texas health and human services | - hhs ombudsman ......inquiries received during the fourth...

Quarterly Report from

the HHS Ombudsman

Managed Care

Assistance Team

4th Quarter FY 2020

As Required by

Section 531.0213 of the

Government Code

Office of the Ombudsman

March 2021

ii

Table of Contents

Executive Summary ............................................................................ 1

Introduction ....................................................................................... 3

Background ........................................................................................ 4

A Case Study: OMCAT In Action .......................................................... 5

Consumer Contacts and Complaints .................................................... 6

Barriers and Recommendations for Improvement ............................ 39

Conclusion ........................................................................................ 40

Glossary ........................................................................................... 41

List of Acronyms ............................................................................... 43

1

Executive Summary

In accordance with Government Code Chapter 531, Section 531.0213(d)(5), the Health and Human Services Commission is required to collect and maintain statistical information on a regional basis regarding calls received by the Ombudsman Managed

Care Assistance Team (OMCAT), and publish quarterly reports that:

● list the number of calls received by the region;

● identify trends in delivery, access problems, and recurring barriers in the Medicaid system; and,

● indicate other problems identified with Medicaid managed care.

The data contained in the reports are exclusive to contacts received by OMCAT and does not include contacts received by other areas within Health and Human Services (HHS).

Therefore, the reports do not include all Medicaid managed care complaints received by the agency, vendors, or Managed Care Organizations (MCOs).

During the fourth quarter of fiscal year 2020 (FY20), OMCAT received 6,204 contacts; of which, 1,925 were complaints and 4,279 were inquiries.

Out of the 1,925 complaints received, 1,905 complaints were resolved within the fourth

quarter and are categorized as follows:

● 329 were substantiated;

● 187 were unsubstantiated; and, ● 1,389 were unable to be substantiated (e.g. there was not enough evidence to

determine whether agency policies or expectations were violated).

The most common reasons for these complaints were related to:

● Medicaid eligibility/recertification;

● Access to home health; ● Inability to access to prescriptions due to other insurance on Medicaid case; ● Balance billing; and,

● Case information errors.

In addition to presenting data trends of the contacts received, the report contains

recommendations to mitigate issues identified as barriers to care that drive Medicaid managed care consumers to contact OMCAT.

Figure 1 below shows the total number of inquiries and complaints received which make

up the total number of contacts received by OMCAT during the fourth quarter. Figure 1 also includes the number of complaints that were substantiated during the quarter.

https://statutes.capitol.texas.gov/Docs/GV/htm/GV.531.htm#531.0213

2

Figure 1 4th Quarter FY20 Contacts by Type

3

Introduction

Government Code Chapter 531, Section 531.0213(d)(5), directs OMCAT to publish quarterly reports that provide quantitative contact data, highlight trends, and identify issues affecting Texans who receive or inquire about Medicaid benefits and services

through HHS programs and their vendors.

The quarterly reports provide high-level analysis of data regarding consumer inquiries

and complaints reported to OMCAT, identify barriers and problems with the managed care system, and provide recommendations to address the most frequent complaints. The reports include contacts from consumers on fee-for-service Medicaid, Medicaid

managed care, and those who do not have any Medicaid benefits at the time of contacting OMCAT.

The analyses consist of:

● Total number of inquiries and complaints received;

● Types of inquiries and complaints received; ● Top complaints by entity against which the complaints are made; ● Number and types of inquiries and complaints by region and managed care

delivery model; and, ● Number of complaints resolved that were substantiated, and summaries of cases

that illustrate relevant patterns or trends.

Wherein possible, OMCAT provides recommendations to address barriers within the health and human services system.

4

Background

Government Code 531.0171 requires the HHS Office of the Ombudsman to provide dispute resolution services for the HHS system and perform consumer protection and advocacy functions related to health and human services. This includes assisting a

consumer or other interested person with raising a matter within the HHS system that the person feels is being ignored, obtaining information regarding a filed complaint, and

collecting inquiry and complaint data related to the HHS system.

Pursuant to legislative direction of Senate Bill 601, 74th Texas Legislature, Regular Session, HHSC established a toll-free Medicaid Managed Care Helpline (the helpline) to

assist consumers with urgent medical needs who experience barriers to receiving Medicaid and Medicaid managed care services. The helpline began operating in January

2, 2001, under a non-profit organization, Texas HEART, contracted by the Texas Department of Health.

On September 1, 2007, HHSC transitioned the helpline into the HHS Office of the Ombudsman.

OMCAT receives contacts from the helpline and online submission forms. Contacts are

captured in the HHS Enterprise Administrative Report and Tracking System (HEART), a web-based system that tracks inquiries and complaints for several HHS programs.

HEART tracks consumer specific information, including consumer issues, regional and program data, as well as the findings and resolutions of OMCAT investigations.

5

A Case Study: OMCAT In Action

OMCAT is comprised of 18 highly trained and experienced team members, who, collectively, possess 35 years of Medicaid managed care experience.

As ombudsmen, team members educate consumers on their rights and responsibilities,

help them navigate the Medicaid managed care system, and resolve complaints.

OMCAT investigates consumer complaints, works with Medicaid & CHIP Services to

determine compliance with state and agency rules and policies, determines if agency expectations were met, and provides recommendations for resolution with the goal of preventing future occurrences.

The following is a case study that highlights the work of OMCAT.

During the fourth quarter of FY20, OMCAT received and resolved a total of 104

complaints from consumers with issues related to COVID-19.

In June 2020, a consumer needed to receive urgent dental care that required

anesthesia. However, the surgical center that the dentalcare provider used was not allowing dental procedures to be performed at the facility during the public health emergency (PHE).

OMCAT worked with the consumer’s dental plan to find another dentalcare provider that had an in-office dental anesthesiologist and could perform the procedure needed.

