Committee Coordination of Care Work Group
Summary: May 25, 2005
Chair: Sheila Amdur
Present: S. Amdur (Chair), Dr. K. Andersson and A. Kamm (DCF), R. Ciarcia, Dr. M. Schaefer & T. Creel (DSS), M.A. Lee (CTVoices), L. Pierce (VOI), Dr.R.Walia & Dr. A. Geertsma (Pediatricians), C. Wamou (DCF Health Assoc), V.Veltri (GHLA), S. Toubman (NHLA), J. Gaito & J. Panzo (PONE), K. Colvin (CHNCT), C. Catrone (SBHC), M. McCourt (staff).
The legislative Committees of Cognizance (Appropriations & Human service Committees) approved the 1915(b) waiver amendment for BH on 5/24. Dr. Schaefer outlined the next steps in the process:
ü The waiver amendment will be submitted to the Centers for Medicare & Medicaid (CMS). The federal agency had indicated to DSS that the review process could be done within 90 days. The State will update the financial component before submitting the amendment to CMS.
ü DCF & DSS will ensure adequate time to carefully complete the processes (including changes to the Coordination of Medical/BH Care document) associated with the implementation of the BH restructuring and finalizing the DSS/DCF & Administrative Service Organization (ASO) contract that will be negotiated with ValueOptions (VOI).
ü Based on the Committees of Cognizance recommendations, legislation will be proposed to the legislature that includes legislative statutory oversight of the BH program.
Ms. Amdur summarized the focus of this group as identifying existing system problems and making recommendations in relation to the coordination of medical care in the MCO with BH services that will be ‘carved-out’ of the HUSKY program and administered through the contracted ASO. The following topics and recommendations were presented at this meeting:
The four managed care organizations will continue to be responsible for providing HUSKY A Medicaid non-emergency medical transportation (NEMT). As noted in the May 3rd meeting, anecdotal reports illustrate client transportation issues in HUSKY; however there has been no quantified assessment of the adequacy of the transportation services. The discussion included the following vehicles for assessing transportation access in the current program:
· R. Ciarcia will request transportation information from the HUSKY Infoline database.
· The DSS will exam specific transportation questions in the MCOs’ member satisfaction surveys as baseline data.
· The DSS MCO Notice of Action (NOA) data will be reviewed for non-BH vs. BH transportation NOA.
The Work Group recommendations for transportation in the
restructured BH system include:
The MCOs will identify BH NEMT data versus medical NEMT data in
their NEMT reporting to DSS as a baseline measure.
Going forward, DSS will collect BH vs. non-BH NEMT data
comparable to the baseline data indicators.
Transportation-specific questions will be included in the
client satisfaction surveys going forward.
DSS will collect any NEMT complaints from the ASO.
Under the waiver amendment, CMS will not require an evaluation of the program by an External Quality Review Organization (EQRO). The DSS stated they would be adding a BH evaluation component to the Mercer HUSKY quality evaluation. The Work Group stressed the importance of program evaluation by an independent contractor that currently does not have a contract with DSS or DCF.
Work Group Recommendation:
There be an ongoing independent impartial comprehensive
evaluation of the BH program by an expert entity that has no contracts with CT
State agencies, managed care organizations or the ASO.
The BH Oversight Committee, along with DSS and DCF, have input
into the development of the evaluation process and review of the evaluation
The four HUSKY A and three HUSKY B managed care organizations will continue to be responsible for pharmacy services in HUSKY A and HUSKY B. Discussion at the May 3 meeting and this meeting conveyed the sense of urgency in resolving pharmacy access issues, especially in light of the ‘carve-out’ of BH services from managed care. DSS stated they don’t currently have data to quantify the extent of the PA problems; work group participants noted that the current process of prior authorization (PA) creates a major obstacle to HUSKY clients’ access to mental health drugs: PA rejections and the associated process for the provision of temporary drugs per DSS/MCO contract remain flawed in the two largest MCOs (Preferred One does not have a formulary and CHNCT implements close to an automatic override at the pharmacy for rejected drug authorizations).
