Connecticut

Medicaid Managed Care Council

                                                             

Legislative Office Building Room 3000, Hartford CT 06106

(860) 240-0321     Info Line (860) 240-8329     FAX (860) 240-5306

www.cga.ct.gov/ph/medicaid

 

 

 Quarterly Report:  1st Quarter 2009

Accepted 4-17-09

 

This report of the Medicaid Managed Care Council is submitted to the General Assembly as required under CGS 17b-28.  This report is for the time period of January through March 2009. The Medicaid Managed Care Council is a collaborative body established by the General Assembly in 1994 to advise the Department of Social Services (DSS) on the development and implementation of Connecticut’s Medicaid Managed Care Program (HUSKY A), in 1998, the State Children’s Health Insurance Program (SCHIP), which is HUSKY B and in 2006 the managed care portion of the State General Assistance (SAGA) program.  The law also charges the Council with monitoring and advising DSS on matters including, but not limited to, program planning and implementation, eligibility standards, benefits, health care access and quality measures. The Council consists of legislators, consumers, advocates, health care providers, representatives of managed care plans and state agencies.  The Council has three working subcommittees: Consumer Access, Quality Assurance and Women’s Health Subcommittees.

 

 

Both the Medicaid Council and Subcommittees met monthly during this 2009 quarter.  The meetings focused on:

  • Program administration that included the outcome of the final HUSKY transition, HUSKY member default assignment, provider network development for HUSKY & Charter Oak Health Plan, Primary Care Case Management (PCCM), potential impact of federal stimulus bill and Children’s Health Insurance Reauthorization,
  • DSS policy changes and enrollment changes and challenges to application processing.
  • Quality Reports and data completeness problems,
  • Special reports included CT Voices CY 2007 HUSKY A children’s preventive care and dental utilization, Medicaid managed care plans outreach process and a Yale student Council project proposal on Medicaid “Report Cards”.

 

Program Administration

 

Ø      Centers for Medicare & Medicaid Services (CMS) approved CT HUSKY mandatory enrollment as of Feb. 1, 2009 in one of three at-risk managed care organizations (MCOs):  Aetna Better Health, AmeriChoice and Community Health Network of CT (CHNCT).

 

Ø       During the month of January 2009 ~ 145,221 HUSKY A & B Anthem and HUSKY A Medicaid fee-for-service (FFS) members were informed via mail that they must choose one of the three health plans by Jan. 31, 2009. 

 

o       ~ 62,000 individual members (25,000 households) had not chosen a new plan by Jan. 31, 2009 and were defaulted into Aetna or AmeriChoice.  DSS stated CHNCT was not designated as an initial default plan to allow the two new plans to establish financial stability through member enrollment.  Due to a system glitch causing uneven default assignments between Aetna and AmeriChoice, starting February into March non-plan choosers will be enrolled only in AmeriChoice to increase that plan’s default enrollment levels to equal Aetna’s default assignment level. Once AmeriChoice’s default assignment level reaches that of Aetna, the default assignment methodology will return to rotating assignments among all three MCOs.  

o       DSS, with input from MCO medical directors, including Anthem’s, implemented a transitional care coordination process that included scheduled transportation for Anthem & FFS members.  The plans continue to work with DSS regarding coordination of ‘carve-out’ services.

o       Anthem and DSS have a termination contract after Anthem’s participation in HUSKY ended Feb. 1, 2009.  Anthem reportedly experienced data reporting problems beginning in the last half of 2007 and into 2008 that have led to incomplete data submission. Sen. Harp urged Anthem to resolve the data reporting problems in order to more completely assess utilization trends before, during and after the program delivery system changes.  Anthem is working to resolve claims reporting issues. Most program expenditures are claims based and claims need to be accounted for in obtaining federal match.

o       DSS was asked to provide the Council with a financial analysis of full risk MCO versus non-risk Prepaid Inpatient Hospital Plan (PIHP) that included Anthem and CHNCT during the 2008 transition period. The DSS Commissioner stated in January that lag time in claims processing would delay such a report for 3-4 months.

 

Ø      Provider network adequacy for HUSKY and Charter Oak Health Plan (COHP) (MCO/provider contracts for the programs were “de-linked” November 2008) reports provided at each meeting show an overall increase in HUSKY provider network with limited growth for COHP networks.

o       At the Jan. 2009 meeting DSS reviewed the algorithms for determining network adequacy.  While there is no established ratio of members/provider specialty, DSS does use established ratios for primary care, dental and OBGYN member/provider/county.  CMS participated in the Jan. 09 Council discussion and said the federal agency will continue to closely monitor Medicaid managed care network adequacy.

o        DSS reported on the department’s provider phone survey done during the voluntary transition period that began 9/1/08 and ended 12/31-08 when mandatory enrollment began 1-1-09.  Highlights of the survey results included:

o       47% (369) of providers were enrolled in HUSKY A, B & COHP. 

o       53% (421 of 787 contacted providers) participate in all 3 MCOs.

o       81% (626) report an ‘open panel’ (taking new patients) and 19% (151) had a ‘closed panel’, keeping their current Medicaid patients only.

