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 14, 2003

( Next Meeting:  Dec. 19 at 9:30 AM  in LOB RM 1D)

Present:  Sen. Toni Harp (Chair), Rep. Villano, David Parrella & Rose Ciarcia (DSS), Jeffrey Walter, Dr. Henry Goldstein, Dr. Victoria Niman (DCF), Dr. Ardel Wilson (DPH), Thomas Deasy (Comptroller’s Office), Terry Nowakowski (DMHAS), Dr. Edward Kamens, Dr. Alex Geertsma, Kim Turner for Rev. Bonita Grubbs.

Also Present:  William Diamond (ACS), Dr. Mark Schaefer (DSS), Martha Okafor (DPH), Chet Brodnicki (Child Guidance Clinics), Deb Poeia (FQHC’s), Judith Solomon, Sylvia Kelly (CHNCT), Paula Smyth (Anthem BCFP), Naida Arcenas (DCF), Joan Morgan (Preferred One), Council staff.

Department of Social Services

HUSKY Program Changes

The DSS reviewed the program changes and expected implementation dates:

*Note: Pharmacy or outpatient services cannot be denied to recipients for failure to pay co-pays

Service carve-out updates:

·             Dental services to HUSKY A, B and Medicaid FFS recipients is planned for 7/1/04. 

·             Behavioral health services could potentially be carved-out in July 2004.

Medicaid eligibility groups were outlined in the DSS handout (see attachment A).  The DSS stated that traditional Medicaid services defined by federal regulations (i.e. EPSDT) would need to be retained for mandatory populations under a Health Insurance Flexibility & Accountability (HIFA) Sec 1115 waiver.  A list of Mandatory versus optional services were also included in the handout (see attachment A).  States determine the optional services that will be provided through their Medicaid State Plan.

The Department was asked to identify services currently provided that MAY not be covered under the State Employee-POE (SE-POE) benefit package {for HUSKY A recipients}:

·             Medical Equipment/supplies including eye glasses, wound care supplies outside of home health, incontinence supplies

·             Intermediate Care Facility/MR

·             Long-term care

·             Non-Emergency Medical Transportation

·             Over-the-Counter Drugs

·             EPSDT including case management, interperiodic encounters, screenings in excess of those in the periodicity schedule, Personal Care Services, appointment-scheduling assistance.

This list does not reflect what would ultimately be excluded in covered services in a final plan.

The Department was asked to provide PROJECTED co-pay costs for HUSKY A and B under the benefit restructuring legislation.  HUSKY A benefits would be substantially similar to the SE-POE plan and HUSKY B benefits would be substantially similar to the largest State commercial HMO plan. The following provides a summary of the PROJECTED co-pays:

* PCP visits for preventive care do not require co-pays.

** A family’s total yearly health care cost sharing including premiums cannot exceed 5% of the family’s gross income and co-pays are capped at $760/year.   Families that have children with high health care needs as compared to the family with a basically healthy child may reach the co-payment cap earlier.  The MCO will identify when the family reaches the yearly capped co-payment level and inform the provider that for the remainder of that year the family is not liable for any further co-pay costs.

Key questions/discussion related to this information included:

Ø      Under the HUSKY B chronic illness scenario, is the provider at risk for the loss of co-pays beyond the cap?  The DSS stated that the provider and MCO would need to consider this in contract negotiations.  The client cannot be billed for the co-pays beyond the capped amount.

Ø      The State may remove children with special needs (CSHCN)  from the commercial-like benefit package in the HIFA waiver or place them in the PLUS wraparound program.

Ø      Are dual eligible recipients (Medicare & Medicaid) exempt from the current co-pays?  The DSS stated only adults exempted from co-pays by federal regulation ( institutionalized) are exempted; otherwise co-pays apply to the dual eligibiles.

Ø      Without a waiver, premiums cannot be applied to those in the “categorically needy” group (i.e. newborns, pregnant women, children, TANF recipients, SSI) but can be imposed on the medically needy category recipients (includes those >65 years and/or the disabled).  Within this category individuals that exceed the income and assets of the mandatory population become eligible for Medicaid once their medical expenditures over 6 months meet the medically needy income limit (MNIL).  Premiums will also be imposed on those in the “zero spend down” category (eligible for Medicaid based on income, not medical expenditures).  The State estimated this legislative mandate would impact 25,000 individuals; however some of these recipients should actually be classified as categorically needy, thus exempt from the premiums (without a waiver).  The DSS is evaluating this.

Ø      The DSS expects to apply for a HIFA waiver in the 2004 summer and possibly implement an approved waiver in July 2005.  This time line is probably overly optimistic as two CT Sec 1115 waivers have been waiting for CMS approval for about 1.5 years from the time of final submission. While there is no indication that CMS may delay approval of state HIFA waivers, two other CT cost containment waivers have not yet been approved.