Additional examples of COVID-19 related complaints received and resolved by OMCAT include:

● Consumers who:

o Turned 21-years-old and were supposed to continue with dental benefits during the PHE, but the dental plan was terminated;

o Left a nursing facility and were still reflecting as being in a nursing facility on their Medicaid case which made it difficult for them to receive durable medical equipment (DMEs) or home health services;

o Disagreed with the COVID-19 safety procedures of providers’ offices; ● Parents not wanting to take children into the provider’s office for check-ups due to

fear of possible exposure to COVID-19; and, ● Providers not accepting new patients due to fear of exposure to COVID-19.

6

Consumer Contact and Complaints

Contact Data Analysis

OMCAT received 6,204 contacts in the fourth quarter of FY20. Compared to the third quarter of FY20, this was an increase of 21 percent or 1,081 more total contacts related

to Medicaid benefits and services. (Total contacts include general inquiries and complaints from consumers, legislative staff on behalf of consumers, and other stakeholders).

Inquiry Data Analysis

OMCAT received 4,279 inquiries, which is an increase of 28 percent (or 926 more

inquiries), in the fourth quarter compared to the third quarter of FY20. Inquiries remain

an important indicator of member’s educational needs and requests for information.

OMCAT experienced an increase in inquiries regarding:

● Access to or change of PCP; ● Reporting changes to Medicaid case; ● Applying for healthcare coverage;

● Explanation of benefits or policy; ● Changes in health plan;

● Access to vision services; and, ● Access to specialist.

Top 10 Inquiries

The top ten inquiries listed below represent 61 percent (or 2,622) of the total number of

inquiries received during the fourth quarter.

Table 1: Top 10 Inquiries

Inquiry Reason Count Percent of Total

Verify Health Coverage 563 13%

Access to PCP/Change PCP 453 11%

Explanation of Benefits/Policy 291 7%

Reporting Change 285 7%

Apply for Health Coverage 251 6%

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Inquiry Reason Count Percent of Total

Change Plan 215 5%

Billing Inquiry 185 4%

Other/NA 131 3%

Obtain Health Plan ID card 129 3%

Access to Specialist 119 3%

Complaint Data Analysis

OMCAT received 1,9251 complaints, which is an increase of nine percent (or 155 more complaints) compared to the third quarter of FY20.

OMCAT experienced increases in complaints regarding:

● Provider treatment inappropriate/ineffective; ● Inability to access home health provider services;

● Inability to access prescriptions due to other insurance showing on consumer file; ● Inability to access services due to other insurance showing on consumer file; and,

● Inability to access an out-of-network provider.

Substantiated Complaints

In the analyses that follow, OMCAT categorizes complaints received as: substantiated, unsubstantiated, and unable to substantiate. (For a definition and example of each of

these categories please see the Glossary.)

Complaints include those received by consumers on fee-for-service Medicaid, Medicaid

managed care, and by consumers applying for or whose Medicaid has lapsed.

In the fourth quarter, OMCAT substantiated 17 percent of complaints received. This is an increase of one percent compared to the third quarter of FY20.

Figure 2 below shows how many resolved complaints were: substantiated, unsubstantiated, or unable to be substantiated.

1 Twenty complaints received during the fourth quarter were still being investigated by team

members, and therefore not resolved at the time the data were compiled, and as such not

represented in the pie chart on the next page in Figure 2.

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Figure 2 Complaints Assessments

In accordance with Government Code Chapter 531, Section 531.0213, OMCAT is

required to educate consumers so that they can advocate for themselves.

When consumers are educated on how to file their complaint with the appropriate area,

this results in an initial referral to the health plan or appropriate HHS program. In these cases, OMCAT will not have the final resolution to the complaints and therefore cannot determine if the complaints were substantiated or not.

This statutory requirement may in part explain the number of “unable to be substantiate” cases.

Top Ten Substantiated Complaints

As identified in Figure 2 above, OMCAT received and substantiated a total of 329 complaints. Table 2 below presents the 10 most common substantiated complaints.

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Table 2: Top 10 Complaints

Complaint Reason Count

% of Total

Substantiated

Access to Prescriptions - Erroneous Insurance

on Consumer’s File 45

14%

Access to In-Network Provider (non-PCP) 31 9%

Access to Home Health Services 29 9%

Access to Prescriptions - Consumer Not

Showing as Having Active Medicaid

25 8%

Errors on the Medicaid case 22 7%

Access to Prescriptions - Pharmacy Billing

Wrong Health Care Coverage

15 5%

Consumers Being Billed 13 4%

Access to DME 12 4%

Access to Out-of-Network Provider 12 4%

Access to Prescriptions Not on Formulary 10 3%

All Complaints by Responsible Entity

In addition to reviewing complaints by type, OMCAT reviews the data for potential trends with responsible entities. The responsible entity refers to the area found or presumed

responsible for the program or service about which the consumer is contacting OMCAT.

Most of the complaints received were found to be associated with three responsible entities: HHSC, Managed Care Organizations, and providers.

An analysis of the data found the following:

● Managed Care Organizations were the responsible entity in 43 percent of

complaints (or 823); ● Providers were the responsible entity in 29 percent of complaints (or 550); ● HHSC was the responsible entity in 21 percent of complaints (or 408); and,

● Various entities not already mentioned comprised seven percent (or 144).

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Figure 3 below shows the three major entities responsible for complaints as well as the percentage of complaints attributed to these entities.

Figure 3 Complaints by Responsible Entity

Top 5 Complaints by Responsible Entity

The tables below show the top five complaints by responsible entity.

HHSC as the Responsible Entity

Of 4832 complaints received where the responsible entity is HHSC, 39 (or eight percent) were substantiated complaints. The fourth quarter had an increase of four percent (or 17 more) in complaints compared to previous quarter (which had a total of 466). The fourth

quarter substantiated complaints had a decrease of one percent (or 1 fewer) compared to the third quarter substantiated complaints.

The tables below highlight the top 5 substantiated complaints received by each entity. The columns in the table present the total number of complaints received for the

2 Figure 3 shows the unduplicated count of 408 complaints with HHSC as the responsible entity.

The total number of complaints received about HHSC is 483. The difference between the counts is

due to occurrences where a client contact generates multiple complaint reasons being logged.

