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

November 16, 2001

Present: Sen. Toni Harp ( Chair), Rep. Vickie Nardello, David Parrella, Charelene Casamento (DSS), Gary Blau (DCF), David Guttchen (OPM), Robert Gribbon (Comptroler's Office), Marie Roberto (DPH), Phyllis Rotella-Soderberg, Dr. Edward Kamens, Lisa Sementilli-Dann, Ellen Andrews, Janice Perkins, Patrick Carolan.

Also present: Deborah Hine (ABCFP), Sylvia Kelly (CHNCT), Tejas Patel (Preferred One), Donald Topor (CompCare), Chet Brodnicki(Child Guidance Clinics), Jack Huber & Paula Doyle (Qualidigm), Dorothy Gomez (PH staff).

Department of Social Services

Overview of HUSKY B Contracts

HUSKY B, Connecticut's Title XXI (SCHIP) program, is a stand-alone health coverage program for children <19 years that is based on the State employee program benefits. HUSKY B is a non-entitlement program for children at or above 186% FPL: copays are required based on income level and full premium payments are required for family incomes above 300% FPL. Two programs for children with special needs (HUSKY Plus Physical and Behavioral Health) augment the HUSKY B benefit coverage; however children above 300% are not eligible for the Plus coverage. As of November 1, 2001, HUSKY B enrollment exceeded 10,000 members and the four HUSKY A health plans now participate in HUSKY B. HUSKY B capitation rates mirror the Medicaid HUSKY A rates,

David Parrella (DSS) reviewed the key components of the DSS/MCO HUSKY B contract. Although the program has been in place since July 1998, this is the first formal contract between DSS and the health plans. David Parrella (DSS) reviewed the key components of the DSS/MCO HUSKY B contract:

• The contract provisions clearly define the HUSKY B benefits in relation to the Plus programs, benefit limitations, Durable Medical Equipment, identification of those services for which prior authorization is prohibited as well as those services (preventive) excluded from copayments.
• MCO's must have written procedures to identify special needs children, inform parents of the Plus programs, coordinate care with the Plus program with, at minimum, monthly conferences and participate in the development of the child's global plan of care with the Plus team. HUSKY B benefits identified in this plan must be exhausted first before the Plus benefits are used. Failure to comply with the provisions can result in a Class A financial sanction.
• Health plans may use pharmacy formularies that are subject to DSS review and changes. Unlike HUSKY A,

HUSKY B does not provide a temporary supply of non-formulary drugs at the prescribing provider's request.

• Past CT mental health parity legislation, implemented earlier in HUSKY B, is part of the contract; however parity does not apply to mental retardation or other conditions not defined in the DSM IV manual. Mental health service coverage is offered to the same extent as medical services (i. E 100% inpatient, $ 5 copay for outpatient services). The benefit limitations include:

• 30 outpatient visit limit with some copayments for the 11-30th visit.
• Maximum 60 inpatient days exchangeable with alternative levels of care.

• Comprehensive coverage of well-child visits (including vision & hearing screens, dental assessments and immunizations) are based on recommendations of the American Academy of Pediatrics. HUSKY B coverage does not include all the Medicaid EPSDT parameters.
• MCO's must have a tracking system in place for member cost-sharing contributions, reimburse families for overpays and give advance notification to families of premium payments due date and the consequences of non-payment (disenrollment and 3 month lock-out for services). The MCO must inform Benova of the member's overdue premium payments that were associated with the disenrollment.
• The client appeal process includes an MCO Internal Appeal Process, written service denial notices & explanations to members, member information about the internal expedited review of the member's appeal and the Dept of Insurance external appeal process and filing procedures.

Mr Parella outlined similarities in the HUSKY A & B contract provisions that include:

• Use of the prudent laymen's definition for access to emergency services.
• Inclusion of timely provider payment criteria (I. E. 45 days).
• Same MCO claims reporting format to DSS.
• Performance bond or payment withhold requirements for Behavioral Health and Dental subcontractors.
• Provision for contract termination payment withhold for those subcontractors with risk-based contracts in which the subcontractor is responsible for claims payment.
• DSS definitions of medical necessity & medically appropriate must be included in all subcontracts.
• Same provider credentialing criteria, statewide coverage requirement, monthly submission of updated provider files to Benova and a separate abortion contract to meet federal payment criteria. State funds will reimburse for abortion services outside the federal limits.

There are differences in the HUSKY B contracts, primarily because it is not a Medicaid entitlement program, including:

• Benefit limitations (I. E. vision services, number of outpatient MH visits).
• No 30-day tempory supply of denied drugs deemed necessary by the prescriber.
• Well child visit criteria based in AAP recommendations rather than Medicaid EPSDT guidelines.
• Member cost-sharing that is prohibited in Medicaid programs.
• Use of the Dept of Insurance external appeal process rather than the DSS internal process.
• Quality assessment through standardized utilization reports twice yearly rather than encounter data reports in HUSKY A. Plus program utilization reports are submitted quarterly.

