Connecticut Medicaid Managed Care Council Legislative Office Building Room 3000

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: January 16, 2004

Present: Sen. Toni Harp (Chair), Rep. Vickie Nardello, Rep. David McCluskey, David Parrella, Rose Ciarcia (DSS), Dr. Ardell Wilson (DPH), Ellen Andrews, Dr. Leonard Banco, Dr. Wilfred Reguero, Dr. Edward Kamens, Jeffrey Walter, Janice Perkins, Henry Goldstein, Dr. Alex Geertsma, Dorothy Allen.

Also present: Maria Cerino (ACS), Mark Scapellati (CHNCT), Paula Smyth (Anthem BCFP), Douglas Hayward (Preferred One), Deb Poeria (SBHC), Jody Rowell (Child Guidance Clinics), MA Lee for Judith Solomon.

Department of Social Services

HUSKY Program Update

· The notice for the release of the RFP for the contract for the external quality review organization (EQRO) has been published in the newspaper. Decisions will be made by the end of March. (CMS allowed the State a year to re-contract for the EQRO. There was no EQRO oversight for the HUSKY program during this time).

· The Dental Administrative Organization (ASO) evaluation committee will meet February 5 to begin scoring the bids submitted for the dental ASO contract.

· Three of the HUSKY plans (CHNCT, Health Net, FirstChoice/Preferred One) have signed a contract extension through September 30, 2004. Anthem BCFP signed the contract through June 30, 2004.

· The legislature, three State agencies and OPM continue to discuss the Behavioral Health Partnership. (Meetings are now scheduled for Jan 30 (issues -UM, QA, evidenced-based practices), Feb 10 (Mercer Report) and Feb 26 (issues- rates/reimbursements), all meetings are at 2 PM in LOB RM 1D).

· BH Pharmacy issues were discussed with the BH work group and Sen. Harp on Jan 12. Short-term initiatives were identified to relieve some of the administrative burdens (i.e. standardizing the Prior Authorization forms, creating a “quick-look” reference for BH prior authorization drugs that are on/off formulary). The DSS stated the agency is considering moving to a single formulary for the HUSKY program by October 1, 2004.

The Department was asked to comment on the status of the legislative changes (PA 03-3, Sec 43) to the State Assistance (SAGA) program, which capped the funding for this state-based program but retained service entitlement. Medical services will be provided through hospitals, Federally Qualified Health Centers (FQHCs) or other primary care provider specified by the DSS Commissioner. The current status of the service components was reviewed.

· The hospital inpatient/outpatient program funding has been established at $46.5 M/year, compared to FY04 cost estimates of $59.6M. DSS policy for hospitals, effective January 1, 2004 can be found at: www.ctmedicalprogram.com/bulletin/pb03_124.pdf. . Aggregate monthly allotments to hospitals total $3.875M; the DSS will adjust payments to ensure the aggregate payment is within the cap. There is also a process that ensures that payments for retroactively eligible recipients are not claimed against the annual SAGA hospital medical appropriation.

· The development of the community component is in progress. The DSS is talking with CHNCT about the provision of a managed care model for the SAGA program. The community service details are not complete, however the capped funding will result in reductions in FQHC and pharmacy reimbursements along with hospital-based services.

Ø Will the distressed hospital funding increase offset some of the losses from the capped SAGA funding? Most hospitals that provide SAGA services meet the distressed hospital definition. Mr. Parrella stated that while the DSS can apply appropriations to increase that part of the Disproportionate Share Hospital (DSH) pool to hospitals in communities with large uninsured populations, this would not offset the full impact of SAGA capped funding. Reimbursement changes require a Medicaid State plan amendment that must be approved by the Centers for Medicare & Medicaid Services (CMS) before implementation. There will be a lag time in applying this legislative mandate and at least 3-4 months to see the impact of the DSH increase on hospital SAGA losses.

Ø Legislation requires DSS to include the SAGA program into an 1115 HIFA waiver: would this add dollars for hospital services? The DSS stated there is no promise of additional dollars, however the State would receive a federal match for Medicaid services that are now provided in a state-only program. Under an 1115 waiver, the SAGA program would be restored to a Medicaid-like program (which would preclude funding or enrollment caps).

Ø The congressional Medicare bill included a mandate to include $250M in each FFY going forward from FFY 05-08 to provide states with a percentage of the money ($167M) based on the 2000 decennial census. In addition to these allotments, $83M would be given to each of the 6 states with the highest number of undocumented alien apprehensions for each FFY. These dollars are expected to be included in the FFY 05 budget, not yet released. The provisions can be found on www.thomas.loc.gov, PA 108-173, Title X, subtitle B, federal reimbursement of undocumented aliens (information provided by OFA after the Council meeting).