Ø       The Department commented that the Centers for Medicare & Medicaid Services (CMS) is under scrutiny from the federal OMB to contain costs in their programs in the face of federal deficits related to the economic downturn, the pending $400 billion Medicare program revision, the war costs.  Therefore CMS is scrutinizing states’ funding in relation to appropriate leveraging of federal match, looking for evidence that states are taking advantage of loopholes or duplication of federal matches.  The CMS is revisiting states’ waiver configurations and more closely assessing new waivers.  The CMS approach of identification of and reduction of state-level abuses and spending could remove states’ need for continued enhanced state federal matches. The enhanced FMAP is available to states until July 2004 and while the National Governors Association may request an extension to this enhanced match, it is unclear if this would be granted.

DSS/MCO contracts have been extended through November 2003 and may require another extension through December as the State waits for final CMS approval of the fiscal soundness of the rates.  The Department is going forward with rate adjusts that reflect the new/increased co-pays for HUSKY A adults. 

Dr. Mark Schaefer (DSS) reviewed the Behavioral Health Partnership (BHP) status. The Office of Policy Management (OPM) and the three state agencies have provided answers to legislators’ questions, which will presented at the legislative/public meeting Wednesday December 17, at 1:30 in the LOB RM 2A.  The discussions will include concepts on alternative rate structures and the inclusion of adult FFS in the BHP.  The DSS was asked to explain the BH data discrepancies and how the BH subcommittee could work with DSS & BH MCOs in improving data reporting.  Dr. Schaefer stated that the Mercer (State Actuarial contractor) is re-analyzing the projected costs of the BHP program policy changes.  While current baseline data does not indicate excessive costs thus keeping the goal of cost neutrality, more recent 2003 data is being used in the re-analysis.

One preference, according to the DSS, is to carve-out BH HUSKY services prior to the implementation of the HIFA waiver, thereby creating a broader benefit than what is in the SE-POE benefit plan (i.e. home-based intensive BH services).  The DSS, DCF, BH MCOs and providers have developed a uniform Prior Authorization and reimbursement process for these services.

Senator Harp spoke of the legislature concerns about linking adult mental health services to the BHP.  While there is support to carve out children’s services and support KidCare, there must be careful assessment of the impact of the BHP on inclusion of appropriate adult services and realistic funding that does not create infrastructure instability nor do harm to patients.  Connecticut is the first state to bring child and adult mental health programs together in a statewide initiative.  The financial and program impact of this has not been clearly identified.

HUSKY Enrollment: November 1, 2003

                                            Enrollment Summary November 2002-November 2003

Over the past month:

·             Total HUSKY A enrollment increased by 2,246 enrollees (603 adults and 1643 children).

·             HUSKY B enrollment decreased by 518.  ACS has attributed the November decrease is due to a backlog of applications as a result of implementing a new eligibility system.  ACS feels that

December enrollment will once again show an increase as a result of reducing the backlog of applications (information received after the 11/14/03 meeting).

Recent overall enrollment changes:

·             Overall Husky A enrollment numbers decreased by 11,615 members during June and July 2003 (4079 adults and 7536 children (>19).   

·             Enrollment for adults and children has begun to increase after July, with a gain of 7092 enrollees (2070 adults, 5022 children) in August through November 1, 2003. This increase represents approximately 61% of the total enrollment losses from June-July 2003 (67% of child enrollee loses, 51% of adults).

·             HUSKY B enrollment increased by 828 children from May through October 1, 2003.

Comments:

Sen. Harp noted that adult enrollment continues to increase and asked the DSS if the adults associated with the court appeal with earned income (16,000) and over the 100%FPL (new state eligibility level) remain in HUSKY A.  The Department stated there has been no court decision to date; these adult parents/caregivers remain in the HUSKY A  program.

The DSS stated that the process currently in place in HUSKY B Band 2 for non-payment of premiums will apply to Band 1: there is a 3 month health coverage lock out unless there is good cause reason for late payments.  The MCOs give families some leeway for late payments, (i.e. accept a member’s call that the payment is forthcoming), before notifying ACS.

Department of Public Health: CT’s Title V Children with Special Health Care Needs (CSHCN) Program

Dr. Ardel Wilson and Martha Okafor provided the Medicaid Council with an overview of the Department’s initiatives related to CSHCN.  There are approximately 120,000 CSHCN in Connecticut. The Federal Maternal Child Health Bureau (MCHB) established federal goals for the Title V program for CSHCN that include:

·             Family participation and satisfaction measurement,

·             Access to a Medical Home (defined as a community-based primary care practice which is accessible, family-centered, continuous, comprehensive, coordinated, compassionate and culturally competent),

·             Access to affordable insurance,

·             Early & continuous screening,

·             Easy-to-access community-based service systems,

·             Services necessary for children to transition to adulthood.

