You asked for brief summaries of the HUSKY and family Medicaid programs. You also wanted to know (1) whether medical providers have the option to accept patients with either insurance, (2) if program enrollees need referrals to see specialists, (3) what happens when no specialists are available, and (4) whether the managed care organizations (MCOs) operating the programs must send updated provider lists to enrollees.

SUMMARY

HUSKY A (Medicaid for children under 19 and families) and HUSKY B offer subsidized, managed health insurance to lower-income children and some adults. HUSKY A is available to families with incomes up to 185% of the federal poverty level (FPL, $32,560 annually for a family of three in 2008). Enrollees pay nothing for care. HUSKY B (which serves children in families with incomes between 185% and 300% of the FPL) requires nominal co-payments, and premiums once income reaches 235% of the FPL. Unsubsidized HUSKY B coverage is available to children in families with incomes over 300% of the FPL.

During the last year, there has been significant turmoil in the HUSKY program. It began when the governor terminated the HUSKY contracts the Department of Social Services (DSS) maintained with four MCOs. The addition of the Charter Oak Health Plan has complicated things further as the governor required MCOs bidding on that plan also to serve HUSKY recipients. Most recently, the governor relaxed that requirement, but concerns about network adequacy have raised doubts about the future of managed care for HUSKY recipients.

The state (or the MCOs with which it contracts) cannot force medical providers to accept a certain number of HUSKY patients. Any attempts to do so could be counterproductive as the provider simply could decide to abandon the program altogether.

If a specialist is not available within an MCO's provider network, DSS expects it to find one outside the network. In some cases, these specialists are located out-of-state. According to DSS Medical Director, David Parrella, there is no longer any “gatekeeping” on referrals to specialists in either MCOs or fee-for-service (FFS) Medicaid. But most specialists will not schedule appointments without some clinical background from a primary care provider.

HUSKY B is funded in part by the federal State Children's Health Insurance Program (SCHIP). SCHIP regulations require the state to make available to HUSKY B applicants and enrollees the names and locations of current participating providers (42 CFR § 457.110). Federal Medicaid regulations require MCOs to supply provider names, locations, and phone numbers to prospective and current enrollees (42 CFR § 438.10). DSS' website (www.ctdssmap.com) contains this information for Medicaid FFS applicants and enrollees. And the HUSKY MCO contracts require each MCO to provide DSS with a monthly list of all network providers. DSS' Parrella reports that the HUSKY MCOs provide lists to their enrollees. And the program's enrollment broker maintains a composite list of all providers across the health plans.

HUSKY

HUSKY is the umbrella name for the state's insurance program for low-income families. HUSKY A provides Medicaid-covered benefits to children and adult caretaker relatives in families with incomes up to 185% of the FPL. HUSKY B provides subsidized health care to children in families with incomes between 185% and 300% of the FPL. Families with incomes above 300% of the FPL can buy into the HUSKY B program by paying the full monthly premium ($195 per child per month). Families in HUSKY A have no cost sharing obligations; families with children enrolled in HUSKY B with incomes between 235% and 300% of the FPL pay premiums ($30 per child per month, $50 maximum per family), and all Part B families pay nominal co-payments. Cost sharing is capped for families in the subsidized part of HUSKY B.

HUSKY in Transition

Interim Program. HUSKY is currently in transition. Late last fall, Governor Rell terminated the contracts of the four MCOs administering the HUSKY program at that time, largely because two of them refused to comply with the state's Freedom of Information Act (FOIA). DSS instead decided to provide benefits through non-risk, administrative services organization (ASO) contracts, under which it paid a nominal per member, per month fee to companies to perform certain administrative functions.

Specifically, DSS took over certain functions that the full-risk MCOs had assumed: provider rate setting, prior authorization criteria, and provider enrollment criteria, while the ASOs were responsible for member services, provider enrollment, claims processing, case management, and outreach and education. HUSKY A recipients were asked to choose between Anthem, Community Health Network of Connecticut (CHNCT), or traditional FFS Medicaid (which was also the default for people who did not choose). HUSKY B recipients could move into Anthem or CHNCT; those failing to choose were placed in one or the other on a rotating basis. Non-subsidized HUSKY B recipients were disenrolled from the program until they selected one of the new plans and pre-paid the first month's premium.

Move Back to Managed Care. The transitional program was meant to be temporary, pending DSS' contracting with new full-risk plans willing to comply with the FOIA, and take on Charter Oak Health Plan members as well. DSS ultimately negotiated contracts with three health plans to do this: Aetna Better Health, AmeriChoice, and CHNCT. (CHNCT has been serving HUSKY recipients for many years and also serves State-Administered General Assistance (SAGA) medical assistance clients.) DSS began taking applications and enrolling people in Charter Oak on July 1, 2008. Since that time, HUSKY enrollees have been asked to voluntarily choose one of the three plans, which many have done.

But the move back to full-risk care has met obstacles, primarily the lack of an adequate provider network. (CHNCT is acknowledged to have a fairly robust provider network.) Advocates have repeatedly asked DSS to postpone the move, citing concerns about the lack of access that clients will face. Responding to these concerns, Governor Rell recently delayed until February 1 the December 1 deadline for HUSKY enrollees currently in FFS or Anthem to enroll in one of the new plans. (It is not clear what will happen to the nearly 170,000 clients currently enrolled in Anthem who do not choose a provider by December 31 when Anthem's ASO

contract expires. According to DSS' Parrella, these clients will have an additional month (until January 31, 2009), presumably as a result of a temporary contract extension).

Severing HUSKY/Charter Oak Link

Since the Charter Oak request for proposals (RFP) was issued last fall, many advocates and legislators have expressed concerns about the requirement that health plans serve both HUSKY and Charter Oak enrollees, with some suggesting that the combined program could dilute HUSKY's strengths. A 2008 bill (sHB 5618) would have severed the link, requiring separate contracts for each program, but it failed to pass. But last Friday (November 14, 2008), Governor Rell announced that she is going to allow the MCOs to enroll providers (e.g., doctors, hospitals) in HUSKY without requiring them to simultaneously enroll with Charter Oak. The plans will still administer both programs. The advocates and the Attorney General are pushing for a full de-linking of the two programs.

PROVIDER OPTION TO SERVE

Medical providers cannot be forced to accept patients and in fact, for financial and other reasons, most of them limit the number of public health insurance patients in their practices. In their provider agreements with the MCOs, providers are supposed to notify the plans if they are going to close their practices to HUSKY members. But according to DSS' Parrella, this rarely occurs.

Parrella adds that most pediatric and obstetric providers do at least some HUSKY work, simply because HUSKY is such a huge share of the market (over 340,000 enrolled as of November 1, 2008).

SPECIALISTS

When a HUSKY enrollee needs to see a specialist and none are available in the MCO's network, the MCO is expected to look outside their network and pay for the specialist care, if it is available. The contract between DSS and the MCOs requires DSS to measure this access by examining and reviewing confirmed complaints received by the MCOs, the enrollment broker, DSS, or the HUSKY hotline. But DSS can amend the specialist provisions in the contract, particularly as they relate to the network's adequacy of dermatologists, neurologists, orthopedists, and other specialists (these are specialties for which even commercially insured people have access problems).

ADDITIONAL INFORMATION

“Medicaid—Access to Providers,” OLR report 2008-R-0601, October 30,

2008

RC:ts