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 12, 2001

Council members present: Sen. Toni Harp (Chair), Rep. Vickie Nardello, Thomas Deasy (Comptroller Office), Gary Blau (DCF), David Parrella, Rose Ciarcia (DSS), Dr Edward Kamens, Dr. Wilfred Reguero, Patrick Carolan (Benecare), Judith Solomon, Janice Perkins (Health Net), Jeffery Walter, Lisa Sementilli-Dann.

Also Present: Rep. Toni Walker, Jack Huber (Qualidigm), Deborah Hine (Anthem BCFP), Mark Scapellati (CHNCT), Tejas Patel (FirstChoiceCT), Don Toper (CompCare), Jody Rowell (CGC), Jesse White Fresse (FQHC), Mark Schaefer, James Linnane, Charlene Casamento (DSS), Paula Armbruster, Mariette McCourt (Council staff).

Department of Social Services Report

David Parrella announced that two experienced staff from the HUSKY division, James Linnane and Adele Kusznitz, would be leaving the Department November 1, 2001. Mr. Parrella stated they are valued members of the HUSKY program and will be missed by DSS. Senator Harp presented Mr. Linnane and Ms. Kusnitz with legislative citations recognizing their dedication and diligence in working with the Medicaid Managed Care Council. The Council applauded their work in the HUSKY program and with the Council and subcommittees.

Claims Resolution

PROBH Payment Resolution

Both Health Net and FirstChoiceCT/Preferred One summarized the status of the PROBH run out claims for behavioral health services that is now completed.

• FirstChoiceCT/Preferred One: Tejas Patel reported that since September 13^th, 6,117 pre-March claims received prior to 8/15/01 have been adjudicated. The last batch of checks is being processed now. Approximately $ 1. 5 million has been paid out for the total run out claims.
• Health Net: Janice Perkins reported that there has been a gradual decrease in run out claims since July 2001 (945 claims) to October 2001 (173 claims). All but 133 claims, which came in after October 4, have been processed. Outstanding claims payments to 29 facilities have been reconciled; Health Net is working with 2 remaining facilities to complete the reconciliation process. Janice Perkins stated she is pleased that this concludes the PROBH runout claims issue.

HealthRight Outstanding Claims Resolution

The Department has responded to a Hartford law firm representing HealthRight in residual business issues to inform them the Department will not release the termination withhold funds until the law firm informs DSS on how they will resolve the remaining universe of HealthRight claims sent to them. The Department has received $ 300,000 in outstanding claims for all services. The termination withhold amount is $ 100,000.

Managed Care Reimbursement of Medical Admissions for Children's Psychiatric Diagnoses

Follow up on HUSKY MCO reimbursement for ED holds over 23 hours and medical unit placement of children with primary psychiatric diagnoses (September meeting):

• FirstChoice/Preferred one confirmed that payment is made for medical /ED placement. The diagnosis, procedure codes are followed up with the main MCO and behavioral health subcontractor to determine which entity reimburses the stay. Don Topor (CompCare) stated that the BH subcontractor pays all BH claims. If a psychiatric bed is unavailable, then payment should be made until the specialty bed is available. These claims are identified in the claims system.
• Health Net, CHCT and ABCFP will report in November on their reimbursement policy for ED and medical unit stays and what the bed rate is based on, either the behavioral health rate or the med-surg bed rate.

Senator Harp stated that the hospitals' concern is the relationship of the ED payment (beyond the 23 hour hold) to comparable hospital overnight rates. If there is a claims system in place, then it is important to obtain the claims data from this system to track utilization and payment of primary psychiatric children's medical admissions, including ED stays, as hospital staffing in the ED and pediatric medical units is affected by the psychiatric inpatient stays on medical units or in the ED.