Sen. Harp thanked the Department for this report. David Parrella will provide the Council with the HUSKY B utilization reporting format at the December meeting.

HUSKY Managed Care Organization's Follow Up on Child Psychiatric Admissions

The Council requested information from the HUSKY MCO's regarding their individual policy of reimbursing hospitals for medical admissions/ED holds and the parameters of that reimbursement. Each of the four plans stated that reimbursement is tied to the individual contract between the hospital and the health plan. If there is a contractual obligation to pay for ED observation rooms or Pediatric medical admissions for a primary psychiatric diagnosis because of lack of children's psychiatric bed availability, then a psychiatric bed rate is paid. Two of the MCO's (Health Net and CHNCT) commented that they have not received provider complaints from their Provider Appeal units and questioned if this is a problem.

Sen. Harp responded that hospitals have identified this as a problem in addition to the lengthy wait time for authorization for inpatient treatment .

The health plans (Health Net & ABCFP) commented that medical admissions for a psychiatric diagnosis is a complex problem that involves reimbursement to hospitals that have psychiatric care in place to meet the temporary care needs until an inpatient bed is available as well as children's psychiatric bed capacity. Sen. Harp stated that medical placements for psychiatric diagnoses are a huge problem for hospitals and ED's with ultimately a serious negative impact on the child and family. The Senator suggested that all the health plans join the children's psychiatric bed working group to attempt to collaboratively find solutions to this complex problem.

Senator Harp requested DSS to make data available on existing claims for ED holds of HUSKY enrollees and frequency of hospital admissions of these children. Mr. Parrella agreed to look at this, noting that it may be difficult to identify ED holds as they may be coded under medical admissions or observation hold.

Medicaid State Plan Amendment: Breast & Cervical Cancer Treatment

State Plan Amendment (SPA) No. 01-009, effective 7/2/01, provides full Medicaid benefits to women under 65 years, regardless of income who:

• Have been screened for breast or cervical cancer under the CDC Prevention's National Breast and Cervical Cancer Early Detection Program where clinical services were provided by all or in part by the CDC Title XV funds.
• Require treatment of breast or cervical cancerous or pre-cancerous conditions.
• Do not have insurance coverage.

Presumptive eligibility begins on the day the determination for treatment is made. A one-page application that includes the CDC-funded site, evidence of a positive test, date of birth, and self-disclosure of lack of health insurance. The application is processed through the DSS central office in one day. To date over 50 women have been enrolled in this Medicaid fee-for service program, with the expectation of a maximum enrollment of 100-150 women.

Council questions included:

• The length of Medicaid coverage, which is based on the course of treatment of about 5 years; however coverage would be extended upon health provider verification of the need for further treatment.
• Screening is done based on CDC program criteria, which may include age restrictions related to mammography. DSS does not establish the program protocols, rather covers the cost of care.

Other questions for DSS

Rep. Nardello requested DSS provide information, including the project evaluation process that will be the basis for replication, on the dental projects funded with $ 500,000 (DPH budget) made available December 2000. Mr. Parrella stated that two projects, developed in collaboration with UCONN are being funded:

• The West Haven project pays dentists for restorative care provided at the University of New Haven.
• A private practice site in Hartford.

Benova Report

William Diamond reported on the upward trends in HUSKY A and B enrollment since July 2001, with the most significant enrollment increases from September through November 2001:

Benova call volume for information and phone applications has also increased, averaging 1000 calls/day compared to previous levels of 800-900/day.

The enrollment increases are attributed to:

- Outreach initiatives that include school lunch programs, the DSS grant efforts (CCHI), the media initiative supported by the Robert Wood Johnson Foundation.

- DSS policy changes that include the parent expansion to 150% of 1/01/01, self-declaration of income on applications begun July 2001, decrease in the HUSKY B crowd-out (uninsured) period from 6 months to 2 months, and expanded presumptive eligibility qualified entities.

- Economic changes related to the September 11 terrorist attacks, job losses and high COBRA payments, raising medical inflation and double-digit insurance premium costs that are, or will be passed on to the employee through increased copays.

