Connecticut
Medicaid Managed Care Council
Quality Assurance Subcommittee
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

Pediatric Obesity Work Group

Meeting Summary: December 18, 2003

HUSKY Obesity MCO Matrix

In review of the current information in the matrix, the following questions were asked:

·             How are nutritional counseling services at Community Health Clinics reimbursed if they are not part of a “hospital-based nutritional counseling services”?

·             School Based Health Clinics are not considered part of the Primary Care Provider (PCP) system, yet may refer overweight children & youth for obesity-related services.  These referrals may not be approved because they originate outside the PCP system.  Preferred One (POne) and Health Net are assessing the role of SBHC providers and PCP role.

·             Three of the HUSKY health plans do not have a primary care gatekeeper system – Anthem BCFP does have the gatekeeper model.  In this model the PCP must make referrals.

·             Since the broad EPSDT ‘medical necessity’ definition in Medicaid does not apply in HUSKY B, a non-entitlement Title XXI program, are nutritional services approved for children with obesity associated with co-morbid conditions, not for BMI >85% without other documented medical conditions?

·             Explicit guidelines for healthy nutritional choices and physical activity are available (i.e. Bright Futures, the recent AAP overweight and obesity recommendations).  Consider strengthening attention to the growing obesity problem in Medicaid by:

o       Encouraging the use of different tools to calculate the Body Mass Index (BMI) and record on the chart.  Dr. Kamens commented that the Fairfield Medical Society is working with a funder to provide small calculators that provide the BMI.

o       Identify documented anticipatory guidance items that target eating behaviors, food choice and time spent in sedentary versus physical activity.

o       Random chart audits to focus on recorded BMI, guidance and other appropriate follow up such as family nutritional counseling.

Next steps include:

·             Send the individual MCO matrices to the health plans with the questions raised today; revise the matrix for the Jan. 15 meeting.

·             Work with DPH to survey FQHCs, SBHCs and School nurses regarding obesity-related programs at their sites.

·             Encourage participation from professional organizations in the Work Group, as well as other entities such as Parish Nursing programs that could help families with identification of the seriously overweight child and healthy life style choices.

Quality Assurance Subcommittee

Meeting Summary:  December 18, 2003

Adolescent Health

Maureen Mullen followed up with the recommendation in the Adolescent Health Work Group to better define the anticipatory guidance items for HUSKY A adolescents.  The QA subcommittee had offered to initiate the process with proposed changes for the DSS periodicity schedule anticipatory guidelines, which would be reviewed and approved by MCOs, practitioners and the DSS.  Discussion:

·             One of the work group recommendations was performance and documentation of a health risk assessment that would be the basis for anticipatory guidance of key focus areas, determined by the practitioner and the patient.  Providers use various risk assessment tools.  The DSS does provide age-appropriate health assessment tools/basic guidance areas; however this is not uniformly used.  It was suggested that:

o       Changing to a one-page/age/ well visit assessment form would allow providers to use the form as part of chart documentation, reducing documentation time.

o       Health Net noted that the New Jersey plan and the other 4 Medicaid plans use a common three-part form for the well visit that includes a chart document, patient/family form and a billing form.  Maureen Fiore (CT Health Net) will provide the form, information at the next SC meeting.

o       If there was agreement on a multi-use well visit form among MCOs/practitioners and adolescents, MCOs could test the efficacy of the form in large pediatric practices.

·             Adolescents are required by statute to have a school physical at least twice in the 7-12 grade period.  Adolescent EPSDT screens are higher in the third quarter of each years, suggesting that youth are seen for school physicals.  Revision of the school health form to include the well visit documentation noted above would promote the school physical as an effective preventive, well care visit for teens.

Next steps:

·             Review the New Jersey Health Net form and it’s efficacy and efficiency in the New Jersey Medicaid program.

·             Contact the Department of Education representative for CT school physicals to attend future meetings, as well as the professional academies.

Discussion of the QA focus was deferred to the January meeting, as well as updates from DSS, DPH.

The QA Subcommittee will meet Thursday January 15, 10:30 AM, preceded by the HUSKY Obesity Work Group at 9:30 AM.  Both meetings are scheduled in LOB RM 3800, conference room 3803.

{12/19/03 Email to the four health plan representatives, with each MCO Obesity matrix}

Attached are the Pediatric obesity matrices for the 4 MCOs.  As we discussed at today's work group meeting there are some areas for clarification:

·          When is Prior Auth (PA) required for HUSKY A Nutritional services, when it is deemed medically necessary by the provider as part of EPSDT, &/ or only for out-of-network services?

·          Nutritional services are accepted from hospital -based clinics:  Where do FQHC's fit in this, as they may provide nutritional counseling to their clients. Obviously reimbursement is an issue.

·          Do you each need to specify that nutritional services for adults is OK based on obesity/co-morbidities?

·          What about HUSKY B kids: if the EPSDT doesn't apply, can providers refer for nutritional services for a youngster who has a BMI >85% with no co-morbidities?

·          POne & Health Net are working on SBHC APRN's reimbursement for obesity services.  Anthem, CHNCT any thoughts on this?

CHNCT: would appreciate your completion of the matrix, clarification that nutritional services would be provided under HUSKY A kids under EPSDT medical necessity.  It would seem that only services related to medical conditions are allowed.  Under How does the provider know about nutritional services in their area, you may want to move the info in that row to another item and provide the Provider directory # (

See other the grids).

ALL: please note I indicate clients may self refer for BH services. Is this true for HUSKY A adults and HUSKY B kids?  Anything I left out???

We will meet again Jan 15:  any chance you can respond after the holidays?  Thanks MSM