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Connecticut Department of Social Services

Connecticut Department of Social Services. Prospectus: Health Care Contracting Opportunities Charter Oak – HUSKY A – HUSKY B. October 2007. M. Jodi Rell, Governor Michael P. Starkowski, Commissioner. Section Page Introduction 4 Purpose 5 Opportunity 7 HUSKY A/B/Plus 9

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Connecticut Department of Social Services

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  1. ConnecticutDepartment of Social Services Prospectus:Health Care Contracting Opportunities Charter Oak – HUSKY A – HUSKY B October 2007 M. Jodi Rell, Governor Michael P. Starkowski, Commissioner

  2. Section Page Introduction4 Purpose5 Opportunity7 HUSKY A/B/Plus9 Charter Oak11 Procurement14 Timeline16 Process18 Rate Setting21 Section Page Program Design27 Target Population37 Benefits52 Network56 Becoming an MCO60 Sample Contracts64 Appendices66 Websites67 Sample RFP Library68 Contact Info69 Prospectus - Table of Contents

  3. “My goal is to make sure that every adult and child in Connecticut has access to health insurance.”Governor M. Jodi Rell(December 27, 2006)

  4. Introduction:DSS to Release RFP in November 2007 • Connecticut Department of Social Services (DSS) anticipates releasing a Request For Proposal (RFP) in November 2007 for qualified carriers and managed care organizations to provide health care services to the combined HUSKY and Charter Oak programs • This prospectus is intended to provide interested parties with background information about the upcoming opportunity to win a contract under DSS’s competitive procurement to provide health care services to an estimated 350,000 Connecticut citizens

  5. 1. PURPOSE

  6. Purpose:Competitively Procure Health Care Contracts July 1, 2008 • Section 23 of Public Act 07-02 (June Special Session) authorized DSS to enter into contracts with carriers and managed care organizations effective July 1, 2008, to provide services for the newly created state-sponsored health coverage program known as the Charter Oak Health Plan • Charter Oak, designed to provide premium assistance in the form of premium subsidies to uninsured adults, with incomes up to 300% of the federal poverty level (FPL), is one piece of the state’s commitment to provide universal access to affordable health insurance for Connecticut adults of all incomes • DSS’s existing managed care programs, HUSKY A & HUSKY B, have approximately 320,000 covered lives. DSS will enter into new contracts with carriers and managed care organizations, effective July 1, 2008

  7. 2. OPPORTUNITY

  8. Opportunity:Combined HUSKY/Charter OakProcurement • A combined procurement for HUSKY and Charter Oak will cover an estimated 350,000 Connecticut citizens for a period of at least 3 years and up to 5 years, with a total contract value projected to be in excess of $3.5 billion over the five-year contract • Successful bidders will be required to meet the network, operational, contractual, and financial standards as laid out in the RFP and provide services for both HUSKY programs, as well as the Charter Oak program • All 350,000 lives will potentially be available under this new contract. New contractors will have the opportunity to enroll individuals and families through an initial open enrollment period and receive newly eligible individuals and families

  9. 3. HUSKY A HUSKY B/HUSKY PLUS

  10. DSS Health Care Programs:HUSKY Plan • HUSKY A — Comprehensive health care coverage serving low-income children, parents, relative caregivers with incomes up to 185% of FPL • Includes pregnant women with incomes up to 250% of FPL • Traditional Medicaid health coverage • HUSKY B — Health coverage for uninsured children in moderate and higher income families, 185% - 300% of FPL (unsubsidized group rate coverage over 300% of FPL) • HUSKY Plus — A supplemental program for children with special medical needs available to participants enrolled in HUSKY B (185% -300% of FPL). HUSKY Plus benefits are paid on a fee–for-service basis through DSS contracts

  11. 4. CHARTER OAK HEALTH PLAN

  12. DSS Health Care Programs:Charter Oak Health Plan • Charter Oak is designed to provide an affordable health insurance product to adults of all incomes at a target total premium of $250 per member per month • Charter Oak is not Medicaid: benefits will be based on a commercial model, with enforceable deductibles, co-pays, and coinsurance • For individuals with incomes less than 300% of FPL, premium will be subsidized by the state according to a fixed sliding scale