HUSKY A & B MCO's Timely Claims/Interest Payment Reports

David Parrella stated measurement of timely claims payments, requested by the Council in the past, was to be addressed by Mercer's assessment of the encounter data. However, Mercer determined that encounter data is not the best nor most accurate way to assess this issue. The new MCO/DSS contract now includes MCO/subcontractor claims reports that Charlene Casamento, CPA,from DSS is organizing. Ms. Casamento provided an overview of the report objectives and format, welcoming the Council's input to the process:

• The objective of the reports is to quantify the volume and dollar amounts of claims for the main MCO's and their subcontractors that include pharmacy, dental, vision and mental health. In addition the reports will assess claims turn around time and plan's adherence to the timely payment standards. These quarterly reports are due to DSS 45 days after the close of the quarter.
• The Department and the MCO's have been designing the report format since June 2001 and will develop guidelines for standardized reports in November after internal review and input from the MCO's, Council and subcommittees. The reports include:

• Claims (in dollars) in process during the quarter and unpaid adjudicated claims.
• Claims (volume) inventory of those in process, those not yet adjudicated, those adjudicated claims but the check has not been cut.
• The number of paper and electronic claims processed within specific time periods (i. e. 0-31, 31-45 days, etc). The separation of paper/electronic claims addresses the probable differences in the efficiencies of the claim submission process.
• Claims volume over 45 days and interest payments made for these claims.

Ms. Casamento stated that this reporting format provides the Department with vendor- specific information at a given point in time that had not previously been available. Since all of the subcontractors may not have signed a contract with an MCO by August 2001, it may take several reporting cycles to obtain the full claims information.

Questions from the Council participants reflected the importance of the guidelines the Department and MCO's will be developing:

• The receipt date for incomplete claims sent back to the provider will be the receipt date of the completed claim to the MCO/subcontractor.
• When a claim denial results in an appeal, the receipt date will be the date of the appeal decision, starting the 45-day time clock.
• These reports are based on the premise of appropriate accepted/denied claims. Inappropriately denied claims cannot be captured in these reports: this should be addressed to DSS through other avenues for resolution.

The Department invited Council input as to the format of the reports that will be given to the Council. Senator Harp suggested the Council subcommittees consider this, with recommendations to the Council. Senator Harp commended the Department for their work in this area and the Council looks forward to these important reports.

HUSKY Enrollment & Presumptive Eligibility (PE)

The PE Qualified Entities now include School Based HC, Federally Qualified HC, Head Start Providers, CCHI (HUSKY outreach grantees)/Healthy Start, State-funded Child Care Centers and WIC programs. David Parrella and Rose Ciarcia (DSS) reviewed the number of PE cases from 1/01-9/30/01:

• Total number of PE cases: 2,990
• Number granted ongoing eligibility: 1,341
• Number denied: 1,145
• Unreturned HUSKY application: 504

In response to questions as to the reason for the number of denied applications, Ms Ciarcia stated that

• Follow up does occur both through the regional CCHI in conjunction with the qualified entities outreach staff and the PE staff in the central DSS office.
• During this early PE period, income verification was required; as of July 1, 2001 legislation has allowed DSS to accept self-reported income. This has often been cited as a barrier to HUSKY enrollment, therefore it is expected there will less application denials. Ms. Ciarcia stated it would be useful to look at denial trends before and after the change in income reporting.

HUSKY A enrollment is now at 248,359. There was an increase of 1,828 HUSKY A's (493 children and 1,520 adults) and 493 B's in September 2001, attributed to the Enrolling Kids program and the media campaign that placed ads at prime TV times. Overall growth in children's enrollment from 7/1/98 to 10/1/01 was 20,909, adults, 6,637. Adult growth was the most significant in September, while children's growth averaged 567/month during 7/98-8/01 and 493 in September 2001. The Department stated that increased adult enrollment may reflect the economic downturn and the 1/01 inclusion of adult caretakers of HUSKY children at 150% FPL. HUSKY B enrollment is nearing 10,000 as of 10/01 (9,757), with an average monthly growth of 228. 3 in 2001.

Managed Care Network Capacity Report

The Department monitors MCO capacity, based on pre-determined member/provider-type ratios. If a plan exceeds the ratio by 90% in a given county, plan enrollment is frozen until the enrollment cap is below 90%. (The new DSS. MCO contract applies a financial sanction to a health plan that does not correct the provider access problem reflected in the ratios).

