Presentation To The Senate Committee On Health & Human .

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Presentation to theSenate Committee onHealth & HumanServicesCecile E. YoungExecutive CommissionerMarch 10, 2021 (revised 3-10-2021)

Foster Care LitigationVictoria Ford, MPAChief Policy & Regulatory Officer2

Foster Care Litigation(FCL) Overview On March 29, 2011, Children’s Rights, acting on behalf ofseveral individual foster children (Plaintiffs), filed alawsuit against the Department of Family and ProtectiveServices (DFPS), the Health and Human ServicesCommission (HHSC), and the Governor in federal districtcourt Plaintiffs claimed, generally, that Texas fails to protectfoster children from harm and to provide foster childrenwith appropriate care, treatment, and services The Court certified a General Class: all children now, orin the future, in DFPS’s Permanent ManagingConservatorship (PMC) The case went to trial on December 1, 2014 The Court ruled in favor of Plaintiffs on December 17,2015, finding that the State violated Plaintiffs’ DueProcess rights3

Foster Care Litigation(FCL) Overview (cont.) Through a series of appeals, the 5th Circuit vacatedseveral injunctive provisions and forced the DistrictCourt to modify others The Court issued an injunction and appointed Monitors toreview documents and information for reporting to theCourt on the Defendants’ compliance with the injunction HHSC began implementing the remedial orders on July30, 2019 The injunction will remain in effect for three years afterDefendants reach compliance HHSC’s efforts to comply with those injunctions arebeing, and will continue to be, scrutinized in detail4

FCL Remedial Ordersfor HHSCRO#Description12Effective immediately, ensure the Residential Child Care Licensing (“RCCL”)investigators, and any successor staff, observe or interview the alleged child victimsin Priority One child abuse or neglect investigations within 24 hours of intake13Effective immediately, ensure RCCL investigators, and any successor staff, observeor interview the alleged child victims in Priority Two child abuse or neglectinvestigations within 72 hours of intake14Effective immediately, ensure RCCL investigators, and any successor staff, completePriority One and Priority Two child abuse and neglect investigations within 30 daysof intake, consistent with DFPS policy15Effective immediately, ensure RCCL investigators, and any successor staff, completePriority Three, Priority Four and Priority Five investigations within 60 days of intake,consistent with DFPS policy16Effective immediately, ensure RCCL investigators, and any successor staff, completeand submit documentation in Priority One and Priority Two investigations on thesame day the investigation is completed17Effective immediately, ensure RCCL investigators, and any successor staff, completeand submit documentation in Priority Three, Priority Four and Priority Fiveinvestigations within 60 days of intake18Effective immediately, the State of Texas shall ensure RCCL investigators, and anysuccessor staff, finalize and mail notification letters to the referent and provider(s)in Priority One and Priority Two investigations within five days of closing a childabuse and neglect investigation or completing a standards investigation19Effective immediately, ensure RCCL investigators, and any successor staff, finalizeand mail notification letters to the referent(s) and provider(s) in Priority Three,Priority Four and Priority Five investigations within 60 days of intake5

FCL Remedial Ordersfor HHSCRO#20DescriptionWithin 120 days, RCCL, and/or any successor entity charged with inspections of child careplacements, will identify, track and address concerns at facilities that show a pattern ofcontract or policy violationsSuch facilities must be subject to heightened monitoring by DFPS and any successor entitycharged with inspections of child care placements and subject to more frequent inspections,corrective actions and, as appropriate, other remedial actions under DFPS’ enforcementframework21Effective immediately, RCCL and/or its successor entity, shall have the right to directly suspendor revoke the license of a placement in order to protect children in the PMC class22Effective immediately, RCCL, and any successor entity charged with inspections of child careplacements, must consider during the placement inspection all referrals of, and in addition allconfirmed findings of, child abuse/neglect and all confirmed findings of corporal punishmentoccurring in the placementsDuring inspections, RCCL, and any successor entity charged with inspections of child careplacements, must monitor placement agencies’ adherence to obligations to report suspectedchild abuse/neglectWhen RCCL, and any successor entity charged with inspections of child care placements,discovers a lapse in reporting, it shall refer the matter to DFPS, which shall immediatelyinvestigate to determine appropriate corrective action, up to and including termination ormodification of a contractB3Within 150 days of the Court’s Order, DFPS, in consultation with the Monitors, shall establishinternal guidelines for caseload ranges that RCCL investigators, or any successor staff, cansafely manage based on the findings of the RCCL investigator workload study, including timespent in actual investigationsIn the standard established by DFPS, caseloads for staff shall be prorated for those who are lessthan full-time. Additionally, caseloads for staff who spend part-time in the work described bythe RCCL, or successor entity, standard and part-time in other functions shall be proratedaccordingly6

