Medicaid Council Meeting Summary: 

January 21, 2005

Present:  Sen. Edith Prague, Rep. Vickie Nardello, Rep. David McCluskey, David Parrella (DSS), Thomas Deasy (Comptroller Office), Mary Lou Fleissner (DPH), Pat Rehmer (DMHAS), Dr. Victoria Niman (DCF), Robyn Hoffman, Dr. Edward Kamens, Janice Perkins, Linda Pierce (MCO reps), Dr. Alex Geertsma, Ellen Andrews.

Also Present: Hilary Silver, Dr. Mark Schaefer (DSS), William Diamond (ACS), Deb Poerio (SBHC), Mary Alice Lee, Sylvia Kelly (CHNCT), Paula Smyth (Anthem BCFP), David Smith (PONE), Chet Brodnicki (Child Guidance Clinics), Christine Bianchi, M. McCourt (Council staff).

Department of Social Services

HUSKY Program Update

Ø      The DSS is not implementing the dental service carve-out. 

o       A review of the HUSKY dental fees showed that a surprising number of dentists receive reimbursement above the average rates.  This relates to their ability to negotiate higher rates with MCOs that need to maintain their network capacity.  Applying a weighted average to create the carve-out fee schedule would result in lower fees for these dentists and the potential for reduced access.  At this time the DSS has no solutions to this, so dental service delivery will remain as it is.

o       Dental litigation has not been resolved; the request for ‘immediate injunction relief’ has been pending.  Ultimate direction from the Court on Medicaid reimbursement affects the Agency’s flexibility of making program changes.

Ø      The current HUSKY contract extension between DSS & MCOs ends Jan. 31, 2005.  The DSS and MCOs are currently negotiating a contract extension through December 31, 2005.  The Department stated that if DSS has the financial resources, the agency would consider passing dollars on to the MCOs to enhance provider rates.

Ø      The Behavioral Health (BH) restructuring remains the top priority of the agencies (DSS & DCF). 

o       The agencies are targeting a September/October 2005 time frame for the implementation of the BH carve-out. The DSS is looking at MCO capitation rates and relative amounts that would be deducted from the MCO capitation rates.

o       The DSS & DCF have offered Value Options (VOI) the opportunity to negotiate a contract for the BH Administrative Service Organization (ASO).  Part of the negotiation process will be the ASO rate.  The ASO will be responsible for administrative functions while the DSS/DCF will be responsible for provider credentialing, provider reimbursement.

Dr. Mark Schaefer stated the agencies expect to present the provider rate methodology to the Medicaid Council BH Oversight Committee for review in either February or March. The approach is a weighted average of rates/level of care to ensure minimal provider rate change. The BH Oversight Committee can make recommendations on the rate methodology to the agencies and the legislative Committees of Cognizance.  There is a 90-day review period for the entire process from initial BH Committee review to Committee Cognizance review.

Council questions/comments:

Regarding Behavioral Health:

ü      Will the BH Carve-out support Primary Care Provider (PCP) and psychiatry co-management of children with complex mental health needs and psychotropic medications?  Dr Schaefer stated this is an important area ranging from PCP BH screens, identification of BH service needs, referrals to specialty BH services.  It will take time to develop guidelines to assist the PCP in distinguishing those patients that would benefit from PCP management or specialty services.  The agencies have no direct influence on PCP practice rather the MCOs hold the contracts with the providers.  Dr. Geertsma, a pediatrician, noted that in the past pediatric neurology often dealt with some BH disorders but this specialty is less available now.  Behavioral Developmental Pediatricians are now board certified. 

ü      Will the Agencies consider gathering data on the cost of providing BH services in child guidance clinics (CGC)?  Chet Brodnicki stated the CGC have not had rate increase in managed care since 1996.  Their reimbursement is now one-third the cost of hourly sessions.  Dr. Schaefer they are not anticipating doing rate specific studies but are considering looking more closely at this issue over a 2-year period in the future.  The agencies and the Lt. Governor have raised the issue of reimbursing qualified clinics with enhanced clinic rates; if this is not in the budget, it would be considered in the future.

ü      Comment:  Anthem BCFP stated Anthemdoes not “carve-out” BH services, rather controls claims, customer service, provider network and has quality programs that focus on medical and BH needs through case management.  Anthem has expressed concerns to DSS regarding the loss of the holistic view of health for their members through the proposed BH restructuring.  Anthem stated the additional care coordination with the ASO would add to the plan’s administrative costs.

