Connecticut
Medicaid Managed Care Council
Legislative Office Building Room 3000, Hartford CT 06106
(860) 240-0321 Info Line (860) 240-8329 FAX (860) 240-8307
www.cga.state.ct.us/ph/medicaid
 

MEETING SUMMARY

MAY 5, 2000

Present: Sen. Toni Harp (Chair), Rep. Vickie Nardello, David Parrella and James Gaito (DSS), David Guttchen and Steve Netkin (OPM), Dorian Long for Gary Blau (DCF), Robert Gribbon (Comptroller), Dr. Edward Kamen, Janice Perkins (PHS), Ellen Andrews, Phyllis Rotella, Judith Solomon, Lisa Sementilli Dann, Cynthia Mathews.

Also Present: James Linnane and Rose Ciarcia (DSS), Sheila Allen Bell (Benova), Debra Brackett (Qualidigm), Deb Hines (ABC), Linda Scofield (Preferred One), Mariette McCourt (Council staff).

Department of Social Services Report

1915(b) Prospective Waiver Application

Information on the 1915(b) Waiver application had been mailed to Council members and copies were available at the meeting. James Gaito (DSS) summarized the prospective savings outlined in the waiver application. The 1915(b) waiver provides the State with the legal authority to operate the HUSKY A program. Savings are based on comparing projected program spending without the waiver and under the waiver. (The waiver cost effectiveness provision mandates that the waiver spending must be equal to or less than the program costs under the FFS program). The three waiver demonstration years extend from 3/1/99 through 2/28/02. The following summarizes the comparison of with & without waiver spending:

Comparison of With & Without Waiver spending

The administrative costs for the first year of the demonstration waiver (3/1/99-2/29/00), excluding the offsets, total slightly less than $ 8. 6 million. The distribution of the administrative costs (in $ 1000 amounts) is:

· EDS capitated claims payment: 21% ($ 1,815)

· Mercer, State actuary: <5% ($ 405)

· Qualidigm, External Quality Review Organization: 20. 4% ($ 1,751)

· Children's Health Council: 28. 5% ($ 2,440)

· Benova, the enrollment broker: 16. 5% ($ 1,415)

· DSS staff: <8% ($ 592)

Council members raised the following questions:

· How was the increasing psychiatric inpatient reinsurance amounts included in the waiver projections? Mr. Gaito stated that reinsurance does not affect the with-waiver costs because the money is included in the rate. It does affect the without-waiver projections in that as a benefit limit, the amount is subtracted from the cost of the waiver, which lowers the Upper Payment Limit (UPL), the benchmark for cost effectiveness. The initial estimate of the 1. 6% credit will have to be reconfigured for the next waiver application process as the actual and newly projected costs of reinsurance have been higher than originally forecasted.

· The waiver includes a mandatory Early Periodic Screening Diagnostic Test (EPSDT) rate increase from 40% to 80%, effective 1/1/98 that was a +1. 5% amount of adjustment of the total without-waiver program cost. Since the financial EPSDT quality incentive was removed through reallocation of the $ 1 million to the MCO's, Rep. Nardello asked if mechanisms are in place to achieve the rate goal? David Parrella stated that there has been no change in the contract language; it was and is expected that all plans work toward achieving the 80% EPSDT participation goal. The incentive was designed to reward the MCO that achieved the highest % rate; this bonus has been absorbed into the managed care per member per month (PMPM) rates. There will be replacement language in the contract amendments for the incentives that will deal with quality issues and data reporting. The addition of the $ 7. 6 million to the capitated rate is included in the projected waiver costs.

Behavioral Health Subcontractor Change

The Department was asked to update the Council on the Preferred One behavioral health subcontractor change. Mr. Parrella stated that DSS has been notified, through a letter of intent, that PRO Behavioral Health will be replacing Yale Behavioral Health as the BH subcontractor for Preferred One as of May 1, 2000. The contract will be reviewed by DSS once it is completed, which should be within the next two weeks. The transition has gone smoothly, according to Linda Scofield (P-1) and Steve Ruth (PRO BH). There has been an extensive data exchange between Yale BH and PRO. There is approximately a 98% overlap of both subcontractors' provider network. Both PRO BH and P-1 have incorporated the continuity of care policies and contractual obligations that are associated with MCO transitions within the Medicaid program.

HUSKY Contract Amendments

Over the last month, DSS efforts have been focused on configuring the agency budget. The Department expects to review the final contract amendments with the MCO's before the end of May 2000, after which DSS will present the changes to the Council.

Policy Transmittal to the Health Plans

Mr. Parrella described a significant change in DSS policy that was communicated to the MCO's in an April 18^th letter that addressed the requirement of a written Notice of Action (NOA) to members for partial denial of services. Previously, DSS did not require this in the HUSKY A contract. Thus, if the provider requests 30 outpatient sessions but has not demonstrated to the satisfaction of the MCO that the member will require this number of sessions, the MCO may respond in one of the following ways;

· The MCO determines that none of the services requested are medically necessary and issues a (full) denial of services notice to the member. Continuation of care requirements do not apply nor does the 10 day advance notice requirement apply in this case.