  13. Charter Oak:FPL Table and Projected Enrollment Total Cost of Monthly Premium

  14. 5. PROCUREMENT

  15. Procurement:Combined to Balance Risk and Simplify Administration • DSS will release a Request for Proposals for the combined HUSKY A, HUSKY B and Charter Oak programs in November 2007 • DSS is combining the procurement to allow the successful bidders to balance the familiar risk and large size of the HUSKY enrollment with the less familiar and less predictable size of the Charter Oak enrollment • DSS has a long, proven track record, having administered Medicaid Managed Care since 1995, and the HUSKY Plan (A/B) since 1998. Using this established infrastructure will allow for simplified administration of the combined procurement and reduce the risk to successful bidders by utilizing an existing, known implementation process

  16. 6. TIMELINE

  17. Timeline:HUSKY/Charter Oak Procurement • Release of ProspectusOctober 2007 • Release of RFPNovember 2007 • RFP Bidders’ ConferenceDecember 2007 • RFP Bids DueJanuary 2008 • RFP NegotiationsFebruary 2008 • RFP AwardsMarch 2008 • Open EnrollmentMay 2008 • Contract Effective DateJuly 2008

  18. 7. PROCESS

  19. Process:Soliciting Feedback and Partnering • DSS is soliciting feedback and interest from qualified carriers and managed care organizations up to the release of the RFP in November 2007. Where appropriate, DSS will incorporate the feedback into the RFP • DSS will make the data available electronically used in the HUSKY rate setting process to help interested parties more fully understand the risk of the HUSKY program and assist in projecting risk of the Charter Oak program • DSS will conduct a Bidders’ Conference and will provide a question and answer process to allow interested parties to interact with the State’s health policymakers and more fully understand the HUSKY and Charter Oak programs

  20. Process:Soliciting Feedback • Simultaneous with this prospectus, the Department is finalizing the RFP for the combined HUSKY and Charter Oak procurement. Per the attached timeline, DSS expects to release the RFP within the next 30 days. To solicit comments on the procurement prior to the RFP release, DSS has established the DSS.HealthCare@ct.gov mailbox • Interested parties should e-mail their comments to this mailbox. All comments will reviewed by the Agency. Any comments requiring responses will be sent to all interested parties that register by submitting an e-mail labeled “Request for Registration” to the above mailbox

  21. 8. RATE SETTING

  22. Rate Setting Methodology: HUSKY A & HUSKY B • Rates required to be Actuarially Sound per CMS Requirements • Rates set for State Fiscal Year (SFY). Rates Effective July 1, 2008 will be in effect for SFY09 (July 1, 2008, to July 1, 2009) • Rates are based on Health Plan Financials and Encounter data, adjusted for: • Demographics • Unpaid Claims Liability • Program Changes • Trend

  23. Rate Setting Methodology Changes:Under Consideration HUSKY A & HUSKY B • January 1, 2008 • Maternity and newborn kick payments • Future Rate Years - Changes Under Consideration • Risk-Adjusted Rates • Pay-for-Performance Incentives • Minimum Loss-Ratio Standards • Quality/Evidence-Based Payment Incentives

  24. Rate Setting Methodology:Charter Oak • Rates will be Actuarially Sound and able to meet CMS Requirements • Rates will be set for State Fiscal Year (SFY). Rates Effective July 1, 2008 will be in effect for SFY09 (July 1, 2008 to July 1, 2009) • Rates will be based on HUSKY A adults data, adjusted for differences in: • Demographics • Plan Design • Underlying Risk/Acuity • Reimbursement • Trend

  25. Rate Setting Methodology:Charter Oak • Incentives/Sanctions – DSS is considering placing funds at-risk for contractor performance standards in several areas, including: • Geographic distribution of key provider types for overall network access requirements • Availability of scheduled appointments for primary care and specialty physicians for meeting appointment scheduling waiting standards • Telephonic wait times, call abandonment and resolution rates for member and provider customer service standards • Claims adjudication times for meeting claims payment timeliness requirements

  26. HUSKY A Actuarially-sound Fiscal Year 2005 – 2007 Capitation Rates *FY05 and the First Half of FY06 include capitation amounts for specialty behavioral services ** Second Half of FY06 and FY07 exclude capitation amounts for specialty behavioral services