Ø Can FQHCs receive DSH dollars, as these clinics are in underserved areas, provide care to the uninsured and cannot turn anyone away that seeks health services? While FQHCs receive cost-based reimbursement, this does not cover 100% of uninsured costs. The Social Security Act provided DSH payments only for hospitals. The 2003 CT legislation limited the SAGA dollars for hospitals and community care; the DSS does not have another funding pool to add dollars to community services.

Ø The DSS agreed to provide the Council with a list of pending/implemented Medicaid State Plan amendments.

The Council had requested the DSS provide information on the new MCO rates for the contract extension, including the dollar differences in the rate cells for SFY 03-04. The DSS presented this information, noting that the Medicaid Managed Care Regulations, effective 8/13/03 require rates to be certified as being actuarially sound. The Upper Payment Limits, based on a state’s FFS rates, no longer determine the rate range. William Mercer, Inc did the analysis and certification of the rates. Mercer considered the following factors in the analysis:

· Legislative program changes that included elimination of optional services, pharmacy and outpatient co-payments. A yearly base deduction was calculated, taking into consideration the amount paid and utilization changes.

Mercer developed a rage of rates that were approved by CMS as actuarially sound:

The DSS then presented the MCOs with a dollar amount within this range that was eventually agreed upon by the MCO after negotiation. The rate cells are based on age, sex and county. Aggregate statewide rates, which were increased by 4%, are shown below:

HUSKY rates are assigned by age and county rather than risk-adjusted for special populations. The rank order of counties from highest county rate to lowest are: Tolland, Middlesex, Litchfield, Hartford, New London, New Haven, Windham and Fairfield. The Windham county rate of $169.97 is $1.01 less than the average statewide rate, whereas Fairfield County rate of $158.19 is $12.79 less.

Ø The county rate system may not be appropriate for CT, as members may actually use services in other counties (i.e. special care in Hartford, New Haven areas); however the rates are based on where the enrolled member lives, not based on services. Risk adjusted Medicaid rates are becoming more common in other states. The DSS noted that the council and the legislature may consider Medicaid risk adjusted rates for FY 05-06, with recommendations to DSS, which makes the rate configuration decisions. However, any risk adjustment would greatly change the individual MCO rates, depending upon their percentage of the risk-adjusted populations.

Ø MCO rates have been increased yearly since 1996; however there does not seem to be any provisions to ensure that practitioner rates increase commensurate with the MCO rate increases. The DSS stated that the MCO and practitioner determine provider rates in contracts; the DSS does not set provider rates in Medicaid Managed Care. The DSS does monitor access issues, based on their contract provisions with the DSS and MCOs (i.e. MCO network provider capacity reports).

Ø The cell rate increase for ages 1-14 is $4.37, which may explain the lack of MCO financial incentives to expand mental health services.

Ø Sen. Harp asked if CMS is looking to cap the dollars in Sec.1115 waiver renewals or new waivers? Mr. Parrella noted that in the Missouri experience of expanded Medicaid eligibility, largely financed through provider taxes and state expenditures and federal match, CMS imposed a cap on the 1115 waiver. Missouri owed back federal match dollars of $1.5 B. The CMS is closely scrutinizing states’ basis for federal match dollars. Connecticut chose not to put the ConnPace program under an 1115 waiver because CMS required that the state cap the Medicaid program expenditures, which included nursing facility expenditures.

HUSKY A Utilization Reports

· EPSDT screening and participation ratio for 2^nd half 02 and 1^st half 03, dental services 2^nd half 02, 1^st half 03 (reports are now on a semi-annual cycle rather than quarterly):

ü The percentage of children with any dental service has increased in 02/03, compared to the mean percentage in 00/01 that ranged at 20% and under.

ü EPSDT screen rates have increased compared to the 2001 first 6 months, but lower than the 2002 rates; participation rates are lower than 2002, comparable to 2001 first 6 months. The DSS was asked to present EPSDT ratio by age over time in the HUSKY program to better understand if preventive care utilization trends have changed over time.

· Antidepressant Medication management report includes children newly diagnosed with depression and prescribed antidepressants and timely follow-up with 3 or more visits within 12 weeks, and medication for at least 6 months. Of the 318 children with newly diagnosed depression and medication, 42% (132) had 3 or more follow-up visits within 12 weeks of DX, TX; 29% (91) received 180 days treatment with medication. The DSS was asked to provide follow-up data to the BH subcommittee that identifies the level of the provider and role (i.e. Primary care provider, MH provider).