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complaint category, the total number of complaints substantiated, and the percent substantiated for the complaint category.

Table 3 HHSC Top 5 Substantiated Complaints

Complaints Total of

Received Total

Substantiated % of

Substantiated

Case Information Error 100 15 15%

Access to Prescriptions -

Erroneous Insurance on

Consumer’s File

22 7 32%

Access to Home Health Services 25 5 20%

Medicaid

Eligibility/Recertification

144 5 3%

COVID-19 1 1 100%

Substantiated complaints of incorrect information on consumer cases are related to:

● Incorrect name or spelling of consumer’s name; ● Incorrect date of birth;

● Incorrect gender; ● Incorrect start date for Medicaid coverage;

● Incorrect residential information; ● Consumer showing as having Medicare but is not eligible for Medicare; ● Incorrect type of Medicaid; or

● More than one Medicaid case assigned to a consumer.

Substantiated complaints of inability to access prescriptions due to erroneous insurance

information include:

● Consumer showing as having Medicare on the Medicaid case, although Medicare coverage had terminated;

● Other insurance showing on Medicaid case, but consumer does not have any coverage other than Medicaid; and,

● Other insurance showing in the Medicaid pharmacy system when the consumer does not have any coverage other than Medicaid.

Substantiated complaints of access to home health services include:

● Consumer whose home health services were interrupted by an unexpected change in health plan;

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● Services terminated due to the incorrect type of Medicaid on case; services interrupted by incorrect residential information on the case which placed the

consumer in the wrong service area; and, ● Delay in start of services due to waiting on HHS to make determination of

eligibility for the STAR+PLUS Waiver although the health plan had completed the

assessment for the STAR+PLUS waiver months prior.

Substantiated complaints related to Medicaid eligibility were due to the Medicaid cases

being terminated in error.

The substantiated COVID-19 complaint was due to a consumer being placed in the incorrect type of Medicaid; however, due to the Families First Coronavirus Cares Act, the

type of Medicaid could not be changed back during the PHE.

Managed Care Organizations (MCOs) as the Entity Responsible

Of the 1,0063 complaints received where the entity responsible was an MCO, 175

complaints (or 17 percent) were substantiated. The fourth quarter had an increase of 15 percent (or 135 more) in complaints compared to the third quarter (which had a total of

871). The fourth quarter had an increase of three percent in substantiated complaints compared to the third quarter.

Table 4 Managed Care Plans Top 5 Substantiated Complaints

Substantiated Complaints Count Substantiated

% of

Substantiated

Access to In-Network Provider

(non-PCP) 99 30 30%



Consumer’s File

48 24 50%


Access to Out-of-Network

Provider 70 11 16%


Consumer Not Showing as

Having Active Medicaid

15 8 53%

3 Figure 3 shows the unduplicated count of 823 complaints with MCOs as the responsible entity.

The total number of complaints received for this entity is 1,006. The difference between the

counts is due to occurrences where a client contact generates multiple complaint reasons being

logged.

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Substantiated complaints of accessing an in-network specialist or facility include:

● Consumers not able to locate in-network specialists due to the MCO’s provider

directory being out of date (specialists not taking new patients or no longer accepting the MCO);

● Type of specialist needed is not available in MCO’s network; and,

● A provider refusing to see consumer due to not being paid by MCO.

Substantiated complaints of inability to access prescriptions due to other healthcare

coverage on Medicaid cases include:

● MCO consumer files showing private insurance that the consumer either no longer had or never had; and,

● consumers that showed as having Medicare in the MCO’s system but were not active with that coverage.

Substantiated complaints of access to home health services include:

● Access to personal attendant services;

● Access to nursing services after being discharged from a facility; ● Interruption in home health services; ● Delay in obtaining assessment for home health services;

● Unable to obtain additional hours of attendant services; ● Termination of home health services;

● Home health agency’s system not updated with consumer’s eligibility; ● Access to meal delivery; ● Access to emergency response system; and,

● Access to out of network home health provider after having moved out of the service area.

Reasons for consumers’ inability to access home health services include:

● Services denied; ● Frequent changes in service coordinator or unable to reach service coordinator;

● Agency stopped sending home health provider; ● MCO did not have the authorized representative (AR) on file and therefore would

not assist the AR; ● MCO representative failed to show for the scheduled assessment; and, ● MCO’s system did not show consumer as an active member.

Substantiated complaints of inability to access out of network providers include:

● Pregnant consumers who moved out of service area and MCOs were not able to

find or did not assist with finding an obstetrician gynecologist (OBGYN) in the new area that would see the consumer;

● Consumer unable to find in-network providers that were accepting new patients

and wasn’t assisted by MCO in finding an out of network provider; ● Consumer needed to be seen at out of network hospital for transplant surgery and

hospital was not able to get authorization for care; and,

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● Consumer had temporarily moved out of service area and not assisted by MCO in finding a specialist out of network.

Substantiated complaints of inability to access prescriptions related to the consumer not showing as having active coverage in the MCO’s system are due to the consumer’s enrollment information not being uploaded to the MCO system.

Providers as the Responsible Entity

Of the 6384 complaints received where the responsible entity was a provider, 97 (or 15 percent) complaints were substantiated. The fourth quarter had a decrease of 11

percent (or 76 fewer) in complaints compared to the third quarter (which had a total of 714). The fourth quarter percentage of substantiated complaints remained the same as the third quarter percentage substantiated complaints.

Table 5: Providers Top 5 Substantiated Complaints

Substantiated Complaints Count Substantiated

% of

Substantiated




46 16 35%


Pharmacy Billing Wrong Health

Care Coverage

31 15 48%



Consumer’s File

53 10 19%

Access to Prescriptions - Not on

Formulary

19 8 42%

Consumer Being Billed 61 7 11%

Substantiated complaints of inability to access prescriptions due to not showing active

coverage are related to pharmacies whose systems do not show consumer as having active Medicaid coverage, but the consumer was active with Medicaid at the time of service.