· If the MCO determines that the requested services are medically necessary to some extent, the MCO may partially approve and partially deny the requested services. The MCO could approve 15 sessions, not all 30 sessions requested. The MCO must send a denial notice of those 15 sessions to the member. The member could request a grievance/fair hearing on the remaining 15 sessions, however continuation of care requirements would not apply while the fair hearing is undertaken.

· If the MCO determines that the services are medially necessary, but lacks sufficient information from the provider to make a final determination as to the full scope of the request, the MCO may approve the request with notice to the provider that the MCO will periodically review the medical necessity for the full request (i. e. 30 sessions). Prior to completion of the full service request, the MCO may determine, at a "check-in point", that the remaining sessions are not medically necessary and discontinue coverage of the remaining previously approved sessions. This constitutes a termination of services; the MCO is required to send a 10 day advance notice to the member and continue benefits pending a hearing decision, up to the previously approved number of sessions, if the patient requests a hearing within the 10 day period.

"The Department believes that these options afford the MCO's sufficient flexibility to respond to a request for services while still allowing the MCO to manage the care provided". Failure to issue notices of action as required by the HUSKY A contract and the partial denial requirements may result in the imposition of Class B or C financial sanctions.

The April 18^th letter also re-emphasized existing DSS policies that:

· Require that MCO utilization review be based on an individual determination of medical necessity. An arbitrary time limit on the number of service visits is inconsistent with this policy.

· Require that MCO's are not to deny services on the basis of the chronicity of a condition nor adopt practices that have the effect of denying or limiting access to medically necessary services for chronic or long-term conditions. MCO's are responsible for ensuring subcontractor compliance with these policies.

Managed Care Access and Due Process

Sheldon Toubman, Attorney for the New Haven Legal Assistance Association, reported on the status of current litigation regarding due process in the Medicaid managed care program. New Haven Legal Assistance and the Waterbury and New Britain Connecticut Legal Services have brought this suit against the Department of Social Services and PHS. The litigation addresses concerns about procedures whereby the MCO notifies HUSKY members of changes in the authorization of goods or services that differ from that prescribed by the health care provider. Legal Services has reportedly documented an extensive pattern of MCO, specifically PHS, non-compliance with the DSS policy that requires a written notice of action (NOA) be sent to a member whenever the MCO denies coverage of services or reduces, suspends or terminates ongoing goods or services. It is the belief of Legal Services that this non-compliance allows MCO's to conceal practices of denials of medically necessary service. The failure to send the NOA interferes with the member's right to appeal decisions regarding health services. Prior to the submission of the litigation there was no clear DSS policy regarding partial denials of care. Where there were clear policy directives from DSS regarding NOA, MCO compliance with these policies has been lacking, according to Attorney Toubman.

Legal Services and DSS are involved in ongoing settlement negotiations and both DSS and Legal Services reportedly are optimistic of a June resolution of the due process issues. Attorney Toubman outlined specific concerns of the contract compliance process related to due process:

· The NOA must include the specific definition of medical necessity as the basis for the denial; a general statement related to the denial is not in compliance with the policy. Hence the DSS definition for BH medical necessity, rather than the general definition in the contract, should be applied where appropriate.

· MCO's now need to comply with the new DSS policy of partial denial of services (see above).

· MCO authorization decisions must be based on an individual assessment of medical necessity. The practice of some subcontractors of routinely approving 5-6 sessions or routinely authorizing a set number of sessions per diagnosis is not in compliance with the policy of individual assessment-based authorizations.

· Denial of care based on the chronicity of a condition is not in compliance with DSS policy. There reportedly has been evidence of MCOs' authorization based on the focus of acute symptoms.

· Lengthy treatment without defined improvement may lead to an MCO giving conditional approval for further sessions only if the client is evaluated by child psychiatry for pharmacological intervention. Attorney Sheldon stated that many children treated for behavioral health problems might at best maintain a functional level rather than demonstrate improvement because of the severity and chronicity of the presenting problem.

Mr. Toubman acknowledged that the DSS letter of April 18^th to the MCO's covers the areas of concern in the initial litigation. Aggressive enforcement of the policies is needed to improve the quality of behavioral health care.

The following highlights Council discussion following the presentation:

· There is a need to identify the best practice standards that form the basis of both the providers request for duration and intensity of services as well as the MCOs basis for authorization/denial. Chet Brodnicki, Executive Director of the child guidance clinic Clifford Beers, reported that PRO BH and the clinic have agreed upon standards and measurable outcomes for sexually aggressive youth. Senator Harp suggested that this could be used as a model in addressing broader care management issues.

