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

September 14, 2001

Council members: Sen. Toni Harp (Chair), Sen. Edith Prague (Vice-Chair), Rep. Vickie Nardello, David Parrella, Rose Ciarcia (DSS), David Guttchen (OPM), Thomas Deasy (Office of Comptroller), Gary Blau (DCF), Marie Roberto (DPH), Jeffrey Walter, Janice Perkins, Dr. Edward Kamens, Dr. Wilfred Reguero, Lisa Sementilli-Dann, Dr. Leonard Banco, Judith Solomon.

Also Present: Deborah Hine (Anthem BCFP), Sylvia Kelly (CHNCT), Joan Morgan (FirstChoice - Preferred One), Dr. Robert Zavoski (CT Chapter AAP), Tierney Sherwin, Barbara Casey, Dr. Tom Van Hoof (Qualidigm), William Diamond (Benova), James Linnane, Martha Okafor, Mark Schaefer (DSS), Mariette McCourt (Council staff).

Sen. Harp began the meeting with a moment of silence for those affected by the tragic events of September 11 and commended the Child Guidance Clinics for their community support and outreach during this time. Dr. Gary Blau (DCF) was asked to describe the Department's efforts to meet support needs during this past week. Dr. Blau stated that many State agencies have been operating on `high-alert' status since Tuesday and expressed appreciation for the collaboration and support of DSS, DMHAS, OPM and the Governor's Office in reaching out to CT communities at this time of crisis and sorrow. In addressing potential children's mental health needs, DCF:

• Diverted all children with BH needs from Emergency Departments to ensure available space in the ED's.
• The DCF hot line connects callers with mental health clinicians and other services for families, community -based organizations and health providers. This hot line will remain available.
• The DCF web site contains information from the DCF Director of Psychiatry on helping children deal with this devastating event as well as linkage to other sites throughout the country that provide information on crisis intervention.
• DCF has had public service announcements that include tips for adults in helping children cope with the events of September 11.

Dr. Blau commended the Child Guidance Clinics (CGC) of CT for their individual response:

• All CGC's offered consultative services to schools in their catchment areas, sending notices of offers for assistance in meeting the needs of different aged children in coping with the crisis.
• CGC offered assistance to their local community-based and faith-based organizations as well.
• The CGC's continue to provide DCF with daily reports on calls and service needs.
• The Southern CT CGC and the Executive Director, Sherry Perlstein, were commended for their collaborative work with DMHAS in the crisis team response to those families returning home from New York in the days following the tragedy.

Dr. Blau stated that CGC across the state provided consultation and assistance outreach in addition to carrying their clinic load. Senator Harp stated that the entire state recognizes the support from the CGC and the collaborative efforts among the State agencies during this time of crisis.

Qualidigm Report on Psychotropic Medication Use Among HUSKY A Children

Tierney Sherwin, Project Director, presented the results of the first phase of the project that describes psychotropic drug use in the HUSKY A program. The study was undertaken when Judith Meyers, Executive director of Child Health & Development Institute of CT brought national studies on this topic to the attention of DSS. The Institute, in collaboration with the Yale Child Study Center, DSS and Qualidigm developed the study.

Phase I (See attached slide presentation)

• The purpose of Phase I was to assess psychotropic medication use and the extent of polypharmacy, defined as two or more drugs prescribed, using HUSKY administrative data.
• Children aged newborn through 18 years enrolled in HUSKY A at any point during the 12-month study period were included in the study.
• The data sources used were the Medicaid Managed Care database, the developed database from the psychotropic National Drug Code File and psychotropic medication classifications. The drug classifications included:

• Alpha-2 agonists and stimulants, (I. E drugs prescribed for ADHD),
• Antidepressants, used for depression and anxiety,
• Mood stabilizers, (I. E drugs prescribed for bipolar disorders),
• Antipsychotics, (I. E. those used for schizophrenia),
• Anxiolytics used to treat anxiety disorders.

• The unit of analysis was the child, with a focus on the population of children prescribed psychotropic medications. The prescriptions rates were described by age, gender, race/ethnicity, coverage group and medication class. Polypharmacy was analyzed by using the earliest prescription data as an index event, then looking forward three months for additional medications either within the same drug class or in a different class.
• Psychotropic drug use results:

• 4. 8% 99,447 children enrolled in MMC at any point during the study period received psychotropic medication.
• 5. 5% of the children (7,934) enrolled at least 6 months in MMC received these medications.
• 5. 8% (6,671) children enrolled at least 11 months in MMC received these medications.

• Polypharmacy Use:

• 2702 (42%) children enrolled in HUSKY during the 12-month study time were dispensed more than one psychotropic medication in the 3 month time period.
• Of these enrollees, 1,249 (83%) were dispensed medications in two or more different classes and 274 (10%) were dispensed two or more medications within the same class.
• 179 (7%) were dispensed drugs from two or more different drug classes and were also taking two or more medications within the same drug class.

