Meeting Summary:  February 18, 2005

Next meeting:  Friday March 11, 2005 @ 9:30 AM in LOB RM 2D

Present:  Sen.Toni Harp, Rep. Vickie Nardello, Rep. David McCluskey, David Parrella & Rose Ciarcia (DSS), Dr. Ardel Wilson (DPH), Robyn Hoffman, Dr. Edward Kamens, Janice Perkins, Linda Pierce (MCO reps), Dr. Alex Geertsma, Ellen Andrews, Jeffrey Walter, Mary Alice Lee, Rev. Bonita Grubbs.

Also Present: Kevin Loveland, Dr. Mark Schaefer (DSS), Margaret Dickinson & Linda Thompson (Mercer), Maria Cerino (ACS), Deb Poerio (SBHC), Sylvia Kelly (CHNCT), Paula Smyth (Anthem BCFP), David Smith (PONE), M. McCourt (Council staff).

Department of Social Services

The Department was asked to review the eligibility process for those HUSKY A parent and caregivers that are set to lose health coverage April 1, 2005 and proposed state and federal budget highlights as they relate to Medicaid.

HUSKY A Adult Parent/caregiver Health Insurance 

Kevin Loveland, DSS Director of Family Services, provided background information on HUSKY A adult coverage and the clients’ renewal eligibility process in light of the legislative Appropriation Committee action to extend coverage to these clients through June 30, 2005. 

·        Two years ago the HUSKY A adult income eligibility limit was reduced from 150% federal poverty level (FPL) to 100% FP; 16,204 adults in the program with income >100%FPL were scheduled to lose HUSKY 4/1/03.  The 2nd Circuit Court ruling resulted in parent/caregivers with earned income remaining insured, now through the transitional (Temporary Medical Assistance - TMA) coverage group rather than the section 1931 SSA provision, for 24 months designated in the CT Medicaid State Plan through March 31,2005.  To date, approximately 12,938 of these clients face termination of their Medicaid coverage on 4/1/05. New adult HUSKY A clients were not included in the court actions; these clients’ income eligibility standard is at or below 100% FPL.

·        The Appropriation’s Committee action (SHB6438) seeks to extend coverage of adults in TMA through June 30, 2005.  Mr. Loveland stated that the timing of the General Assembly’s decision on this extension would influence the DSS actions in notifying and re-determining client eligibility.

·        The statutory HUSKY income eligibility remains at 100% FPL unless the CGA changes this during the 2005 session.

·        If there is no legislative change in TMA deadline, DSS will process the renewals members were requested to send in by February 20, 2005.  The outcomes would be:

The DSS plans to send notices to the 12,938 clients the first week of March.  Legislative action would determine the content of the notices.

Rep. McCluskey asked about the universe of Medicaid clients not involved with the lawsuit and if there are any studies of states tracking what happens to families that lose health coverage and impact on state expenditures (i.e. uncompensated care).  The DSS stated:

·        June 30, 2003 2650 clients lost HUSKY coverage because of no earnings, disqualifying them for TMA.  In addition 5000 children lost coverage when children’s 12-month continuous eligibility was eliminated in statute effective 3/31/03.

·        While there are state studies of TANF population there are no state studies on the future impact of changes in Medicaid medical assistance programs, which would be an important study.  Mr. Parrella noted that Tennessee has dis-enrolled over 300,000 Medicaid clients from TennCare, which may provide data on this population.

Proposed State Budget changes in Medicaid (see attached summary of proposed Medicaid changes)

The DSS described some of the provisions in the proposed state budget that impact HUSKY & Medicaid including:

ü      (Reinstating) co-pays of no more than $3.00 per visit for Medicaid FFS clients (co-pays will not apply to HUSKY A) for physician, outpatient and pharmacy visits. (Projected savings FY06=$7.8M, FY07=$8.3M)

ü      Restructure HUSKY B premium payments: (Savings FY06=$2.2M, FY07=$4.8M)

ü      Premium Assistance for HUSKY has two parts:

o       Pilot hopefully targeting family coverage for clients coming off HUSKY in the court-ordered TMA group.

o       More expansive program through a waiver to require HUSKY A clients to enroll in employer health plans when available.  DSS will subsidize premiums, deductibles, and co-pays and provide wraparound services to ensure clients’ medical coverage is similar to existing Medicaid benefit package. The DSS expects to have the waiver under the SCHIP match of 65% (FY07 projected savings $4.9M).