· The issue of MCO's approving further treatment based on the condition of an assessment for medication elicited several different views:

o Linda Scofield (P-1) stated that lack of improvement after a number of sessions suggest, "something else be tried" and believes it is appropriate for a provider licensed to prescribe medications evaluate the child.

o Mr. Brodnicki stated that of the 1200 children seen at the Clifford Beers Clinic, one-third is receiving psychotropic medication. Clinic therapists have at least 10 years professional experience in treating children and children are referred to child psychiatry as needed. However clinics are cautious in using limited resources for "unnecessary" psychiatric referrals.

o Attorney Toubman stated that this practice may lead to possibly excessive medication of the child and believes the concept of individual assessments needs to be applied here, rather than the MCO routinely flagging lengthy numbers of visits and initiating the conditional approval.

· Partial denials became an issue in the litigation, according Attorney Toubman, as it is not an outright denial but a cost control measure used by managed care to cut back services in some manner.

· Judith Solomon stated that the basis of the litigation is the assumption that once members receive information (NOA) they will act upon it, when in reality this does not happen. Eva Bunnell cited national data that only 15% of denials by managed care are appealed; of these 82% are overturned in favor of the client. The CHC has provided brochures for consumers to inform them about the legally written NOA. Senator Harp stated that it is important that members be informed of their right to appeal managed care decisions, through NOA. The Council needs to think about how to best help members respond and exercise their right to appeal managed care decisions.

Other Items Raised by the Council

· Rep. Nardello requested an update from DSS on the receipt of the audited Medicaid line of business reports MCO's were to submit to DSS. Mr. Parrella reported that two reports have now been submitted. The reports were due to DSS in April 2000.

· The Department was asked to comment on the status of the pending legal action regarding dental access. Mr. Parrella stated there is no formal litigation filed by CT Legal Services at this time. Both DSS and the MCO's are working on the extensive FOI request from CT Legal Services as part of the discovery process. The legal process involves the Department's engagement of the Attorney General's Office once a brief is filed. Motions from DSS are filed to dismiss the litigation. The agency and others provide information at the request of the entity filing the suit. Both entities could begin negotiations that could lead to a settlement that involve program changes or the case may proceed to litigation. The future direction of the dental action is unclear, at this time; it could result in litigation.

Quarterly Report

The report was accepted with the addendum with no nays, no abstention, and voice-vote approval.

Subcommittee Reports

Behavioral Health: The priority work group is planning to organize an administrative `best practices' forum in the Fall for providers, MCO's, family advocates. Transportation issues were looked at. The work group will address those specific to BH services provided several times a week, such as Partial Hospitalization Programs and refer general transportation issues to the Council, as difficulty obtaining these services occurs across services in the HUSKY program. The BH Outcomes Study steering group is meeting weekly and is working toward a July 1 start date. The subcommittee heard reports on the BH legislative task force and the Governor's Blue Ribbon Commission, which provide synergy and connection of behavioral health issues for children, adolescents and transitioning youth to adult services.

Consumer Access: Ellen Andrews, Chair, has met with three community-level groups regarding HUSKY and the uninsured; she plans to meet with other groups in the near future. DSS has worked with York Correctional Center to provide HUSKY information for women leaving York. The subcommittee and DSS are developing indicators to track the effectiveness of Correctional Centers' outreach. At the May meeting, DSS will discuss the presumptive eligibility pilot plans and early identification of Special Needs children in HUSKY will continue to be discussed.

Public Health: The subcommittee has worked on two issues: clarifying the credentialing of dental hygienists, now be included in the MCO network, with DSS and MCO's, and the Safety Net system monitoring process. The Community Benefit legislation that arose from the subcommittee provides voluntary hospital and MCO reporting of community programs. Both Houses adopted the bill, funding has been approved and the bill awaits the Governor's signature.

Quality Assurance: The Asthma work group is working with DSS and MCO'S to clarify and provide geographic, plan-specific pharmacy and DME vendor sites and procedures and bring together `best practices' for provider/MCO communication related to treatment plans in a Fall forum. The subcommittee received a report on the HUSKY lead screening rates in five additional towns; over-all compliance with the HCFA mandate of lead screens for children aged 12-24 months is over 80%, higher than national reports. There is a need to identify standard fields in databases among state agencies (that may serve HUSKY children) in order to share data among DSS and other agencies to answer specific questions about the HUSKY population. This will continue to be reviewed in the subcommittee.

Women's Health: The chair asked about the status of the legislation for parent expansion in HUSKY A. The current proposal is to cover parents and relative caregivers up to 150% FPL. This is in the DSS implementer bill that will be voted on in the June special session.

Rep. Nardello stated that the Medicaid Council is effective in bringing all points of view forward, and working with DSS to improve the program. Council members give freely of their time and are thanked for their continuing efforts.

The Medicaid Council will meet next on Thursday June 15 at 9: 30 AM.

The agenda will include:

· The DSS report on the quarterly data, HUSKY B /PLUS expenditures, status of the audited MCO Medicaid line of business financial reports, contract amendments.

· MCO and CT AAP response to the Qualidigm EPSDT study.

· Children's Health Council reports on ambulatory care following psychiatric inpatient care.