Meeting Summary: December 16, 2005
(Next meeting: Friday, January 13, 2006 @ 9:30 AM in LOB RM 1D)

Attendance: Sen. Toni Harp, Rep. Vicki Nardello, Rep. David McCluskey, David Parrella & Rose Ciarcia (DSS), Janice Perkins (Health Net), Mary Alice Lee, Ellen Andrews, Thomas Deasy (Comptroller Office), Dorothy Pacyna (DPH), Dr. Victoria (Niman) Soovajian & Aurele Kamm (DCF), Dr. Alex Geertsma, Jeffrey Walter.
Also Present: Cuyler Massicotte, Hilary Silver, Dr. Mark Schaefer (DSS), Dr. Karen Andersson (DCF), Lori Szczygiel (ASO VOI), William Diamond (ACS), Dr. Larry Loeb (DSS Dental Committee Chair), Paula Smyth (Anthem), Sylvia Kelly, (CHNCT), David Smith (Preferred One), Chet Brodnicki (Child Guidance Clinics), Deb Poerio (School Based Health Centers) M. McCourt (Council staff).

The Medicaid Council recognized Dr. Victoria (Niman) Soovajian’s (DCF Medical Director) untiring efforts in improving services for DCF children in the State. Her compassion and thoughtful interventions will have a continuing positive impact on Connecticut’s children. Dr. Soovajian is leaving the central DCF office to assume responsibilities as the pediatrician for High Meadows program.

Department of Social Services

HUSKY A data reports
HUSKY A EPSDT
Hilary Silver (DSS) reviewed the HUSKY A EPSDT screening and participation ratios for the first-half 2005 compared to previous 6 month periods and comparisons by health plan (click on icon below for the report)

Observations & comments:
• EPSDT Screen/participation ratios

ü The overall screening ratio for the 1^st half 2005 is about 75%, similar to the same period in 2004; however the seasonality seen in the last half of the year related to school mandated physicals for certain ages, brought the rate up to almost 85% in 2004.
ü The participation ratio (the percentage of those that actually got a required well visit) remains below the federal goal of 80% at slightly over 60% overall in the first half of the year. There is about a 5% decrease in 2005 compared to 2004. DSS will break the participation ratios down by MCO to identify if this is an overall reduction or plan specific.
ü The screening ratio is significantly higher for younger children that require more frequent screens compared to children/youth 10 years and older. The preventive visits drop below 50% for the 10-14 year olds and 40% for the 15-18 year olds, yet these youth have the highest risk for preventable medical/mental health problems. Deb Peorio (SBHC) suggested the school physical requirements may need to be changed. Senator Harp noted this has been unsuccessfully attempted through legislation in the past but it is important to pursue again.

• Children receiving the recommended # of screens by age 15 months

ü Health Net had lower overall preventive (EPSDT) rates and lower % of children at 15 months that received the recommended of screens compared to other MCOs. Janice Perkins stated that the MCO’s internal QA review showed that 49.77% of children up to 15 months had the recommended screens in CY 03 and 54.48 in CY 04. The national average is 46.82. Health Net saw a drop in EPSDT screens and responded by revising their mailings to teens and families of younger aged children in July 05. The plan has increased feedback to providers on their preventive care rates to their patients.
ü Anthem and CHNCT had 50% or higher percentage of children that had the recommended number of well visits. CHNCT stated their outreach workers contact members the visit date and again if there has been no visit. Anthem provides telephone outreach and post card reminders for the preventive visits.
ü Sen. Harp noted the improvement in Preferred One performance. Mr. Smith stated that the plan has doubled their member outreach.

• Children ages 3-20 that received any Dental service remains basically unchanged at
< 35% in a 6 month period (optimal rate would be 100%/6 months based on two preventive dental visits/year).

• Percent of HUSKY members that received follow-up care within 30 days of discharge from psychiatric hospitalization for SFY 05:

*Data presented by DSS at 4/16/04 Council meeting

ü About 65% of members 0-12 years met the HEDIS measure; this decreased to 60% for members 13-17 and 18-64 years.
ü Deb Poerio stated that while 60% follow up may seem reasonable, it means that 35-40 of 100 children were discharged from inpatient psychiatric care back into the community and schools without ongoing BH services.

o Jeffrey Walter commented that the national standard is 80%. As Co-Chair of the BHP Oversight Council, Mr. Walter stated this rate can and should improve and will be a focus of the Council.

Behavioral Health Partnership (BHP) (click on icon below for the presentation material)

Dr. Mark Schaefer (DSS) and Dr. Karen Andersson (DCF) reviewed key aspects of the agencies’ preparations for the implementation of the HUSKY A & B behavioral health “carve-out”, the Behavioral Health Partnership (BHP) program, on January 1, 2006.