The DSS continues to work with Anthem and Health Net on creating an electronic screen message about the temporary drug provision in HUSKY A. DSS will continue to review each MCO’s compliance with pharmacy contract provisions and the new DSS staff will meet with each MCO to become familiar with each MCO formulary/pharmacy process and available data in order to be prepared to work with the MCOs on reporting specs. Further, DSS supports the continuation of the previous BH SC initiative to develop a list for providers of psychotropic drugs that require PA by each MCO.
The Work Group recommended the following, with the goal
of preventing parents of children with MH diagnoses or adults with MH diagnoses
leaving the pharmacy without the prescribed medication:
Additions to the current MCO pharmacy reports to DSS that would
be available no later than Oct 1 2005:
Monthly reports by each MCO of the total number of rejections
due to lack of PA.
The number of the rejected authorizations that have NO
temporary drug issued within 24 hours.
The class of the drugs tied to the rejections.
A provisional recommendation was made that would be
implemented if the above data suggests the need for such implementation:
In conformance with state Medicaid fee-for-service policy, at a
minimum, all mental health drugs that require PA have a temporary supply
automatically authorized at the pharmacy for any mental health drug prescription
rejected because of lack of prior authorization.
Emergency Care remains within the MCO responsibility. The work group recommended that there be a process developed by which the ASO will be informed of BH ED visits in a timely manner. DSS will be reviewing this with the MCOs in the near future.
Previous Work Group recommendations are listed below:
Patient continued access to care during conflict of
medical/behavioral health primary diagnosis:
Recommendation: add in ‘admission’ and ‘concurrent’ reviews section “All times are measured from the time the Contractor receives all information deemed reasonably necessary. (DSS added this in the document DETERMINATION OF PRIMARY DIAGNOSIS SUMMARY after the meeting).
Define time lines for prior authorization (PA) and continuity
The timelines in the BH RFP be adopted in the ASO contract:
decision for PA communicated to the provider by telephone within 60 minutes of
the request for hospital admission, PHP, IOP, inpatient detox.
Concurrent reviews decision within 60 minutes or before 5 PM.
The decision for all other service concurrent review requested by the
provider shall be made within 2 business days of the request.
Ø Standard information required of providers for authorization
The WG recommended the
agencies and ASO:
Develop standard information per level of care that identify
specific indicators for that level of care, thereby including the provider as a
partner in working with the family and ASO to secure the appropriate level of
Include the Medicaid definition of “medical necessity”
for material documenting appropriate levels of care.
Dispute Resolution Process
DSS establish a provisional authorization process for 24
hours, determined on a case-by-case basis, which allows family to be connected
to community collaboratives, EMPS and other needed services.
o DSS establish a telephonic immediate appeal process with the authorization entity
Reimbursement for hospital stays during which the diagnosis
changes from primary medical to psychiatric under the ASO/MCO management:
The DSS/DCF discuss this reimbursement issue further with
hospitals to ensure there is an appropriate process in place.
The timeliness of transfer of patients from medical to
psychiatric services upon diagnosis change should be monitored within the ASO.
Primary Care BH referral assistance:
The Work Group recommended that the departments add language to the
ASO contract that the ASO will offer appointment assistance to members either at
the time of the request for BH network referrals of when the member calls back
with further assistance needs.
The BH Coordination of Care Work Group participants support the continuation of this work group to:
· Follow up on the implementation and monitoring of the recommendations.
· Continue to review the “Coverage & Coordination of Medical & BH Services document that will not be included in the actual DSS/DCF/ASO contract in order that changes can be made once the BH program is implemented without re-opening the contract.
A statutory BH Oversight Committee will identify the ongoing work groups & function.
Sheila Amdur thanked the participants and the DSS & DCF staff for their time, energy & expertise in reviewing documents and making recommendations for the agencies to consider as the process moves forward.