Proposed Federal Medicaid Funding Changes

The federal proposals do not include systematic Medicaid block granting but rather proposals that target the Medicaid growth rate and escalating spending.  Mr. Parrella noted that Medicaid case load increases, a contributing factor to escalating Medicaid expenditures, are driven by working families with lower incomes that cannot afford employer based insurance growing cost share, hence there has been a national trend in the shift from the private sector insurance to public programs.

The basic principle in Medicaid is shared state/federal responsibility with a match rate that is based on states’ per capita income.  CT’s Medicaid federal match rate (FMAP) is 50% while other states with lower income rates have a 70-80% FMAP.  State budget shortfalls have made it increasingly difficult for states to allot their state share to meet their increasing Medicaid costs.  States have increasingly looked to support their budgeted state funding of Medicaid through maximizing their federal match in areas that the current proposed federal provisions have highlighted as part of Medicaid cost containment.  These include:

Questions on State/federal budget proposals:

·        Would the agency eligibility system changes (such as on-line applications) be under the federal administrative annual cap?

·        Will TCM be included in this administrative allotment?

After a conference call on these issues 2/18/05, the DSS stated they both would be included in such a cap.

·        The new federal poverty level changes, which will be published in the federal register March, will become part of the renewal eligibility processing for the adult TRO group and others that subsequently apply to HUSKY. (The income levels per FPL increase yearly).  For those that are eligible based on the new FPL, there may be some FMAP claim.

·        If the adults slated to lose eligibility 4/1/05 have NOT received a renewal notice from DSS they should call their DSS caseworker to obtain one.  The renewal notices are crucial to their consideration for Medicaid coverage beyond 4/1/05.

·        Regarding the proposed premium assistance (PA) waiver under the SCHIP(FMAP of 65%):

o       DSS noted that about 25% of HUSKY A members report they could obtain health insurance through their employer but cannot afford the cost share. The PA proposal is viewed by DSS as a cost-effective way to provide family coverage.  The Maine premium assistance plan seeks federal match for state subsidies AND the employer dollars; the CMS decision regarding this is pending.

o       In the PA program, Medicaid would be the secondary payer (TPL).  The DSS believes that given the current stress of the adequacy of the Medicaid provider network, this program would allow members to access the commercial provider networks through their employer-based insurance (EBI). Similar to Rhode Island RiteCare, CT Medicaid would create a new provider category for provider Commercial & Medicaid TPL participation.  These providers would not be required to accept HUSKY members not in the PA program.

o       Medicaid wraparound services would be reimbursed at the Medicaid rates, while commercial benefit services would be reimbursed at the negotiated private sector rate.

o       Currently Medicaid TPL exists.  Some Medicaid/HUSKY members have commercial insurance and the HUSKY MCO coordinates the Medicaid wraparound services and payments.

·        Council member stated there needs to be a public planning process for this waiver that includes consumers, practitioners and the Council.

·        The waiver eligibility may have limited impact on consumers; there still is a need to re-establish the adult/caregiver income eligibility levels back to 150%FPL.

Mercer External Quality Review Report: Margaret Dickinson, Linda Thompson

Mercer Government Human Services Consulting (Mercer), the State Medicaid External Quality Review (EQRO) contractor, provided an overview of their review of the four HUSKY A and three HUSKY B managed care organizations (MCOs) quality assessment, performance improvement projects and compliance with the 1997 Balance Budget Act (BBA) for CY 2003.  The desk (MCO document) and onsite reviews were performed June through September 2004. 

Previous HUSKY A & B EQRO reviews were done prior to the June 2002 federal adoption of the BBA requirements and states’ additional one-year adjustment of MCO contracts. (DSS had also received permission from CMS to forego an EQR for one year while the contracting process for an entity was undertaken).  The 2004 ECR results will:

·        Establish the current status of MCO compliance to BBA,

·        Service as a baseline for future reviews,

·        Establish a starting point for MCO Action (correction) Plans for areas of partial or non-compliance and

·        Provide baseline for Performance Improvement Projects (PIP)

The DSS stated that the presentation to the Council was at a ‘higher level’ and could not contain the detail in the full report.  Key compliance areas were reviewed:

ü      Enrollee Rights and Protections contained 66 criteria, of which 44 criteria were met by all MCOs, one  - advanced directives- was not met by the MCOs, 11 criteria were not met by one MCO.  Anthem, CHNCT and HN were identified as having best practices in meeting some of the criteria.