  27. 9. PROGRAM DESIGN

  28. Program Design:HUSKY A • Geographic Area • Statewide Status: Approved • Program Structure • MCO Original Effective Date: July 20, 1995 • Authority • 1915(b)(1) • Type of Enrollment • Managed Care • TANF, SOBRA, Pregnant Women, Associated Adults (parents of HUSKY A kids) up to 185% FPL, DCF children (Foster care), SSI children who are not Medicare eligible • Excluded HUSKY Populations • SSI Adults without Medicare, Duals, GA (State only) Refugees, QMB/SLMB, ConnPACE (State funded Rx only), CHC (State funded)

  29. Program Design:HUSKY B • Geographic Area • Statewide Status: Approved • Program Structure • MCO Original Effective Date: July 1, 1998 • Authority • State Plan under the State Children’s Health Insurance Program (SCHIP) – Title XXI of the Social Security Act • Type of Enrollment • Managed Care • TANF, SOBRA, Pregnant Women, Associated Adults (parents of HUSKY A kids) up to 185% FPL, DCF children (Foster care), SSI children who are not Medicare eligible • Excluded HUSKY Populations • SSI Adults without Medicare, Duals, GA (State only) Refugees, QMB/SLMB, ConnPACE (State funded Rx only), CHC (State funded)

  30. Program Design:Charter Oak • Geographic Area • Statewide Status: Anticipated Carriers will offer Coverage Statewide • Program Structure • State Program*: July 1, 2008 • Authority • Section 23 of Public Act 07-02 (June Special Session) • Type of Enrollment • Voluntary, Affordable Health Insurance • Individuals without health insurance for the last six months or those who meet certain qualifying criteria to exempt them from uninsurance requirement • Excluded Populations • Individuals currently insured or insured within last six months (exemptions to be determined) • Individuals eligible but not enrolled in Public Programs (SAGA, HUSKY A and B, etc) * DSS anticipates submitting a waiver to the Connecticut Legislature, and if approved, to CMS for Federal financial participation in portions of Charter Oak

  31. Program Design:HUSKY Benefits Coordination • Benefit Design Carve-out: SpecialtyBehavioral Health • Effective January 1, 2006, DSS and the Managed Care Organizations, in coordination with a new behavioral vendor, successfully carved out specialty behavioral health services for HUSKY A and B • Specialty behavioral health services are now authorized and managed under an Administrative Services Organization (ASO) contract with Value Options (VO). VO manages the specialty behavioral health services of HUSKY A, HUSKY B and Department of Children and Families (DCF) funded clients under the CT Behavioral Health Partnership (BHP)

  32. Program Design:HUSKY Benefits Coordination (cont.) • Benefit Design Carve-out: Dental • Effective with dates of service July 1, 2008, and forward, the Managed Care Organizations, or their subcontractors, will no longer manage or pay claims for dental services • Benefit Design Carve-out: Pharmacy • Effective with dates of service July 1, 2008, and forward, the Managed Care Organizations, or their subcontractors, will no longer manage or pay claims for pharmacy services

  33. Program Design:Charter Oak Benefits Coordination • Charter Oak will follow DSS’s successful track record in benefits carve-outs and will carve-out certain services. • Benefit Design Carve-out: Specialty Behavioral Health • Charter Oak contractors will not be required to manage or pay claims for specialty behavioral health services • Benefit Design Carve-out: Pharmacy • Charter Oak contractors will not be required to manage or pay claims for pharmacy services

  34. Program Design:How Benefits Coordination Will Work for HUSKY and Charter Oak Specialty Behavioral Health • Benefit Design Carve-out: SpecialtyBehavioral Health • MCOs have monthly coordination of care meetings with ValueOptions • If there is ever a question of whether med or BH is primary, either party can refer the issue to DSS for review and resolution (<4 in 20 months) • MCOs and ASO have worked together on primary care education and initiatives to improve ease of referral from primary care to BH network • MCOs remain responsible for most BH in primary care settings and all BH non-emergent medical transportation