 

Ø      Member access to out-of-network (OON) services is a contractual provision of the MCOs for HUSKY and COHP.  During the program transition period access to OON services is critical to health care access as members join/defaulted to new health plans and the provider community makes changes from Anthem to other health plans and PCCM.  At the Feb. 09 meeting DSS reported that 100% of practitioners not in an MCO panel have accepted OON service requests and reimbursement.  The March report was provided as a handout (the department will formally present to the Council in April 2009) showed HUSKY A OON requests for Jan & Feb totaled 9,489 with the highest numbers for OON PCP and specialists in Aetna & AmeriChoice;  HUSKY B (total requests 377) and COHP (total requests 691).

 

Ø      HUSKY A Primary Care Case Management (PCCM) pilot in Waterbury and Willimantic areas began Feb. 1, 2009 when the at-risk managed care program began.  As of March there were 160 HUSKY A members enrolled in the program with their PCP enrolled in PCCM.   Advocates that participated in the development of the pilot with DSS stated many providers throughout the state are interested in enrolling in PCCM. There remained keen advocate disappointment that PCCM is limited to two areas with no timetable to expand the program.

 

Ø      ‘Carve-out’ of dental services for HUSKY A & B (dental services for SAGA and Medicaid FFS will also be included) began Sept 1, 2008 under the dental benefit manager BeneCare.  Dr. Donna Balaski (DSS) and BeneCare have worked diligently to expand the dental provider network and in seven months the number of participating dentists increased to 469 compared to 167 under managed care subcontractors. In March there were 818 dental providers including those in clinics and out-of-state. Of the total number of enrolled practices, 7-8% of practices are not accepting new HUSKY patients (closed panel).  There has been a 97% appointment problem resolution on the first member call.  Dental utilization reports will be available to the Council in the next quarter.

 

DSS HUSKY Policies

 

DSS has implemented two new policies that seek to improve children’s services and health in 2009:

  • Pediatric providers can now bill for developmental screens on the same day as a well visit.
  • Pediatric providers that participate in the UConn School of Dentistry ABC education program can now bill, under managed care, for oral health evaluations for patients under age 21 and can apply topical fluoride varnish for children. 

 

While reimbursement is available to support these two policy changes, a Pediatrician observed that the practice’s challenge is in developing practice –based time efficiency strategies to provide these services. DSS was asked for a future report on the number of HUSKY PCPs participating in the dental prevention program.

 

HUSKY Enrollment and Application Issues

 

HUSKY & COHP Enrollment

Compared to Jan. 2009, changes in enrollment numbers in March 2009 included:

  • HUSKY A total - increased by 150 members between Jan & March
    • < 19 yrs – decrease of 810 enrollees
    • > 19 (adults) – increase of 660 enrollees
  • HUSKY B (children only) increased by 394 members since Jan, the first monthly increase seen since May-June 2008.  HUSKY B Plus medical has remained about 30 less members compared to Nov. 2008.
  • COHP membership increased by 2,346 members from Jan. to March to 5,720; of this number ~ 41% are in income band 1, 54% in the two lower income bands 1 & 2, and

      23 %   are in the 2 upper income bands, 4 & 5.

ACS, the enrollment broker, presented ongoing progress reports on improvements in application processing associated with new staff and reorganization of processes.  The delays in processing applications was related to the unanticipated numbers of COHP and HUSKY applications, the complexity of the COHP applications/enrollment and inadequate staffing to meet these unanticipated demands.  The March report showed a decrease in the numbers of pending applications even though the number of applications received (HUSKY & COHP) in Feb. was higher than Jan. 2009.  HUSKY B enrollment increased of 526 members may in part reflect the improvement in more timely processing of pending applications. 

 

HUSKY A Quality Reports

 

Ø      HUSKY A Utilization reports, provided at the Feb. Council meeting showed 6 month utilization data comparisons from 2006 through the first half of 2008.  During the latter time period the HUSKY program changed from four at-risk MCOs to two non-risk PIHP plans.  HUSKY FFS member data was not included; DSS will be reporting in the future on these members’ utilization under FFS compared to their utilization patterns in a MCO prior to Jan 2008.  The reports demonstrated modest variability across plans across time for most measures; however:

o       EPSDT rates suggest seasonality with higher well visit rates in the Jul-Dec. period most likely associated with school/sports physicals.

o       Inpatient days/1000 member months did show higher rates for CHNCT compared to other plans over the 5 reporting periods.

o       Variation in the average hospital length of stay (LOS), excluding newborns, has remained unremarkable ranging from 3.5 to 3.2 days.

o       Complex newborn average hospital LOS, while lower than that of 05-07, is about 17-20 days. Council agreed that further detail of this data would be useful.