Remedial Order 20 – Whatis Heightened Monitoring? Required by the court in Remedial Order 20, HeightenedMonitoring (HM) is an increased frequency of on- andoff-site monitoring of residential child care operations,including General Residential Operations and ChildPlacing Agencies, that serve youth in the permanentmanaging conservatorship of DFPS and have a pattern ofdeficiencies and/or concerns over a 5-year period HM is a coordinated effort between HHSC and DFPS, andit involves conducting an in-depth assessment of everyoperation on Heightened Monitoring HHSC develops an individualized and customized plan toaddress the patterns that led to the operation beingplaced on HM Operations will remain on Heightened Monitoring for aminimum of one year7

Remedial Order 20 HeightenedMonitoring Requirements To assess compliance with the HeightenedMonitoring plan, HHSC and DFPS must conductweekly visits HHSC Child Care Regulation and DFPS residentialchild care contracts share responsibility forconducting weekly unannounced visits to eachoperation on Heightened Monitoring to ensurecompliance and progress with the operation’s plan Child Protective Services (CPS) can also assistwith unannounced visits There are currently 70 operations on HeightenedMonitoring8

Remedial Order 22 RO 22 requires HHSC to do two separate items: Consider during inspections all referrals of allegedabuse/neglect; all confirmed findings of abuse/neglect;and all deficiencies related to discipline – called anextended compliance history review When HHSC discovers an operation’s failure to reportsuspected abuse or neglect, this must be referred to DFPS The court found HHSC in contempt of this RemedialOrder in its December 18, 2020 ruling HHSC has taken multiple steps to comply with thisRemedial Order including: Providing automated reports to DFPS daily related tofailure to reportAutomating extended compliance history reviewsExtending the information considered as part of theextended compliance history review to include closedoperations with connections to the open operationProviding job aides to staff on how to thoroughly completean extended compliance history review9

Remedial Order B3 ResidentialChild Care Caseloads On December 17, 2019, HHSC entered into an agreementwith the plaintiffs and court to have a guideline of 14-17tasks per inspector There are four tasks that comprise an inspector’scaseload: Operations that require regulatory monitoring andoversight Investigations alleging an operation failed to meetrequired minimum standards Investigations transferred from DFPS investigations tomake a determination if minimum standards wereviolated Agency homes assigned for random sampling visits10

HHSC Exceptional ItemRequestExceptional Item #2GeneralRevenueAll FundsFTEs Fiscal Year2022Fiscal Year2023Biennium 20.9 million 17.2 million 38.2 million 20.9 million 17.2 million 38.2 million149.9153.0This request is in response to Foster Care Lawsuit andthe requirements that must be met by HHSC to remainin compliance with the remedial orders Funds increases in the number of staff needed toaddress the agreed upon workload guidelines,heightened monitoring, and implement associatedIT system changes to CLASS, CLASSMate, andpublic and provider applications Includes additional staff for quality assurancereviews and compliance tracking11

HHSC Exceptional ItemRequestHeightened Monitoring To fully implement the process, address the needs of identifiedfacilities, and comply with the order, an additional 64 FTEs arerequiredFY 22: 64 FTEs / FY 23: 64 FTEsCaseload Alignment HHSC entered into an agreement with the court and plaintiffs tomaintain a guideline of 14 -17 tasks per inspector In addition to the 111 current positions, an estimated 20additional FTEs are required to maintain caseloads guidelines asagreed uponFY 22: 20 FTEs / FY 23: 20 FTEsCompliance/Quality Assurance Teams Two regional, six-member teams to focus on quality assuranceand investigation reviews One four-member compliance team focusing on data, reportingand coordinating with IT staff Two FTEs dedicated to overseeing and tracking compliance withall the provisions of the remedial ordersFY 22: 18 FTEs / FY 23: 18 FTEs12