· Pharmacy Report (see attached report from DSS) provides MCO quarterly information on the number of prescriptions/MCO, number and percentage of prior authorization (PA) requests, temporary drug supplies provided and top ten denied drugs.

o What would be the basis for not providing temporary drug supplies? The DSS stated that for the PA requests, the pharmacy may contact the practitioner for approval to use a formulary drug and/or the scrip is not deemed urgent by the prescriber and the PA process can be followed without the temporary supply. Also, members may leave the prescription at the pharmacy and wait for notification from their pharmacy that the script is filled.

o According to DSS, the average time for the completion of the PA process is approximately 4 days.

o PA drugs that are initially denied, in many cases, end up with the denial overturned. The MCOs may want to look at this trend per most frequently denied drugs. The BH Subcommittee work group will be looking at this issue for psychotropic drugs.

o In the clinical world, some patients do have delays in receiving prescribed drugs and do not receive a temporary supply of the drug. The DSS stated that the MCOs are working with their Pharmacy Benefit managers to educate the local pharmacies.

o The summary of the $1.00 pharmacy co-pay report for May through September 2003 shows that of average of the total co-pays, there is a 48% co-pay compared to 52% that are exempt under federal rules.

HUSKY Enrollment

The call center has received more calls probably due to questions related to the DSS letter about the HUSKY B premium changes sent out in December. Overview of enrollment:

· During the past 7 months Husky A total enrollment numbers have returned to the peak May 2003 level.

· The adult enrollment is increasing (89,351) near the peak May numbers of 90,433.

· In January 2004, the child enrollment (209,705) exceeded the May 2003 enrollment (208,624).

· HUSKY B enrollment peaked to 15,242 in October 03, followed by monthly reductions. In January, there are 14,237 children enrolled in HUSKY B (SCHIP). Since October more HUSKY B applications are being referred to DSS for HUSKY A eligibility consideration.

The Council had previously requested the DSS provide information on the disposition of the 7500 children that were dis-enrolled during June/July 0f 2003 for the February meeting.

Other

Anthem HUSKY A Pharmacy Report	4/1/03 – 6/30/03	% of Total Rx filled	7/1/03 – 9/30/03	% of Total Rx filled
Total # Member Months	365,219		364,547
Total # Prescriptions Filled	190,052		180,456
Number of Prescriptions filled PMPM	0.52		0.50
Total # Prior Authorization (PA) Requests (Routine Review and Temporary Supplies Issued)	6,472	3.41%	5,792	3.21%

* Total # Requests with Temporary Supplies	2,597	1.37%	2,419	1.34%
Provider Urgent Requests Confirmed	1,148		1,050
Provider Unavailable for Confirmation	1,449		1,369

Total # Prior Authorization (PA) Requests

Approved	5,623		5,196
Denied (follow-up action includes revising Rx)	849	0.45%	596	0.33%

* Temporary Supplies does not include “One - Time” fills.

CHN HUSKY A Pharmacy Report	4/1/03 – 6/30/03	% of Total Rx filled	7/1/03 – 9/30/03	% of Total Rx filled
Total # Member Months	161,960		158,967
Total # Prescriptions Filled	86,166		79,594
Number of Prescriptions filled PMPM	0.53		0.50
Total # Prior Authorization (PA) Requests (Routine Review and Temporary Supplies Issued)	1,298	1.51%	976	1.23%

* ** Total # Requests with Temporary Supplies	1,259	1.46%	964	1.21
Provider Urgent Requests Confirmed	12		17
Provider Unavailable for Confirmation	1,247		947

Total # Prior Authorization (PA) Requests

Approved	42		62
Denied (follow-up action includes revising Rx)	1,230	1.43%	906	1.14

* Temporary Supplies does not include “One - Time” fills.

** CHN Policy: Except for a small number of drugs that require PA, all PA requests receive a Temporary Supply.

Health Net HUSKY A Pharmacy Report	4/1/03 – 6/30/03	% of Total Rx filled	7/1/03 – 9/30/03	% of Total Rx filled
Total # Member Months	325,896		304,465
Total # Prescriptions Filled	191,339		165,164
Number of Prescriptions filled PMPM	0.59		0.54
Total # Prior Authorization (PA) Requests (Routine Review and Temporary Supplies Issued)	4,716	2.46%	3,528	2.14%

* Total # Requests with Temporary Supplies	1,710	0.89%	916	0.82%
Provider Urgent Requests Confirmed	1,488		893
Provider Unavailable for Confirmation	222		23

Total # Prior Authorization (PA) Requests

Approved	3,818		2,176
Denied (follow-up action includes revising Rx)	785	0.41%	1,352	0.82%

* Temporary Supplies does not include “One - Time” fills.

