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

COUNCIL MEETING SUMMARY

APRIL 20, 2001

Present: Senator Toni Harp (Chair), Rep. Vickie Nardello, David Parrella, James Gaito (DSS), David Guttchen (OPM), Robert Gribbon (Comptroller Office), Gary Blau, Dorian Long (DCF), Dr. Leonard Banco, Ellen Andrews, Barton Bracken, Judith Solomon, Dr. Wilfred Reguero, Dr. Edward Kamens, Lisa Sementilli-Dann, Janice Perkins (PHS), Sherry Quickmyer for Rev. Bonita Grubbs.

Also Present: William Diamond (Benova), Raymond Claytor, Leslie Wolfgang (Department of Insurance, Consumer Affairs), Tejas Patel (FirstChoiceCT/Preferred One), Deborah Hine (ABCFP), Sylvia Kelly (CHNCT), Rose Ciarcia, James Linnane (DSS), Dr. Victoria Niman (DCF), Debra Brackett, Jack Hubert (Qualidigm), Jody Powell (Child Guidance Clinics).

Department of Insurance (DOI): Standardized Claims Criteria

The HUSKY program is under the direct administrative supervision of the Department of Social Services; the Department of Insurance regulates commercial health insurance. Both State agencies have addressed timely claims payment, either through statute (DOI) or contract provisions (DSS). Ongoing concerns about timely payment of `clean' claims prompted the Medicaid Council to invite DOI to discuss their collaborative claims criteria initiative, providing an opportunity for Council discussion on the possible application of similar criteria in the HUSKY program.

Raymond Claytor, Director of Consumer Affairs and Leslie Wolfgang, Attorney for Consumer Affairs, presented the uniform claims criteria that DOI, commercial health plans and providers developed in order to clarify the implementation of CT law (38A-816) that deals with timely payment of service claims.

The Department of Insurance Consumer Affairs Department is involved with auto, life and health insurance, and annuities issues as they affect consumers. Of the 15,000 complaints received by Consumer Affairs in a year, 9000 involved health insurance and 6000 were related to delayed claims payments. The number of claims complaints revealed the confusion on the part of MCOs and providers about the `time clock' related to the payment issues and prompted the Department to address this.

· The work group, led by Leslie Wolfgang, looked at the HCFA 1500 and UB 92 form and identified the items that are required in order for information submitted by a health provider to be considered as a claim. Once the submitted information is considered a "claim", the statutory `clock' starts for payment within 45 days or the MCO request for additional information within 30 days.

· The uniform criterion does NOT identify a "clean" claim, rather the start of processing a claim.

· The DOI Consumer Affairs can now better assess complaints and calculate the interest owed, based on the time frames in the statute, for claims that meet the established criteria.

· Payment complaints, tracked by DOI, have shown a dramatic decline, compared to last year, since the Department issued a bulletin on the criteria and communicated the information to health providers through State professional organizations and MCOs.

Mr. Claytor stated that this presentation does not suggest that information required by the commercial market is similar to the Medicaid market, however the Department would be happy to assist the Council in any way. The Department of Insurance has been receiving requests for information on this process from other states, as timely payments is not indigenous to Connecticut.

Senator Harp and Council members thanked Mr. Claytor and Attorney Wolfgang for the Department's work in collaboratively resolving this basic but critical payment issue. Council questions:

· Sen. Harp asked the Department of Social Services if there are barriers in the HUSKY program to using this type of protocol that DOI described. Mr. Parrella stated there are a handful of different fields required by Medicaid fee-for-service on the 1500 and UB-92 compared to the commercial requirements. There are also additional fields required on the standard encounter data the HUSKY health plans submit to Mercer.

· Rep Nardello asked if the Department could convene the same process with the health plans and providers to adapt criteria that consider the different elements and develop a process to communicate this to providers. Mr. Parrella stated the forum for this would be in DSS as they move forward with new contract provisions, but that this would not be a difficult process to incorporate, as there are few field differences. The Health Insurance Portability & Accountability Act (HIPAA) will require data reporting changes within two years in HUSKY, Medicaid FFS and commercial insurance. The intent of HIPAA is to bring all payer sources in line with common data reporting elements and privacy regulations.

