PL-15_FREW 6_24 - 5_25 Annual Monitoring Report.pdf

FREW, ET AL. V. YOUNG, ET AL. JULY 2025 ANNUAL MONITORING REPORT

REPORTING PERIOD: JUNE 2024 – MAY 2025

INTRODUCTION ¶¶ 1-9

INFORMING AND OUTREACH ¶¶ 10-74, 96, AND 193

HEALTHCARE PROVIDERS ¶¶ 75-95, AND 97-142

DENTAL ¶¶ 143-174

CHILDREN OF MIGRANT FARM WORKERS ¶¶ 176-183

RECIPIENTS IN MANAGED CARE ¶¶ 184-192 AND 194-199

TEENS ¶¶ 200-209

CHILDREN IN CONSERVATORSHIP OF DEPARTMENT OF FAMILY AND PROTECTIVE SERVICES ¶¶ 210-212

TRANSPORTATION ¶¶ 213-238

SCHEDULING AND TOLL FREE NUMBERS ¶¶ 239-247

CASE MANAGEMENT ¶¶ 248-270

STATEWIDENESS ¶¶ 271-281

MEASUREMENT/ACCOUNTABILITY ¶¶ 282-299

MISCELLANEOUS ¶¶ 300-308

Consent Decree ¶¶ 306 and 307 require that Defendants report each January, April, July, and October on each paragraph in the decree which obliges action. On February 10, 2023, Judge Schroeder modified Paragraph 306 of the Consent Decree to require Defendants to produce monitoring reports annually on July 31 of each year, beginning July 31, 2024. 1 Defendants provide this report on a template agreed upon by the parties.2 This report includes the status and supporting documentation for each required activity during the period identified in the title.3

1 Consent Decree ¶ 302 states that the term “will” creates a mandatory enforceable obligation. Defendants use this definition of “will” to identify reporting requirements. Reporting on paragraphs that do not include mandatory, enforceable obligations is provided for clarity and context or to accommodate Plaintiffs’ request. Such reporting does not constitute Defendants’ admission or agreement that actions reported are necessarily required by these orders. Plaintiffs do not agree that the Decree’s mandatory, enforceable obligations are limited to paragraphs containing the term “will.” Any omission from Defendants’ QMR reporting does not indicate Plaintiffs’ admission or agreement that Defendants’ compliance with the omitted Decree or CAO provisions is not required by these Orders.

2 References to the action required by the Consent Decree or 2007 Corrective Action Orders are provided in summary form.

3 Consent Decree requirements for which the parties have agreed are completed are not reported.

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INTRODUCTION ¶¶ 1-9

(NEW AND/OR UPDATED INFORMATION IS IN BOLD FONT)

DECREE OR CAO REFERENCE STATUS REPORT

CONSENT DECREE ¶¶2-3

Infants, children, adolescents, and young adults enrolled in Medicaid are entitled to Texas Health Steps (THSteps) medical and dental checkups and needed follow up care that is permitted by federal Medicaid law.

Defendants' Medicaid State Plan describes how Texas Health Steps (THSteps) medical and dental checkups and other Medicaid benefits will be made available to Texas Medicaid recipients, and how providers will be reimbursed for services. The Texas Medicaid State Plan is available online at:

https://hhs.texas.gov/services/health/medicaid-and-chip/about-medicaid/state-plan.

HHSC has developed a web page where proposed Medicaid policy changes will be listed. Through this website, medical practitioners, program clients, and the general public can give HHSC direct feedback regarding new medical and dental policies or changes to existing policies. In addition, stakeholders can submit a proposal for a Medicaid medical or dental benefit via the HHSC website at: https://hhs.texas.gov/services/health/medicaid-and-chip/about-medicaid/medicaid-medical-and-dental-policy.

Capitated managed care is the primary vehicle by which Medicaid recipients access Medicaid services.

• Children access Medicaid medical services, including checkups and follow-up care, through one of three capitated managed care programs:

o STAR - serving the majority of children with Medicaid.

o STAR Health - serving children under the supervision of the Department of Family and Protective

Services.

o STAR Kids - serving children and young adults under the age of 21 with Supplemental Security Income

(SSI) or disability-related Medicaid and those receiving 1915(c).

• STAR+PLUS - serving individuals with disabilities age 21 and older, persons over 65 years of age, and effective September 1, 2017 women in Medicaid for Breast and Cervical Cancer age 18 and older.

• Children access Medicaid dental services, including checkups and follow-up care, through:

o Children's Medicaid Dental Services - serving most children with Medicaid.

o STAR Health - serving children under the supervision of the Department of Family and Protective

Services.

Defendants include information and reports on utilization of THSteps medical and dental checkups in ¶¶ 165, 171, 192, and 212.

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INTRODUCTION ¶¶ 1-9

DECREE OR CAO REFERENCE STATUS REPORT

The Centers for Medicare and Medicaid Services (CMS) requires each state to file an Annual Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Participation Report (Form CMS-416) on April 1 each year. (EXHIBIT 1)

INFORMING AND OUTREACH ¶¶ 10-74, 96, AND 193

DECREE OR CAO REFERENCE STATUS REPORT

CONSENT DECREE ¶¶ 10-74, 96, AND

Informing recipients about THSteps involves:

• Written information.

• Face-to-face oral informing.

• Oral outreach by outreach units.

• Coordinated efforts with other agencies.

• Media efforts.