4 Figure 3 shows the unduplicated count of 550 complaints with a provider as the responsible

entity. The total number of complaints received for this entity is 638. The difference between the

counts is due to occurrences where a client contact generates multiple complaint reasons being

logged.

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Substantiated complaints of pharmacies billing the wrong health insurance is due to pharmacies billing an MCO of which the consumer was not a member.

Substantiated complaints of inability to access prescriptions related to erroneous insurance are due to pharmacies showing outdated or incorrect private insurance information showing in their systems. Pharmacies are required to bill private insurance

before billing Medicaid; therefore, if there is incorrect or outdated private insurance showing in their system, the pharmacy is not able bill correctly for the medication.

Medications are the only Medicaid service that are paid at the time of service and cannot be billed after the service is provided.

Substantiated complaints of inability to access prescriptions related to the prescription

not being on the Medicaid formulary were due to Medicaid providers prescribing medications that were not covered by Medicaid.

The substantiated complaints of consumers being billed include Medicare providers billing consumers instead of billing Medicaid for the balance that Medicare does not

cover; and Medicaid providers billing Medicaid consumers for services rendered while they are active with Medicaid.

Top 5 Complaints by Medicaid Managed Care Program

In this section of the report, complaints are analyzed by the Medicaid managed care program that consumers had at the time of the complaint. Because OMCAT receives many complaints, the top five complaints may not always comprise most of the total

complaints for each service area. The following tables show the top five reasons for complaints for each managed care program.

STAR+PLUS (536,6075)

Total Complaints Received: 805

Total Substantiated Complaints: 125

Of the 805 complaints received on the STAR+PLUS managed care program, 125 complaints (16 percent) were substantiated. Complaints increased by eight percent (or

60 more) while the percentage of substantiated complaints remained the same as the third quarter percentage of substantiated complaints.

The top five complaints noted in Table 6 below make up 37 percent of the total complaints received by consumers on STAR+PLUS managed care program.

5 The average monthly enrollment for STAR+PLUS program in the fourth quarter of fiscal year

2020.

16

Table 6 STAR+PLUS Top 5 Complaints

Complaint Reasons Count Substantiated % of

Substantiated


Access to DME 63 10 16%


(non-PCP)

46 14 30%

COVID-19 42 1 2%


Substantiated complaints of accessing home health services include:

● MCO or home health agency not showing consumer as active member; ● Consumer disagrees with number of home health hours allotted;

● Assessments not being conducted for home health services; ● Home health attendant not showing up to provide services;

● Home health agency not able to provide attendants for all hours required; ● Denial of services; and ● Interruption in services caused by termination of waiver or Medicaid eligibility, or

change in MCO.

Substantiated complaints related to accessing DME include access to:

● Incontinent supplies, ● Oxygen supplies, ● Mattress,

● Diabetic supplies, and ● Shower supplies.

Reasons for inability to access DME include:

● Denial of services; ● Did not receive assistance from the MCO when requested;

● Consumer’s case showing wrong type of Medicaid; and, ● Unable to make doctor’s appointment to get prescription for DME due to COVID-

19.

Substantiated complaints of access to an in-network provider include access to:

● Psychiatrist,

● Orthopedic specialist, ● Pain management specialist,

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● Ophthalmologist, ● Dental provider,

● Neurologist, ● Neurosurgeon, ● Hand surgeon, and

● Urologist.

Reasons for inability to access in-network specialists include:

● Outdated MCO provider information (listed providers are not taking new patients, have retired, or no longer accepting the MCO);

● MCO does not have the type of specialist needed in the consumer’s service area;

● Consumer does not show as an active member in the MCO system; ● Assigned PCP does not take new patients due to COVID-19, therefore consumer

cannot get referral to a specialist; ● MCO did not have the needed specialist in their network; and

● Service Coordinator does not return calls.

The substantiated complaint related to COVID-19 was related to a consumer needing transportation assistance to take a COVID-19 test.

Substantiated complaints related to consumers being billed include:

● Providers billing consumers for claims denied by the consumer’s MCO;

● Dual eligible consumers (those with Medicaid and Medicare) being billed for copays that should have been billed to Medicaid; and

● Providers billing consumers for services although the consumer was active with

Medicaid at the time of service.

STAR (3,257,9056)


Total Substantiated Complaints: 116

OMCAT received 710 complaints from consumers in the STAR managed care program; of which 116 (16 percent) complaints were substantiated. While the complaints increased by 26 percent (or 147 more), the total substantiated complaints decreased by one

percent compared to the third quarter. The top five complaints noted in Table 7 below comprise 42 percent of the total complaints received by consumers on STAR managed

care program.

6 The average monthly enrollment for STAR program in the fourth quarter of fiscal year 2020.

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Table 7 STAR Top 5 Complaints


Substantiated



Consumer’s File

73 25 34%


Provider 60 10 17%



(non-PCP) 53 13 25%


Substantiated complaints of inability to access prescriptions due to other insurance is

due to pharmacy, HHSC or MCO systems showing consumers as having insurance other than Medicaid, although the consumers were not active with any other insurance.

Substantiated complaints of inability to access out of network providers include: consumers who have moved out of their service area and needed to access an out of network OBGYN but either the MCO did not assist the consumer with finding a provider

in the new area or providers would not accept new patients that are high risk; and consumers that have temporarily moved out of their service area and MCO was not

willing to assist with finding an out of network specialist.

Substantiated complaints of errors on the Medicaid case include: consumer’s Name spelled incorrectly; consumer’s authorized representative’s name is incorrect; incorrect

date of birth; incorrect gender; and a consumer having more than one Medicaid ID assigned.

Substantiated complaints of access to in-network providers include: MCO provider directory information was out of date or incorrect; and consumers not being assisted by their MCO in finding the type of specialist they need.

Substantiated complaints of consumers being billed include: consumers being billed by Medicaid providers although the consumer was active with Medicaid at the time of

service; and a consumer who contacted the MCO about a bill but the MCO did not follow up on the outcome of the complaint.