· Dr. Reguero requested information on the retroactive payment process for providers who are waiting for Medicaid numbers. The DSS policy is to backdate provider Medicaid enrollment up to and exceeding a year for retroactive payment for services provided while waiting for the Medicaid number. The application must be complete and within the Medicaid provider criteria in order for retroactive payments to be made.

Safety Net System Survey

A report on the Institute of Medicine study of the Safety Net Provider system (SNP) was presented to the Council by Judith Krauss in September 2000. The study revealed that SNPs continue to experience challenges competing in the health care market, in part related to the disproportionate funding from Medicaid and Medicare. Subsequent to the report, Rep. Nardello, Sen. Harp and Council staff discussed how Council activity related to SNP could continue. Barton Bracken, a Council member, was asked to work with the Council staff to investigate whether SNPs require additional administrative infrastructure resources in order to succeed in a managed care environment. The investigation used qualitative methodology and focused only on administrative infrastructure issues with "core" outpatient safety net providers. The key findings were:

· SNPs face significant administrative challenges in a managed care environment. The future portends even greater challenges. Managed care and the State require significant amounts of information for service claims in order for reimbursement and compliance with federal and State data reporting requirements. The Health Insurance Portability and Accountability Act (HIPAA) expands the scope and process of data collection. Compliance with these requirements will be burdensome for even the most sophisticated administrative system and more costly than Y2K compliance.

· Administrative shortcomings result in additional threats to SNPs. Many SNPs are not able to efficiently bill or provide complete data to either the State or MCOs, resulting in lost revenue opportunities, potentially inaccurate program performance reports, and relatively high administrative costs. State agencies require FFS billing; the inability to provide more complete data may adversely affect future grants to SNPs.

· SNPs are in need of improved technology infrastructure and support. Administrative and technical capacity varies among SNPs. Few have adequate technology infrastructure and skilled administrative staff to meet current and future administrative requirements in a cost effective, efficient manner.

· The safety net provider system is highly fragmented and decentralized making it difficult to offer uniform solutions. Safety net providers systems vary widely in their administrative capabilities and needs. Some are either connected to larger entities that provide administrative support or have sustainable capitol to support administrative systems while others have no such support. Each SNP is unique and has unique needs, thus making it difficult to offer uniform solutions for support.

· The State is already providing some resources to support SNPs on administrative issues. Both agencies and provider groups identified various technical assistance supports from the State that includes grant monies, administrative and clinical software systems, and targeted staff training for the transition to managed care. Other needs were identified by SNPs that would provide more effective administrative management and enhanced reimbursement:

o MIS infrastructure that allows centralized claims submission via the Internet.

o A common claims data software system applicable across payer sources and adaptable to accommodate frequently changing vendors.

o Support with purchasing, setting up, and maintaining management information systems that accurately and efficiently capture and report on administrative, financial, and clinical information.

o Financial support for hiring and training technical administrative staff.

o Ongoing administrative system technical support.

· Money is available from a number of private and public sector sources that can be used to provide administrative support to SNPs. While some federal funding targets specific SNPs, there has been more attention, on the federal level, to more systematically address SNPs capacity to participate in the changing health care market.

This preliminary assessment of SNP administrative needs resulted in the following recommendations:

1. Funding for one FTE position to be placed within the Department of Social Services. This position would be responsible for:

_ Identifying SNPs with administrative support needs.

_ Working with SNPs to identify and develop priorities for specific administrative needs.

_ Identifying potential sources of funding (private and public) to meet the specific administrative needs identified by the SNPs.

_ Working with the SNPs in securing the funding.

_ Monitoring the SNPs' use of the funding, the impact of administrative support on earned revenue and utilization data and ongoing administrative needs.

2. Hold workshops to train SNP staff on administrative practices. The Medicaid Managed Care

Council would work with providers, State agencies and MCOs in developing a series of workshops with SNPs to improve their skills on various administrative issues such as billing and data reporting. 3. The Council request the Office of Health Care Access (OHCA) address SNP administrative resource and need issues in the study on CT uninsured.

Council response:

· Some states have either initiated SNP studies or developed an entity to identify needs and provide support to SNP. New York State has legislated such an entity.

