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

OCTOBER 27, 2000

Present: Senator Toni N. Harp (Chair), Senator Edith Prague (Vice-Chair), Rep. Vickie Nardello, Deputy Commissioner Michael Starkowski, David Parrella, James Gaito (DSS), Marie Roberto (DPH), Robert Gribbon (Comptroller Office), Dorian Long for Gary Blau (DCF), Holly Miller Sullivan for Paul DeLio (DMHAS), Janice Perkins (PHS), Patrick Carolan (BeneCare), Rev. Bonita Grubbs, Barton Bracken, Dr. Wilfred Reguero, Ellen Andrews, Jeffrey Walter, Lisa Sementilli-Dann, Judith Solomon, Phyllis Rotella.

Also present: James Linnane, Rose Ciarcia, Kevin Loveland (DSS), Debra Bracket (Qualidigm), Sylvia Kelly (CHNCT), Deborah Hine (BCFP), Dr. Kiran Patel, Tejas Patel (Preferred One), Jody Rowell (Clifford Beers Clinic), Dr. Robert Zavoski, Mariette McCourt (Council staff).

Department of Social Services

FirstChoice/Preferred One Introduction

Commissioner Starkowski introduced Dr. Kiran Patel, President and CEO of FirstChoice, who discussed the managed care company participation in the HUSKY A and B programs as of October 1, 2000. FirstChoice has assumed responsibility for approximately 25,000 child and adult members in the HealthChoice/Preferred One plan as of October 1, 2000. The MCO transition will be transparent to members in that FirstChoice has retained the HealthChoice existing staff and facilities in North Haven.

FirstChoice is currently licensed as a commercial health maintenance organization in Connecticut covering 4,200 members, since 1999. The company also covers over 230,000 members in New York and Florida Medicaid managed care programs. The Department of Insurance required FirstChoice (formerly called Wellcare) increase their cash reserves in order to operate a Medicaid plan in CT. The MCO increased their cash reserves by over $ 3. 5 million and agreed to escrow funds in the event that claims payments to providers exceeds 45 days, a provision in the DSS/MCO contract as well as the Department of Insurance.

Dr. Patel outlined the challenges and successes of managed care :

• Challenges for managed care:

• Steadily increasing administrative costs from 3. 6% in 1970 to 6. 5%.
• Administrative costs now account for more than one-quarter of hospital costs.
• Consumer perception of MC performance in that over a third of Americans view MC as doing a bad job in serving patients.

• Success attributed to MC:

• Reduction of health expenditures compared to FFS related to a reduction in hospital admissions, length of stay and ED utilization.
• Diagnosis of cancer in earlier stages.
• 77-80% of managed care patients worldwide reportedly were satisfied with their care, availability and quality of the care.

Dr. Patel described the management effectiveness of the FirstChoice by identifying deficit reduction in Florida and New York plans compared to the previous management:

• In Florida the total deficit was reduced from $ 65. 9 million to $ 3. 1M.
• In New York the company is in a stronger financial position with guaranteed reduction in G&A cost of $ 4-5 million annually.

The success of FirstChoice is based on developing a partnership with patients, health providers and the MCO. This partnering of the primary stakeholders will result in improved quality and continuity of care, stable management of the plan and financial soundness. Dr. Patel stated that FirstChoice expects to be a long-term participant of managed care in CT.

Council members posed the following questions:

1) What is the source of FirstChoice capital? Dr. Patel replied that his personal money has been invested in the plan.

2) What is Preferred One's future plans for a behavioral health vendor? Dr. Patel stated that he is concerned about continuity of care and will work with all parties, including PROBH (their current vendor) to ensure care delivery and resolution of existing problems. FirstChoice will evaluate options for the future delivery of behavioral health services, considering alternate vendors or in-house management, as done in Florida, and make a decision within 60 days.

3) Given the publicity around managed care, how does FirstChoice deal with the challenges of a high risk Medicaid population versus a commercial population? Dr. Patel stated that if a Medicaid recipient is not comfortable knowing they have access to their practitioner or over-the-counter meds, then the patient will use the ED, a higher cost service. Client payer source should not determine quality of care if the practitioner is willing to be a player in care delivery. However the practitioner must be fairly compensated as a member of the team.

