Meeting Summary: April 26, 2006
Next meeting: May 24, 2006 @ 10:30 AM in LOB RM 3800

Prior Authorization (PA) MCO Reports:
The Subcommittee Chair reviewed the PA report parameters with DSS: Quarterly reports of denials and authorizations/1000 Member months by:

• Service categories (dental, durable medical equipment (DME), home health care, inpatient, outpatient surgery & therapies).
• Age: <21 years, > 21 years.
• Number of appeals (NOA) and grievances. The NOA/grievance outcome can supply information on the outcome (i.e. was the client's grievance upheld in the DSS hearings or was the MCO service denial).
• DSS will create a template of the reports and email to the subcommittee before the next meeting.

The initial reports can identify the top reasons for PA service (not claim) denials. HUSKY Infoline could report on their call data within the report timeframes to see if there are common themes.

The HUSKY pharmacy reporting parameters have been revised and reports should be available within the next several months. It was suggested that both the pharmacy & PA reports be presented at the same Medicaid Council meeting.

Update on PE/EE numbers
Observations of EE RPU report from 11/30/05 – 4/14/06 that was presented at the Medicaid Council:

ü 66% of the overall percentage of new applications granted was within one-5 days. Since Dec. 2005 there has been an increase in one-day determinations.

ü 10% of the total applications (2,245) were granted after 5 days. Since Dec.–Jan. there has been a slight increase in this category.

ü 7% of the total was denied and 16% were pending at the end of the period. The percentage of denied applications increased during Feb. – April.

Children's Presumptive Eligibility-PE- (782 since 11/30/05) averages about 56 PE granted per week in the 3 RPUs. The number seems low given the ongoing monthly loss of children in HUSKY A & B (although PE is mainly granted at the time a family seeks health services for their child).
HUSKY Enrollment
About 200 per week lose HUSKY coverage. Actually the enrollment reports represent member loss & gains: the overall enrollment loss of members would be higher.

Addendum: since July 2005

• HUSKY A < 19 years enrollment has had a net loss of 4829 enrollees
• HUSKY B net loss is 1220 since August 2005
• Total net loss of HUSKY A/B children is 6039 since July 2005
• HUSKY A adult net gain is 3079

The transitional medical assistance (TMA) Medicaid coverage period will be reduced to 12 months beginning FY07. Clients will lose TMA after 12 months beginning June 30, 2006. It is expected that a significant number of clients will lose Medicaid coverage if they do not reapply for HUSKY.
o The SC Chair and MCOs asked if each MCO can receive information on their members that will be affected by the TMA change.
o Can outreach entities receive the flyer notifying members of this change to post at their sites.
o Can outreach entities/authorized representative of the clients that help clients with the application process receive an alert about clients at risk of losing coverage if they do not respond to Medicaid notices? These questions will be referred to the Kevin Loveland.

Address Changes: The process to “fix” the address change problem – having a single entity take the responsibility of following up on the completion of the system address changes in HUSKY, which was based on the CHNCT pilot experience- has not been resolved. Given the time put into trying to resolve this “glitch” that can result in child/family disenrollment because of non-renewal of application that was never received by the client, if there is difficulty in putting in place a reasonable process to ensure address changes are put into the system, the Chair of the Medicaid Council may meet with the DSS Commissioner to review the DSS issues.