Meeting Summary:  March 11, 2005

Next meeting: Friday April 8, 9:30 AM in LOB RM 1D)

Present:  Sen. Toni Harp (Chair), Rep. Vickie Nardello, Rep. David McCluskey, David Parrella & Rose Ciarcia (DSS), Julie Konopka for Dr. Ardel Wilson (DPH), Thomas Deasy (Comptroller’s Office), Dr. Victoria Niman (DCF), Barbara Park wolf (OPM), Dr. Edward Kamens, Janice Perkins, Linda Pierce (MCO reps), Dr. Alex Geertsma, Ellen Andrews, Jeffrey Walter, Mary Alice Lee, Rev. Bonita Grubbs.

Also Present: Dr. Mark Schaefer (DSS), William Diamond (ACS), Deb Poerio (SBHC), Sylvia Kelly (CHNCT), Paula Smyth (Anthem BCFP), David Smith (PONE), Chet Brodnicki (Child Guidance Clinics), Marybeth Bonadies & Michael Sabados (Office Health Care Access),

M. McCourt (Council staff).

Office of Health Care Access (OHCA):  2004 Household & Employer Insurance Survey

Michael Sabados and MaryBeth Bonadies provided the report on the OHCA 2004 Household & Small Employer Survey of Health Insurance Coverage (see attached presentation).  Approximately 10% of CT population was uninsured at some point during the past year.  Among the uninsured, 58% were working adults; 60% of these adults worked for employers who did not offer employer sponsored insurance (ESI).  Families with lower income (<185%) were more likely to be uninsured and Hispanics had the highest rate of uninsured (21%). A percentage of the uninsured that required emergency care did not get care (11.3%), 20.6% did not chose to obtain non-emergent care and 18.5% did not fill prescriptions.

Small businesses are the majority of CT employers.  A majority (52%) of firms (2-300 employees) offer employee and dependent coverage health benefits, while 9% covered employees only. Of the 39% of employers that did not offer coverage, affordability was a key factor (34%) and 33% reported employees did not need coverage.  The smallest firms with 10 or fewer employees represented half of the uninsured population.  Construction, wholesale and manufacturing firms were more likely to offer health insurance (68%) compared to agriculture, retail and service firms.

The OHCA plans to:

ü      Survey working parents of HUSKY children paired with non-HUSKY working adults regarding coverage, willingness to participate in coverage options.

ü      Survey top employers of HUSKY parents paired with a sample of employers in similar economic sectors regarding interest in a premium assistance program.

Two suggestions from the Council were 1) consider cell phone numbers in future phone surveys.  OHCA stated that UCONN (does the phone survey) has evaluated this, finding that cell phones are not primary numbers. 2) Sen. Harp suggested continued collaboration with the Office of the Comptroller in purchasing initiatives.

Office of Health Care Access: 2004 Household & Small Employer Surveys of Health Insurance Coverage

Effects of Uninsurance

Individual

Ø  Delayed Care – Poorer Health Outcomes

Ø  Out of pocket health costs

Health Care Providers

Ø  Overcrowded Hospital Emergency Departments

Ø  “Difficult Choices”

Society

Ø  Higher health care costs

Ø  Overcrowded public health facilities

Results from the 2004 Household Survey

Most Connecticut residents have health insurance coverage

Two-thirds have health, prescription, and dental insurance

Connecticut’s Health Insurance System

Who are Connecticut’s uninsured?

Why are workers uninsured?

 
Lower family incomes - more likely uninsured

Hispanics with a high rate of uninsured – 21%

 
Uninsured face barriers to accessing health care services

OHCA’s 2004 Small Employer Survey

Why Target Small Businesses?