Next Steps

• Expand analyses of the Phase I report, which is completed, and submit for publication.
• Continue with Phase II: medical record review of 266 of the youngest children who received psychotropic medication, with the purpose of confirming that the child received the drug and identify the diagnosis and procedures for prescribing the drug(s).
• DSS is collaborating with other New England states in a psychotropic monitoring project, one of the first regional studies in the country.

Council discussion included the following comments/suggestions:

• Identify the provider type ordering the medication, match appropriateness of drug(s) ordered with diagnosis for targeted provider education.
• Since some psychotropic drugs may used for disorders other than behavioral health diagnoses (i. e. seizure, cardiac disorders), this needs to be taken into consideration in the study results.
• Providers cannot wait for FDA approval for specific drugs for certain diagnoses, as in the case of OBGYN or neonatal drugs. Regarding psychotropic medications, it was noted that:

• There currently is little evidence of the safety of drugs for children because they have traditionally been protected from clinical trials, but there are efforts to bring them into research.
• There are few FDA indicators for psychotropic drugs; providers must choose the best drug with parental informed consent.
• There is currently limited evidence of the efficacy of psychotropics across different age groups of children.

• Outcome indicators, while difficult to obtain, are needed to assess drug efficacy on behavior, allowing resources to be used more effectively.
• Will Phase II identify linkage of other behavioral health services with psychotropics and/or alternatives offered to parents? Ms. Sherwin indicated this would be looked at in the chart review.
• The referral source for psychotropic drug evaluation is important, considering the recent legislation preventing schools from recommending pharmacological intervention.

Vision Care in Hartford under the HUSKY Program

At the July 2000 Council meeting, Dr. Banco, representing the CT AAP, stated that no there were no ophthalmologists in Hartford County in the Medicaid network that provide care to HUSKY children. Dr. Banco had agreed to work with Anthem BCFP to improve vision care access in Hartford and reported that:

• A Hartford pediatric ophthalmology group will see ABCFP patient with a direct physician referral.
• CHNCT patients will continue to be seen by one provider in the area.
• Health Net has no formal arrangement in place as yet.

(Addendum: on September 17^th, Janice Perkins informed DSS that Children's Eye Care accepts referrals for Health Net patients in Hartford. The practice is not participating in the Health Net HUSKY line of business nor are they interested in joining the HUSKY Health Net network. )

Department of Social Services Report

HUSKY Contract 2001-02

David Parrella reviewed highlights of the HUSKY A DSS/MCO contract, signed by all the plans, which is in effect through June 30, 2002:

• Emergency services: using the `prudent layperson definition, with no limitations on the number of ED visits, payment cannot be withheld because of member non-report to the MCO prior to or after the ED visit.
• MCO network adequacy: all MCO's are required to maintain specified member/provider ratios in counties. A Class A sanction will be applied, in addition to the county enrollment freeze, when the MCO has not remedied over-enrollment in a county.
• Pharmacy: two of the four plans have pharmacy formularies. MCO's are required to submit their formularies, as well as any additions or deletions to DSS for review. In addition:

• A minimum 30-day temporary drug supply to the member is required if the prescribed drug, initially denied by the MCO, is deemed needed on an "urgent basis" by the prescribing health provider.
• The temporary supply of the prescribed medication would be continued during a member's appeal process.
• Formulary and Prior Authorization (PA) information is to be included in the plan's Member Handbook.
• MCO's are required to submit a quarterly PA report; DSS will assess the operationalization of this contract provision. DSS could require drugs be added to the formulary if the MCO's process is determined to be unsatisfactory.
• MCO's are required to comply with CGS 20-619(b) and (c), which addresses generic drug substitutions for Medicaid recipients.

• Mental Health: MCO's and their mental health providers are required to participate in the Behavioral Health Outcomes study. Providers' failure to do so will result in the loss of `benchmark' status.
• Timely provider payments: language is clarified for timely adjudication of claims and payments to providers. MCO's will be required to submit two reports to DSS:

• Claims Aging Inventory Reports, to be broken out between medical and behavioral health
• Claims Turn Around Time Reports for medical and behavioral health claims.

• Subcontractor provisions, addressed in 2001 GA legislation, include:

• All subcontracts are required to include the DSS definitions of Medical Necessity and Medically Appropriate.
• The MCO will include requirements of a performance bond, letter of credit, statement of financial reserves or payment withhold for Dental and Behavioral Health in their subcontracts.
• MCO's are required to include a provision for contract termination payment withhold for those subcontractors responsible for claims payments.

• Children With Special Health Care Needs (CSHCN): CMS (formerly HCFA) required states to identify CSHCN in the Medicaid program and assess care to this population.