4) Dr. Patel was asked to comment on the Department of Insurance report of Wellcare's commercial MCO performance. This report card measured MCO performance on 12 indicators: WellCare performed better than the average HMO for PCP and specialty board certification, average for Breast cancer screening and adult access to care, below average for PCP turnover rate (78% vs. 14% other HMO's), cervical screening (31% vs. 69% HMO), child immunizations (51% vs. 69%), PNC in 1^st trimester (63% vs. 87% HMO), diabetic eye exams (24% vs. 48% HMO). Dr. Patel stated that FirstChoice inherited a company with performance/financial problems. He is aware that much work must be done as FirstChoice starts anew, in particular dealing with MD's on a one-on-one basis. For the Medicaid population, he hopes to develop a stable base of providers: membership may shrink but a successful program will be developed.

5) Wellcare was purchased by Dr. Patel in June 1999.

Senator Harp thanked Dr. Patel for his presentation, welcomed him to the HUSKY program and stated, "We want you to succeed".

MCO Quarterly Data Review

James Linnane (DSS) reviewed highlights of the 1999 4^th quarter maternal/prenatal reports and the 2000 1^st quarter reports of other data:

• Well child visits (WC) CHNCT revised their WC visit rates, based on internal data process changes that resulted in a 10-15% quarterly increase in reported WC visits. The MCO WC utilization is now closer to or exceeding the other HUSKY plans' performance. The revised data influenced the overall HUSKY WC ratios by 1-2%. Sylvia Kelly stated that a review of the high utilization PCP's (>100 PCP's) in capitated payment arrangements with the plan showed that CHNCT was not capturing the CPT codes that determine the utilization ratios. This was related to the submission of revenue and CPT codes and variability in individual practice billing systems, which led to the MCO's difficulty in capturing the EPSDT data. The MCO worked with DSS and the Primary Care Provider Association consultant to identify the problem and correct it. Internal plan processing changes have resulted in more accurate WC data. While the CHNCT overall screening ratio is under 80%, the MCO now reports ratios over 80% for children aged <1 to age 3-5 years. Sen. Harp commended CHNCT for their efforts and performance in delivering WC care to their enrollees.
• Maternal/Prenatal Care (PNC) Mr. Linnane provided comparative 1999 (4Q) data of the HUSKY program and 1997 statewide measures. The HUSKY program performance for enrollees receiving >80% of PNC visits is close to the state wide average and the incidence of low birth weight infants is slightly higher than the state average. The most notable difference is in the percentage of enrollees receiving PNC in the 1^st trimester. As has been discussed previously in the Council, the aggregate data consistently shows an overall low percentage of 1^st trimester care utilization in HUSKY. The Council has indicated that this percentage reflects only the care that can be accounted for in the HUSKY data, as women may be accessing PNC outside the program, in FFS, until they are enrolled in HUSKY and a HUSKY MCO. Care outside the HUSKY program is not contained in the quarterly data. Mr. Linnane stated that DSS and DPH are working together to identify 1^st trimester PNC utilization from birth certificates in order to identify the true scope of PNC for women eventually enrolled in the HUSKY program that is outside the MCO data. The Council appreciated both agencies' efforts to determine the reality of early PNC for women eventually enrolled in a HUSKY plan.
• Dental AccessThere has been a decline in (any) dental service utilization among three of the four HUSKY plans, comparing 1999 (1Q) with 2000 (1Q) data. CHNCT showed an increase in dental access between these two quarters; Anthem BCFP has the overall highest dental access rates in both quarters. In previous Council meetings the department reported that DSS (Martha Okafor) is working with the MCO's to develop MCO action plans to improve dental access.

1. Inpatient utilization/ALOS days per 1000 Member Months Mr. Linnane presented bar graph comparisons of 1994 FFS and 2000 HUSKY data (1Q) of hospital data that excludes behavioral health admits/discharges.