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STAR Kids (164,1007)


Total Complaints Substantiated: 31

Of the 200 complaints received on the STAR Kids managed care program, 31 (16

percent) complaints were substantiated. While the complaints increased by 25 percent (or 40 more), the total substantiated complaints decreased by three percent compared to the previous quarter. The top five complaints noted in the table below make up 34

percent of the total complaints received by consumers in STAR Kids managed care program.

Table 8: STAR Kids Top 5 Complaints


Substantiated




Consumer’s File

13 7 54%

COVID-19 13 0 0%



Provider 9 1 11%

Substantiated complaints of inability to access home health services include instances where a consumer:

● was not able to start attendant services due to their service coordinators being changed several times;

● whose home health agency did not show the consumer with active coverage;

● was unable to start respite care due to HHSC not providing the MCO with a start date to the waiver; and,

● was not assisted in setting up urgent respite care.

Substantiated complaints of inability to access prescriptions due to erroneous insurance

include: consumers’ MCO showed active Medicare when the consumer did not have

7 The average monthly enrollment for STAR Kids program in the fourth quarter of fiscal year

2020.

20

Medicare; and MCO showing consumers with active private insurance although the consumers did not have active private insurance.

Substantiated complaints related to access to DME include: inability to obtain orthopedic equipment due to service coordinator not following up with the consumer’s request for assistance; and a consumer was not assisted by the MCO in finding a new DME company

after the previous DME company’s contract was terminated.

The substantiated complaint of access to an out of network provider was regarding a

consumer not able to locate any in-network providers of the specialty needed.

STAR+PLUS Dual Demo (39,1478)



OMCAT received 34 complaints from consumers in the STAR+PLUS Dual Demo program in the fourth quarter and of those 5 (15 percent) complaints were substantiated. Complaints increased by 13 percent (or 4 more) and substantiated complaints increased

five percent. The top five complaints noted in the table below make up 56 percent of the total complaints received by consumers on STAR+PLUS Dual Demo.

Table 9: STAR Plus Dual Demo Top 5 Complaints


Substantiated

Access to Home Health

Services 8 0 0%

Medicaid

Eligibility/Recertification 3 0 0%


COVID-19 3 0 0%

Incorrect Information or

Guidance 2 1 50%

The substantiated complaint of incorrect information/guidance was related to a consumer given incorrect information about her Medicaid eligibility by a provider.

8 The average monthly enrollment for STAR+PLUS Dual Demo program in the fourth quarter of

fiscal year 2020.

21

STAR Health (35,3749)



OMCAT received 25 complaints from consumers in the STAR Health program in the

fourth quarter and of that three (12 percent) complaints were substantiated. Complaints decreased by 38 percent (or 15 fewer) and substantiated complaints increased nine percent. The top five complaints noted in the table below make up 60 percent of the

total complaints received by consumers on STAR Health.

Table 10: STAR Health Top 5 Complaints


Substantiated


Other 5 1 20%

Medicaid




Clinical Prior Authorization 2 0 0%


The substantiated complaint of inability to access prescriptions due to other reasons is related to a consumer showing as active with two MCOs in the pharmacy system.

The substantiated complaint of a consumer being billed was related to a consumer who

was billed by a hospital and was not assisted by the MCO in addressing the issue even though the consumer was active with the MCO at the time of service.

9 The average monthly enrollment for STAR Health program in the fourth quarter of fiscal year

2020.

22

Dental Managed Care (3,105,79610)



OMCAT received 79 complaints from consumers in the Dental Managed Care program in

the fourth quarter and of those nine (or 11 percent) complaints were substantiated. Complaints increased by 126 percent (or 44 more) and substantiated complaints decreased by 12 percent. The top five complaints noted in the table below make up 56

percent of the total complaints received by consumers on Dental Managed Care.

Table 11: Dental Managed Care Top 5 Complaints


Substantiated

Provider Treatment

Inappropriate/Ineffective 12 0 0%

Authorization Issue 9 3 33%

Access to Dental Services

(adult) 8 0 0%



(non-PCP) 7 2 29%

Substantiated complaints related to authorization issues include: consumer who was authorized for the removal of some but not all teeth that needed to be removed; and consumers unable to access facilities that were accepting dental patients that required

anesthesia.

Substantiated complaints of case information error include: authorized representatives

of consumers (AR) trying to get assistance from the dental plan however the plan did not show the Ars in their system and refused to assist; and a consumer whose Medicaid number was not correct in the dental plan’s system.

Substantiated complaints of access to in-network providers are due to ARs unable to change the dental provider or find a dental provider with the dental plan due to the plan

not showing the ARs in their system.

10 The average monthly enrollment for Dental Managed Care program in the fourth quarter of

fiscal year 2020.

23

Fee-for-Service/Traditional Medicaid (192,89411)



OMCAT receives contacts from all consumers on Medicaid. This includes those that are

on fee-for-service Medicaid which means they are not enrolled with an MCO.

OMCAT received 222 complaints from consumers in the Fee-for-Service/Traditional Medicaid program in the fourth quarter of fiscal year 2020, and of those 37 (17 percent)

were substantiated. Complaints decreased by 14 percent (or 35 fewer) and the fourth quarter percentage of substantiated complaints remained the same as the third quarter

percentage of substantiated complaints. The top five complaints noted in the table below make up 44 percent of the total complaints received by consumers on fee-for-

service/Traditional Medicaid.

Table 12: Fee-for-Service Top 5 Complaints


Substantiated




21 6 29%

Access to Prescriptions - Non-

Medicaid Provider 21 8 38%

Medicaid




Consumer’s File

19 4 21%


Substantiated complaints of inability to access prescriptions regarding consumer not showing as having active coverage are due to consumer’s eligibility not showing in the

HHSC pharmacy system; pharmacy running the prescription under a previous MCO when the consumer was on traditional Medicaid at time of service; and pharmacy system not

showing consumer as active with Medicaid.

11 The average monthly enrollment for Fee-for-Service Medicaid in the fourth quarter of fiscal

year 2020.