HHSC Exceptional ItemRequestInformation Technology Upgrades Implementation of system changes to the CLASS, CLASSMate,and Public and Provider applications such as: Documentation of each facility’s heightened monitoringplan Evaluation of the facility’s compliance with the plan Notation of weekly visits to the facility, includingdocuments and photographs obtained during the visit. Upgrades also include new letters, coding, caseassignments, and the ability to generate additional reports.FY 22: 42.2 FTEs / FY 23: 45.1 FTEsLegal Services and Human Resources Includes one FTE for legal services and one for HR for each fiscalyear to maintain additional workloadAgency Administration Support CostsFY 22: 3.7 FTE and FY 23: 3.9 FTE13

Senate Bill 781Jean ShawAssociate Commissioner, Child Care Regulation14

HHSC Implementation ofSenate Bill 781 The bill created new requirements for General Residential Operations(GROs) that provide treatment services for children with emotionaldisorders and adds requirements regarding the Child Care Regulation(CCR) enforcement framework impact all child care operations HHSCregulates SECTIONS 5 and 10 made multiple changes to requirements for GROapplicants planning to serve children with emotional disorders,renewal of these permits, and required collaboration with the TexasEducation Agency (TEA) Changed requirements for public hearings for GROs who servechildren with emotional disorders Added public hearing requirements for permit renewals forGROs when requested by the County Commissioner Added an operational plan as an application requirement SECTIONS 6-9 impacted CCR’s enforcement framework, removedevaluation as a type of corrective action available, and updatedlanguage in statute accordingly SECTION 8 broadened the 5-year application ban to operations thatchoose to voluntarily close in lieu of disciplinary action15

HHSC Implementation ofSenate Bill 781Public Hearings Statute was amended to remove the waiver forpublic hearings for a GRO applicant that plans toprovide services to children or young adults withemotional disorders, even if the GRO plans toprovide services to trafficking victim services Statute was amended to require a hearing in orderto receive public input on the renewal of a GRO’slicense if requested by a county commissionerscourt HHSC is adopting procedures regarding thehearing through the rule making process Rules are anticipated to be effective in April 202116

HHSC Implementation ofSenate Bill 781Operational Plans As of September 1, 2019, anyone who submits anapplication for a GRO license must submit anoperational plan during the application process HHSC created a form to assist applicants incapturing all required elements of the operationalplan The operational plan is evaluated by HHSC prior toacceptance of any GRO application17

HHSC Implementation ofSenate Bill 781Enforcement Framework Statute was amended to remove evaluation as acorrective action Statute was amended to require a five-year ban toan operation that voluntarily closes or relinquishesa permit in lieu of disciplinary action CCR updated policies for determining appropriatedisciplinary action for providers18

HHSC Implementation ofSenate Bill 781Coordination with TEA HHSC was tasked with collaborating with TEA todevelop best practices for the education ofchildren placed in GROs HHSC, in coordination with TEA, gatheredfeedback from GRO providers about their needsand questions relating to the education providedin their operations HHSC and TEA are creating a best practicesdocument that will be made available to the publicby April 202119

Medicaid Managed CareReform ImplementationStephanie StephensState Medicaid Director20

OverviewBillsKey Areas of FocusHB 4533Complaints, appeals, and fairhearingsPrior authorizationsSB 1207STAR Kids and MDCPSB 10963/10/2021Other bill requirements21

Complaints, Appeals,and Fair HearingsTopicOverviewComplaintsHB 4533 (posting of data completes implementation) Create a no wrong door process for Medicaid managed care complaintsubmission Standardize definitions and categorizations of managed carecomplaints within HHSC and managed care organizations (MCOs) Establish procedures to expedite resolution of access to carecomplaints; and make public verified complaints dataIndependentReviewOrganizationSB 1207 (timeline contingent on solicitation responses) Requires an independent review organization (IRO) to perform anexternal medical review when requested by members who have had adenial or reduction of Medicaid managed care services based onmedical necessity and for denials based on eligibility for certainprogramsMemberCommunication3/10/2021SB 1207 (implements fall 2021) Notices sent by HHSC or a Medicaid MCO to a Medicaid recipient orprovider regarding denial of coverage or prior authorization for aservice must include certain elements22

Prior AuthorizationTopicOverviewCommunicationSB 1207 (implementation complete) Requires MCOs or other entities responsible for authorizing coveragefor health care services under Medicaid to maintain prior authorizationinformation on their websiteTimelines andReconsiderationSB 1207 (implements spring 2021) Establish a process and timeline for MCOs to reconsider adversedeterminations on requests that resulted from insufficient orinadequate documentation in consultation with the State ManagedCare Advisory CommitteeTimelines forHospitalizedIndividualsSB 1096 (implementation complete) MCOs must review and issue prior authorization determinations withinspecific timeframes for members who are hospitalizedOversight3/10/2021SB 1207 (implementation complete) Annual review of MCO’s prior authorization requirements, notincluding prior authorizations for the vendor drug program23

