Special Populations Managed Care Organization Contract Provision (UMCC Section 8.1.14.1) (PDF)

HHSC requires managed care organizations to have a program for targeting, outreach, education and intervention for members who have high utilization patterns that indicate typical disease management approaches are not effective. These are submitted on an annual basis using the template provided in the Uniform Managed Care Manual, Chapter 9.4.

A summary of the plans is available here:

CMS Improving Care for Medicaid Beneficiaries with Complex Needs and High Costs

Texas was selected in September 2015 by CMS to participate in a multistate Innovation Accelerator Program (IAP) focused on beneficiaries with complex needs and high costs (BCN). This population is more generally known as “super-utilizers”.

Targeted program support is available for up to ten states that have ongoing efforts to improve care coordination for Medicaid beneficiaries with complex needs and high costs. Medicaid IAP’s specific goals are to (1) enhance state capacity to use data analytics to better serve the BCN population; (2) develop/refine payment reforms to support BCN programs; and (3) facilitate the replication/spread of BCN programs demonstrating promising results. Structured program support will be offered over the course of ten months. After that time, participating states can access additional one-on-one program support designed to move states towards broader health care delivery and payment reform efforts.

The Texas approach will focus on three areas:

  1. Partnering with providers and health plans that are implementing effective approaches to care for complex need/high cost beneficiaries
  2. Developing supportive state payment policies to sustain effective projects
  3. Building data analytics and information sharing capacity.

Project documents describing the CMS BCN IAP are available here:

Webinars*

For more information, or *for an accessible version, please email HHSC Quality