Preferred One HUSKY A Pharmacy Report *	4/1/03 – 6/30/03	7/1/03 – 9/30/03
Total # Member Months	52,156	60,260
Total # Prescriptions Filled	19,402	27,341
Number of Prescriptions filled PMPM	0.37	0.45

* Preferred One does not use a formulary.

Summary

	4/1/03 – 6/30/03					7/1/03 – 9/30/03
	# Member Months	Rx Filled	Filled Rx PMPM	PA Denied	% Denied	# Member Months	Rx Filled	Filled Rx PMPM	PA Denied	% Denied
Anthem	365,219	190,052	.52	849	0.45%	364,547	180,456	.50	596	0.33%
CHN	161,960	86,166	.53	1,230	1.43%	158,967	79,594	.50	906	1.14%
Health Net	325,896	191,339	.59	785	0.41%	304,465	165164	.54	1,352	0.82%
Total	853,075	467,557		2,864		827,979	425,214		2,854
Average			0.54		0.613%			0.51		0.671%

Top Ten Denied Drugs

Anthem September 30, 2003 - Third Quarter

Authorization Reviews Completed This Quarter Reason for Denial

	Brand Name of Drug	Therapeutic Class	Total	Approved	Denied	Percent Approved	Percent Denied	Temp. Supply	Step Therapy Criteria Not Met	Quantity Limits Exceeded	Equally Effective Alternative on Formulary
1	Zyrtec	AH - NS	400	292	108	73.00%	27.00%	50			108
2	Ortho Evra	CC-TD	148	54	94	36.49%	63.51%	27			94
3	Lexapro	SSRI	162	86	76	53.09%	46.91%	42			76
4	Ambien	NB - GRM	83	21	62	25.30%	74.70%	20			62
5	Elidel	MI - T	134	75	59	55.97%	44.03%	46			59
6	Patanol	OA	66	24	42	36.36%	63.64%	22		39	3
7	Advair Diskus	AC	140	102	38	72.86%	27.14%	20		38
8	Bactroban	AB - T	154	117	37	75.97%	24.03%	49	37
9	Prevacid	PPI	78	41	37	52.56%	47.44%	22			37
10	Macrobid	U - AI	61	24	37	39.34%	60.66%	9			37

Top Ten Denied Drugs

Anthem June 30, 03 – Second Quarter

Authorization Reviews Completed This Quarter Reason for Denial

	Brand Name of Drug	Therapeutic Class	Total	Approved	Denied	Percent Approved	Percent Denied	Temp. Supply	Quantity Limits Exceeded	Equally Effective Alternative on Formulary
1	Zyrtec	AH - NS	789	537	252	68.06%	31.94%	114		252
2	Patanol	CC-TD	218	56	162	25.69%	74.31%	54	141	21
3	Ortho Evra	SSRI	147	52	95	35.37%	64.63%	24		95
4	Clarinex	NB - GRM	171	96	75	56.14%	43.86%	24		75
5	Elidel	MI - T	156	88	68	56.41%	43.59%	47		68
6	Allegra	OA	231	168	63	72.73%	27.27%	27		63
7	Lexapro	AC	111	51	60	45.95%	54.05%	23		60
8	Ambien	AB - T	70	18	52	25.71%	74.29%	25		52
9	Paxil CR	PPI	76	32	44	42.11%	57.89%	16		44
10	Allegra-D	U - AI	100	65	35	65.00%	35.00%	26		35

Anthem Therapeutic Class Code

Antihistamines - Non-Sedating AH – NS Adrenergic Combinations AC

Combination Contraceptives – Transdermal CC-TD Antibiotics – Topical AB -T

Selective Serotonin Reuptake Inhibitors (Ssris SSRI Proton Pump Inhibitors PPI

Non-Benzodiazepine - Gaba-Receptor Modulators NB – GRM Urinary Anti-Infectives U - AI

Macrolide Immunosuppressants – Topical MI – T Decongestant & Antihistamine DC - AH