STAR Kids and MDCPTopicOverviewEligibilitySB 1207 Requires consideration of compassionate allowances conditions andMedicaid hospice or palliative care service receipt in MDCP and DBMDeligibility (CMS indicates not allowable) Ensures children do not have to stay in a nursing facility for an extendedperiod of time before being determined eligible for MDCP (aligns withMedicaid policy)Interest ListSB 1207 (implementation complete) Allows a child denied MDCP the option to: (a) be placed at the top of theMDCP interest list in to receive a new assessment from a different MCO,or (b) join another waiver interest list in a position based on the date thechild was first placed on the MDCP interest listSK-SAISB 1207 Streamlines the SK-SAI and reassessment process (implements winter2021/2022) MCOs must ensure STAR Kids service coordinators provide results ofMDCP assessment to parent/LAR, and offer an opportunity for a peer-topeer with a physician of the member’s choosing. (implementationcomplete)3/10/202124

STAR Kids and MDCPTopicOverviewServiceDeliverySB 1207 Develop policy for coordination of benefits when a child has private healthinsurance and Medicaid (implements spring and summer 2021) Create a Medicaid escalation helpline for individuals in MDCP and DBMDwaivers (implementation complete) Conduct an evaluation of risk adjustment for STAR Kids (evaluation complete)HB 4533 Expands the availability of the Consumer Directed Services (CDS) option inthe MDCP waiver program (implementation complete) Requires HHSC to explore with STAR Kids Advisory Committee the feasibilityof providing Medicaid benefits to children enrolled in STAR Kids through anaccountable care organization (ACO) or a proposed alternative model (RFIposts spring 2021)Oversight1096 (ongoing implementation of quality improvement)SB 1207Limited annualthe abilityof MCOsin thecaregivers,STAR Kidsannualprogramto impose Conductsurveysof MDCPfocusgroups,drug-relatedandprior authorizations.measureperformance of MCOs Explorefeasibility of adoptinga private duty nursing assessment.SB1096 (implementationcomplete) Conduct a utilization review on a sample of cases for children enrolled in theSTAR Kids managed care programAdministration3/10/2021HB 4533 Extends the STAR Kids Advisory Committee through December 31, 2023 also required in SB 1207 (implementation complete)25

Other Bill HB 4533 (implements September 2022) HHSC must ensure MCOs are accredited26

Access to Services:Telemedicine and TelehealthStephanie StephensState Medicaid Director

Telemedicine andTelehealthBillOverview Removed the requirement for a health professional to bepresent with a client during a school-based telemedicine service Required HHSC to ensure MCOs meet specified requirements forreimbursing telemedicine and telehealth services and promotingpatient-centered medical homes Prohibits MCOs from denying reimbursement for coveredservices solely because they are delivered remotely andrequires MCOs to consider clinical and cost-effectiveness todetermine whether a telemedicine or telehealth service isappropriate Authorized HHSC to allow Federally Qualified Health Centers(FQHCs) to be telemedicine distant and patient site providers,contingent on appropriationsSB 670Implementation complete with ongoing monitoring3/10/202128

TelemonitoringServicesBillHB 1063Overview Required HHSC to provide reimbursement for home telemonitoringservices provided to pediatric clients with end-stage solid organdisease, who have received an organ transplant, or who requiremechanical ventilation Removed the reimbursement sunset date for the Medicaid hometelemonitoring services Required HHSC to include a cost-savings analysis of telemedicine,telehealth, and home telemonitoring services in its 2020 biennialreport HHSC Rider 178 is a contingency for HB 1063 that requires HHSCto implement the provisions of the bill out of funds appropriated tothe agencyImplementation complete3/10/202129

Rural Pediatric HealthTeleconnectivityBillRider 94,Article II,HB 1Overview A pediatric telemedicine grant program to enable non-urbanhealthcare facilities to obtain pediatric telemedicine services Rider 94 specifies that appropriations include 1.2 million inGeneral Revenue and 1.3 million in Federal Funds in fiscal year2020 and 1.2 in General

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