The CT DPH initiatives targeting these goals include:

·             An Internal Needs Assessment performed with key stakeholders.

·             Participation in a Medical Home Learning Collaborative, a partnership effort between MCHB and the National Initiative for Children’s Healthcare Quality (NICHQ).  Three practice sites are involved in the collaborative – St. Mary’s Hospital Children’s Health Center, Whitney Pediatric & Adolescent Medicine, in Hamden, the Pediatric Center of Stamford.  The key accomplishments of the collaborative include systems improvement to identify CSHCN in the practice, a standard screening tool to determine CSHCN in the practice, use of family surveys for suggestions to more effectively meet the family/child needs and the family’s level of satisfaction with the office visits, family health information, , and participation in the National Data Bank for the Medical Home project.

·             Assessment of Respite Care needs and impact on families with CSHCN and development of a tool kit for families and providers on quality Respite Care.

·             Development of a process that utilizes the Child Development Infoline (2-1-1) as a central portal entry point for CSHCN in CT.

·             Re-direction of the CT Title V programs through standardized contracts for the two centers (includes linkage to the Infoline, use of standard assessment tools, expansion of the Medical Home project to 7 new Pediatric PCP locations, continuous Quality Improvement projects that target specialty care coordination, and evaluation of family satisfaction).

 Next steps include:

·             Evaluation of the Medical Home Model

·             Development of CT specific medical home curriculum in partnership with the CT Chapter of the American Academy of Pediatrics (CT-AAP).

·             Evaluation of the CSHCN program

·             Development of a business plan to implement Integrated Local Systems of Care for CSHCN in Connecticut.

Senator Harp and Council members commended the DPH’s work in this important area.  It was noted that the DCF KidCare collaboratives have identified non-mental health chronic needs for children, which are outside the BH collaboratives focus; however this may be a source of information and linkage of services.  In addition to Infoline data, other sources of information that will inform the State about CSHCN are the Birth-to-Three- assessments, the Help Me Grow program, and the Title V centers information on co-morbidities.  The 2-1-1 Infoline is a resource for linking community-based services for both medical and non-medical needs.  The Council looks forward to future updates on the DPH progress on these creative initiatives.

Quarterly Council Report & Subcommittee Updates:

There was request for clarification about the carve-out for BH services in HUSKY related to the need for a 1915(b) waiver amendment versus a new HIFA waiver.  The report review was tabled until the December meeting when the DSS could clarify this.

Behavioral Health Subcommittee:  Jeffrey Walter summarized the activities that included:

·             Regular reports from DSS, DCF and DMHAS on the BHP and from DCF on KidCare evaluation reports,

·             Follow-up on the intensive home services uniform standards and BH MCO/provider contracts,

·             Formation of a pharmacy work group to address access to psychotropic drugs and develop recommendations to the Council to resolve problem areas, in collaboration with the DSS, DCF, MCOs, family representatives and practitioners.

Sen. Harp thanked Mr. Walter and the subcommittee participants for their diligence and work.

The Medicaid Council will meet Friday December 19 at 9:30 AM in LOB RM 1D.

DRAFT Comparison Table HUSKY B and Commercial Plan Benefits Tentative Implementation Date – 7/1/04
Benefit	HUSKY B	Plan 1	Plan 2
Prescription Drug	$3 Co-Pay generics; $5 Co-Pay oral contraceptives; $6 Co-Pay Brand	$5 Co-Pay generics; $15 Co-Pay listed Brand; $25 Co-Pay non-listed Brand	$10 Co-Pay generics; $20 Co-Pay listed brands with no generic equivalent; $35 Co-Pay non-listed brand
Dental	Plan Allowance: 100%: 6 mo. exam/service; $725 per orthodontia; $50 per procedure, $250 per year for crowns, root canals, dentures, extractions	Plan Allowance: $1,500 annual maximum 100% - exams, fluoride, X-rays 70% with $50 deductible/  individual and $150 deductible/family: fillings, root canals, steel crowns, extractions, oral surgery periodontics, repair dentures 50% with deductibles: crowns, post and core, inlays, onlays, prosthodontics	Not Offered
Vision	Plan Allowance: 100% covered - exams; $100 for lenses and frames / 2  yrs.	$15 Co-Pay per exam; Plan Allowance: $50 per exam; Frame $30 per year; Lenses $50 per year; Contact Lenses $80 per year	$15 Co-Pay per visit; Plan Allowance: Frame $50 per 24 months; Lenses 100% per year; Contact Lenses $75 / 2 yrs