Ø Small firms are majority of CT employers

Ø Smallest firms (10 or fewer employees) employee half of the uninsured

Majority of Connecticut firms (2 – 300 employees) offer health benefits

 Average firm and employee shares
of least expensive monthly premiums

Certain types of firms more likely to offer health insurance coverage

 Next Steps

•      Survey of working parents of HUSKY children

vPaired sample of demographically similar working adults

•      Survey of top employers of HUSKY parents

vPaired sample of employers in similar economic sectors

Department of Social Services

DSS Presentation to the Medicaid Council 3/11/05 meeting

Overview: Third Party Liability (TPL) in Medicaid

TPL in Medicaid

•       Approximately 20,000 HUSKY A recipients have TPL through:

•      The non-custodial parent, or

•      Employer

•       The other insurance acts as the primary payer

•       Medicaid becomes payer of last resort

How TPL works today:

n     Claim is first submitted to other insurance

n     Claim is submitted to Medicaid after it is paid/denied by other insurance,

u  To EDS for FFS

u  To MCO for HUSKY A

n     Balance is processed and paid up to the Medicaid rate

n     Services not covered by other insurance can be billed directly to EDS and MCO

TPL Challenges

n     Coordination of Benefits

n     Providers balance billing Medicaid patients

TPL Benefits

n     For many services, private insurance usually reimburses more than Medicaid

n     Greater provider availability for clients  

Premium Assistance

What is Premium Assistance?

n     A health insurance coverage strategy

n     A subsidy to eligible populations as incentive to purchase family coverage through employer.

n     Also known as

u  Health Insurance Premium Payment (HIPP)

u  Premium support

Why implement Premium Assistance?

n     Because the majority of the uninsured are in working families

n     Promotes self sufficiency/attachment to workforce

n     To strengthen the private insurance market- maintain the expectation that employers provide coverage to workers and their families

n     May help small employers to reach or maintain minimum participation rates that are required for employer health plans

n     To encourage and support work and work-based coverage

n     To take advantage of the employer contribution toward the cost of the employees’ health insurance

n      “Stretches: Medicaid dollars and provides a mechanism to cover more people (i.e. the entire family vs. just the children)

n     Provide access to more expansive panel/network of providers.

u  Employees and their families will have access to other health care providers thereby reducing the pressure on the Medicaid provider networks.

n     Encourage preventive and primary care by having the whole family in the same health plan.

Who has a Premium Assistance program?

n     Sixteen (16) states currently have some form of Premium Assistance Program in place, including:

u  Rhode Island

u  Massachusetts

u  Pennsylvania

n     Several states are at a various points in planning a Premium Assistance Program

Features of Other State’s Programs

n     Choice of either state coverage or employer sponsored insurance (no wrap).

n     Mandate client take the employer sponsored insurance if determined to be cost effective (provide wrap).

n     Choice of either state coverage or employer sponsored insurance even if employer insurance is cost effective (provide wrap).

n     States vary in who is eligible for coverage  with regard to income level and age

Benefit Requirements

Premium Assistance Strategy for Connecticut

§       Implement a premium assistance strategy for HUSKY A families for whom it is cost effective:

§     Subsidize employee premium share

§     Provide wrap for Medicaid eligible children

§     Provide wrap for Medicaid eligible adults

§     Making HUSKY eligibility a qualifying event for enrolling in employer sponsored insurance

§       Additional Options:

§     Extend coverage to low income workers not currently eligible for Medicaid through a pilot subsidy program

§     Extend to HUSKY B population

§     Small employer pilot to encourage small employers to provide health insurance

HUSKY A   - Preliminary Analysis/Projections

n     26% of AU’s have access to employer sponsored insurance (approximately 86,000 HUSKY A eligible individuals) 

n     2007 Projected average monthly employee contribution towards family coverage = $221.00

n     2007 Projected average monthly HUSKY A capitation = $201 PMPM x 2.6 (average AU size) = $522.60

n     Cost savings can be achieved within the $301 difference

Program Update

The Governor signed SHB 6423 (PA No 05-1) that extends medical assistance to HUSKY adults who would become ineligible for such assistance 3/31/05, continuing coverage through June 30, 2005.  These adults would lose coverage July 1, 2005 if no further action were taken.  The DSS regional offices have been instructed to continue coverage for these clients.  No discontinuance notices had been sent to clients in March 2005.

Medicaid Third Party Liability (TPL) and overview of Premium Assistance (see attached copy of meeting handout).