• Just prior to the Medicaid Council meeting CMS informed the Partnership that the HUSKY A 1915(b) waiver amendment for the BHP program was approved.
• DCF is providing extensive regional staff training and technical assistance. Added DCF identifiers were entered into the DSS EMS system allowing DCF and DSS to identify the children involved in DCF, their type of involvement, services used and costs. This will provide information for future program planning.
• Non-HUSKY DCF populations will be phased into the BHP program; DCF will remain responsible for services and costs for these clients.
• Residential group home management is targeted for February 1, 2006; DCF has been meeting with providers on the BHP management issues.
• BHP provider fee schedules have been posted at www.CTBHP.com ; hospital rates were issued 12/05/05 and other rate configurations are in progress.
• The concept of enhanced care outpatient clinics that will initially focus on access is moving toward reality through the work of the BHP and the BHP Oversight Council subcommittees.

Lori Szczygiel, CEO of the CT BHP Administrative Service Organization (ASO) ValueOptions, reviewed the status of the extensive ASO activities undertaken to meet the BHP implementation date of January 1, 2006. The ASO has been working with the BHP Oversight Council, subcommittees, providers, HUSKY MCOs and family advocates in the ASO implementation plans and activities.

• CT BHP VOI has been doing system readiness reviews and beta-tests for full system cycles with two providers.
• ASO coordination and transition of care: ASP VOI is entering the Anthem, CHNCT, Health Net MCO BH subcontractors BH service authorizations beyond 21/21/05 into their system. The ASO will honor these authorizations. PONE/CompCare vendor is providing authorization reports to ASO.
• CT BHP VOI has been recruiting BH providers into the system (providers have to be credentialed through the DSS EDS system in order to begin receiving payments for services January 1, 2006). To date more than 50% of the providers have requested EDS applications and 122 have been approved or in process at DSS. The ASO is, at the recommendation of the BHP Council, also contacting DCF Mobile Crisis Teams for community provider referral lists in their areas.
• CT BHP VOI has hosted a well-attended provider forum and also several consumer forums; the latter will be repeated in January-February 2006. Provider and consumer information and brochures can be found at www.CTBHP.com .

Council comments:

ü Sen. Harp stated that an initial goal of the Medicaid managed care program was the integration of medical and BH care, yet this system actually moved away from that goal. The re-designed system under the BHP will have better integration of primary care and mental health services through contractual provisions.
ü Dr. Niman suggested VOI outreach to child/adolescent fellow in training.
ü Dr. Geertsma commented that a linkage with care coordination in the DPH medical home model is needed. Currently practitioner–directed care coordination is only reimbursed for behavioral health complex clients. The BHP has been working toward developing supports for primary care/psychiatry services.
ü The HUSKY B BH PLUS services are now included in the BHP program and will therefore not continue as a separate program in HUSKY B.
ü The Enhance Care Clinic (ECC) model, which initially focuses on improving access, will be associated with a 25% rate increase. The BHP Oversight Council will review the adequacy of this increase in the 1^st quarter of 2006. While the 130 clinics would not initially meet the ECC criteria, the goal over the next few years is to engage all the clinics in this process. Sen. Harp asked:

o Why an ECC grant is not being used to determine the best way to implement ECC, as clinics would need more dollars up-front to develop the resources to comply with the ECC criteria? Dr. Schaefer stated the 25% increase would be available up-front, based on the application content. There will be continued assessment of the adequacy of funding for ECCs.
o In the past the MMCC initiated an outcomes study of outpatient BH services. How will BHP measure outcomes in year 1, 2 of the BHP program? Dr. Schaefer stated the BHP agencies are developing performance indicators for a ‘report card’ of the program through a grant from the Center of Health Care Strategies. The project grantee, Health Services Research Institute, has been working with the BHP and the BHP Council and Quality Subcommittee in finalizing the initial list of indicators that will be both process and outcome measures.

Senator Harp thanked both Agencies (DSS & DCF) for their dedicated work in developing the BH system change, noting that the legislature had misgivings about this program but do expect the agencies to succeed in this endeavor and look forward to continued discussion of the BHP program in the Medicaid Council and BHP Oversight Council.

DSS/MCO Contract Status

DSS has secured the four MCOs participation in HUSKY for SFY 06 and into FY 07. Previous contracts had been amended for 6 month periods. DSS wants to provide more stability to the plans and the program through longer contract periods.