Ophthalmic Antiallergic OA

Top Ten Denied Drugs

CHN – September 30, 2003 - Third Quarter

Authorization Reviews Completed This Quarter Reason for Denial

	Brand Name of Drug	Therapeutic Class	Total	Approved	Denied	Percent Approved	Percent Denied	Temp. Supply	Equally Effective Alternative Formulary
1	Prevacid Cap 30 Mg	PPI	156	146	10	93.59%	6.41%	146	146
2	Patanol Sol 0.1% Op	OA	136	133	3	97.79%	2.21%	133	133
3	Elocon Cream 0.1%	TD	113	104	9	92.04%	7.96%	104	104
4	Protonix Tab 40mg	PPI	88	79	9	89.77%	10.23%	79	79
5	Ultracet Tab 37.5-325	NN - A	79	71	8	89.87%	10.13%	71	71
6	Bextra Tab 20 Mg	C2 - I	58	51	7	87.93%	12.07%	51	51
7	Strattera Cap 40	PT	50	30	20	60.00%	40.00%	30	30
8	Strattera Cap 25	PT	30	22	8	73.33%	26.67%	22	22
9	Aldara Cream 0.5%	TD	25	21	4	84.00%	16.00%	21	21
10	Percocet Tab 5-325mg	NA	26	21	5	80.77%	19.23%	21	21

Top Ten Denied Drugs

CHN –June 30, 2003– Second Quarter

Authorization Reviews Completed This Quarter Reason for Denial

	Brand Name of Drug	Therapeutic Class	Total	Approved	Denied	Percent Approved	Percent Denied	Temp. Supply	Equally Effective Alternative Formulary
1	Patanol Sol 0.1% Op	OA	307	290	17	94.46%	5.54%	290	307
2	Prevacid Cap 30mg Dr	PPI	169	147	22	86.98%	13.02%	147	169
3	Elidel Cream 1%	TD	147	131	16	89.12%	10.88%	131	147
4	Protonix Tab 40mg	PPI	126	100	26	79.37%	20.63%	100	126
5	Ultracet Tab 37.5-325	NN - A	92	84	8	91.30%	8.70%	84	92
6	Elocon Cream 0.1%	TD	91	76	15	83.52%	16.48%	76	91
7	Skelaxin Tab 400mg	AS	67	61	6	91.04%	8.96%	61	67
8	Prevacid Cap 15mg Dr	PPI	52	44	8	84.62%	15.38%	44	52
9	Bextra Tab 20mg	C2 - I	48	41	7	85.42%	14.58%	41	48
10	Strattera Cap 40mg	PT	44	37	7	84.09%	15.91%	37	44

CHN Therapeutic Class Code

Proton Pump Inhibitor PPI Psychiatric Tx PT

Opthalmic Anti Allergen OA Topical Derm TD

Topical Derm TD Narcotic Analgesic NA

Non-Narcotic Analgesic NN – A Antispasmodic AS

Cox 2 Inhibitor C2 – I

Top Ten Denied Drugs

HN –June 30, 2003– Second Quarter

Authorization Reviews Completed This Quarter Reason for Denial

	Brand Name of Drug	Therapeutic Class	Total	Approved	Denied	Percent Approved	Percent Denied	Temp. Supply	Inappropriate Diagnosis	Lack of Info.
1	Clarinex 5mg Tablet	AH	143	81	62	56.64%	43.36%	1	21	13
2	Zyrtec 10mg Tablet	AH	150	95	55	63.33%	36.67%	1	11	14
3	Ambien 10mg Tablet	SH - NB	62	22	40	35.48%	64.52%	2	12	4
4	Singulair 10mg Tablet	LRA	92	54	38	58.70%	41.30%	1	16	5
5	Singulair 5mg Tablet Chew	LRA	101	64	37	63.37%	36.63%	0

Age	SFY 03 statewide rates	SFY 04 Statewide rates	Statewide Dollar Difference
< 1 year	$593.18	$616.91	$23.73
1-14 years	109.33	113.70	4.37
15-39 Male	137.21	142.70	5.49
15-39 Female	227.91	237.03	9.12
40 plus years Male	249.67	259.66	9.99
40 plus years Female	239.69	249.28	9.59
TOTAL	170.98	177.82	6.84 (4% increase)

Service across all plans	1^st Half 03	1^st Half 02	2^nd Half 02	1^st Half 01
EPSDT Screens	68%	72%	78%	65%
EPSDT Participation	56%	60%	64%	58%
Preventive Dental 3-20 years	23%	22%	22%	?
Any Dental age 3-20	32%	NA in 3/03 report	30%	18.9%

Meeting Summary: January 16, 2004

Department of Social Services

HUSKY Program Update

HUSKY A Utilization Reports

HUSKY Enrollment

Other

Anthem

HUSKY A Pharmacy Report

Total # Member Months

CHN

HUSKY A Pharmacy Report

Total # Member Months

Health Net

HUSKY A Pharmacy Report

Total # Member Months

Preferred One

HUSKY A Pharmacy Report *

Total # Member Months

Anthem September 30, 2003 - Third Quarter

Anthem June 30, 03 – Second Quarter

Zyrtec