Topic:
CHILD HEALTH; POVERTY; JUVENILES; STATISTICAL INFORMATION; SOCIAL SERVICES; MEDICAID; HEALTH INSURANCE;
Location:
INSURANCE - HEALTH;

OLR Research Report


August 2, 2005

 

2005-R-0592

HUSKY

By: Robin K. Cohen, Principal Analyst

You asked for a general overview of the HUSKY program (A and B). You specifically wanted to know its (1) history, (2) covered populations, (3) benefits and cost sharing, and (4) strengths and weaknesses.

SUMMARY

Since 1998, the HUSKY program has provided managed health care to the state's low-income children. Run by the Department of Social Services (DSS), the program consists of three parts—Part A, Part B, and HUSKY Plus. Part A is Medicaid for children living in families with income up to 185% of the federal poverty level (FPL, currently $29,766 for a family of three) and their parent and caretaker relatives with incomes up to 150% of the FPL. Part B provides identical services to children in families with higher incomes. Unlike Part A, Part B families have cost sharing requirements, such as co-payments and premiums. In addition, the HUSKY Plus program provides supplemental coverage for children with severe behavioral and physical health care needs.

The program offers a very comprehensive service package, including well child visits and prescription drugs. One of its goals is to ensure that children receive routine, preventive care with a community provider rather than in the hospital emergency rooms.

Currently, four managed care organizations (MCOs) manage Part A enrollees' care (three in Part B), for which the state pays them a monthly “capitated” rate. It is expected that this per member, per month payment will cover all services the enrollee needs during the month. The MCOs contract with dental and behavioral health subcontractors, which manage those benefits for HUSKY enrollees.

In addition, DSS contracts with an enrollment “broker” or “servicer,” to take applications and help enrollees choose a health plan.

DSS is responsible for providing outreach and currently maintains contracts with community providers, including 211-Infoline, to fulfill this mandate. State funding for this function has been reduced significantly over the last few years.

The statutorily established Medicaid Managed Care Council (MMCC) oversees the HUSKY program's administration. This group meets monthly and makes recommendations for program changes to both DSS and the legislature. In addition, DSS maintains contracts with outside entities to perform quality reviews and measure how the program meets established goals.

The program has been very successful in decreasing the number of uninsured children and adults, although some contend numerous uninsured children are still not enrolled even though eligible for benefits. But the legislature has made program cuts, in both 2003 and 2005, that may reverse the first trend. Moreover, concerns have been raised about the lack of information available from the MCOs, especially concerning providers. This information is essential for the state to measure the program's success in providing not only coverage but access to the coverage. Access to mental health services for children has been another issue. A new initiative is expected to address this concern.

Another concern has been raised about HUSKY subsidizing care for employees who do not have access to employer-sponsored health insurance or do but cannot afford the cost sharing. The legislature considered but did not pass two related bills—one would have required employers to cover their employees or pay into a fund (dubbed “pay or play”) and another would have required DSS to provide premium assistance. A third bill would have required DSS to report more regularly on the extent to which HUSKY provides coverage for employees working for employers in the state.

HUSKY—HISTORY, ELIGIBILITY, BENEFITS, ADMINISTRATION

Establishment

Since 1965, the federal Medicaid program has provided public health insurance for children living in Connecticut's low-income families. Although states that run Medicaid programs must cover certain low-income children, over the years, Connecticut has taken advantage of federal options to expand coverage to children at higher income levels.

As a result, when the legislature enacted the HUSKY law in 1997, Connecticut was ahead of most states in terms of its child coverage under Medicaid (up to 185% of FPL with no asset limit). PA 97-2, November Special Session, was the state's response to federal State Children's Health Insurance Program (SCHIP) legislation, enacted in 1997, which established a new federal block grant for states to provide more health insurance coverage to children. The state's primary SCHIP program became HUSKY B, which provides coverage to children with incomes above 185% of the FPL and subsidies to families with incomes up to 300% of the FPL. Medicaid (for children and subsequently caretaker adults) was re-named HUSKY A. (HUSKY Plus was also created at that time to provide supplemental coverage for children with severe physical or mental disabilities.)

Benefits

From the outset, HUSKY was to follow a managed medical care model, whereby the state contracted with a number of MCOs (currently four) to provide all of the covered benefits. The 1997 law enumerated what services had to be offered to HUSKY B recipients, which were and continue to be the same as those in HUSKY A.