24

Substantiated complaints of inability to access prescriptions due to prescribing provider not being enrolled with Medicaid include: consumers that needed prescriptions filled

while temporarily out of state; and consumers that were prescribed a medication by a physician at a Medicaid enrolled clinic however the prescribing physician was not enrolled with Medicaid.

The substantiated complaint of Medicaid eligibility was regarding a consumer whose Medicaid case was terminated erroneously.

Substantiated complaints of inability to access prescriptions due to erroneous insurance include pharmacies systems or the HHSC pharmacy system erroneously showing consumers as having private insurance or Medicare although the consumers only had

Medicaid at the time of service.

Substantiated complaints of case information error include: a consumer’s case that

erroneously showed active with Medicare; and a consumer’s case that erroneously showed FFS Medicaid instead of showing active with an MCO.

Non-Medicaid



OMCAT receives inquiries and complaints from consumers that may not be in a Medicaid program, or may have a type of Medicaid that only pays for their Medicare premium,

copays and deductibles for Medicare services. Many of these contacts are related to clients applying or reapplying for Medicaid.

Of the 217 complaints from consumers who were not in a Medicaid program, 3 (or one percent) were substantiated. Complaints decreased by 16 percent (or 41 fewer) and substantiated complaints decreased by one percent. The top five complaints noted in the

table below make up 65 percent of the total complaints received of No Medicaid.

Table 13: Non-Medicaid Top 5 Complaints


Substantiated

Medicaid



COVID-19 12 0 0%

Access to Home Health

Services 10 0 0%

25


Substantiated


The substantiated complaint related to Medicaid eligibility was regarding a child that was not added to the family’s Medicaid case.

The substantiated complaint related to billing was regarding a Medicare consumer with

qualified Medicare beneficiary benefits (QMB) that was billed for the remaining 20 percent that Medicare does not pay for instead of it being billed to Medicaid.

Service Area Complaints and Inquiries

The map in Figure 4 below includes all complaints and substantiated complaints by Medicaid managed care program type for each service area.

26

Figure 4 Managed Care Service Areas and Related Complaints – Q4 FY20

Table 14: Managed Care Service Areas and Related Complaints – Q4 FY2012

Service Delivery

Area STAR STAR Kids STAR+PLUS

Bexar

49 Complaints

9 Substantiated

complaints

13 Complaints

4 Substantiated

complaints

71 Complaints

18 Substantiated

complaints

Dallas

71 Complaints

12 Substantiated

complaints

28 Complaints

3 Substantiated

complaints

117 Complaints

23 Substantiated

complaints

12 Table 14 provides the same data as Figure 4 but in table format for easier reading.

27

Service Delivery


El Paso

15 Complaints

3 Substantiated

complaints

6 Complaints

1 Substantiated

complaints

10 Complaints

1 Substantiated

complaints

Harris

123 Complaints

31 Substantiated

complaints

34 Complaints

10 Substantiated

complaints

119 Complaints

20 Substantiated

complaints

Hidalgo

34 Complaints

5 Substantiated

complaints

10 Complaints

0 Substantiated

complaints

44 Complaints

5 Substantiated

complaints

Jefferson

13 Complaints

0 Substantiated

complaints

2 Complaints

1 Substantiated

complaints

18 Complaints

7 Substantiated

complaints

Lubbock

25 Complaints

3 Substantiated

complaints

1 Complaints

0 Substantiated

complaints

16 Complaints

3 Substantiated

complaints

Medicaid Rural

Service Area

Central

36 Complaints

7 Substantiated

complaints

6 Complaints

1 Substantiated

complaints

39 Complaints

8 Substantiated

complaints

Medicaid Rural

Service Area

Northeast

53 Complaints

13 Substantiated

complaints

17 Complaints

4 Substantiated

complaints

64 Complaints

12 Substantiated

complaints

Medicaid Rural

Service Area

West

51 Complaints

8 Substantiated

complaints

3 Complaints

0 Substantiated

complaints

39 Complaints

12 Substantiated

complaints

Nueces

25 Complaints

4 Substantiated

complaints

5 Complaints

2 Substantiated

complaints

22 Complaints

2 Substantiated

complaints

Tarrant

86 Complaints

16 Substantiated

complaints

19 Complaints

3 Substantiated

complaints

62 Complaints

12 Substantiated

complaints

28

Service Delivery


Travis

44 Complaints

5 Substantiated

complaints

10 Complaints

2 Substantiated

complaints

23 Complaints

2 Substantiated

complaints

Table 15: Medicare-Medicaid Plan by Counties Complaints and Substantiated

Complaints

County Complaints Substantiated

Complaints

Bexar 4 Complaint 1 Substantiated complaints

Dallas 10 Complaints 2 Substantiated complaint

El Paso 0 Complaint 0 Substantiated complaints

Harris 5 Complaints 1 Substantiated complaints

Hidalgo 5 Complaints 0 Substantiated complaint

Tarrant 3 Complaints 1 Substantiated complaint

Top 5 Reasons for Complaints by Service Area

The following tables contain the top five reasons of complaints received by service area. Complaints include those that are substantiated, unsubstantiated and unable to

substantiate.

Bexar Service Area (356,14413)



OMCAT received 161 complaints from consumers in the Bexar Service Area in the fourth quarter and of those 32 (or 20 percent) were substantiated. Complaints increased by 16

percent (or 22 more) and substantiated complaints increased by three percent. The top five complaints noted in the table below comprise 35 percent of the total complaints

received of Bexar Service Area.

13The average monthly enrollment in Bexar Service Area in the fourth quarter of fiscal year 2020.

29

Table 16: Bexar Top 5 Complaints


Substantiated14




Consumer’s File

14 6 43%


Other Insurance 9 0 0%

Access to Prescriptions – Other 9 1 11%

Dallas Service Area (518,39215)



OMCAT received 279 complaints from consumers in the Dallas Service Area in the fourth quarter and of those 40 (14 percent) were substantiated. Complaints increased by 18

percent (or 42 more) and substantiated complaints decreased by two percent. The top five complaints noted in the table below make up 39 percent of the total complaints received of Dallas Service Area.