  35. Program Design:How Benefits Coordination Will Work for HUSKY Dental • Benefit Design Carve-out: Dental (HUSKY Only) • MCOs and ASO will work together on primary care education and initiatives to improve ease of referral from primary care to the dental network • Pediatricians will be able to receive reimbursement for provision of dental screens and fluoride treatments to children under 3 • MCOs will retain responsibility for HUSKY A dental non-emergent medical transportation

  36. Program Design:How Benefits Coordination Will Work for HUSKY and Charter Oak Pharmacy • Benefit Design Carve-out: Pharmacy (HUSKY and Charter Oak) • Coordination will be required between the MCOs, the Department and Fiscal contractor (e.g., data sharing, client eligibility, cost sharing, etc,); monthly coordination meetings would be held among all contracting parties (MCOs, DSS, Fiscal Contractor) • DSS’s Pharmacy Program Structure: • Preferred Drug List (PDL), prior authorization • One Pharmaceutical & Therapeutics (P&T) Committee & Drug Utilization Review (DUR) Board

  37. 10. TARGET POPULATION

  38. Target Population:HUSKY and Charter OakMember Enrollment Procedures • The State, or its designee, determines eligibility for Managed Care Programs • The State, through a centralized enrollment broker, handles the enrollment, disenrollment and initial selection of the primary care provider (PCP) • Enrollments and disenrollments are transmitted electronically daily to each MCO • Enrollment is continuous and members may change plans at any time (membership done on a full-month basis) Source: 2007 HUSKY A and HUSKY B Contract Source: http://www.ahcpr.gov/chip/content/benefit_design/state_ben-husky__features.htm

  39. Target Population:Recent HUSKY A Eligibility Changes • Eligibility Expansions • July 1, 2007: • Increase eligibility criteria for parents and caretaker relatives of children in HUSKY A from 150% FPL to 185% FPL • HUSKY coverage provided for all uninsured newborns. • If enrolled in HUSKY B, state coverage of premium costs for first four months of life. • January 1, 2008: • Expand HUSKY A eligibility for pregnant women from 185% to 250% FPL

  40. Target Population:HUSKY - Who is eligible? Sources: FPL Data: http://aspe.hhs.gov/poverty/07poverty.shtml HUSKY Enrollment: http://www.huskyhealth.com/qualify.htm Note: Children in families with income above 300% of the federal poverty limit can also enroll in HUSKY B, but are required to pay the full cost of the premium

  41. Average HUSKY Managed Care Enrollment by Calendar Year Monthly Enrollment Year Source: HUSKY A and B Enrollment Reports *As of October 2007

  42. Target Population:Connecticut Counties

  43. HUSKY A Enrollment by County July 2007 Source: HUSKY A and B Monthly Enrollment Reports

  44. HUSKY A Enrollment by MCO by County July 2007 Source: HUSKY A and B Monthly Enrollment Reports

  45. HUSKY A Enrollment by Age and MCO July 2007 Source: Mercer Encounter Eligibility Records for July 2007

  46. HUSKY A Enrollment by Age and MCO July 2007 Source: Mercer Encounter Eligibility Records for July 2007

  47. HUSKY B Enrollment by MCOJuly 2007 Source: HUSKY A and B Monthly Enrollment Reports

  48. Target Population:Sources of Health Insurance Coverage Source: Results of the Office of Health Care Access 2004 and 2006 Household Survey http://www.ct.gov/ohca/lib/ohca/publications/2007/household06_databook_1-31_version.pdf

  49. Target Population:Connecticut Population Breakdown Sources: CT Office of Health Care Access 2006 Household Survey and population figures from U.S. Census Bureau March 2005 Current Population Survey 1 The 95 percent confidence interval provides a range of estimates, suggesting that if this survey were repeated 100 times, the share of people uninsured at the time of the survey would range from 5.7 percent to 7.2 percent in 95 of 100 surveys, as the Household Survey has a margin of error of ± 0.7 percent. 2 Rounded to nearest hundred. Source: Results of the Office of Health Care Access 2006 Household Survey http://www.ct.gov/ohca/lib/ohca/publications/2007/household06_databook_1-31_version.pdf

  50. Target Population:Projected Charter Oak Enrollment by County – SFY09 Source: DSS Budget Projections adjusted by County

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