Council questions/comments:

• Can we serve families that are or will be faced with escalating insurance premiums? Mr. Parrella stated there is no crowd-out (uninsured) waiting period for HUSKY A, so children up to 185% FPL income and parents up to 150%FPL income are eligible at any time. There is the 2-month crowd-out waiting period for children at incomes above 185%FPL (HUSKY B).
• Is the Department tracking the impact of the recent increases in enrollment on the DSS budget? Mr. Parrella stated that the budget estimates do not reflect the surge in enrollment over the past three months. It is expected that the demand will level off; the trend will be more apparent in December. If the increasing enrollment trends persist, there will be an impact to the budget.
• Since HUSKY is a public safety net program, can CT receive any additional federal funding related to September 11 funds, based on expanding enrollment? Mr. Parrella commented that every state Medicaid program has deficiencies, some of which have been exacerbated by the September 11 events. High impact states would like more federal support through a temporary increase/stabilization of the federal match rates (FMAP), which are currently set to be deceased based on a state's two year past spending history. Connecticut has a low match rate of 50% compared to other states with enrollment problems that receive 70-75% FMAP.

DCF Draft Psychotropic Drug Guidelines

Dr. Patricia Leebens reviewed the need for and the proposed DCF drug guidelines with the Council to request involvement of the Council and the HUSKY managed care organizations in the process as the development of the guidelines moves forward.

Over the past several years there has been a marked increase in the use of psychotropic drugs for children and adolescents, in particular prescriptions for multiple drugs (polypharmacy). Dr. Leebens outlined the challenges in managing mental health care, including medications, for medically complex children, especially for those DCF-committed or in foster care, which prompted the formation of a multidisciplinary DCF Psychotropic Drug Advisory group that has developed draft guidelines for drug use and monitoring.

The trend in reliance of psychotropic drug utilization as a cornerstone of treatment is complicated by the rapidly changing clinical practices in child psychopharmacology and the increasing medical, behavioral and social complexity of foster care and DCF-committed children in a overburdened and compromised mental health system.

Increasing medication utilization is attributed to:

- Increasing survival rates of fragile infants that have or may develop complex medical and psychiatric problems as well as the numbers of children suffering the negative effects of toxic social situations, requiring chronic treatment.

- More research on child psychopathology and the FDA approval of `safer kid drugs'.

- Managed Care pressure for shortened hospital stays and reimbursement for "active" (medication) treatment as reimbursement for therapy declines.

Challenges of DCF/foster children treatment include:

- Increasing rates of medical and psychiatric conditions and co-morbidity disorders within the population.

- Exacerbation of psychiatric illnesses from social factors (I. E. trauma, neglect, abuse).

- Inadequate information of the child's past history as well as lack of continuity of care and education related to the child's multiple re-locations/caregivers in the setting of often complex living arrangements.

- Psychiatric symptoms may compromise treatment in the absence of consistent caretakers and treatment oversight.

System problems include:

- Difficulties accessing child psychiatry, although CT ranks 5th in the ratio of child psychiatrists per 100,000 children.

- Service `gridlock" throughout the mental health system.

- Inadequate oversight of mental health and medical services for children in the child welfare system.

- Inadequate educational, mental and physical health services, and housing for this special population.

- Inadequate spectrum of treatment options and safe housing that results in medication "containment" of the child.

The above circumstances result in problems of:

- Excessive/inappropriate polypharmacy and/or abrupt discontinuation of drugs, which lead to serious medication side effects, exacerbation of psychiatric symptoms.

- Avoidable excessive medication costs.

- Increasing health care access problems as fewer medical professionals can accept children with complex, difficult-to-manage medication regimens.

- Over-reliance by caretakers/youth on medication with decreasing personal efficacy in managing complex or serious disorders.

- Conversely, societal biases against any medication contribute to hospitalizations and possible out-of-home placements.

The DCF Advisory group, led by Dr. Adele Martel and comprised of Pediatricians, APRN's, child psychiatrists, DCF mental health program directors and pharmacists, have drafted guidelines that address:

- Symptom and medical evaluation tests at baseline and during medication treatment.

- Assessment of the efficacy of the medication trial.

- Patient compliance and changing circumstances across the various domains of the child's life.

- Family education regarding the medication that is directed toward targeted symptoms.

- Planned discontinuation of medications, identification of effective maintenance dosages.

The purpose of these guidelines is to support practitioners who work with special needs children, to guide rationale treatment of children and inform DCF supervisors that must approve treatment for the DCF-committed child. Recently, child psychiatrists and pediatricians met to begin working on a collaborative approach to children's psychotropic treatment.

Senator Harp and Rep. Vickie Nardello commended Dr. Leebens and the Advisory Group in addressing the serious and difficult problems in treating children with complex health needs. The extent and impact of polypharmacy is astounding when individual cases are described. Janice Perkins (Health Net) commended Dr. Leebens and DCF and requested that the MCO's be included in future guideline developments so both providers and health plans can work together.

The Council would like to be kept informed of the progress of the Advisory Group.

The December Council meeting is scheduled for Friday December 14 at 9: 30 AM in LOB RM 1D.