Information must be provided in a manner convenient to the recipient or responsible adult and can be provided to other family members.

Information must be:

• Relevant to recipients’ needs.

• Reasonably interesting.

• Presented in a manner sensitive to different backgrounds.

In April 2015, Defendants filed a Rule 60(b)(5) motion seeking to vacate the First Modified Corrective Action Order: Outreach and Informing, Section III of the Corrective Action Order: Managed Care, and the related paragraphs of the Consent Decree. See Dkts. 1298, 1379, 1412, 1422, 1782, and 1784. On December 11, 2020, Defendant's Rule 60(b)(5) motion was granted in full by Judge Schroeder in Dkt.

1788. Plaintiffs appealed this ruling to the Fifth Circuit (Case No. 21-40028), and on January 13, 2022, the Fifth Circuit affirmed the dismissal. Defendants are no longer required to report on the applicable Consent Decree paragraphs and Corrective Action Orders. The April 2022 QMR was the final quarterly report entry for ¶¶ 10-74, 96, 176-183, and 193.

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INFORMING AND OUTREACH ¶¶ 10-74, 96, AND 193

DECREE OR CAO REFERENCE STATUS REPORT

• Presented in a way that encourages the full use of services.

CAO: OUTREACH AND INFORMING

Assessment of outreach and informing activities.

In April 2015, Defendants filed a Rule 60(b)(5) motion seeking to vacate the First Modified Corrective Action Order: Outreach and Informing, Section III of the Corrective Action Order: Managed Care, and the related paragraphs of the Consent Decree. See Dkts. 1298, 1379, 1412, 1422, 1782, and 1784. On December 11, 2020, Defendant's Rule 60(b)(5) motion was granted in full by Judge Schroeder in Dkt.

1788. Plaintiffs appealed this ruling to the Fifth Circuit (Case No. 21-40028), and on January 13, 2022, the Fifth Circuit affirmed the dismissal. Defendants are no longer required to report on the applicable

HEALTHCARE PROVIDERS ¶¶ 75-95, AND 97-142

DECREE OR CAO REFERENCE STATUS REPORT

CONSENT DECREE ¶¶ 75-87, 89, 92,

and 97

Per Dkt. 1280, these paragraphs "mainly contain background information and do not require any action by Defendants" making modification of these paragraphs unwarranted. The parties agreed in 2007 that reporting on these paragraphs was not necessary; the parties continue to agree that reporting on these paragraphs is not necessary.

CONSENT DECREE ¶¶ 88, 90, 93, and 98-103

Per Dkt. 1280, Defendants have met the objectives of ¶ 88 and have satisfied ¶¶ 90, 93, and 98-103. The Fifth Circuit remanded a portion of Dkt. 1280; the remand was specific to components of the Corrective Action Order: Adequate Supply of Health Care Providers. The dismissal of these consent decree paragraphs remains undisturbed. The April 2012 QMR was the final quarterly report entry for ¶¶ 90 and

103. The January 2015 QMR was the final quarterly report entry for ¶¶ 88, 93, and 98-102.

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DECREE OR CAO REFERENCE STATUS REPORT

CONSENT DECREE ¶ 91 Completed.

CONSENT DECREE ¶ 94

DSHS Texas Health Steps provider relations staff will work with providers to reduce or eliminate problems to encourage participation in Texas Health Steps.

On May 5, 2023, the District Court granted Defendants’ Unopposed Motion to Terminate and released Defendants from the terms of Consent Decree paragraphs 91, 94, and 239 through 245. (Dkts. 1971 and 1989). The July 2023 Quarterly Monitoring Report was the final entry for these paragraphs, including examples of the efforts of DSHS provider relations staff to assist THSteps providers, and the final submission of the DSHS Texas Health Steps Providers Activities Report.

CONSENT DECREE ¶¶ 106-123, and

CAO: HEALTH CARE PROVIDER

TRAINING

Per Dkt. 1396, obligations associated with Consent Decree ¶¶ 106-109, 111-112, 115-117, 120, 122-123, and 131 and the Corrective Action Order: Health Care Provider Training have been satisfied. The July 2015 QMR was the final quarterly report entry for these paragraphs.

CONSENT DECREE ¶¶ 124-130

CAO: RX, MEDICAL EQUIPMENT AND

SUPPLIES

Per Dkt. 1114, decree paragraphs ¶¶ 124-130 and the CAO: Prescription and Non-Prescription Medications, Medical Equipment and Supplies have been satisfied and Defendants are not required to take further action. On March 5, 2015, the Fifth Circuit Court of Appeals affirmed the district court's ruling in Frew v. Janek, 780 F.3d 320 (5th Cir. 2015). The January 2014 QMR was the final report entry for these paragraphs.

CONSENT DECREE ¶¶ 136-141 Per Dkt. 1396, the obligations associated with these paragraphs have been satisfied. The July 2015 QMR was the final quarterly report entry for these paragraphs.

CONSENT DECREE ¶ 142 Per Dkt. 1396, the obligations associated with this paragraph have been satisfied. The July 2015 QMR was the final quarterly report entry for this paragraph.

CAO: CHECKUPS

Coordinate decisions for implementing changes in THSteps checkup elements with appropriate professional organizations.

THSteps Medical Policy

The United States Department of Health and Human Services ended the federal public health emergency (PHE) on May 11, 2023. Effective with the end of the PHE, HHSC ended the temporary flexibility for remote delivery of certain components of medical checkups that had been allowed for THSteps checkups, Case 3:93-cv-00065-RWS Document 2098-1 Filed 07/31/25 Page 5 of 43 PageID #:

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as communicated in prior notifications to the court.