Table 1 describes HUSKY B benefits, coverage limitations, and cost sharing requirements. Until 2005, HUSKY A had no cost sharing (see below).

Table 1: HUSKY B—Benefits, Coverage Limitations, and Co-Payments

Benefit

Coverage Limitation, Co-Pays

Preventive care—periodic and well child visits, immunizations, WIC evaluations, and prenatal visits

 

Birth to age 1

Six exams

Ages 1-5

Six exams

Ages 6-10

One exam every two years

Ages 11-19th birthday

One exam a year

Outpatient physician

100%

Inpatient hospital

100%

Outpatient surgical facility

100%

Ambulance

100% if determined to be an emergency, in accordance with state law

Pre-Admission/Continued Stay

Arranged through provider

Prescription Drugs

$3 co-pay `on generics, $6 for brand names; formularies

Mental Health--Inpatient

100%, except 60 day limit for certain conditions, such as mental retardation, learning, motor skills communication, and caffeine-related disorders (HUSKY Plus available to supplement)

Mental Health--Outpatient

$5 co-pay, with some exceptions

Substance abuse

100% for detoxification; 100% for inpatient with some exceptions and durational limits; 100% for outpatient with same limits as inpatient

Skilled nursing

100% with prior authorization

Home health

100%

Hospice

100%

Short-term rehabilitation and physical therapy (PT)

100%

Long-term rehabilitation and PT

Supplemental coverage available under HUSKY Plus for medically eligible children

Lab and X-Ray

100%

Pre-admission testing

100%

Emergency care

$25 co-pay, unless determined to be an emergency in accordance with state law—fee waived if patient admitted

Durable medical equipment

100% with prior authorization

Prosthetics

100% with prior authorization; supplemental coverage available under HUSKY Plus

Eye care

$5 co-pay on exams; optical hardware partially covered--lenses and up to $50 for frames, once every two years, with $100 maximum for lenses and frames per prescription

Hearing—exams and aids

$5 co-pay; aids covered under HUSKY Plus

Nurse midwives

$5 co-pay

Nurse practitioners

$5 co-pay

Podiatrists, chiropractors, naturopaths

$5 co-pay

Speech and occupational therapy

Short-term coverage with prior authorization

Dental

100% except co-pays for bridges and crowns, root canal, dentures, extractions; orthodontia covered up to allowance

Family planning

$5 co-pay for contraceptives; family planning services covered in full

Source: DSS—HUSKY Website

Eligibility

HUSKY A. When first established, HUSKY covered children only. In 1999, the legislature expanded HUSKY A to cover adult caretaker relatives of children receiving HUSKY with incomes up to 185% of the FPL by taking advantage of a new federal Medicaid coverage group, Section 1931. (Adult coverage under HUSKY B was difficult to achieve because of the way the SCHIP law was written, although newer federal waivers have made this easier.). In addition to covering more uninsured adults, many believed that if the state covered these relatives, they would be more likely to sign up their kids for coverage. Adult coverage at this income level never took effect because in 2000, the legislature reduced the limit to 150% of the FPL and delayed its implementation until 2001.

In 2003, the legislature reduced the adult income limit to 100% of the FPL, effective April 1, 2003. But a lawsuit and subsequent Appeals Court ruling allowed most adults with incomes between 100% and 150% of the FPL to continue to receive benefits up until April 1, 2005. PA 05-1 extended this coverage until June 30, 2005, and PA 05-280 makes the income limit 150% of the FPL, effective July 1, 2005.

HUSKY B. The HUSKY B income limits have remained the same since the program was first created. Children in families with incomes up to 300% of the FPL are eligible for subsidized assistance.

Cost Sharing

HUSKY A. Until this year, there was no cost sharing in the HUSKY A program. The legislature had imposed co-payments in 2003 on families but subsequently rescinded them. (PA 03-3, June 30 SS imposed a $3 maximum co-payment for medical services and $1.50 for prescription drugs; PA 04-258 repealed them.)

PA 05-280 requires DSS to seek a federal waiver to impose a $25 monthly premium and $1 co-payments on HUSKY A families with incomes above 100% of the FPL. Both of these provisions are expected to be implemented in 2006.

HUSKY B. Since its inception, HUSKY B has had cost-sharing requirements for families. Families with incomes between 185% and 235% of the FPL (Band 1) made co-payments, up to a maximum of $650 annually. Families with incomes between 235% and 300% of the FPL (Band 2) had a $1,250 maximum annual cost sharing cap, which included premiums.