Regarding Dental issues:

ü      Rep. Nardello asked if the DSS has planned another way to address the long- standing dental access problems now that the carve-out, which was to improve access, is not going forward? The DSS does not have a new approach at this time; the outcome of the litigation will affect future plans to improve dental access.

ü      For the record, Rep. Nardello stated there is a fairness issue with the rate variance among providers.  Some providers receiving lower reimbursement rates provide similar services to those provided by practitioners receiving higher rates. Rep. Nardello is very concerned, for this reason and others that the dental carve-out is not going forward.  

ü      Janie Perkins, Health Net asked DSS if they are willing to look at the provider ratios (i.e. 1 dentist/486 members) as this ratio drives provider rates and results in health plan enrollment freezes. The DSS stated they are interested in leveling the rates, not lowering them.  This could be done through ratio adjustments.  Ellen Andrews stated there must be other measures to ‘fix the problem’ without reducing access standards.

ü      Ellen. Andrews commended the DSS for the public process underway in the BH rate methodology review and would encourage a similar public review process for adequately funding health services in HUSKY after BH dollars are deducted from the capitation amounts.  The DSS stated this is a valid point and would speak further with Ms. Andrews regarding this.

MCO Network Capacity Report

MCOs must report to DSS monthly provider enrollment changes.  Provider to client ratios are used to determine plan capacity for five key provider categories based on Medicaid Fee-for-service (FSS): PCPs for adult, children’s PCPs, women health providers, mental health providers and dental providers.  The percentage of member enrollment to provider capacity (in the MCO provider network) measures the adequacy of the MCO provider network in each of the 8 counties.  When a health plan’s enrollment in a county exceeds 90% capacity, DSS sends a warning letter to the plan.  If enrollment remains over 90% capacity the health plan’s enrollment is ‘frozen’ until the plan either has a reduction in member enrollment or increases their provider network to lower the percent capacity below 90%.  Below is a summary of the report.

·        Anthem is at or over 90% in 2 counties, Hartford and Tolland.  Hartford capacity is related primarily to dental capacity. There are fewer dentists in Tolland and of those, few participate in Medicaid.

·        Health Net has exceeded the 90% in Fairfield county, with dental capacity the main problem area.

The DSS stated that there are no similar capacity calculations for other specialty services; however the DSS will be assessing specialty access more closely in the future and developing contract standards.  The DSS did begin to look at neurologist & orthopedists participating in each MCO, noting that out-of-network providers are included in the count.  Overall, there are significantly less neurologists that orthopedists participating in each plan.

Council comments;

§         Anthem stated that their consumer satisfaction surveys show satisfaction with access to PCPs and specialty services.

§         The “safety net providers” have little leeway in determining which plans they participate with; however private providers may choose to limit their participation to one or two plans and often choose HUSKY plans with whom they also have commercial contracts.

§         The DSS noted that the provider capacity is influenced by reimbursement and steadily growing enrollment in public programs.

MCO Performance Improvement Projects (PIPs)

While MCOs have been required to do PIPs for the past several years, federal rules about monitoring them led DSS to establish several PIPS that will be uniform across the four MCOs.  The MCOs have leeway in developing activities to improve outcomes within the PIPs.  There is a federal clearinghouse of PIPS as well as a New England consortium that meets quarterly about managed care quality initiatives. The key purpose of PIPs is to establish best practices, improve health outcomes and control costs.  Several projects are already in process:

ü      Appropriate asthma medication (a HEDIS measure) for members aged 5-54 with persistent asthma, with the goal of increasing the number of members that receive appropriate medication.

ü      Emergency Room use related to asthma diagnosis; the goal is to decrease the number of HUSKY A members that had received prior asthma-related services being seen in the ED.

ü      The MCOs had submitted plans to improve the quality and access of adolescent preventive care in 2004.  The DSS will be following up with the MCOs on the outcomes of the projects.  The initiative has strong potential for expansion to a PIP.

The DSS will also be working with Mercer to:

ü      Analyze service utilization patterns of DCF clients by diagnosis and provider type.

ü      Study the encounter data to identify ICD9 or CPT codes that relate to pediatric obesity and related co-morbidities such as diabetes.