• DSS will identify CSHCN (not included in the DCF categories) based on section 1932 of the Social Security Act in the HUSKY program.
• MCO's are required to identify other CSHCN in their membership, conduct an assessment of all identified CSHCN in their plan and report utilization and case management of these members to DSS.

• Miscellaneous provisions include:

• Bi-weekly Discharge Planning Report of DCF children awaiting psychiatric hospital discharge, the costs of which are now reimbursed, incrementally, by the State reinsurance plan.
• MCO's are required to develop goals and action plans for targeted services' incremental increase in service utilizations (I. E. postpartum care, adolescent health).
• Passive billing: MCO reimbursement from DSS is now based on Benova enrollment data, which will reduce MCO administrative costs.
• Language clarification for issuance of client Notice of Action and provision for expedited Fair Hearing reviews.
• A separate contract will be signed with the MCO's for the State-reimbursed abortions that fall outside the federal reimbursement guidelines (I. E. pregnancies other than those due to rape, incest or place the mother's life at risk). This does not affect HUSKY abortion coverage; rather the State is coming into compliance with federal funding rules for abortions in public programs. DSS will make available this contract upon completion.
• Addition of provider Fraud and Abuse detection language and reports to DSS. The Department can make this technical language, based on federal law, available.

Council comments:

• It was suggested that the four MCO's come to an agreement on how the prescribing health provider indicates urgency related to the temporary drug provision. This uniform approach and documentation will make it easier to track problems in this process.
• Regarding the BH Outcomes study, the administrative processes for hiring the study coordinator is complete and the coordinator should start the last week in September.
• Sen. Prague noted that one of her constituents and a member of Anthem BCFP has encountered difficulty finding a HUSKY BH provider in the north eastern part of the state. Providers contacted by the member reported that some providers do not wish to join the ABCFP network because of payment problems with the health plan. Deborah Hine stated she was not aware of this issue; however ABCFP takes these issues seriously and the plan is looking into this.

Sen. Harp and Council members commended DSS and the MCO's for the important changes in the new contract that will strengthen the program, and the evidence that the Council concerns were addressed in the contract changes.

(See 1999-2001 contract provision comparisons provided by Joan Morgan, FirstChoiceCT on web site under "what's new")

Behavioral Health Claims

The Department followed up with the Council's request to investigate the payment status of outstanding claims of methadone and child guidance clinic programs that were mediated by DSS. The summary of the findings of the include:

• Three of the four MCO's participated in the claim resolution process:

• CHNCT and FirstChoice/Preferred One indicate they have made payment and there are no outstanding balances due, based on the mediation process.
• Health Net sent payments for methadone treatment to four clinic on July 30, 2001
• Anthem BlueCare Family did not participate in the mediation proposal determined by DSS; the health plan did review each agency's account receivables for the period of time in question.

• Three health plans (Kaiser, Oxford and HealthRight) no longer have contract with DSS, therefore the Department has no jurisdiction to require payments from these plans. As part of the termination agreement, HealthRight did submit a $ 100,000 withhold. The Department is working with the Attorney General's office to work on a process to pay claims against the withhold amount. There should be a resolution of this by October.

Benova Enrollment Report

William Diamond (Benova) and Judith Solomon (CHC) described the media campaign funded through a Robert Woods Johnson grant, an additional grant under the Covering CT Kids RWJ grant. Connecticut was one of 5 states to receive the grant, which provided technical assistance for intense media coverage of the HUSKY program. The media campaign, led by Lieutenant Governor M. Jodie Rell, raised the awareness of HUSKY B. Infoline calls doubled; the impact on enrollment numbers should be seen in October. In addition, every HUSKY outreach program held numerous events in a `back to school campaign' that created a HUSKY presence in many schools.

Changes in enrollment numbers, comparing 2000 to 2001 were reviewed:

• In July 2001, there was a 30% response rate to the DSS mailings informing families of the end of the 12-month continuous eligibility period. There was a 2500 member loss this July compared to 4000 in July 2000.
• Overall, there has been an increase of 15,911 members (6. 5% increase) in HUSKY A as of 9/01 compared to 9/00.
• Since January 2001, when the adult expansion was implemented, an additional 10,524 members over age 19 years have enrolled in HUSKY A. Prior to January, the enrollment numbers for >19 was level; it is assumed that the additional enrollees can be attributed to the legislation.
• HUSKY B enrollment increased by 2,549 (27%) this September compared to one year ago. Again, it is hoped that HUSKY B enrollment will exceed 10,000 in October, in response to the media ads.
• The average weekly application volume to Benova has increased from 289/week to 535/week, representing an average increase of 85%.

Council Quarterly Report

The report was accepted without change by the Council. .

The Medicaid Managed Care Council will meet on Friday October 12, 9: 30 AM in LOB RM 1D. The Department was requested to present the Mercer report on timeliness of claims payments, the Health Net and Preferred One/PROBH payment summary and a report on the Presumptive Eligibility initiative, begun by DSS October 2000.