The report shows that:

• There is additional capacity for HUSKY enrollees/provider in each of the eight counties, with Hartford and Fairfield showing the greatest potential capacity and Middlesex, Tolland and Windham the least. Each of the Health plans has a degree of excess capacity in each county. Several health plans in Middlesex County have minimal excess capacity (FirstChoice, CHNCT) and Windham (Firstchoice, Health Net and CHNCT). {In the 12/00 network capacity report, ABCFP was at 92. 4% capacity and HN was at 86. 6% in Windham, ABCFP at 80. 8% in Hartford, and FirstChoice at 1028% in Middlesex county}.
• Each of the four MCO's has additional overall capacity, with CHNCT and FirstChoice showing the greatest excess capacity (beyond the current enrollee/provider ratios).
• ABCFP enrollment capacity and enrollment by County as of 10/01 shows the MCO has capacity for more members/providers.
• The highest reported enrollment caps (over 75%) per provider type are in:

• Children's providers in Hartford @ 77. 45%.
• Dentistry in Hartford @85. 21% and New Haven @ 88. 12%.

Council questions:

• Within the EDS provider database is there a process in place to sample providers to determine if Medicaid providers are taking new patients? The Department stated there is no sampling, as provider ability to take new patients changes weekly. Deborah Hine (Anthem BCFP) commented that the health plan does sample provider groups regarding ability to take new patients and appointment wait times, recognizing that access can frequently change.
• There have been reports of delays as long as 3 months in securing follow up appointments. Ms. Hine responded that the plan follows up on complaints from members and that delays are related to the type of service (i. e. appointment with a child psychiatrist has the longest wait time).
• Based on the Children's Health Council CHIL Infoline calls, MCO member services provide members with a list of providers. Members report that they encounter long appointment wait times or a listed provider that no longer takes Medicaid clients when they contact providers. The health plans were encouraged to update the member service provider list more frequently.
• While reassured that there is an adequate number of providers in the HUSKY program, Senator Harp questioned if we know that enrollees actually have access to care and is Qualidigm looking at this? David Parrella stated that the Consumer surveys, done annually by each HUSKY MCO, addresses questions about access to care, timely appointments. These reports should be available after January 2002.

Medicaid Council Quarterly Report

The report was accepted with the addition of James Linnane's comments (DSS) about the Northeast Regional Psychotropic study in progress, of which CT is a participant.

Subcommittee Reports

Behavioral Health: Jeffrey Walter reported that:

• A coordinator, Judith Jordan, has been hired by DSS and there will be continued monitoring of the Behavioral Health Outcomes study.
• A report of a collaborative project between Anthem BCFP and Wheeler Clinic on the integration of behavioral health and Primary Care suggests, in the preliminary data, that there can be an impact on hospitalization through early intervention/prevention by psychologists on site in Pediatric offices. The subcommittee recommended the report be presented to the Council when ore data is available.
• Behavioral Health subcontractors have begun to report on the reimbursed non-traditional services provided to the HUSKY population. The subcommittee will convene a working group of MCO's, providers, DSS and DCF to more clearly define the services and reimbursement codes.

Quality Assurance: Paula Armbruster reported that:

• The subcommittee is addressing adolescent health care issues, based on the Qualidigm report and as a collaborative effort with the Children's Health Project of the CHC.
• The asthma work group and MCO/provider asthma group have requested the Council consider a recommendation for approval. The recommendation requests the MCO's to identify pharmacy/DME vendors within New Haven and Waterbury that carry all of the basic asthma items, including dust mite covers, nebulizers and accessories and spacers. Indentification of these vendors is important to facilitate health providers and their patients access to these items at one site. This information will be reviewed by the subcommittee work groups, which include the 4 HUSKY MCO's, to determine the feasibility of further surveys of vendors in other geographic areas. Consideration of the recommendation was moved by Patrick Carolan, seconded by Rep. Nardello: the recommendation was approved with no abstentions, as amended with a change of the MCO reporting time from November to December.

Public Health: Representative Nardello reported that the subcommittee reviewed the Hartford dental utilization data; it remained unclear if the decline in Hartford utilization reports was related to data issues and /or a decline in dental participation in HUSKY in this area. Dr. John Shaw will survey Hartford dental providers regarding their participation and/or changes in participation in the HUSKY program. The results of the survey should be available for the November (26^th) subcommittee meeting.

The Medicaid Council will meet on Friday November 16, 9: 30 AM in LOB RM 2D (please note the room change). The Department of Social Services agreed to defer their report on the HUSKY B managed care contracts to the November meeting.