THSteps Dental Policy HHSC has completed a comprehensive review of the THSteps Dental Preventive Services Policy. Initial input on policy changes was received from dental maintenance organizations, the Texas Dental Association, and the Texas Association of Pediatric Dentists. Changes to the policy include the addition of caries arresting medicament as a covered dental benefit. The policy was implemented on September 1, 2023.

On March 3, 2025, HHSC implemented teledentistry services, as required by House Bill 2056 of the 87th Legislature, Regular Session, 2021.

CAO: ADEQUATE SUPPLY OF HEALTH

CARE PROVIDERS

Per Dkt. 1280, most of the obligations associated with this CAO have been satisfied and Defendants are not required to further action. The Fifth Circuit Court of Appeals remanded portions of bullet points 5, 8-10 of this CAO. The parties filed supplemental briefing that is currently pending resolution by the District Court. (Dkt. 1883)

DENTAL ¶¶ 143-174

DECREE OR CAO REFERENCE STATUS REPORT

CONSENT DECREE ¶¶ 143, 165, and 171-172 Defendants must provide periodic dental checkups and needed dental services to relieve pain, restore teeth, and maintain dental for recipients.

Effective March 1, 2012, THSteps recipients began receiving dental services through capitated managed care. HHSC has developed a “Performance Indicator Dashboard” for dental managed care plans. The dashboard is a series of performance measures that identify key aspects of performance to ensure each dental plan’s accountability. The measures are not all-inclusive, but HHSC intends for the measures to incentivize excellence. The Medicaid Dental Quality Performance Indicator Dashboard in the Uniform Managed Care Manual (UMCM) Chapter 10.1.10 includes measures for dental services on THSteps dental

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checkups and receipt of sealants. The link to the UMCM chapter is available at:

https://hhs.texas.gov/services/health/medicaid-chip/provider-information/managed-care-contracts-manuals. More information for Medicaid dental quality measures is available on the Texas Healthcare Learning Collaborative website at https://thlcportal.com. Select the Public Portal, then select Dental, then filter by year, program, and/or dental plan.

As required by ¶ 165 of the Consent Decree, the THSteps Active and Enrolled Dental Provider Participation Report 1996-Current is attached. (EXHIBIT 2) Paragraph 171 requires that Defendants prepare a report of the number and percent of recipients who receive one checkup each year and two dental checkups each year. Defendants report a summary of annual changes in the number and percent of Medicaid recipients under age 21 who received one or more dental checkup for state fiscal years 2007 through 2024 in the attached report, Texas Health Steps Recipients Dental Checkups 2007-2024. (EXHIBIT 3)

CONSENT DECREE ¶¶ 154, 158, 159

DSHS Oral Health Program may perform dental screens and provide dental sealants for recipients in public school.

The DSHS Oral Health Improvement Program’s (OHIP) regional dental teams perform dental screens (also known as limited oral evaluations) and preventive dental services at schools and Head Start facilities throughout Texas. The teams offer evaluations at each selected school and facility for all children who receive parental permission, so children with Medicaid for whom written parental/guardian permission is obtained are included within the populations evaluated and eligible for preventive dental services.

Depending on the grade levels at the selected schools, children in grade levels from pre-K to twelfth grade may receive limited oral evaluations. See also ¶ 16.

DSHS OHIP regional dental teams offer dental sealants as part of the preventive dental services provided in school settings to children with signed permission forms. DSHS does not bill these services to Medicaid, so HHSC does not capture these services as Medicaid claims or encounters. HHSC does not include these services on the CMS-416 or the other Texas Health Steps (THSteps) dental utilization reports. Exclusion of services provided by OHIP results in under-reporting of THSteps recipients who receive dental sealants.

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DECREE OR CAO REFERENCE STATUS REPORT

For the 4th Quarter period, June 2024 – August 2024, the DSHS OHIP Regional Dental Teams provided:

· 8 children enrolled in Medicaid a limited oral evaluation

· 6 children enrolled in Medicaid a fluoride varnish application

· 2 children enrolled in Medicaid dental sealants

For the 12-month period, September 2023 – August 2024, the DSHS OHIP Regional Dental Teams provided:

· 3671 children enrolled in Medicaid a limited oral evaluation

· 3481 children enrolled in Medicaid a fluoride varnish application

· 78 children enrolled in Medicaid dental sealants

All data above is final and not subject to change.

For the 1st Quarter period, September 2024 – November 2024, the DSHS OHIP Regional Dental Teams provided:

· 1999 children enrolled in Medicaid a limited oral evaluation

· 1858 children enrolled in Medicaid a fluoride varnish application

· 51 children enrolled in Medicaid dental sealants

For the 2nd Quarter period, December 2024 – February 2025, the DSHS OHIP Regional Dental Teams provided:

· 509 children enrolled in Medicaid a limited oral evaluation

· 471 children enrolled in Medicaid a fluoride varnish application

· 47 children enrolled in Medicaid dental sealants

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For the 3rd Quarter period, March 2025 – May 2025, the DSHS OHIP Regional Dental Teams provided:

· 341 children enrolled in Medicaid a limited oral evaluation

· 298 children enrolled in Medicaid a fluoride varnish application

· 32 children enrolled in Medicaid dental sealants

All data above is preliminary data and is subject to change.