CTVoices: HUSKY A Ambulatory Services for CY 2003 (see report www.ctkidslink.org)

Rates for ambulatory care for children ages 2-19 years continuously enrolled for 12 months in HUSKY A (Jan 1, 2003-Dec 31, 2003):

·        Well care for 6-10YO was down to 41% (CY03) from 43%(FFY02).

·        Well care for HUSKY A members 16-19 was 40% in FFY02 and 39% in CY03.

·        Members in Bridgeport had the highest well care rate (58%) compared to Hartford (47%), New Haven (48%) and all other towns (51%).  Dr. Kames noted Bridgeport has a strong community outreach and suggested further work could be done through the Bridgeport Medical Association.  Ms. Poerio stated that 93% of youth are involved in SBHC in Bridgeport.

·        In CY 03, similar to 2002, 5% (7,542) of children with no ambulatory visits recorded had other types of care (dental, prescriptions, lab tests) suggesting these children had to have had some PCP contact.  However, more than 10% (15,798) had no records of any care in CY 2003.

·        Rep. Nardello asked CTVoices to calculate the MCO capitation rates for this 10% with no recorded care, by age, gender and county and report back to the Council.

Impact of the CT Health Foundation (CHF) Investment in Oral Health

As a follow up to the December meeting discussion on dental utilization in HUSKY A, Mary Alice Lee presented information on preventive dental care service utilization in towns funded by the grant and other towns:

HUSKY Enrollment January 2005

ü      HUSKY enrollment has continued to increase over the past 12 months, averaging 1000-1500 additional members monthly, with the exception of May-July when enrollment decreased by 1681 members over those two months.  In January enrollment increased by 1359 (1070 children and 189 adults) for a total of 307,048 enrollees. HUSKY B has increased more slowly and actually saw a decrease of 138 enrollees to 15,116 from December to January 2005. 

ü      43% of applications received by ACS (new & renewals) were referred to DSS for eligibility determinations.

ü      ACS reported the main reason for HUSKY B denials was incomplete applications (56%).

Legislative Program Review & Investigation Committee:  Recommendations in Medicaid Eligibility Study (see attached summary).

The Program Review Committee (LPRIC) authorized a study in 2004 of 1) the DSS implementation of the Medicaid application and eligibility determination process and 2) the impact of state employee layoffs, early retirements and DSS restructuring on the administration of the Medicaid eligibility determinations.  The Committee had previously provided the Council with details of the study process and now reviewed the recommendations from the study approved by this legislative committee.

Key findings in the four major areas resulted in the Committee adopting 31 recommendations, 10 of which will require legislative action and the remaining 21 administrative recommendations can be accomplished within the DSS agency.  Some of the recommendations address issues discussed in the Council and Subcommittees:

·        Centralized the address change process,

·        Restoration of 14 more positions of the early retirement losses,

·        Apply “expedited eligibility” system to pregnant women with improved outreach, regional staff education, flagging application for timely eligibility determinations, routine analysis of processing times for pregnant women’s eligibility.

·        Re-establish presumptive eligibility for children, streamlining the application process.

·        DSS should issue a RFP for the HUSKY single point of entry and enrollment broker services, develop more detailed contract language for the vendor that includes performance measures.

·        Limit the number of times Medicaid MC clients can change plans to 1 time/6 months unless there is a good cause reason,

·        DSS should begin planning for an EMS system now,

·        De-link the TFA/Medicaid eligibility in the EMS system by 10/1/05,

·        Begin planning for online applications system,

·        DSS central office should take a greater leadership role with district offices including upgrading the phone systems, ensuring service standards are met.

·        The DSS should submit a waiver request to CMS extending the standard of promptness for long-term care applications from 45 days to 90 days.

The Program Review staff and committee will monitor the implementation of recommendations to state agencies, providing a follow up report the following year on an agency’s corrections that have been implemented.

Council Activities

The Council quarterly report was approved without changes.

Dr. Edward Kamens reviewed the Quality Assurance Subcommittee 2004 progress and 2005 focus.  One significant area of discussion is the need for a more uniform data system using the commercial  web-based system technology, with retrospective information that is vital for policy and concurrent practitioner level data that will provide the most impact.  The Department of Social Services will discuss the agency’s data warehouse  plans at a future meeting.