• There is little change in the managed care average length of stay (ALOS): 3.4 days under MC, 3.5 days under FFS.
• There are fewer hospital admissions under managed care (10. 2), compared to FFS (11).
• There has been a decrease in inpatient days under managed care (34. 6 days/1000MM) compared to FFS (38. 9 days/1000MM).
• Behavioral Health inpatient utilization and ALOS, per 1000MM Overall there has been a reduction in BH admissions but an increase in ALOS/1000MM when comparing FSS (1994) to MC (1Q, 2000):
• Admissions/1000MM have decreased from 2. 7 (FFS) to 1 (MC).
• Inpatient days/1000MM have decreased from 23 under FFS to 18. 1 under MC.
• The ALOS/1000MM has more than doubled under MC (18. 7) compared to FFS rates in 1994 (8. 5 days).

Council discussion identified three areas of concern regarding timeliness of provider payments and the impact on health care access in HUSKY:

1) Sen. Prague stated that providers in her district (Norwich area) have told her of long lag times in paying claims. Jeffrey Walter stated that this is a problem in the commercial sector as well: the MCOs report that the turn-around time for clean claims is 15-25 days. The Department was asked to comment on the Agency's monitoring process for timeliness of claim payments and contract provisions for interest payments.

• Mr. Linnane stated that Mercer, the State actuary, will be tracking timeliness of payment for encounter claims. In response to Mr. Walter's question regarding the percentage of clean claims submitted to HUSKY MCOs. Mr. Linnane stated this would be difficult to track as Mercer receives the information after the MCO has processed the claims. Patrick Carolan (BeneCare, dental vendor) stated that an issue in the claims process is provider delay in submitting the claim for a date of service beyond the remittance time frame.
• Michael Starkowski, Deputy Commissioner, DSS, stated that there is a contractual provision for interest owed to providers by the MCO for clean claims payments made beyond 45 days. The Department may sanction a MCO for failure to adhere to this provision.

2) What is the contractual standard for clean claims and how is this communicated to providers?

• David Parrella stated there is a definition of a clean claim in the contract. Janice Perkins (PHS) stated that the commercial MCOs, the Dept. of Insurance (DOI) and providers worked together to define a clean claim and identified fields that must be completed for a clean claim submission. Mr. Parrella was not aware of the DOI initiative, as the HUSKY MC is not under DOI; however more specific provisions could be included in the new contract.
• Mr. Parrella stated the clean claim definition has been communicated to the MCOs. The Department did not distribute this to providers, assuming the MCOs, with whom the provider contracts with, would inform providers. Ms. Perkins stated that the DOI specifications for clean claims have been disseminated to providers in a June bulletin and through provider representatives in professional groups and the CT Hospital Assoc. Sen. Harp stated that providers have basic information about clean claims, but more to the issue, providers have to borrow money to cover expenses because of slow reimbursement.

3) Timeliness of provider payments can impact care access. Can the Department monitor the impact of contractual payment provisions on access? Commissioner Starkowski commented that more information from Mercer would be needed to make a correlation between payments and access. Sen. Prague questioned if there is evidence of provider dropout of the HUSKY program? Mr. Parrella stated the Department monitors, on a monthly basis, the adequacy of the MCOs' provider network. According to Mr. Parrella, the number of providers within the program is not problematic; dental participation and utilization is a problem.

Senator Harp requested the following:

• Invite DOI to a future meeting to present that department's current standards for clean claims.
• The Department provide information, within 90 days, to the Council regarding the correlation of timeliness of payments and service access.
• The Department and Council consider a future provider conference to clarify the clean claims parameters.

PHS/PRO Payment Status

Specific questions regarding the PHS/PRO payment issues and DSS subcontractor oversight, raised at the September Council meeting, were communicated to the Commissioner of DSS at the end of September. The following information relates to the request for further information from DSS.

DSS oversight/monitoring of MCO & Vendor contract provisions and performance

James Gaito (DSS) provided an overall description of DSS subcontractor oversight, which involves the review of all subcontracts to ensure that these include any general requirements of the HUSKY A contract as applicable to services provided. All subcontracts are subject to DSS review and approval. The Department monitors MCO/subcontractor performance through Mercer site visits (PHS, April 2000), Qualidigm operations audit site visits and follow-up visits for deficiency corrections (PHS, Nov. 7, 2000). Regarding PHS, Qualidigm recorded an acceptable score of 82% on subcontractor oversight and PHS administrative oversight was substantial regarding resources and reporting. There have been periodic visits by PHS liaison/other DSS staff.