Until 2005, Band 1 families paid no premiums and Band 2 families paid $30 per child, per month, with a $50 maximum per family. PA 05-280 directs DSS to impose the $30/$50 premium on Band 1 families and raise the premiums to $50 per child, with a $75 maximum, for Band 2 families. The overall cost sharing caps can now go as high as 5% of family income.

Managed Care Networks

HUSKY services are managed by four MCOs that maintain contracts with DSS: Anthem Blue Care, Community Health Network (CHN), Health Net, and Preferred One/FC. Anthem had the largest number of HUSKY A enrollees in the beginning of June 2005 (129,827) and B enrollees (11,216), with the next highest CHN (57,401 and 2,499, respectively). (Health Net does not serve HUSKY B children.)

Capitation Rates

DSS pays the MCOs a monthly capitation rate, which is an amount that is expected to cover the plans' cost of caring for the enrollees. In FY 2006, the average per member per month (pmpm) rate will be $194.56, which is almost a 50% increase since the program began in July 1998, when the average was $132.22. Table 2 shows the average pmpm from FY 98 through FY 06 for HUSKY A. (The HUSKY B pmpms would be lower for Band 2, reflecting that enrollees have paid premiums and co-payments.)

Table 2: Average PMPM in HUSKY A—FY 98 through FY 06

Fiscal Year

Average PMPM in HUSKY A

FY 98

$132.22

FY 99

143.65

FY 00

153.83

FY 01

146.91 [1]

FY 02

158.41

FY 03

173.17

FY 04

179.21

FY 05

187.85

FY 06

194.56

Source: OLR analysis of Office of Fiscal Analysis monthly figures.

[1] This figure should probably be higher. The methodology used to calculate the annual monthly average factors out a month in which the average was significantly lower than any other month that year.

Outreach

When first enacted, the HUSKY law directed the DSS commissioner to develop outreach for both parts in consultation with the Medicaid Managed Care Council, the Children's Health Council, and Infoline. The law requires DSS to report annually on its outreach efforts (CGS 17b-297(a)). (The legislature established the Children's Health Council (CHC) in 1995 to, among other charges, do outreach and ensure statewide uniform health care access for children.)

The CHC was the state's primary outreach entity for HUSKY, and DSS provided it with over $1 million for these efforts until its funding was cut in half in early 2002. (Governor Rowland had recommended its elimination in FY 03.) Since then, the council's funding has continued to dwindle, and its functions have been taken up largely by Voices for Children, a New Haven based child advocacy group.

According to OFA, outreach funding for HUSKY in FY 06 is about $850,000. Over $700,000 funds DSS contract with 211-Infoline, as well as internal DSS outreach costs, such as mailings. An additional $125,000 in DSS' Community Services line item, according to OFA, is a grant to the Hartford Foundation for Public Giving, which subcontracts with Connecticut Voices. And $25,750 in a CHC line item goes directly to Voices. (A multi-year Robert Wood Johnson Foundation grant to Voices earmarked for outreach is ending in December 2005.

Administration

Affiliated Computer Services-State Healthcare (ACS) has carried out four main HUSKY program functions. It (1) is the state's Medicaid managed care enrollment broker (since 1995) (2) serves as the single point of entry provider for family Medicaid (since 1998), (3) calculates monthly capitation fees due to HUSKY A MCOs (since 2001), and (4) determines HUSKY B eligibility. (Federal law requires the state's Medicaid agency to do eligibility determinations, but ACS determines whether applications should go to DSS or be redirected to HUSKY B). DSS paid ACS $6.9 million for the period July 2003 through December 2004.

In 2004, the Legislative Program Review and Investigations Committee (LPRI) studied Medicaid eligibility. One part of the study focused on the ACS contract, and its recommendations on the contract related were ultimately adopted by the 2005 legislature. These include requiring DSS to develop one or more contracts for these services, to limit the contacts' duration to seven years, and to ensure that future contracts contain performance measures (PA 05-280).

Oversight

For the last 10 years, the Medicaid Managed Care Council has served as the primary watchdog for HUSKY A and B. Established in 1994 (PA 94-5, May Special Session), the council is comprised of legislators, executive branch employees, health care providers and advocates, and consumers. It meets monthly and is charged with a variety of tasks, including making recommendations to the legislature regarding access to HUSKY A. To help with the large volume of work, the Council established four subcommittees that hold additional meetings during the month: Behavioral Health, Consumer Access, Public Health, and Quality Assurance.