CONSENT DECREE ¶ 174

CAO: HEALTH OUTCOMES MEASURES

AND DENTAL ASSESSMENT

Defendants will assess recipients’ dental health and will conduct corrective action after the first assessment required by the CAO.

Defendants completed the second dental assessment required by the CAO: Health Outcomes Measures and Dental Assessment on April 8, 2014. A copy of the second assessment was provided as Exhibit 14 to the April 2014 QMR. Defendants amended the report to address comments made by Plaintiffs. The amended report was provided as Exhibit 9 to the July 2014 QMR. With the completion of the second dental assessment, the period of corrective action came to an end. The parties were not able to reach agreement on what, if any, further action was required. On August 25, 2014, Defendants filed a Rule 60(b)(5) motion seeking an end to the dental assessment portion of the corrective action order and the dental-related paragraphs of the consent decree [Dkt. 1225]. Plaintiffs filed a response in opposition to this motion on May 15, 2015 [Dkt. 1332]. Defendants filed their reply on September 25, 2015 [Dkt. 1378]. Plaintiffs' sur-reply was filed on January 15, 2016 and amended on January 19, 2016, and again on January 20, 2016 [Dkts. 1431, 1435, and 1436]. Defendants and Plaintiffs both sought leave of Court to file additional briefs beyond the sur-reply. Both requests were granted by the Court. Briefs were filed on January 29, 2016 [Dkt.

1440] and February 8, 2016 [Dkt. 1442]. This issue is now fully briefed.

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CHILDREN OF MIGRANT FARM WORKERS ¶¶ 176-183

DECREE OR CAO REFERENCE STATUS REPORT

CONSENT DECREE ¶¶ 176-183 AND

CAO: MANAGED CARE SECTION III

Outreach will be provided to children of migrant farm workers to help them receive as many THSteps services as possible while they are in Texas.

In April 2015, Defendants filed a Rule 60(b)(5) motion seeking to vacate the First Modified Corrective Action Order: Outreach and Informing, Section III of the Corrective Action Order: Managed Care and the related paragraphs of the Consent Decree. See Dkts. 1298, 1379, 1412, 1422, 1782, and 1784. On December 11, 2020, Defendant's Rule 60(b)(5) motion was granted in full by Judge Schroeder in Dkt.

1788. Plaintiffs appealed this ruling to the Fifth Circuit (Case No. 21-40028), and on January 13, 2022, the Fifth Circuit affirmed the dismissal. Defendants are no longer required to report on the applicable

RECIPIENTS IN MANAGED CARE ¶¶ 184-192 AND 194-199

DECREE OR CAO REFERENCE STATUS REPORT

CONSENT DECREE ¶¶ 191-192 AND

CAO: MANAGED CARE

Defendants will assure by various means that data for those who receive checkups when due and information for outcomes research is accurately collected, that managed care organizations provide for checkups to new members within 90 days of enrollment and timely checkups to existing members, and that managed care organizations will have the capacity to accelerate services for children of migrant farmworkers.

The parties have filed motions for the CAO: Managed Care, CAO: Check Ups, and consent decree paragraphs 175, 184-192, 195-196, and 198-212. Plaintiffs filed a motion for further action in January 2016, and Defendants filed a Rule 60(b)(5) motion and response to Plaintiffs' motion in March 2016. See Dkts. 1437, 1446, 1491, 1495, and 1496.

MEANS FOR COLLECTING ACCURATE DATA (¶191)

Accenture, operating for Texas Medicaid as the Texas Medicaid & Healthcare Partnership (TMHP), receives encounter data from Medicaid managed care organizations (MCOs). TMHP applies business and transaction edits to inbound encounter data to validate data content prior to accepting the data. The edits validate a host of data elements, such as, that the provider is Medicaid enrolled and that the financial arrangement codes and encounter status codes are present and valid. If data content does not meet requirements, TMHP rejects the encounter. When TMHP rejects an encounter, TMHP returns it to the MCO and does not load it into the encounter data warehouse. THMP loads data that meet the minimum validation into the encounter data warehouse and eventually sends it to the external quality review organization (EQRO), where additional data validation activities occur.

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In accordance with federal regulations on mandatory and optional activities for Medicaid managed care external quality review, Texas' EQRO annually validates encounter data for accuracy and completeness by comparing claims against a representative sample of dental or medical records. The EQRO validates medical and dental encounters data in alternate years. The EQRO summarizes encounter validation studies in the companion to the EQRO Annual Technical Report. The state fiscal year 2024 EQRO Annual Technical Report is available in the External Quality Review Section External Quality Review of Texas Medicaid and CHIP Managed Care Annual Technical Report for SFY 2024; and Health Plan Performance in Texas Medicaid & CHIP Companion to External Quality Review of Texas Medicaid & CHIP Managed Care Annual Technical Report.

In addition, each Medicaid managed care contract requires MCOs to submit complete and accurate encounter data no later than the 30th calendar day after the last day of the month in which the MCO adjudicates the claim. MCOs must correct encounter data that does not meet quality standards. See § 8.1.18.1 of the Uniform Managed Care Contract, § 8.1.18.1 of the STAR+PLUS Expansion Contract 1, § 8.1.18.1 of the STAR+PLUS Medicaid Rural Service Area Contract, § 4.1.22.1 of the STAR Health Managed Care Contract, § 8.1.20.1 of the STAR Kids Managed Care Contract, and § 8.1.12.1 of the Dental Services Contract. Links to each contract are available at:

https://hhs.texas.gov/services/health/medicaid-and-chip/provider-information/managed-care-contracts-and-manuals.