Strengthening of DSS oversight of MCO/vendor compliance with contract provisions

As reported by Commissioner Starkowski (see above), Mercer will track payment timeliness for clean claims. Specific to PHS, Mr. Gaito stated that PHS will submit a monthly report to DSS on claims lag and claims resolution with selected providers (high volume providers and SNP). These reports will be shared with the Council.

DSS monitoring of the PHS claims resolution

Mr. Gaito stated that DSS is working in partnership with PHS to identify the payment issues and facilitate resolution as well as contacting provider entities (CAMHCC, individual Child Guidance Clinics, Natchaug Hospital, IOL, and St. Francis/Elmcrest) regarding the scope of the payment issues. Mr. Gaito provided a chronology of the PRO claims payment issues as it relates to DSS:

• April, 2000: DSS informed that PROBH is experiencing problems paying reinsurance claims to providers.
• May-June: DSS became aware of PROBH payment issues with outpatient providers.
• June: PHS established an escrow account to facilitate provider payment.
• July: DSS works with CG Clinics and other providers on outpatient claims.
• August: DSS began reimbursing MCOs monthly for reinsurance claims.
• September-October: DSS continues to work with PHS and providers to resolve the payment issues.

The following information regarding the payment issues was provided by PHS:

Karla Austen, General Manager, PHS,CT and Janice Perkins, PHS VP Medicaid programs responded to the questions posed by the Council. While the Council addressed concerns related to the HUSKY program, the PHS/PROBH payment problems also affect commercial lines of business.

Ms Austen stated that PHS has a commitment to participation in the Medicaid program, assure access and services to members, meet /exceed DSS performance standards, develop a long-term collaborative resolution of the payment issues while ensuring ongoing timely payments to providers and work in partnership with the provider community to resolve the problem. Connecticut's largest HMO has an exclusive relationship with the CT State Medical Society IPA; they jointly contracted with PROBH for mental health services. PHS became aware in the spring of 2000 that PROBH had issues involving timely payments to mental health providers. PHS sought to stabilize the situation through:

• Establishment of an escrow account in June 2000 to expedited the payment stream to providers.
• Outreach to providers regarding timely payments and reduction of backlog payments.
• Assure member access through a member hotline.

Resolution of claims backlog

PHS has put an additional $ 7 million into the Commercial/Medicaid system to process outstanding claims through 9/15/00:

• $ 4. 4M double payments in September
• $ 2. 2M October payment
• Expedited state reinsurance payments were made to facilities:

• $ 2. 1M paid 7/13/00 for services dates in March, April & May.
• $ 1. 17M paid 9/27/00 for June & July services.
• $ 184,890 paid 10/23 for August service dates.
• September reinsurance claims have already been submitted to DSS.

Reconciliation of Claims

PHS/PROBH will meet with high volume facilities (hospitals, child guidance clinics) to reconcile outstanding receivables. PHS/PROBH will offer meetings during the next two weeks. PHS will continue to offer resources to interested providers. The PROBH contract has been extended through 12/31/00 with an option to continue on a monthly basis.

Next steps include consideration of a new approach, finalize BH vendor selection, acquisition of PRO CT assets, establish current and future liability plans, establish a new service agreement, obtain DSS approval. Ms. Austen stated that the MCO intends to fulfill their contract with DSS and is working with DSS for the payment reconciliation, continuance of monitoring member access to services and timely provider payments and improve provider partnerships.

Council questions addressed other questions in the Council written query to DSS:

How is PHS dealing with PROBH liability, especially as claims continue to roll forward?

PHS is working on a mechanism that will address the liability issue.

Has PHS considered an ASO arrangement with their future service contract?

Ms. Austen stated the health plan is considering all options at this time.

Provider reimbursement issues effect access; request PHS to comment on this.

PHS was not aware of service access issues; they have dealt with only 6 complaints from PROBH members over 6 months. PROBH deals directly with the provider and member complaints. DSS also has assessed the impact on access and has not seen any evidence of this to date, but will continue to monitor this.