Table 17: Dallas Top 5 Complaints


Substantiated16


(non-PCP) 32 9 28%



14 Represents the percent of substantiated complaints. 15 The average monthly enrollment in Dallas Service Area in the fourth quarter of fiscal year

2020. 16 Represents the percent of substantiated complaints.

30


Substantiated16


COVID-19 13 0 0%

El Paso Service Area (157,51817)



OMCAT received 40 complaints from consumers in the El Paso Service Area in the fourth quarter and of those 5 (or 13 percent) were substantiated. Complaints increased by 14 percent (or 5 more) and substantiated complaints decreased by one percent. The top

five complaints noted in the table below make up to 33 percent of the total complaints received of El Paso Service Area.

Table 18: El Paso Top 5 Complaints


Substantiated18




Consumer’s File

3 2 67%

Fair Hearing/Appeals 2 0 0%

Access to PCP 2 1 50%


17 The average monthly enrollment in El Paso Service Area in the fourth quarter of fiscal year


31

Harris Service Area (947,04219)



OMCAT received 350 complaints from consumers in the Harris Service Area in the fourth quarter and of those 62 (or 18 percent) were substantiated. Complaints increased by 3

percent (or 10 more) and substantiated complaints increased by three percent. The top five complaints noted in the table below make up 33 percent of the total complaints received of Harris Service Area.

Table 19: Harris Top 5 Complaints


Substantiated20




Consumer’s File

24 8 33%

COVID-19 24 1 4%


(non-PCP)

21 5 24%


Hidalgo Service Area (463,39221)



OMCAT received 118 complaints from consumers in the Hidalgo Service Area in the

fourth and of those 10 (or eight percent) were substantiated. Complaints increased by 18 percent (or 18 more) and substantiated complaints decreased by three percent. The top five complaints noted in the table below make up 42 percent of the total complaints

received of Hidalgo Service Area.

19 The average monthly enrollment in Harris Service Area in the fourth quarter of fiscal year

2020. 20 Represents the percent of substantiated complaints. 21 The average monthly enrollment in Hidalgo Service Area in the fourth quarter of fiscal year

2020.

32

Table 20: Hidalgo Top 5 Complaints


Substantiated22



Access to PCP 8 1 13%


COVID-19 7 0 0%

Jefferson Service Area (115,35123)



OMCAT received 45 complaints from consumers in the Jefferson Service Area in the

fourth quarter and of those 8 (or 18 percent) were substantiated. Complaints increased by seven percent (or 3 more) and substantiated complaints increased by eight percent. The top five complaints noted in the table below make up 47 percent of the total

complaints received of Jefferson Service Area.

Table 21: Jefferson Top 5 Complaints


Substantiated24

COVID-19 7 1 14%



Provider

4 0 0%

Medicaid

Eligibility/Recertification

3 0 0%

22 Represents the percent of substantiated complaints. 23 The average monthly enrollment in Jefferson Service Area in the fourth quarter of fiscal year


33


Substantiated24

Other Insurance 2 0 0%

Lubbock Service Area (101,14625)



OMCAT received 42 complaints from consumers in the Lubbock Service Area in the fourth quarter and of those 6 (or 14 percent) were substantiated. Complaints increased by 91 percent (or 20 more) and substantiated complaints decreased by 13 percent. The

top five complaints noted in the table below make up 43 percent of the total complaints received of Lubbock Service Area.

Table 22: Lubbock Top 5 Complaints


Substantiated26




Provider

3 0 0%



(non-PCP)

3 0 0%

MRSA Central Service Area (195,66427)



OMCAT received 98 complaints from consumers in the MRSA Central Service Area in the

fourth quarter and of those 16 (or 16 percent) were substantiated. Complaints increased

25 The average monthly enrollment in Lubbock Service Area in the fourth quarter of fiscal year

2020. 26 Represents the percent of substantiated complaints. 27 The average monthly enrollment in MRSA Central Service Area in the fourth quarter of fiscal

year 2020.

34

by 32 percent (or 24 more) and substantiated complaints increased by 11 percent. The top five complaints noted in the table below make up 38 percent of the total complaints

received of MRSA Central Service Area.

Table 23: MRSA Central Top 5 Complaints


Substantiated28

Access to Prescriptions - Erroneous

Insurance on Consumer’s File

11 3 27%


Balance Billing 7 0 0%



MRSA Northeast Service Area (245,56229)



OMCAT received 159 complaints from consumers in the MRSA Northeast Service Area in the fourth quarter and of those 29 (or 18 percent) were substantiated. Complaints

increased by eight percent (or 12 more) and substantiated complaints increased by two percent. The top five complaints noted in the table below make up 36 percent of the total complaints received of MRSA Northeast Service Area.

Table 24: MRSA Northeast Top 5 Complaints


Substantiated30



Insurance on Consumer’s File

14 6 43%

28 Represents the percent of substantiated complaints. 29 The average monthly enrollment in MRSA Northeast Service Area in the fourth quarter of fiscal

year 2020. 30 Represents the percent of substantiated complaints.

35


Substantiated30




(non-PCP)

8 3 38%

MRSA West Service Area (215,52631)



OMCAT received 108 complaints from consumers in the MRSA West Service Area in the fourth quarter and of those 20 (or 19 percent) were substantiated. Complaints increased

by 27 percent (or 23 more) and substantiated complaints increased by 5 percent. The top five complaints noted in the table below make up 39 percent of the total complaints

received of MRSA West Service Area.

Table 25: MRSA West Top 5 Complaints


Substantiated32


Insurance on Consumer’s File 15 5 33%




Access to Prescriptions - Consumer

Not Showing as Having Active

Medicaid

5 3 60%

31 The average monthly enrollment in MRSA West Service Area in the fourth quarter of fiscal year


36

Nueces Service Area (124,19633)



OMCAT received 65 complaints from consumers in the Nueces Service Area in the fourth quarter and of those eight (or 12 percent) were substantiated. Complaints increased by

33 percent (or 16 more) and substantiated complaints increased by four percent. The top five complaints noted in the table below make up 43 percent of the total complaints received of Nueces Service Area.

