In accordance with Rider 61, General Appropriations Act, 85th Legislative Session, the Texas Health and Human Services Commission contracted with an external entity to evaluate potential improvements to the agency's managed-care oversight business practices.

HHSC contracted Deloitte to conduct the evaluations and report on areas of opportunity. These reports serve as a roadmap for strengthening oversight of the Texas Medicaid program over the next few years.

Areas of Focus

HHSC's immediate focus is continuing to enhance activities that were already underway and comprehensive planning for activities in four major areas.

We will post regular updates for these activities on this page.

Network Adequacy and Access to Care

The overall goal of this initiative is to build a comprehensive monitoring strategy that supports an accountability system with specific incentives and disincentives to ensure client access to services.

HHSC continues to move forward with initiatives related to strengthening Texas’ assessment of network adequacy and access to care within Medicaid and CHIP. Activities under way include:

  • Improving the accuracy of provider directories, including implementing more robust MCO validation requirements, and conducting an analysis of critical processes that impact directory accuracy.
  • Increasing the use of telemedicine by identifying and remediating administrative obstacles to ensure that access to these services continues to expand and better integrate within the Texas managed care system.
  • Reducing administrative burden related to network adequacy reporting and monitoring. Efforts include cross-agency coordination with the Texas Department of Insurance to ensure HHSC achieves an accurate and complete assessment of Texas’ provider network in a way that is minimally burdensome to providers, MCOs, and HHSC.
  • Integrating network adequacy reporting to include additional measures, such as the appointment availability studies and targeted encounter data.
  • Other activities include working to address the special needs of rural counties, enhancing our provider relations function, and automating internal processes for calculating travel time and distance standards.

Complaints Process and Data Analytics

The focus of this initiative is to improve collection and analysis of complaint data to more efficiently identify potential problems in the Medicaid program or opportunities for improved MCO contract oversight. Activities under way include:

  • An improvement to data collection and system processes that will enhance how HHSC trends and analyzes managed care member complaint data.
  • An initiative to standardize complaint categories used by HHSC and the MCOs. This will allow HHSC to trend data related to complaints, and quickly address potential problems within managed care.
  • Documenting the current journey through the complaints process and identifying how to streamline and effectively communicate the process for clients using the complaints system.

Outcome Focused Performance Management

This initiative will enhance cross-functional managed care oversight capabilities with a focus on specific performance.

Activities under way include:

  • Enhancements to the MCO Operational Review process, including developing new modules to more accurately assess the full range of MCO performance, in addition to refining and streamlining review processes to minimize administrative burden.
  • Strengthening integration of managed care oversight across divisions to ensure assessment activities are robust and are an accurate assessment of MCO performance across multiple domains.
  • Review and vetting of MCO deliverables to ensure reporting requirements provide meaningful information on targeted performance.

Strengthening Clinical Oversight

This initiative is focused on strengthening the oversight of utilization management practices to include prior authorization policies and processes used by MCOs.

Activities under way include:

  • Leveraging prior authorization data to identify trends and anomalies for Medicaid services and focusing on trends within specific Medicaid programs. 
  • Developing a structured process to trend utilization data for specific programs.
  • Enhancing oversight to ensure consistent, medically appropriate approval of Medicaid services.
  • Expansion of sample sizes where appropriate.

Service and Care Coordination

HHSC has recently established a workgroup to assess and implement improvements related to Service and Care Coordination within managed care.

Activities under way include:

  • An analysis of other state Medicaid programs to assess best practices for service and care coordination within Texas’ managed care programs.
  • Assessing and addressing any state level barriers that hinder MCO delivery of service and care coordination services.
  • Simplifying terminology and definitions of service coordination and service management activities across product lines.
  • Assessing possible contract improvements to ensure utilization of service coordination and service management is consistent with HHSC contract requirements.

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Deloitte Presentation Rider 60 and 61a (PDF)
Deloitte Presentation Rider 61bcd (PDF)