Jeffrey Walter stated that the absence of access problems is a credit to providers who continued to see clients and take new PHS/PROBH clients in spite of the payment issues. Commissioner Starkowski agreed, thanking the providers for continuing to serve clients while they worked with DSS staff and PHS staff to resolve the payment issues. Safety Net financial resources are not unlimited; payment issues can and will effect service access. Senator Harp commented that at least one clinic has reportedly had to lay off staff and this may become a problem for other SNP's in the near future.

Senator Harp asked DSS if the department has considered changes that need to be made in order to identify problems as early as possible. The department plans to review information from the PHS monthly reports and the Mercer analysis of claims/timeliness of payments to consider parameters for an early warning system that will allow appropriate intervention. Senator Harp commended the work of all parties to resolve this serious payment problem.

HUSKY Enrollment/Outreach Initiatives

In August 2000, Senator Harp requested information from the Department regarding the DSS assessment of the significant loss of HUSKY members (4011) between June-July and the Department's plan to address this in the future. The Department has been concerned about the loss of enrollees at critical periods as well as the modest increase in HUSKY B enrollment and responded to the information request at this Council meeting. Commissioner Starkowski and David Parrella provided an overview of the combined HUSKY program, enrollment since 1998, identification of ongoing and new outreach initiatives, problem diagnosis and proposed solution plans (handouts available in LOB RM 3000).

The HUSKY program initiated in 1998 sought to reinvent the Medicaid program as well as create a new program, using federal Medicaid and SCHIP dollars. The Medicaid (HUSKY A, Title XIX) program used SCHIP matching funds (65/35%) to expand the age of children covered at 185%FPL through age 18. The SCHIP program (HUSKY B, Title XXI) is a non-Medicaid program, based on the State Employee benefit program, that covers children to age 19, at >185-300% FPL. Individual buy-in for children >300%FPL is available at the State premium rate. In addition, the State designed a PLUS program for children with special physical needs (based at the Title V Centers) and behavioral health needs (at Yale Child Study Center) for services beyond those covered by HUSKY B managed care. Compared to other states CT had a more inclusive Medicaid program prior to 1998, thus limiting federal spending of SCHIP dollars. Federal funding for HUSKY, a partial reimbursement after State spending that goes into the State General Fund as revenue, includes three main reimbursement sources: 50% Medicaid, 65% SCHIP and 90% Section 1931.

• Most public outreach/customer service was claimed under the 90% reimbursement stream from Section 1931.
• DSS claimed about 75% of the initial SCHIP reimbursement allocation.
• Approximately $ 25. 5 million was reimbursed to the General Fund for $ 39 million in State expenditures for SCHIP (@ 65% return).

HUSKY program benchmarks since 1998:

• Pre-HUSKY (Title XIX, under 19 years) enrollment in June 1998: 158,600 children.
• As of October 2000 there are 180,700 children enrolled in HUSKY.

• Title XXI: 6952 new children in HUSKY B, 3,800 in the HUSKY A expansion under SCHIP dollars, approximately 11,000 children are currently enrolled under SCHIP funding.
• HUSKY A: 11,425 new children enrolled.

• Net increase of 22,100 children who have health coverage now compared to July 1998.
• A total of approximately 25,000 children have been served under SCHIP funding since July 1998.
• Since July 1998, more than 55,000 applications have been received for the HUSKY program.

There have been numerous cooperative outreach initiatives, the most recent being the implementation of Presumptive Eligibility (PE) beginning with 4 SBHC. As a federally qualified entity (i. e. FQHC's, SBHC's, HeadStart centers and WIC sites), the clinics will forward a new single page `fast form' to the DSS central office, which will follow-up for the formal application. Children may access health care prior to the final eligibility determination. The Department plans to meet with the remaining SBHC and FQHC that can participate in PE as a qualified entity. The HUSKY Healthcare initiative contracts are about to be signed. The Department also has several grant proposals out for technical assistance in identifying and solving some of the coverage lapse problems.