VARIOUS MEANS FOR ASSURING TIMELY CHECKUPS AND ACCELERATED SERVICES (¶192)

Medical Checkups The Medical Checkups section of each contract for managed care programs serving recipients birth through age 20 requires health plans to develop effective methods to ensure that children birth through age 20 receive Texas Health Steps (THSteps) services when due and according to the recommendations of the THSteps periodicity schedule, including arranging for these services except when members or their representatives knowingly and voluntarily decline or refuse services after receiving sufficient information to make an informed decision. The health plans must also offer new members birth through age 20 a medical checkup as soon as practicable, but in no case later than 14 days after enrollment for newborns and no later than 90 days after enrollment for all other eligible child members. The health plans are also

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DECREE OR CAO REFERENCE STATUS REPORT

required to ensure a THSteps annual medical checkup for an existing member, age 36 months and older, occurs no later than 364 calendar days after the child’s birthday.

See § 8.2.2.3.1 of Att.B-1 to the Uniform Managed Care Contract, § 8.1.22.3.1 of Att.B-1 of the STAR+PLUS Expansion Contract, § 8.1.24.3.1 of Att. B-1 of the STAR+PLUS Medicaid Rural Service Area Contract, and § 8.1.24.3.1 of the STAR Kids Managed Care Contract. Refer to § 4.1.26.3.1 of the STAR Health Managed Care Contract for additional timeliness requirements specific to STAR Health.

Links to each contract are available at: https://hhs.texas.gov/services/health/medicaid-and-chip/provider-information/managed-care-contracts-and-manuals.

In October 2021, HHSC joined the Infant Well-Child Visit Affinity Group (AG). The AG is a national learning collaborative and quality improvement initiative hosted by the Centers for Medicare and Medicaid Services (CMS) and Mathematica. The project’s goal is to improve the use and quality of well-child visits among Medicaid beneficiaries ages 0 to 15 months. With technical assistance from CMS and Mathematica, states conducted quality improvement (QI) projects in partnership with MCOs and local health organizations. HHSC partnered with nine Medicaid MCOs for this initiative. Each MCO tested various small-scale QI projects. Results were presented at a CMS Quality Conference in April 2024 and published in the peer-reviewed journal Healthcare in October 2024.

Dental Checkups Effective March 1, 2012, with few exceptions, Medicaid recipients receive dental services via a managed care delivery model. As required in Section 8.2.2.1.1 Dental Checkups of the Dental Services Contract, Dental Plans must: develop effective methods to ensure that children birth through age 20 receive THSteps dental services and arrange for these services for all eligible members except when a member knowingly and voluntarily declines or refuses services after receiving sufficient information to make an informed decision. Dental Plans must ensure new members receive a dental checkup no later than 90 days after enrollment. The Dental Plans are also required to provide dental checkups to their members every six months, starting at 6 months of age.

Children in STAR Health receive dental services through STAR Health and not Children’s Medicaid Dental Services. § 8.1.18 of the STAR Health contract requires the initial dental checkup within 60 days of enrollment for children older than 6 months of age at time of enrollment in STAR Health, or within 30

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days of turning 6 months of age if younger than 6 months of age at time of enrollment in STAR Health.

This same section requires the plan follow the American Academy of Pediatric Dentistry recommendations and policy for receipt of checkup services.

Accelerated Services for Children of Migrant Farmworkers HHSC contracts with health plans and dental plans to identify children of migrant farmworkers and inform their families about Medicaid services, and to provide accelerated services to migrant farmworkers.

Managed Care Annual Medical Checkup Reports As required by the Corrective Action Order: Managed Care, each health and dental plan is required to submit an annual report of timely checkups for new and existing members. The results are validated by the External Quality Research Organization, and a ranking is included in each October QMR, and published on the HHSC website. On February 10, 2023, Judge Schroeder modified Paragraph 306 of the Consent Decree to require Defendants to produce monitoring reports annually on July 31 of each year, beginning July 31, 2024. The ranking is now included in these annual reports.

For new members, it lists the total number of members, total number who received a checkup within 90 days, those who received a checkup prior to enrollment, and those who refused a checkup by plan and service area in the STAR, STAR Kids, and STAR Health programs. For existing members (enrolled in a plan continuously at least 90 days) it lists the total number of members, those who were due for and received all THSteps checkups, those who received a checkup prior to enrollment, and those who refused a checkup by plan and service area in the STAR, STAR Kids, and STAR Health programs.

Defendants submit the SFY 2022 Medicaid Managed Care Texas Health Steps Medical Checkups Annual Report (Preliminary) ranking MCO performance. (EXHIBIT 4)

INCENTIVES AND DISINCENTIVES (CAO: MANAGED CARE)

As required by the Corrective Action Order: Managed Care, HHSC developed a plan for a system of incentives and disincentives concerning timely medical checkup reporting and identifying children of migrant farmworkers. The UMCM, Chapter 12.18 outlines the incentives and disincentives methodology. In SFY 2012, HHSC began a system of non-financial incentives. HHSC recognizes health and dental plans for identification of and outreach to children of migrant farmworkers by ranking health

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and dental plans based on activities and supporting documentation submitted with annual migrant farmworker reports. HHSC also ranks each health plan based on their timely checkup participation rates by program and service area calculated from their annual checkup reports.