ü      Quality Assessment & Performance Improvement (QAPI) had 101 criteria:

o       All MCOs had 100% compliance in 8 areas (delivery network, timely access, cultural considerations, primary care, privacy protection, provider selection, subcontractual relations and Health IS (systems ability to provide data and information within the QAPI categories).

o        Two criteria were partially or not met by all MCOs that included MCO shared assessment results with other MCOs and Program Improvement Programs.

o       Two MCOs partially or did not meet 3 criteria that related to consistent use of criteria in making authorization decisions, dissemination of practice guidelines to providers & members, mechanisms to assess quality & appropriateness of care for special needs members (this seemed to be the lowest performing area across all MCOs but Anthem).

o       Anthem was noted for best practices in internal integration care management program and comprehensive clinic guideline processes.

ü      Grievance, Appeals & State Administrative hearing that included review of requirement compliance, timeliness of steps in the process and compliance in record keeping and reporting.  The MCO ratings were all above 95% in this area, with Anthem at 100%, HN at 98%, PONE at 97% and CHNCT at 95%.

ü      The Performance Improvement Project (PIP) review results, with 2004 as the baseline year, revealed the expected need for improvement and clarification of PIP design.

Council members recognized the extensive work in this report, however requested:

·        An assessment of how CT MCOs performance in relation to other state Medicaid programs that Mercer does the EQR review.

·        Comparisons of performance among the MCOs, identifying disparities and best practices and recommendations for each MCO based on the review.

·        How will DSS use this information?  Rose Ciarcia stated the MCOs will develop correction plans that will monitored over the next year through a more focused report now that the baseline report is complete.  The DSS expects to focus on individual plan deficiencies over the next two years.

The Department will have Mercer return to provide more detail of the report at future meetings.

HUSKY Data Reports

·        Preventive (EPSDT) Screen ratio: The overall average of EPSDT screen, which represent the number of screen performed as a percent of the number that should have been done based on the number of children enrolled, is approaching 80%. 

·        EPSDT Participation ratio:  this overall ratio, which represent the number of children who received at least one EPSDT visit compared to the number who should have been screened, is about 60%, with the highest rate for under one year olds and lowest (<40%) for youth aged 15 years and older.

·        Preventive dental care: while there is an increase from the 2^nd half 03 to the 1^st half 04, the pattern persists of about 1/4 of the children receiving this service in a 6 month period.

·        Any dental service: approximately 1/3 of children receive any service in the 6-month period.

Senator Harp noted that the improvement in EPSDT reports is encouraging but HUSKY dental care remains sub-optimal at best.  The DSS noted that the plans for the dental carve-out have halted, and there is no magical resolution to inadequate dental access.  Some FQHC’s are contracting with dental practices as one approach to broadening access; the FQHC provides scheduling and billing services for those practices.  The DSS dental advisory committee will continue to meet even though the dental restructuring will not occur.  Sen. Harp requested a report from this committee to the Council.

HUSKY Enrollment

HUSKY A enrollment is at the highest level in the program - 307, 586 enrollees and HUSKY B has 15,423 members.

Incomplete applications/renewals account for 39% of the HUSKY B denials (56% in 1/05), 18% had employer- sponsored insurance and 28% were already receiving HUSKY A.  The HUSKY B denial notice tells these families their children are already in HUSKY A.

Update on Behavioral Health Committee and BH Budget

Jeff Walter reviewed the 4 Committee work groups, three of which have the immediate task to review the coordination and quality of care proposals for the DSS/DCF/ASO contract and the transitional work group will convene in April to review, make recommendations on the change in the BH delivery system.

Mark Schaefer, Ph.D (DSS) outlined:

·         BH funding will be discussed further at the March 9 Committee meeting.  The proposed budget includes an additional $9.8M for administrative and service growth costs.  The BH carve-out service dollars will be taken from the MCO PMPM capitation rates, except for administrative dollars that allow for fixed costs, coordination with the ASO and coordination of BH and medical services.  The agencies recognize the important of transparency in the process, and validation of the carve-out dollars.

·         DSS & DCF expect to complete the ASO contract with ValueOptions in about 6 weeks.

·         The Waiver amendment process for the BH carve-out includes published plans in March followed by public comment, review of the waiver by the legislative Committees of Cognizance to approve, deny or make changes in the waiver prior to submission to CMS.  The BH Committee will make recommendations regarding the budget, ASO contract issues to the Committees of Cognizance, as the Committee deems necessary.

Sen. Harp suggested the DSS should look at the Medicaid budget proposal to determine if the BH Carve-out could potentially destabilize the program.

The Medicaid Managed Care Council will meet March 11, 2005 @ 9:30 AM in LOB RM 2D.