· Rep. Nardello spoke from experience as a SNP, commenting that the challenges of administrative tasks create frustration and encroachment on clinical services, since most SNP operate on a limited budget. The Council needs to consider strategies to improve the effectiveness of the SNP as it goes forward with this study. The irony is that helping SNP improve their billing structure will improve health care access yet create more costs for MCOs.

· The Department of Social Services reacted to the study, stating that the Department has limited resources that are already strained in monitoring the HUSKY program. The Department does not see technical support to providers or grant writing as their primary function. Other State agencies such as DPH, OCHA, DMHAS, or DCF have a mission to ensure their providers have adequate assistance to fulfill their contracts with these agencies. Mr. Bracken stated that the placement of the position is not the central component of the recommendations; rather the focus is on identifying administrative need and available resources to meet these needs.

Rep. Nardello thanked Mr. Bracken for his work on this important issue and the Council will take DSS comments into consideration as further work is done in this area.

Department of Social Services

Arnie Pritchard has taken a position with DCF. Mr. Pritchard provided the quarterly data reports, along with a concise evaluation of changes represented in the data. The Council expressed their wishes for Mr. Pritchard's success in his new position and thanked him for his excellent work and important contributions in enhancing the Council's understanding of the quality of the HUSKY program.

Quarterly Data: James Linnane presented preliminary data on the annual HCFA 416 report that showed increases in EPSDT and "any" dental service rates and a reduction in preventive dental services.

July-September 2000 data:

· Behavioral Health penetration rates, which include MH and substance abuse services, showed a 0. 5% decline from the previous quarter, with the 3^rd quarter rate of 5. 8%. Preferred One did not submit data; the other 3 plans showed utilization decreases in this quarter (in the past, lower utilization rates in the 3^rd quarter were attributed to seasonal variables, school break).

· Children receiving any dental service in 3Q00(16%), declined1% from the 3Q99.

· First Trimester prenatal care (PNC) for women enrolled in HUSKY in 2Q00 is 62. 6%, an 8% decrease from 2Q99. Postpartum care for continuously enrolled women at least 56 days post delivery remain modest at 59. 6%, with a 10% increase from 2Q99.

Council discussion highlighted the following areas:

· Variations in PNC/Postpartum care may be confounded by: when the woman enrolls in HUSKY related to gestational time period, global fee rate that makes it difficult to sort, by code, specific services, and a growing reluctance of providers (hospitals) to give data beyond that required on the birth certificate. Privacy concerns make it difficult for MCOs to recoup incomplete data.

· Dental care may decrease in the 3^rd quarter because of school vacation. Overall, two-fifths of HUSKY children are receiving care, according to the HCFA 416 annual report.

Monthly PHS/PROBH report

The PHS/PROBH claims lag report for January 20001 was presented:

James Gaito (DSS) stated that approximately $ 6. 1M was paid February-April 2001. In response to Dr. Banco's question, Mr. Gaito stated that aggregate outpatient claims were 7000 compared to 770 claims for inpatient in January 2001. Dr. Banco noted that while an increasing percentage of aggregate dollars are being paid within the 45-day period, the total paid /% paid is weighted to the smaller number of claims for inpatient. The lower percentage paid on outpatient suggests there is a disproportionate impact on outpatient providers. Mr. Gaito stated this would be considered in the next report.

Rep. Nardello asked FirstChoiceCT/Preferred One to comment on claims issues with P-1/PROBH that are now being reported. Providers have been told by PROBH to contact CompCare regarding past (January and beyond) claims issues. Tejas Patel (P-1) stated that CompCare is now the BH subcontractor. The vendor had an ASO contract for March 1, 2001 and tracked claims one month back to 2/01; the risk-based BH contract began 4/1/01. Mr. Patel stated that his plan is having difficulty obtaining data past 3/1/01 from PROBH but will work with providers through a manual process, if necessary, as well as entertain other solutions from providers in order to obtain data for past claims adjudication and payment. Jody Powell (Clifford Beers) stated that manual `pulling' of authorization data creates a significant burden on clinics, forcing them to "shut down" in order to focus on the claims retrieval. Requiring this data from PROBH by either the MCO or DSS is now difficult because the MCO no longer has a contract with PROBH. Council Chair and members urged DSS to consider contractual language that will repair vendor non-compliance with the DSS/MCO contract, the "weakest link" in the program. The Department agreed that this aspect of vendor oversight has been a problem and language in the new contract will further strengthen the MCO responsibility for vendor compliance with DSS contract provisions.