HHSC posts migrant rankings and timely checkup rankings on the HHS website at:

https://hhs.texas.gov/services/health/medicaid-chip/provider-information/managed-care-incentives-disincentives. SFY 2022 data for timely checkups is currently undergoing validation. Final reports will be published on the HHSC website as soon as validation is complete. The MCOs submitted preliminary timely checkup data for SFY 2023 on May 12, 2025. HHSC is currently reviewing those submissions. The annual Outreach and Identification of Children of Migrant Farmworkers for SFY 2024 was published on the HHSC website in July 2025.

CAO: MANAGED CARE STUDY OF CHILDREN WITH NO CARE FROM MCO

The CAO: Managed Care (CAO) required Defendants to retain an independent vendor to study children with Medicaid who are under the age of 21 who do not receive any form of health care covered by Defendants’ contracts with their managed care organizations. This study has been completed, in addition to further analysis that Defendants voluntarily conducted. Although Plaintiffs’ counsel disagrees, Defendants maintain that corrective action is not warranted. Defendants now consider party discussions on corrective action complete.

The independent study finds that 91.9 percent of children enrolled in managed care during the study period received treatment paid for by their managed care organization(s). Of the 8.1 percent receiving “no care,”

10.4 percent received some care, limited to emergency or inpatient services.

The CAO requires a second study that emphasizes examining the effectiveness of corrective action. Since Defendants will not be taking corrective action, Defendants will not conduct a second study unless the Court directs otherwise.

The parties have included the CAO: Managed Care in the briefing for the CAO: Check Ups. In accordance with the agreed-upon briefing schedule, Plaintiffs filed a motion for further action on January 22, 2016, and Defendants filed a Rule 60(b)(5) motion and response to Plaintiffs' motion on March 4, 2016. Briefing

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DECREE OR CAO REFERENCE STATUS REPORT

on these motions is complete, see Dkts. 1437, 1446, 1491, 1495, and 1496.

CONSENT DECREE ¶ 194 Per Dkt. 1396, obligations associated with Consent Decree ¶ 194 and the Corrective Action Order: Health Care Provider Training have been satisfied. The July 2015 QMR was the final entry for this paragraph.

CONSENT DECREE ¶ 195

Recipients receiving services from managed care organizations are entitled to challenge decisions by fair hearing.

HHSC requires MCOs to notify and educate their members about the availability of fair hearings and how to request them in a timely manner. Each contract includes fair hearing requirements in the member complaint and appeal sections. See § 8.2.6 of the Uniform Managed Care Contract, § 8.1.27 of the STAR+PLUS Expansion Contract, § 8.1.29 of the STAR+PLUS Medicaid Rural Service Area Contract, § 4.1.31 of the STAR Health Managed Care Contract, § 8.1.29 of the STAR Kids Managed Care Contract, and § 8.2.5 of the Dental Services Contract. Medicaid recipients enrolled in managed care are entitled to challenge decisions through fair hearings. The recipient or the recipient's caregiver receives notification of this right in MCO member handbooks, and in letters when an MCO reduces, modifies, or denies a requested service.

CONSENT DECREE ¶ 196

HHSC will only contract with managed care organizations that are financially sound.

Defendants contract with MCOs that are financially sound, as required by federal and state law. 42 C.F.R.

§ 438.6 requires that the Centers for Medicare and Medicaid Services review and approve all managed care contracts. In addition, 42 C.F.R. § 438.6(c) requires that capitation rates be actuarially sound.

Additionally, the Texas Department of Insurance (TDI) requires MCOs operating in Texas to maintain a fiscally sound operation. The terms and conditions in HHSC's contracts with the MCOs require the MCOs to maintain compliance with the TDI rules regarding financial soundness and require that each MCO have a plan, and take appropriate measures, to ensure adequate provision against the risk of insolvency as required by the TDI.

CONSENT DECREE ¶ 197 Per Dkt. 1280, the obligations associated with this paragraph have been satisfied. The Fifth Circuit remanded a portion of Dkt. 1280; the remand was specific to components of the Corrective Action Order:

Adequate Supply of Health Care Providers. The dismissal of these consent decree paragraphs remains undisturbed. The January 2015 QMR was the final quarterly report entry for this paragraph.

CONSENT DECREE ¶ 198 The enrollment broker receives a notice when a person receiving Texas Medicaid moves from one service

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Defendants will assure a system that allows recipients to enroll promptly with a new managed care organization when recipients move from one area to another in Texas.

area to another in the state. The enrollment broker (currently Maximus) sends an enrollment packet to the member to enroll in a health plan in the new service area. The enrollment broker follows the standard enrollment process, meaning that if the client does not choose a plan within the defined timeline, assignment will default to a plan and a primary care provider.

For children in conservatorship, the service area is statewide, rather than regional service areas. One health plan serves all members in all counties of the state. When a child conservatorship moves within the state, their health plan remains the same. Members may choose a new primary care provider in their local area at any time by contacting their health plan.

For Children’s Medicaid Dental Services, the service area is statewide, as opposed to the regional service areas used by the medical health plans. The dental maintenance organizations (DMOs) serve all members in all counties of the state. When a person receiving Children’s Medicaid Dental Services moves within the state, their health plan might change but their dental plan remains the same. Members may choose a new main dentist in their local area at any time by contacting their dental plan.

