might follow suit with similar reductions.

Women's Center Expansion Discussion

Carrie reported that their organization has recovered well from recent challenges and their women's residential center is operating successfully with state funding. The center has been running at full capacity for a month and was easily licensed under an existing outpatient clinic number. Carrie sought guidance about expanding services to a nearby county, asking about the process for using their current license at a satellite location, and Ivonne explained that this would require a site license extension similar to what was done in the past.

Contract Funding Flexibility Discussion

Carrie clarified that HHSC did not add additional funds to her contract but allowed her to use existing funds for residential services, which will help utilize remaining TRA money before the current year ends. Ivonne explained how combining contracts provides more flexibility in moving funds between service types, reducing the previous frustration of having to return unspent money. Both participants agreed that this flexibility is beneficial for adjusting to changing community needs and service demands.

Service Prioritization and Prediction

Noelle discussed concerns from the state about unclear service prioritization and the need for better prediction of shifting community needs. She explained that while the current process has been beneficial, the state wants more visibility into how residential and outpatient services are changing. Ivonne suggested providing regular reports to the state with billing data to help keep them informed of community needs, though she noted the difficulty in predicting service trends accurately.

Treatment Data Forecasting Challenges

The team discussed challenges with forecasting and reporting treatment data, particularly around residential versus outpatient services. Noelle suggested sharing information with grants managers through regular meetings to keep them informed about shifting trends, while Ivonne explained that providers currently have a 25% allowance for moving funds between service categories without additional approval. The discussion highlighted the difficulty in predicting census numbers and insurance coverage, making it challenging to forecast financial needs accurately.

Executive Finance Forum Leadership Update

Anna announced that Victor will serve as the networking lead for the executive finance forum, with meetings scheduled for the second Friday of each month at 10 a.m. Central Time starting next month. Ivonne raised concerns about HHSC billing practices, explaining that when actual Medicaid enrollment differs from contracted numbers, organizations face compliance issues and potential financial penalties. Ivonne shared a historical example from 2010 where her organization exceeded client targets but struggled with the "last resort" requirement due to Medicaid enrollment patterns, suggesting that removing this requirement could help better align funding with actual service capacity.

Medicaid Wraparound Payment Implementation

Ivonne proposed implementing wraparound rates for Medicaid clients to cover services not covered by insurance, similar to existing programs for youth outpatient and opioid treatment. She suggested extending this approach to all treatment services and including payment of admission fees and co-payments to reduce barriers to treatment. Kathy raised a concern about how these wraparound payments would be counted in HHSC's headcount numbers, which Noelle acknowledged as a potential challenge focused on outputs rather than outcomes.

Patient Medication Billing Challenges

The group discussed billing challenges for patient medications, particularly for indigent clients who cannot afford antibiotics and other necessary medications. Ivonne explained that their organization absorbs these costs or partners with pharmacies like Juvenile to provide medications at reduced prices when patients have no insurance coverage. The discussion also covered broader challenges with unfunded mandates, including expenses for special formulas, diapers, clothing, and other basic needs that exceed the daily rates provided by the state. The conversation ended with a discussion about Medicaid billing restrictions and unit limits, with participants sharing experiences about denials and authorization challenges, particularly at year-end when clients have already reached their annual limits at other providers.