 

Ø      CT Voices 2007 HUSKY A children’s well visit and dental services report was presented Jan. 2009 and the report can be found at www.ctkidslink.org   Utilization varies from DSS reports in that the reports identify services of continuously enrolled children rather than all children in the report time period (DSS), EPSDT services rates were  limited to children ages 2-19, excluding well visits in the first 2 years of life, compared to utilization of all enrolled children ages 0-19 in the DSS report.

o       Preventive dental services for children 3-19 increased in 2007 compared to previous years.

o       EPSDT rates decline in these reports may be related to: 

§         Anthem data problems in the latter half of 2007

§         CHNCT noted that a large "capitated-reimbursed” provider did not submit 2007 data. 

Special Reports

Ø      Yale Student project concept ‘Medicaid Report Card’, requested by the Council, was presented to the Council in February.  The student proposal included a sample member satisfaction survey; Council comment suggested the survey response would be complicated by the program transition and member/provider confusion and that a ‘report card’ denotes compiling plans’ performance on key health indicators on an annual basis.  The team will revise their approach to project outlined to them and report in April.

Ø      MCO Outreach:  the Council request at the February meeting, each MCO provided an overview of their outreach activities at the March meeting.

 

  • Aetna described their biopsychosocial model that is a holistic approach to member health and wellbeing assessments that includes medical, behavioral and social needs.
  • AmeriChoice discussed the plan’s grass roots outreach, community education and neighborhood events.  Member assessment is based on a personal care model of a holistic approach to health care and socio-economic needs. The plan coordinates out-of-network services, does member health risk assessments and has a Health First Steps outreach/case management and BHP connection for perinatal depression.
  • CHNCT has 12 full time care coordinators and person health educators fluent in Spanish that coordinate appointments and identify case management/disease management needs.  The plan is piloting a “nurse chat room” as part of their asthma program, does pregnant member health risk assessments, connecting member to community care and intensive case management.  CHNCT is working with CTBHP/VO on a post partum depression pilot.  A member services escalation unit assists members with connection to primary care/specialist providers, appointment and transportation assistance.

 

Ø      DSS provided an overview of the federal American Recovery & Reinvestment Act (ARRA) 2009 at the March meeting.  The Governor has convened a central state work group of state agencies to ensure that CT accesses all appropriate FMAP dollars.  While CMS is in the process of developing state guidance for the many provisions in the bill, DSS outlined what some of the basic guidelines appear to be:

 

  • DSS said that over the recession adjustment period of 10/1/08 – 12/31/010 every state will receive a 6.2 percentage point increase in FMAP as well as possible additional bonus points for high employment rates.  This means the CT FMAP will be close to 60% with CT receiving ~ $1.3B over the designated adjustment period. 

 

  • States must meet certain conditions in order to access the enhanced Medicaid FMAP that includes maintenance of effort (MOE) provisions.  States can make changes to services under the State Plan, which include co-pays but not make changes in ‘eligibility standards, methodologies or procedures’ that affect eligibility after July 2008.  The Governor’s proposed budget includes two changes that could jeopardize the enhanced match:  apply premiums to Medicaid enrollees and eliminate self-declaration of income.  DSS is waiting for CMS guidance on this.

 

  • Federal COBRA 65% federal subsidy for those with involuntary job loss over a 9 month period is available now.  The Department of Labor is responsible for informing the public and employers of this assistance.

 

  • Health IT for the development of electronic health records with provider grants and direct funding to Medicaid @ 90% administrative FMAP.

 

  • ARRA includes wellness and prevention grants.  Council suggested that certain prevention activities be considered: include smoking cessation in Medicaid state plan and restore adult Medicaid dental non-emergent services as prevention of dental decay/infection that affects overall health.

 

Ø      The Children’s Health Insurance program (previously SCHIP, in CT this is the HUSKY B program) reauthorization act (CHIPRA) was discussed.  Key provisions in this federal legislation that affects CT budget and proposed budget:

 

  • CT can now claim the CHIP federal match difference of Medicaid (50%) and CHIP

      (65%) for HUSKY children with family income of 133% to 185% FPL (had been to 150%               FPL).

  • States can exercise the option to eliminate the 5 year wait period for federal/state coverage of legal immigrant children and pregnant women; CT budget proposal eliminates state coverage other than emergency Medicaid services to this group. DSS will seek clarification from CMS if CT can begin to draw down CHIP federal match dollars for children & pregnant women covered under the state-only funded program as of April 1, 2009 when this provision is in effect. 
  • CHIP and Medicaid citizenship verification will be streamlined by allowing states to verify citizenship status through electronic match with social Security.  Newborn verification will no longer be required for Medicaid eligible babies born in CT hospitals.