The Department reviewed the current TPL process, in which the Medicaid client’s other insurance is the primary payer and Medicaid becomes the payer of last resort.  Approximately 20,000 HUSKY A recipients have TPL through their employer or non-custodial parent insurance coverage. Medicaid fee-for-service claims are paid through the DSS EDS system while the HUSKY A claims are paid through the HUSKY MCO.  The balance of a claim is processed and paid up to the Medicaid rate; however services not covered by the other insurance can be billed directly to EDS and MCOs.

The Medicaid TPL  presents challenges in coordinating benefits between the two payers and for providers billing the balance for Medicaid patients.  The benefits of TPL include higher private insurance provider reimbursement and a broader provider network available to clients through the private insurance network.

Premium Assistance

The DSS provided information on CT’s Premium Assistance (PA) strategy, a health insurance coverage approach that provides 1) a subsidy for employee premium shares to eligible HUSKY A families and 2) Medicaid wrap-around services for Medicaid eligible children and adults that are not in the employer health benefit plan but are part of the federal regulations for Medicaid clients.

Sixteen states including Rhode Island, Massachusetts and Pennsylvania currently have some form of Premium Assistance programs.  The Governor’s budget includes a Premium Assistance pilot for 3600 clients.  Additional options could extend the strategy to the HUSKY B population and develop a “small employer” pilot to create incentives to offer ESI.

Approximately 26% of the HUSKY A eligibles (86,000 individuals) have access to employer sponsored insurance.  The DSS presented preliminary analysis of cost savings in Premium Assistance, using the assumption that 2007 projected average monthly HUSKY A capitation is $522.60 for a family of 2.6, the projected average monthly employee contribution is $221, resulting in projected cost savings within the $301 difference.

Council Questions/comments

·        Under the current Medicaid TPL process, are there administrative costs coordinating the two payers versus straight HUSKY administrative costs? The DSS noted there are costs for TPL through a DSS contract with a firm to manage TPL and MCO administrative costs; however the DSS noted that TPL administrative cost is part of all insurance, including the private sector.

·        The CT Health Policy analyses of the PA/HUSKY A break- even costs differ from DSS analysis. The DSS stated they would be willing to review their numbers with others, taking into consideration that the DSS numbers are preliminary.

·        Has the DSS considered other options such as a HUSKY buy-in besides the Premium Assistance plan?  The DSS responded that there are concerns about a HUSKY buy-in, specifically involving adverse selection and creating (unintended) competition between public and private programs.  The DSS is authorized to do a pilot; however the DSS is willing to work with others on other options.  Since this (PA) is complicated, the DSS suggested a policy steering committee composed of consumers and advocates, business, health practitioners and managed care organizations that would provide a forum for the broader discussion of health coverage.

·        Have any other states with Premium Assistance programs seen an increased shift in the employee contribution costs toward the state?  The DSS will inquire of the other states. Generally PA program enrollments are small; those that have been unsuccessful had applied the program to a very narrow income range, limiting enrollment and viability of the program.

·        Drawbacks to PA were noted in the context of the current Medicaid funding:

o       PA may have an adverse impact on safety net providers, in that the loss of privately insured patients and higher reimbursement rates may impede the provider’s ability to underwrite the costs of uninsured health care.

o       The Medicaid FFS base rates haven’t been increased in 10 years, artificially keeping the Medicaid  program costs low and adversely affecting the provider system and access to services. Sen. Harp noted that adjustment of the Medicaid rate issues requires attention: PA might put the current system at risk.

o       Commercial market rates may increase without improving Medicaid FFS rates.

·        The HUSKY MCOs commented that the Premium Assistance pilot provides the opportunity to assess program impact on consumers, health care providers and provider network capacity; however one plan noted there remains the need to look at the underlying base Medicaid fee-for-service rates.

Behavioral Health Carve-out

Mark Schaefer (DSS) and Jeffrey Walter (Co-chair of BH Oversight Committee) discussed budget information presented at the March 9^th Committee meeting.  The BH carve-out estimates are higher than the budget estimate.  The Mercer assumptions and other data led to the new estimates:

·        Total BH dollars for SFY 06 - $79, 650, 917.