Table 26: Nueces Top 5 Complaints


Substantiated34



COVID-19 6 0 0%

Staff Behavior 6 0 0%



(non-PCP) 4 0 0%

Tarrant Service Area (360,40035)



OMCAT received 198 complaints from consumers in the Tarrant Service Area in the fourth quarter and of those 32 (16 percent) were substantiated. Complaints increased by

47 percent (or 63 more) and substantiated complaints decreased by three percent. The top five complaints noted in the table below make up 32 percent of the total complaints received of Tarrant Service Area.

33 The average monthly enrollment in Nueces Service Area in the fourth quarter of fiscal year

2020. 34 Represents the percent of substantiated complaints. 35 The average monthly enrollment in Tarrant Service Area in the fourth quarter of fiscal year

2020.

37

Table 27 Tarrant Top 5 Complaints


Substantiated36


(non-PCP) 17 6 35%





Medicaid Eligibility/Recertification 11 0 0%

Travis Service Area (197,42737)



OMCAT received 86 complaints from consumers in the Travis Service Area in the fourth quarter and of those 9 (or ten percent) were substantiated. Complaints increased by

four percent (or 3 more) and substantiated complaints decreased by one percent. The top five complaints noted in the table below make up 38 percent of the total complaints received of Travis Service Area.

Table 28: Travis Top 5 Complaints


Substantiated38

Access to Out-of-Network Provider 9 2 22%




36 Represents the percent of substantiated complaints. 37 The average monthly enrollment in Travis Service Area in the fourth quarter of fiscal year


38


Substantiated38


(non-PCP) 4 1 25%

39

Barriers and Recommendations for Improvement

OMCAT collaborates with HHS programs and MCOs in identifying and resolving barriers to accessing Medicaid services.

OMCAT is responsible for facilitating the Managed Care Support Network which is a

collaboration of HHS program areas that have a direct or indirect impact on the delivery of Medicaid services to HHS consumers.

The network meets quarterly to share information regarding barriers to care that Medicaid consumers experience, discusses how to mitigate or resolve barriers to care, and provides training to ensure all HHS areas participating in the network are aware of

the work and functions of their counterparts.

In previous quarterly reports, OMCAT has provided recommendations to mitigate

incorrect insurance information on consumer cases in HHS systems and recommendations to add language in the managed care contracts to address consumers

not showing as active in MCO systems. OMCAT will provide updates on these recommendations as they become available. There are no new recommendations for the fourth quarter of FY20.

40

Conclusion

OMCAT is the HHS public facing contact for consumers who need to make complaints and inquiries regarding Medicaid services. As such, the HHS Office of the Ombudsman’s goal in this report is to spotlight issues that Medicaid consumers face and provide

recommendations to remove barriers where possible, thereby improving the experience of Texas Medicaid consumers.

The HHS Office of the Ombudsman welcomes feedback from stakeholders and is committed to finding ways to improve our business practices to better serve our clients.

41

Glossary

Contact – An attempt by HHS consumers to inquire or complain about HHS programs or services.

Complaint – A contact regarding any expression of dissatisfaction.

Fiscal Year 2020 - The 12-month period from September 1, 2019 through August 31, 2020, covered by this report.

HHS Enterprise Administrative Report and Tracking System (HEART) – A web-based system that tracks all inquiries and complaints OMCAT receives.

Inquiry – A contact regarding a request for information about HHS programs or

services.

Lock-In Program – The program restricts consumers whose use of medical services is

documented as being excessive. Consumers are "Locked-In" to a specific pharmacy to prevent consumers from obtaining excessive quantities of prescribed drugs through

multiple visits to physicians and pharmacies.

Managed Care Organization - A health plan that is a network of contracted health care providers, specialists, and hospitals.

Managed Care Compliance Operations - The area within HHSC that provides oversight of the managed care contracts.

Medicare Savings Program – The use of Medicaid funds to help eligible consumers pay for all or some of their out-of-pocket Medicare expenses, such as premiums, deductibles or co-insurance.

Provider - An individual such as a physician or nurse, or group of physicians and nurses such as a clinic or hospital, that delivers health care directly to patients.

Resolution – The point at which a determination is made as to whether a complaint is substantiated, and no further action is necessary by the OMCAT.

Substantiated – A complaint determination where research clearly indicates agency

policy was violated or agency expectations were not met. (Example: Consumer complains that their home health attendant did not show up for duty. Research shows

that the home health agency confirmed that the attendant was not able to work that day.)

Texas Medicaid Healthcare Partnership – The authorization and claims payment

entity for consumers on traditional, fee-for-service, Medicaid.

Unable to Substantiate – A complaint determination where research does not clearly

indicate if agency policy was violated or agency expectations were met. (Example:

42

Consumer has a complaint about accessing medical services and is referred to their MCO to address the complaint since they have not yet tried to work with their MCO.)

Unsubstantiated – A complaint determination where research clearly indicates agency policy was not violated or agency expectations were met. (Example: Consumer complains that that their prescription was rejected at the pharmacy. Research shows

that the consumer is not yet due to refill that prescription.)

43

List of Acronyms

CHIP - Children’s Health Insurance Program

DME - Durable Medical Equipment

LTSS - Long Term Services and Supports

MCO - Managed Care Organization

MCCO - Managed Care Compliance Operations

MDCP - Medically Dependent Children’s Program

MRSA - Medicaid Rural Service Area

PAS - Personal Attendant Services

PCP - Primary Care Provider

PHE – Public Health Emergency

PDL - Preferred Drug List

PDN - Private Duty Nursing

TDD - Telephonic Device for the Deaf

THS – Texas Health Steps

TMHP - Texas Medicaid Healthcare Partnership

YES – Youth Empowerment Services

texas health and human services | - hhs ombudsman ......inquiries received during the fourth...

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