The group reviewed the problem statement/proposed action grid:

Problem 1: Patient access to dust mite barriers.

· Dr. Gertsma reported that he looked into his hospital's billing practices for the covers and spacers and found that the hospital may not be billing the insurance companies, however they do have internal codes to track spacer use. The clinic provides these items to families, often without charge; however the annual clinic budget is not predicated on the last fiscal year utilization, making it difficult to provide equipment at will.

· Billing code for spacers/dust mite covers does not exist. The health plan contracts with the local vendor to supply these. The lack of billing code makes it difficult for MCOs to track utilization and may be a barrier for some local vendors to supply the item if the reimbursement process is somewhat unclear. The State is moving away from `state-only' codes. CMS (HCFA) is revising their DME/pharmacy codes, which should be available in another year. The question remains what can be done in the Medicaid program over the next 13 months that would facilitate tracking and reimbursement of these items

· A provider described the difficulties a patient is having in securing basic asthma DME. The discussion raised the following points:

o Denied services prescribed by a health provider must be followed by a written notice of action (NOA) by the MCO to the patient, which allow the patient to file a grievance and fair hearing request. Health providers play a crucial role in ensuring patients are aware of this. Patients should also be referred to the CHIL line to obtain assistance in going thru the grievance process. These two aspects of ensuring access to care may not be known by most providers and some HUSKY members.

o One health plan's PA criteria for dust mite barriers appear very restrictive: individual patients should be referred to CHIL to obtain this medically necessary service. A dialogue with the MCO director, Medical director and Council Chair can provide an opportunity for understanding the plan's and Council's concerns regarding this criteria.

Problem 4 (on grid): Patient access to basic asthma DME/pharmacy supplies may be spread across several local vendors, creating difficulties for families to secure these prescribed items. It was suggested that Medicaid Council request the HUSKY plans identify the basic asthma equipment supplied by each of their local vendors in one CT city. The basic items include: spacers, nebulizer and nebulizer accessories and dust mite covers. The MCO's are requested to indicate which of these items require prior authorization. Once the list is compiled, from each vendor, it would be possible to then determine those local vendors that carry all the listed supplies. From this process, the feasibility of doing this in other geographic areas can be determined.

The MCO/Provider work group will meet at CHA on October 23 at 5:30 PM. Again, the MCO medical directors participation is essential to moving forward in the action plan process.