Measuring Outcomes

As a condition of receiving federal funds for managed Medicaid and SCHIP programs, states must measure the performance of their MCOs to ensure that they meet certain minimum quality standards. Moreover, federal law requires that certain services be offered to program beneficiaries. States generally use the Health Plan Employer Data and Information Set (HEDIS), developed and maintained by the National Committee for Quality Assurance (NCQA) or some variation of it when evaluating their programs. Connecticut uses both of these. Surveys are also performed.

Mercer Report (April 2005) In 2004, DSS contracted with Mercer Government Human Services Consulting to perform an external quality review of HUSKY A. A summary chart, presented at the Medicaid Managed Care Council's April meeting, measuring the MCOs' success in meeting national benchmarks for a number of performance measures, such as the number of Neonatal Intensive Care Unit (NICU) admissions per 100 births and emergency department visits, shows that the NICU numbers for all four plans fell within both the national and state averages. The emergency visits for all but one plan (Health Net) were higher.

Mercer also reported on Performance Improvement Projects which measure how well a particular plan met its goals for improving health outcomes.

PROGRAM SUCCESSES

Effects on Number of Uninsured

Although a June 2005 Families USA report shows that over 11% of the state's population is uninsured in 2005, the HUSKY program can be credited for reducing the number of uninsured residents. A May 2005 Voices report notes that 75,000 more children have health insurance than in July 1998. And passage of the 2005 adult expansion is expected to reduce the number of uninsured adults by about 17,000 over the next two years.

More Screenings

At the June 2005 MMCC meeting, the state's Medicaid director, David Parrella, pointed to rising preventive services screenings in HUSKY A. In 1994, the preventive screen ratio (which measures the degree to which children get basic prevention screenings) was 49%. In the last half of 2004, all MCOs achieved an 80% ratio and cumulative ratio of 84% in the utilization reports, consistent with federal goals, according to Parrella.

LPRI Review

The LPRI Medicaid eligibility study and many of the issues it raised and subsequent recommendations pertain to HUSKY. One reason for the study was to get a sense of how state employee layoffs (about 25% of DSS eligibility workers statewide) had affected DSS' ability to process applications in a timely manner.

Some of the concerns the study raised included (1) high numbers of overdue family applications (pending DSS review and granting of eligibility) and disparities among the district offices; (2) difficulty in getting client information changes (such as address) processed; (3) lack of uniformity among the offices in notifying pregnant applicants when necessary application information is missing; and (4) frequent plan changes by HUSKY A beneficiaries.

Many of these recommendations were incorporated into PA 05-280, including a 12-month bar on HUSKY A recipients switching MCOs (previously, they could switch plans at any time).

PROGRAM SHORTCOMINGS

Access--Accountability

State law requires each participating MCO to have a sufficient number of appropriately trained and certified health care clinicians. It also requires that the plans maintain primary responsibility for ensuring that their dental and behavioral health care subcontractors adhere to the MCOs' contracts with DSS and requires that the MCOs impose a performance bond, letter of credit, statement of financial reserves, or payment withhold for these services. Over the years, a concern has been raised about the lack of information available on the plans, and the legislature has from time to time considered bills to obtain more information.

A recent Hartford Courant article highlights this issue as it relates to the number of providers with whom the HUSKY MCOs contract for services. In it, the author mentions several New Haven clinics that noticed their patients were having difficulty finding cardiologists and gastroenterologists and suspected low fees from the MCOs was a strong factor. But DSS has consistently argued that it does not have the information (the MCOs have it but apparently do not pass it on to DSS), thus it is not subject to the state's Freedom of Information laws. Although Attorney General Blumenthal is sympathetic to the people seeking the information, he is obliged to defend DSS' position. The MCOs have argued that the information is proprietary and would reveal commercial trade secrets, and they contend that they are not performing a government function.

The Mercer report referenced above had attempted to measure provider adequacy but limitations in encounter data prevented such measurement in a “meaningful” way, according to its authors. Mercer hopes to include this in future reviews.

Dental Services—Lawsuit and Delay of “Carve Out”

Dental participation in the Medicaid program has been poor for many years, even before HUSKY was established. (Connecticut has not raised dental reimbursement rates for children since 1993.) The lack of participation is due mainly to very low reimbursement rates and the fairly high patient no-show rates that have chronically plagued the program.