CONSENT DECREE ¶ 199

Managed care organizations will be subject to independent evaluation of their members' health outcomes, satisfaction, and process measures.

HHSC's external quality review organization (EQRO) calculates annual performance measures about the quality of care experienced by people covered by Medicaid fee-for-service and Medicaid managed care (i.e., STAR, STAR+PLUS, STAR Health, STAR Kids, and Dental). The quality-of-care measures include Healthcare Effectiveness Data and Information Set (HEDIS) measures endorsed by the National Committee on Quality Assurance (NCQA). In addition to calculating quality of care measures, the EQRO conducts Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys for Medicaid and CHIP managed care members. CAHPS surveys ask Medicaid and CHIP members (including caregivers of those under the age of 21) in managed care programs for opinions and feedback on their access to care, benefits usage, satisfaction with care, and unmet needs. The EQRO Annual Technical Report includes quality of care and survey results. The most recent report, for 2024 data, is available at: External Quality Review of Texas Medicaid and CHIP Managed Care Annual Technical Report for SFY 2024 and Health Plan Performance in Texas Medicaid & CHIP Companion to External Quality Review of Texas Medicaid & CHIP Managed Care Annual Technical Report. Additional information on Medicaid quality measures is available on the Texas Healthcare Learning Collaborative website at THLC Portal.

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144572 https://www.hhs.texas.gov/sites/default/files/documents/eqro-annual-technical-report-contract-sfy-2024.pdf https://www.hhs.texas.gov/sites/default/files/documents/eqro-annual-technical-report-contract-sfy-2024.pdf https://www.hhs.texas.gov/sites/default/files/documents/eqro-annual-technical-report-contract-sfy-2024-companion.pdf https://www.hhs.texas.gov/sites/default/files/documents/eqro-annual-technical-report-contract-sfy-2024-companion.pdf https://nam12.safelinks.protection.outlook.com/?url=https%3A%2F%2Fthlcportal.com%2Fhome&data=04%7C01%7CShannon.Stewart%40hhs.texas.gov%7Ca21ded05715042250c4408da17327f56%7C9bf9773282b9499bb16aa93e8ebd536b%7C0%7C0%7C637847802887007716%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=X4dBmZaCzJAN5d6J1NsG6s%2BnzFuNfU5IDkuP34hdMp0%3D&reserved=0 https://nam12.safelinks.protection.outlook.com/?url=https%3A%2F%2Fthlcportal.com%2Fhome&data=04%7C01%7CShannon.Stewart%40hhs.texas.gov%7Ca21ded05715042250c4408da17327f56%7C9bf9773282b9499bb16aa93e8ebd536b%7C0%7C0%7C637847802887007716%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=X4dBmZaCzJAN5d6J1NsG6s%2BnzFuNfU5IDkuP34hdMp0%3D&reserved=0

TEENS ¶¶ 200-209

DECREE OR CAO REFERENCE STATUS REPORT

CONSENT DECREE ¶¶ 205 AND 207

Use innovative means to provide THSteps services to teenagers and during efforts to inform teens and their parents about THSteps, address the complex privacy and consent issues involved.

Defendants included Consent Decree Paragraphs 200-209 in their 2016 Rule 60(b)(5) motion for the CAO:

Check Ups and CAO: Managed Care. Briefing is complete. See Dkts. 1437, 1446, 1491, 1495, and 1496.

UTILIZATION OF THSTEPS BY TEENS (¶ 205)

Defendants use innovative means to provide Texas Health Steps (THSteps) services to teenagers. The innovative means include teen-focused outreach and informing efforts by MAXIMUS and the MCOs to encourage preventive medical and dental checkups, as well as teen-specific online education modules for healthcare providers. However, Defendants do not use DSHS staff or contract with THSteps providers to routinely conduct checkups for teens in non-traditional locations.

This decree paragraph requires Defendants to offer services to teens in locations “where teenagers go, when possible.” In April 2011, Defendants discussed the issue of preventive care for teens with the THSteps Advisory Panel (members at that time included an obstetrician/gynecologist, a general practitioner who specializes in adolescent health, general pediatricians, and family practice physicians) and reviewed information and literature on teens and access to preventive health care. While there was consensus that teens have a continued and ongoing need for preventive services and anticipatory guidance, there has been little success with improving rates of teens who seek preventive medical checkups or well-childcare. Conducting checkups “where teens go,” however, is not practical. Physicians need a clinical setting with private areas and access to full medical and ancillary equipment and services. In the experience of members of the THSteps Advisory Panel, “places teens go,” such as malls, sports venues, and recreation centers, cannot accommodate clinical and privacy needs. While a school setting might better accommodate clinical needs, privacy and confidentiality remain key concerns, as teens may perceive that school personnel might have access to their health clinic records. Recommendations from the THSteps Advisory Panel mirror those of much of the literature: it is most appropriate to tie teen checkups to the medical home (i.e., a teenager’s primary care provider). Encouraging use of the medical home offers the best opportunity for each recipient to establish an ongoing relationship with a practitioner. An ongoing relationship with a medical home increases the likelihood that teens will receive preventive services and suitable anticipatory guidance.

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THSteps Outreach Unit Maximus encourages outreach to teens with Medicaid by providing THSteps information and literature to:

• High school staff;

• Teen pregnancy centers and Planned Parenthood staff;

• Pregnant and parenting teen classes;

• Teen programs at locations such as teen centers;

• Locations where teenagers gather;

• Preparation for Adult Living (PAL) Conferences.