• Individual MCO rate adjustments above the budgeted 2% were made retroactive to July 1, 2005. The rate increases ranged from 2% (PONE) to 5.5% (Anthem) with an average rate adjustment of 4-4.5%.
• Since the SFY 07 rate increases are unknown at this time, the MCOs agreed to the following proviso:

o Remain in the program through June 30, 2006.
o When the July 1, 2006 program dollars are put in the State budget, the MCO would continue if rates based on the budget meet their expectations or, if the MCO determines the rates are insufficient, the plan would give DSS notice to withdraw; however the plan is obligated to stay for 6 months beyond that time to January 1, 2007. DSS expect rate discussions in Spring 2006. Anthem noted that after the New Year, the MCO would begin negotiating rates for July 1, 2006, supporting their negotiations with data that show double digit cost trends.

• Other contract issues including the FOI decision reportedly will impact the MCOs and program costs. DSS has sent the MCOs conforming contract amendments to implement the FOI decision.
• The negotiations of the BH carve-out dollar amount from the MCO per member per month payment will begin in January/February 2006.

Comments/recommendations:

• HUSKY program changes enacted during legislative sessions make it difficult to have longer term MCO contracts. Rep. McCluskey noted that program changes, focused on short term savings, are disruptive to the program. It would seem that the Executive and Legislative branches would want to develop a longer term budgetary approach to Medicaid program dollars, which would provide for programs’ stability.

Sen. Harp stated that the budget process is controlled by the constitutional spending cap; however there is no clear definition of this cap. Public programs’ stability is related to economic growth trends and adherence to the spending cap. Slow economic growth adversely impacts public programs at a time when the need for these programs increases (the DSS budget is the largest state agency budget). It is economic growth (either increases or decreases) coupled with the spending cap that lends to public program instability. Political will is needed to look at public program stability by addressing the complexity of the budgetary cap issues.

• Sen. Harp requested the DSS to provide the Council with future reports on:

o Trends in subspecialty utilization since the start of the managed care program and compare subspecialty use to that in Medicaid fee-for-service. Need to determine if we are gaining or losing ground in subspecialty service access. Such a report can provide tools to argue budget allocations. The DSS agreed, noting that DSS is working with the MCOs on subspecialty services access in health plans. Health Net just completed a data integrity review of their network. Contract amendments will require MCO provider network integrity reports.
o HUSKY A adult dental care access beginning in 2006.

Status Update of Children’s Presumptive Eligibility (PE) and Pregnant Women’s Expedited Eligibility (EE) Policy Implementation (addendum: click on DSS PE Policy below)

Cuylar Massicotte (DSS) stated that both policies are in place and three Regional Processing Units (RPUs) in Middletown, New Britain and Bridgeport have begun accepting PE applications from the 73 Qualified Entities and all pregnant women’s applications. The agency developed the 3 RPUs to consolidate the sites that will process these applications.

• All the Regional DSS offices have designated a liaison in each office to sort through applications, pulling those for pregnant women and sending these to one of the RPUs. This change seems to respond to concerns raised by the Consumer Access Subcommittee and the Council about timely processing of pregnant women’s applications and ensuring that there are minimal “glitches “in the implementation of the new policy.
• The number of Qualified Entities may be slightly more than the past number, but the agency expects to expand the number in the future.

HUSKY Enrollment: ACS

• HUSKY enrollment by race from 2001 through 2005:

o HUSKY A changes were small over the past 5 years, with a 3% decrease in African American enrollment, a 3% increase in Caucasians, <1% increase in Asians and stable Hispanic enrollment.
o HUSKY B, which has a much smaller enrollment, had very small enrollment by race changes over the same time period.

• Since January 2005, HUSKY A has lost members, most notably from June to July that had a loss of 9781 enrollees. Summary of overall enrollment change in 2005 comparing 1/05 to 12/05:

• HUSKY B enrollment increased by 185 members in December 2005 compared to January 2005.
• HUSKY B applications denied or closed in November 2005 remain 4.4 times the number in July 2005.
• HUSKY B pending application at the end of the month is remain 1.5 times the number reported in July 2005.
• It is important to know the extent of similar changes in HUSKY A as well as the percentage of those that lost eligibility in July that have subsequently re-enrolled in HUSKY A.

DSS implemented the elimination of families self declaration of income on applications July 18, 2005 (PA05-280). Prior to this policy change, DSS offices used labor, SS, unemployment and child support data to identify significant differences in the self-declared income on the application and followed up with the applicant for further income verification. Self employed applicants had to provide supporting income documentation with the application.

Senator Harp stated that the origin of the projected budgetary savings is puzzling as it does seem there was agency oversight of income self attestations. Given the evidence that elimination of self declaration of income is creating barriers to application processing and reductions in enrollments/renewals in HUSKY, it really makes more sense to go back to the self-declared process.

Medicaid Council will meet Friday, January 13, 2006