·        Total BH administration dollars SFY06 - $5,957,889.

·        The non-Riverview BH reinsurance dollars - $14,671,960

·        $9.8M in new dollars, a portion of which is for administrative costs, most is for service growth.

The level of care rates will be presented at the April 12 BH Committee meeting.  Outpatient rates will still be based on the MCO rates (higher than Medicaid FFS).  The Committee had expressed concern that the legislature will be asked to approve the BH waiver amendment before the final dollars are approved in the state budget and completion of the DSS/MCO negotiation for the MCO per member per month (PMPM) capitation rate adjustment (summer of 2005).

HUSKY Enrollment

HUSKY A March enrollment is again at the highest level in the program with 308,468 enrollees and HUSKY B has 15,456 members.  Program enrollment change 2004 – 2005:

The reasons for HUSKY B denied applications were reviewed.  The top 3 reasons for 1/04-12/04 were:

·        Incomplete documentation – 56%.  In Jan. 05 this was 39%, Feb. 05 it was 44%.

·        Client receiving HUSKY A already – 17%.  This was 28.4% in Jan.05 and 20% in Feb 05.

·        Employer Sponsored Insurance – 17%.  In Jan 05 this was 18% and 22.3% in Feb. 05.

Council members commented:

ü      The Consumer Access Subcommittee co-chair, Christine Bianchi, will bring the issue of the high percentage of incomplete applications back to the subcommittee for review and discussion.

ü       Mary Alice Lee expressed concern that families applying for HUSKY B that are already enrolled in HUSKY A may not realize they have health coverage and may not be accessing services.  Sen. Harp requested the DSS develop a mechanism to follow up with these families.  The DSS stated they would work with ACS to determine why the member may not be aware of their HUSKY A coverage.

HUSKY A Asthma Report 2003:  CTVoices (find report at www.ctkidslink.org)

Comparison of data from Children’s Health Council 2001, 2002 asthma reports:

Council comments, suggestions:

ü      Follow up after ED asthma –related visit unchanged.  There are some differences among MCOs in this measure. 

ü      There remains a consistent problem with care coordination of children with asthma that utilize higher cost services such as ED/hospitalization and timely follow up PCP care.  Sen. Harp referred this to the Quality Assurance Subcommittee.

ü      Smoking cessation services, which CMS identified as medically necessary services in Medicaid are not part of the HUSKY MCO/DSS contracts.  The DSS noted that “medical necessity” applies to children and youth under EPSDT.

Medicaid Council Subcommittee reports

Ø      Behavioral Health Oversight Committee:  see above

Ø      Consumer Access Subcommittee:  Christine Bianchi, Co-Chair provided an overview of activities:

·        Imputing member address changes into the DSS MMIS system is being piloted by CHNCT and DSS, with a review of the pilot expected in June 2005.

·        A subcommittee work group has met to review MCO marketing plans and provide DSS with recommendations, at the request of DSS in compliance with CMS regulations.

·        2005 HUSKY legislative proposals were discussed and the Chairs were asked to bring these issues to the full Council:

o       PRI report: Apply an MCO “lock-in” for HUSKY A members (HUSKY B has a lock-in).  The ACS recognizes that the reason codes for changing health plans needs to be updated.  Some plan changes may be the result of access issues. The ACS will develop, with Subcommittee input, a brief voluntary telephone survey of members when they call in their plan changes.

o       Self declaration of income on HUSKY/Medicaid applications:  the Governor’s budget and Bill 6688 eliminates this, with projected savings of $2M per year for SFY06 and 07. Eliminating self declaration of income re-creates an enrollment barrier. The current system has checks and balances: 1) the DSS matches reported income with the Department of Labor data and addresses significant changes/differences with the client and 2) self-employed applicants are required to provide substantiating income documentation.  There has not been an increase in DSS error rates since the implementation of self declaration of income in 2002.  Raised Bill 1323, referred to the Committee on Human services does not eliminate self declaration of income.

The Medicaid Council will meet Friday April 8 in LOB RM 1D.  The DSS EQR consultant Mercer will provide more specific information on their External Quality report, as requested by the Council in February.