PHS Name Change

Janice Perkins, Vice President, Medicaid Gov't Relations, PHS reported that the PHS name will change as part of a united national marketing process; THERE HAS BEEN NO CHANGE IN PLAN OWNERSHIP. The name transition will be a two-step process:

· Effective May, 2001, PHS becomes HEALTH NET, Formerly PHS Health Plans.

o New and existing members will receive ID cards and member materials with the new logo; there will be a run out of Marketing and Communications materials through December 31, 2001.

o The Web site address will change to www. health. net

o The email address will change to www. ne. health. net.

· Effective May 1, 2002, the "formerly PHS' will be dropped from the logo.

Benova Report

William Diamond, Regional Director of Benova, provided information requested at the March Council meeting:

· HUSKY B length of time to enrollment: for the total sample (2305), approximately 95% are enrolled in 60 days. Band 1, 95%, Band 2, 95% and Band 3 (pay one month full premium prior to enrollment) 92% enrollment within 60 days.

· Net enrollment in HUSKY B over 3 months shows that there was approximately a 2-3% net gain when dis-enrollments were figured in, except for March when there was a 0. 6% decrease because of changes in the FPL that made some HUSKY B members eligible for HUSKY A.

· HUSKY B dis-enrollment reasons (744 over a two-month period) were mainly related to no renewal application (37%), non-payment of premiums (27%), referral to HUSKY A (18%), incomplete renewal application process (8%). Four percent had obtained employer-based insurance.

· Lockout data: 91 children in HUSKY B were dis-enrolled 3/01/00 for non-payment of premiums. Of these 3 (3%) re-enrolled after the expired lockout period of 3 months, 41 (45%) remained dis-enrolled, 47 (52%) re-enrolled into their MCO with NO gap in coverage. Lockout provisions are based on DSS regulations, not in the statute.

· HUSKY B Plus enrollment: As of 4/1/01, 166 children are enrolled in Plus physical programs (Yale - 55), CCMC -11) and 10 are enrolled in behavioral Plus programs (Yale - 10).

· School Lunch HUSKY information requests totaled 3000; 962 applications were sent out, 495 families were referred to DSS for HUSKY A, 313 did not return a signed application. , 72 applications were denied, 71 were approved.

Rep. Nardello thanked Mr. Diamond for providing the requested information and requested the following:

· The role of the consumer's MCO in alerting the member of the time of renewal? Rose Ciarcia stated that Benova does send letters out for renewal and does follow-up through phone (2 calls) and mail in an attempt to re-engage the potential HUSKY B enrollee as well as those at the renewal period. Rep. Nardello suggested DSS consider a role for the MCO in alerting their enrolled member prior to the renewal time.

· It would be helpful to have a geographical breakdown of the 3000 school lunch information requests in order for targeted outreach to these schools and families.

· Can Benova aggregate the reasons that HUSKY B members do not enroll (i. e. the 313 that did not complete the application process) or re-enroll? Mr. Diamond will look at this.

Behavioral Health Outcomes Study

James Gaito stated that Sen. Harp, the BH subcommittee chair/co-chair, Alan Kazdin and Commissioner Wilson Coker and Commissioner Ragaglia met to reassess strategies to move the study forward. Initial OTR numbers are increasing (1000 more since the March Council meeting) but discharge form numbers remain low. The Department is obtaining BH utilization data and will meet again May 1. Rep. Nardello commented that the Council remains supportive of the study, as the information is critical to future policy and financial decision-making. The increasing involvement of providers, reflected in the increase in submitted forms, is crucial to aggregating information about outpatient mental health services in HUSKY.

Council Quarterly Report

The quarterly report for the 1^st quarter, 2001, was accepted without change.

The Council will NOT meet in May; the June meeting date, to be scheduled after the end of the 2001 session, will be announced.