Medical Assistance Program Oversight Council June 13, 2014

1. Medical Assistance Program Oversight CouncilJune 13, 2014

2. Today’s Agenda • Overview of Medicaid-related results of legislative session • Budget • Access • Coverage • Requirements for Participation • Administration 2

3. Overview of Legislative Results: Budget 3 Via Public Act 14-47 (effective July 1, 2014): based on updated estimates of current costs and caseload trends: Medicaid is net appropriated (this does not include federal share) at $2,279,268,579 (SFY'15) – this represents a reduction of $10,300,000 HUSKY B is funded at $28,036,000 (SFY'15) – this represents a reduction of $2,500,000

4. Overview of Legislative Results: Access 4 • The budget also includes funding for 35 new DSS eligibility services positions associated with the timely processing settlement, which is part of an increase of 138 positions in the total authorized count • The budget adds 100 new slots to the Katie Beckett Waiver • Katie Beckett is currently capped at just over 200 slots with a significant waiting list • Expansion will allow more medically fragile children to access services in a more timely manner and will support parents as primary caregivers

5. Overview of Legislative Results: Access 5 • Section 73 of P.A. 14-217 (effective 7/1/14)(the human services implementer): increases the total number of slots in the state-funded Connecticut Home Care Program for Adults with Disabilities, which serves eligible individuals with neurodegenerative disorders, from 50 to 100 • This will open up opportunities for people who are currently waitlisted for these services and will prevent nursing home placement for individuals who would quickly turn to Medicaid as their payment source

6. Overview of Legislative Results: Coverage 6 • The budget includes a commitment to add self-directed Personal Care Assistance as a Medicaid State Plan service under the Community First Choice (CFC) option. • CFC permits states to provide community-based personal care assistance and other services to individuals with disabilities who would otherwise require an institutional level of care • This will qualify Connecticut for an additional six percentage points in federal matching funds

7. Overview of Legislative Results: Coverage 7 • Section 220 of P.A. 14-217 (effective July 1, 2014)(the human services implementer): requires DSS to amend the Medicaid state plan to include services provided by the following licensed behavioral health clinicians in independent practice to Medicaid recipients who are twenty-one years of age or older: • licensed psychologists • licensed clinical social workers • licensed alcohol and drug counselors • licensed professional counselors • licensed marital and family therapists

8. Overview of Legislative Results: Coverage 8 • Section 74 of P.A. 14-217 (effective from passage)(the human services implementer): permits DSS to cover over-the-counter (OTC) drugs that have a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force – this will permit coverage of aspirin and folic acid  [See also P.A. 14-157]

9. Overview of Legislative Results: Terms of Participation 9 P.A. 14-142 (effective July 1, 2014): eliminates the social services cost cap within the client cost cap for the Connecticut Home Care Program for Elders Social services include, but are not limited to, homemaker, companion and adult day care services.

10. Overview of Legislative Results: Terms of Participation 10 Section 76 of P.A. 14-217 (effective from passage)(the human services implementer): limits Medicaid recovery for HUSKY D participants to medical assistance paid on behalf of individuals age 55 and older for nursing facility services, home and community-based services [HCBS] and related hospital services and prescription drugs - DSS will not seek recovery for other Medicaid services, including, but not limited to, physician services

11. Overview of Legislative Results: Terms of Participation 11 Section 78 of P.A. 14-217 (effective from passage)(the human services implementer): requires DSS to analyze the cost of providing services under the Connecticut Home Care Program for Elders (CHCPE) and Connecticut Home Care Program for Adults with Disabilities (CHCPDA), and to issue a report regarding reimbursement to providers

12. Overview of Legislative Results: Terms of Participation 12 • Section 136 of P.A. 14-217 (effective from passage)(the human services implementer): requires DSS to submit a State Plan Amendment to increase, within available appropriations, the rates paid to private Residential Treatment Facilities (PRTFs) • Section 193 of P.A. 14-217 (effective from passage)(the human services implementer): requires DSS to accept electronic prescriptions for durable medical equipment, including, but not limited to, wheelchairs, walkers and canes