Rose Ciarcia (DSS) elaborated on the enrollment issues, reporting that the July 2000 decrease (3,549 children) was related to the continuous eligibility (CE) end date of 6/30 assigned more frequently than other months. While there was a decrease in enrollment last July, this year the (significantly) larger decrease was due to more children reaching the end of the 2-year transitional Medicaid coverage. Ms. Ciarcia stated that enrollment increases have been offset by retention problems. The Department has taken numerous steps to reduce the renewal process problems, including:

• Improve communication to enrollees: discontinuance notices now include the HUSKY toll free # (4/00), earlier notice to families about the pending CE period end (spring 2001), notice to the family's MCO for follow up, personal follow-up by Benova for those who do not return the renewal forms, implementation of a streamlined form (spring 2001).
• Improve regional DSS staff training (12/00) and policy clarification, simplified HUSKY A/B referral process (4/00).
• Program changes: re-ordering of coverage group hierarchy from more to less restrictive criteria, PE (10/00), adult expansion (1/01).
• Tracking/outreach: 34,000 letters sent to families that lost or were denied eligibility since 6/1/98, with 586 re-applications received, new reports to identify children that have lost HUSKY A, may qualify for B (4/01).
• Technical assistance from HRSA COMPCARE to develop geographic tracking/outreach and trend analysis, and prospective RWJ grant to diagnose problems and resources for implementation of corrective action measures.

Since a great deal of information was presented by DSS related to outreach and the decreasing enrollment in July, the Council had limited time to discuss the topic at this meeting. Further discussion was requested at the December Council meeting. Specific questions were asked:

• Rep. Nardello questioned that if 55,000 applications were received and there were 22,000 new enrollees, what happened to the other 30,000 applicants? Ms. Ciarcia stated that some were denied HUSKY coverage: 33% did not complete the income verification part of the application process.
• Has the Department considered allowing self-report of income? Kevin Loveland (DSS) stated that the Commissioner of DSS has expressed interest in looking into the feasibility of passive registration (income self-report); however income verification still needs to be done to fulfill the HCFA requirements. This can be done after enrollment.
• What is the scope of the MCO marketing to members who are nearing the end of their enrollment period? Ms Ciarcia stated that Managed Care Plans can market HUSKY only to their members that are approaching the end of their renewal period; global marketing would not be done by individual plans.
• Rep. Nardello stated that effective outreach include:

• School-based integration of HUSKY outreach and requested DSS provide feedback on this effort at the December meeting.
• While mass marketing outreach is important, it is time the State think about more targeted outreach to specific populations.

• Senator Harp requested more information from DSS about regional staff training: who will do this, how will it be done and what will be planned for post training follow-up.

Senator Harp thanked the Department for the information presented and requested that DSS present the following information at the December meeting:

• Presumptive Eligibility process.
• HUSKY outreach through schools and the SBHC grant outcomes.
• DSS plans for the adult HUSKY expansion that will be implemented January 1, 2001.
• There be a more in depth discussion by DSS and the Council about HUSKY access issues in December.

Senator Harp encouraged those interested in access issues to participate in the Council's Consumer Access subcommittee, chaired by Ellen Andrews.

Subcommittee Reports

Behavioral Health Subcommittee: Jeffrey Walter reported that the subcommittee has completed two Forums:

• Six provider-training sessions were held for the BH outpatient Outcomes study. There was modest attendance at these training sessions and data (pre-post treatment) is slowly being submitted. Mr. Walter expressed concern about provider participation in this important study and the subcommittee will work with DSS, DCF, providers and health plans to complete this study being done with Yale University.
• Two BH Administrative Forums were held in October that addressed the issues of billing and authorization of services (raised earlier in this meeting). The subcommittee will follow up on `next steps' identified at the Forums that include continued staff education and administrative system issues.

Consumer Access: Ms. Andrews reported the subcommittee would be reviewing draft language related to a recommendation to DSS regarding the assessment of HUSKY outreach.

Quality Assurance: The subcommittee will host a HUSKY Asthma Administrative Forum on Friday November 17, 8: 30-12: 30 at the LOB. Sen. Harp and Commissioners Joxel Garcia, M. D. , DPH and Patricia Wilson-Coker (DSS) will participate.

Senator Harp thanked the Department of Social Services for their continued support and participation in the Council subcommittees.

The Senator reminded the subcommittees to consider legislative proposals for the 2001 session in December.

The next meeting of the Council will be on Friday December 15, at 9: 30 Am in RM 1D.