Medicaid managed care pushed reimbursement for most children's dental care into the monthly capitation rates DSS pays the MCOs, which in turn subcontract with two dental MCOs to serve clients. A 2004 report by Connecticut Voices for Children found that fewer than half of children enrolled in HUSKY A received any dental care in 2003. But Voices also found a steady increase in preventive care services over 2000.

PA 03-155 directed DSS to hire an administrative services organization (ASO) to manage dental services for HUSKY beginning in late 2004. It was believed that this “carve out” of dental services would improve access. DSS announced in early 2005 that it was abandoning this plan because it did not believe it would lead to greater access for patients. In the meantime, legal aid advocates sued the state in 2003 for failing to provide dental services to the poor. The case remains in federal court.

Legislation to increase dental rates has been proposed but not passed during the last several legislative sessions. But the federal Medicaid agency has recently approved the state's plan to allow federally qualified health centers (FQHC) to contract with local dentists. These centers generally get higher reimbursement from Medicaid, which could mean higher rates that might attract more providers willing to serve poor residents, including HUSKY recipients.

Disparities in Health Care

A June 2005 report by Voices shows continuing disparities between whites and non-whites in utilization rates of well-child care and hospital emergency rooms in 2003. The report's main conclusions were mixed: African American children were significantly less likely to receive well child care, other ambulatory care, and preventive care than white children, while Hispanic children were significantly more likely than white children to receive preventive dental care.

Hispanic children were more likely to have emergency care or be hospitalized than white children. And, both African American and Hispanic children had more asthma care and more emergency asthma care, but were no more likely to be hospitalized for asthma.

State Subsidizing Care for People Potentially Eligible for Employer Sponsored Heath Insurance

Three OLR research reports from earlier this year highlight an emerging issue: for some of the largest employers, the state may be subsidizing the health insurance of employees when such coverage is available from these employers. The legislature considered a bill (SB 1147) that would have required these employers to “pay or play,” but the Senate recommitted the bill to the Labor Committee on the last day of the regular session.

Bills to require DSS to report on the employers of people whose children receive HUSKY likewise did not pass in 2005 (PA 05-280).

Other Legislative Changes that Could Negatively Affect Enrollment and Access

Although the 2005 legislature increased the income limit for adult HUSKY A coverage, it also imposed new or higher cost sharing requirements in both A and B, such as monthly premiums and co-payments in HUSKY A. And it reduced from two years to one the time families can receive Transitional Medicaid.

This same legislation eliminated self-declaration of income in HUSKY A and B. Under this procedure, DSS had to rely on information that the recipient provided when determining whether someone continued to be eligible, rather than requiring a more in-depth review of the family's financial circumstances.

These changes, along with cuts made in 2003 (e.g., elimination of continuous eligibility for children, which had provided continuous coverage during a 12-month period, even if the caretakers financial circumstances changed during that time), may be having a negative effect on enrollments.

Behavioral Health “Carve Out”—Waiver

For several years the state has been grappling with how to provide necessary mental health services to children and to ensure that the state has access to any available federal funding to pay for these services. As mentioned above, these services are available under HUSKY and HUSKY Plus, the funding for which comes from the monthly capitation the MCOs receive from DSS. But this system has continually been faulted for failing to meet the mental health needs of the state's poor children, including creating long and unnecessary hospitalizations and emergency room visits.

DSS and the Department of Children and Families have been working for the last five years to fix the problem. In May 2005, they submitted a federal Medicaid waiver request to begin to build an integrated, family-driven behavioral health system that combines the broad ranges of services and supports provided by both departments. It essentially “carves out” mental health services from the capitation and allows for HUSKY payments on a more traditional fee-for-service basis. An administrative service organization (ASO), Value Options, will administer the initiative, which DSS anticipates will start on January 1, 2006.

The legislature built on this initiative with passage of PA 05-280. This act, among other things, (1) expands community-based services, while reducing the state's reliance on institutional care; (2) improves performance monitoring, and (3) establishes a Behavioral Health Oversight Council.

Higher Cost of Employer Sponsored Coverage and Expansion Options

As employers continue to increase the amount employees must pay for coverage and small employers find it harder to pay rising premiums for their employees, the uninsured rates could rise further despite the success HUSKY has had in covering more children and adults. Some have called on the state to expand HUSKY further to cover those people, including childless adults, who cannot afford their employers' coverage or who are working for an employer that does not offer coverage. Federal waivers are available to states to do such expansions, which would give Connecticut a higher match (65% instead of 50% available for adult coverage in HUSKY A). The legislature has considered such initiatives but none have passed.

RC:dw