Defendants offer THSteps medical and dental checkup and appointment education brochures and a website targeting THSteps recipients 13 through 20 years of age. The brochures and website include positive messages to encourage teens to get THSteps checkups, explain the benefits of preventive healthcare, and encourage teens to call the THSteps toll-free help line for assistance in locating a THSteps provider, scheduling a checkup, and/or arranging transportation to the checkup. Defendants routinely provide these materials to agencies and offices, such as the Department of Family and Protective Services, HHSC Access and Eligibility Services, and Health Service Regions, to promote outreach and informing activities for the teen population. Brochures are available to order or download at https://hhs.texas.gov/doing-business-hhs/provider-portals/health-services-providers/texas-health-steps/thsteps-catalog.

Medicaid Managed Care The majority of managed care organizations (MCOs) use their standard methods of outreach for all members, including teenagers. MCOs address teen privacy and consent issues through the various forms of communications MCOs have with their members. The majority of health plans include privacy and consent language in their member handbooks, new member packets, and on their websites. When speaking with the teens and/or their parents via phone or home visits, the health plans take steps to ensure that staff only discuss confidential information with approved representatives for the member.

See Consent Decree ¶ 192, ¶ 212, and ¶ 245 of the Activities Report for Medicaid Managed Care Organizations for information on MCO outreach activities. (EXHIBIT 5)

PRIVACY AND CONSENT (¶ 207)

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DECREE OR CAO REFERENCE STATUS REPORT

THSteps Outreach Unit Maximus addresses teen privacy and consent issues through the various forms of communication Maximus has with Medicaid recipients. When speaking with teens and/or their parents via phone or home visits, Maximus ensures staff discuss confidential information only with approved representatives for the member.

CHILDREN IN CONSERVATORSHIP OF DEPARTMENT OF FAMILY AND PROTECTIVE SERVICES ¶¶ 210-212

DECREE OR CAO REFERENCE STATUS REPORT

CONSENT DECREE ¶ 212

Defendants will:

• Provide training about THSteps to parents or adult caretakers before recipients are reunited with their families.

• Assure timely checkups and report the number and percent of recipients under the supervision of DFPS who receive all of their medical and dental checkups when due.

• Establish procedures to refer recipients to appropriate case managers when needed upon recipients’ release from DFPS supervision.

Defendants included Consent Decree Paragraphs 210-212 in their 2016 Rule 60(b)(5) motion for the CAO:

Check Ups and CAO: Managed Care. Briefing is complete. See Dkts. 1437, 1446, 1491, 1495, and 1496.

TRAINING TO PARENTS AND ADULT CARETAKERS BEFORE REUNIFICATION

Maximus engages in outbound oral outreach to THSteps recipients transitioning from foster care by generating a monthly list (the first of each month) of recipients who are no longer enrolled in STAR Health but continue to be eligible for Medicaid. When contacted, Maximus educates the recipient about THSteps services with a focus on enhanced informing about Case management for Children and Pregnant Women services. For additional information about case management efforts, see the monthly EB-210 and EB- 211 reports found in the Maximus THSteps Reports for the months of June 2024, July 2024, August 2024, September 2024, October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, April 2025, and May 2025. (EXHIBIT 6)

Maximus also engages in community outreach with various state and community agencies and foster parent groups and associations. Maximus staff participates in meetings and community outreach events to conduct presentations and provide information about THSteps services to staff, parents or caregivers, foster parents, and others involved with recipients transitioning out of foster care and reuniting with their families. For additional information about these proactive outreach efforts which include children leaving foster care, see the quarterly EB-216, EB-217, and EB-219 reports found in the Maximus THSteps Reports

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for the months of June 2024, July 2024, August 2024, September 2024, October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, April 2025, and May 2025.

(EXHIBIT 6)

ENCOURAGING THSTEPS FOR CHILDREN IN DFPS CONSERVATORSHIP

The STAR Health Managed Care Contract includes requirements for initial medical and dental checkups and periodic checkups. Per the contract, STAR Health Members must receive Texas Health Steps medical checkups within 30 days of enrollment, and dental checkups within 60 days of enrollment. The STAR Health plan must provide other checkups according to the periodicity schedule, see §§ 1.6.5, 8.1.18, 8.1.18.2, 8.1.28.3. In addition, the Education/Outreach section of the STAR Health contract includes requirements regarding THSteps education and outreach, see § 8.1.28.3.4. A link to the STAR Health contract is available at: https://hhs.texas.gov/services/health/medicaid-and-chip/provider-information/managed-care-contracts-and-manuals.

REPORTS ON THSTEPS UTILIZATION FOR CHILDREN IN DFPS CONSERVATORSHIP

Defendants provide the report as required by Decree ¶ 212, Texas Health Steps Medical and Dental Checkups for Children in Foster Care SFY 2024. (EXHIBIT 7)

PROCEDURES TO REFER CHILDREN IN CONSERVATORSHIP OF DFPS TO CASE MANAGEMENT WHEN NEEDED Maximus utilizes its Special Services Unit (SSU) staff to provide oral outreach and facilitate case management referrals to recipients transitioning out of foster care. Each month, Maximus identifies recipients who are no longer enrolled in STAR Health but remain eligible for Medicaid. SSU staff then attempt to contact these recipients by phone. If SSU staff successfully contact the recipient, the staff provide education about THSteps and the use of case management services as a way to assist the recipient in accessing THSteps services.