13. Overview of Legislative Results: Administration 13 • P.A. 14-62 (effective July 1, 2016) – • establishes contract requirements for the medical and behavioral health Medicaid ASOs to reduce inappropriate use of the ED, including: • provision of Intensive Care Management • identification of high utilizers of the ED • identification of hospital EDs with high numbers of Medicaid clients with 10 or more annual ED visits • creation of regional intensive case management teams to work with ED doctors • required outreach to beneficiaries to connect them with providers

14. Overview of Legislative Results: Administration 14 • requires the medical and behavioral health ASOs to conduct assessments of primary care and behavioral health providers and specialists to determine ease of access (wait times, whether panels are accepting new Medicaid patients) and to perform outreach to Medicaid beneficiaries (especially those who frequently use the ED) to inform them of the advantages of using primary care and to connect them with providers

15. Overview of Legislative Results: Administration 15 • requires the medical ASO to report annually to DSS MAPOC on the following: • a breakdown of the number of unduplicated clients who visited an emergency department • for frequent users of emergency departments: • the number of visits categorized into specific ranges as determined by the Department of Social Services • the time and day of the visit • the reason for the visit, whether hospital records indicate such user has a primary care provider, whether such user had an appointment with a community provider after the date of the hospital emergency department visit, and the cost of the visit to the hospital and to the state Medicaid program

16. Overview of Legislative Results: Administration 16 • requires DSS to use the report to monitor the performance of an administrative services organization, including, but not be limited to, whether the ASO helps to arrange visits by frequent users of emergency departments to primary care providers after treatment at an emergency department

17. Overview of Legislative Results: Administration 17 • requires DSS to place the name and contact information of Medicaid beneficiaries' PCPs on their cards • requires DSS and DMHAS, in consultation with OPM, to ensure that all expenditures for targeted case management that are eligible for Medicaid reimbursement are submitted to the Centers for Medicare and Medicaid Services

18. Overview of Legislative Results: Administration 18 • P.A. 14-150 (effective July 1, 2014): requires DSS to: • continuously operate the current Medicaid acquired brain injury (ABI) waiver, not to phase out services for participants, and to ensure that no individuals receiving services be institutionalized in order to meet federal cost neutrality requirements • seek federal approval for a second ABI waiver • establish an advisory committee for the ABI waiver, which must meet no less than four times per year • submit to the legislature no later than 2/1/15 an initial report concerning the impact of the individual cost cap in the proposed second ABI waiver

19. Overview of Legislative Results: Administration 19 • P.A. 14-160 (effective January 1, 2015): permits, concurrent with implementation of hospital payment reform (Diagnostic Related Groups, DRGs), emergency department physicians to: • enroll separately as Medicaid providers; and • qualify for direct reimbursement for professional services he or she provides in a hospital emergency department to Medicaid recipients

20. Overview of Legislative Results: Administration 20 • P.A. 14-162 (effective July 1, 2014): modifies aspects of the Medicaid provider audit process as follows: • limits the circumstances in which DSS may extrapolate audited claims • clarifies that an audited provider or facility may present evidence to the commissioner or an auditor to refute the findings of an audit • requires DSS and DSS-contracted auditors to have on staff or consult with, as needed, health care providers experienced in relevant treatment, billing, and coding procedures

21. Overview of Legislative Results: Administration 21 • requires DSS to establish and publish on the department website audit protocols to help providers and facilities comply with state and federal Medicaid laws and regulations • requires DSS to provide free training to providers and facilities to help them avoid clerical errors • requires DSS to report on the revised audit protocols and procedures

22. Overview of Legislative Results: MAPOC 22 • P.A. 14-206 (effective from passage): creates a standing sub-committee of MAPOC, to study and make annual recommendations to the council on evidence-based best practices concerning Medicaid cost savings, and composed as follows: • a member of the Connecticut Hospital Association • two representatives of the business community with experience in cost efficiency management • a representative of the for-profit nursing home industry • a physician who serves Medicaid clients • a representative of the not-for-profit nursing home industry

23. Questions or comments?