HUSKY Health Program and Charter Oak Health Plan Medical ASO Programs and Services

1. HUSKY Health Program and Charter Oak Health PlanMedical ASOPrograms and Services

2. Medical ASO Introduction The Medical ASO program is essentially managed fee for service. Connecticut has taken the best of the MCO and FFS programs to create the only Medical ASO delivery model in the country for its Medicaid program. Program attributes include: • Care coordination focusing on the whole person and improved outcomes • Nationally recognized Person-Centered Medical Homes that provide an enhanced care experience for members and caregivers • Single provider network (CMAP), enrollment process and provider reimbursement methodology • Streamlined administrative processes for the providers, including one claims payment system and policies • Single data warehouse that includes all Medicaid claims data • New technology introduced, which allows the program to assess and predict member risk, profile provider performance, measure outcomes and analyze the costs and utilization of the entire Medicaid population

3. Services for Members • Centralized Member Call Center for: • Benefit Information • Assistance with PCP Selection • Identification of CMAP Specialists & Other Providers • Appointment Coordination and Scheduling The Call Center handled the following Member calls: • 278,131 in 2012 • 161,647 between Jan-June 2013 • Referrals to Community Resources • Member Education and Forums • Nutrition Workshops • Member Web Portal • Health Education Materials • Coordination with other ASOs • 24/7 Nurse Advice Line • Crisis Line Services

4. Members Have Access to an Escalation Unit • The Escalation Unit handles the more complex Member access to care issues. • Members are referred to the Escalation Unit by Call Center and Intensive Care Management (ICM) staff, providers, state agencies, Member advocates and others. • The Escalation Unit assists Members by: • Identifying and scheduling appointments with multiple providers • Referring to community resources, other ASOs and ICM • Arranging transportation to appointments • Coordinating medical record transfers to new providers The Escalation Unit assisted 4,790 Members in 2012 and 2,832 Members between Jan-June 2013.

5. Services for Members • Care Coordination Outreach: • Welcome Calls/ Health Risk Screenings • Members with no PCP • Missed Appointments • ED Utilizers • Wellness Program • Well Care Reminders and Condition-Specific Coaching • Preventive Care Screening Reminders • Gaps in Care Member Calls • Smoking Cessation Programs • Authorizations for Selected Services • Inpatient Discharge Planning • Pre-Discharge Visitation • Post-Discharge Follow-Up • Collaboration with Waiver and Community-Based Programs • Intensive Care Management • Member Risk Stratification

6. Member Risk Stratification through Predictive Modeling During 2012, the Medical ASO merged 140,473,306 claim lines (medical, behavioral, pharmacy and dental claims) from four different data sources (3 MCOs and FFS) into a single data warehouse. For the first time, the State is able to conduct data analytics on its entire Medicaid population. • The initial data has been loaded into a data analytics and predictive modeling tool and is updated monthly. • The tool uses a diagnosis-based, case-mix methodology to describe or predict the overall population for past, current or future healthcare utilization and costs. • The tool also provides population-specific reports and profiles provider performance. • Members are stratified by risk category, allowing identification of care opportunities.

7. Population Stratification Community Support Services Risk stratification is one of many ways for a Member to enter ICM. There’s no wrong door… Member Call Center and 24/7 Nurse Advice Line

8. Intensive Care Management (ICM) The ICM team recognizes that members present with complex needs and barriers that place them at higher risk for poor health outcomes. Utilizing a culturally aware and person-centered approach, the ICM program strives to minimize these barriers by: • Providing both face-to-face visits and telephonic outreach by Regionalized Care teams of ICM Nurses • Utilizing Evidence-Based Practices • Collaborating with Providers • Educating Members ICM takes into account the many factors that can impact a person’s ability to successfully manage their health, such as: • Social • Environmental • Behavioral • Physical Conditions • Cultural • Financial Between July 1, 2012 to June 30, 2013: • 43,074 Members were outreached for ICM • 16,836 Members enrolled in ICM

9. Additional ICM Team Members The ICM Multidisciplinary team also includes support services from a Registered Dietician, Pharmacists and Human Services Specialists. • The Registered Dietician and Pharmacists provide individualized Member consults as part of ICM care planning process. • Human Services Specialists providing face-to-face visits with Members/ caregivers to address and resolve social/ environmental issues by: • Establishing relationships/ collaborations with community-based agencies to connect members with available resources • Coordinating with Providers and ICM when non-medical needs are identified • Assisting the Member to identify natural supports • Encouraging self-advocacy (e.g., in completing an application for resources such as housing, food, clothing, employment, etc.) • Completing Ages and Stages Questionnaires for children under the age of 5 ½ within the household to assist in identifying children with developmental and/or behavioral health concerns and referring to ICM / early intervention programs (211, Child Development Infoline)

10. ICM Process • Member is assessed • Immediate needs are addressed • Barriers, problems and strengths are identified • A person-centered care plan is developed with the Member/caregiver and their provider • Member-specific short and long-term goals and timeframes are developed • Interventions are carried out

11. A Member is Considered Self-Managing When… The Member/ caregiver: • Agrees their healthcare goals have been met; • Is able to advocate for him/herself and has the knowledge and understanding to seek out the appropriate care and resources; and • Can successfully manage their conditions. Before a care plan is closed, members are informed: • If any changes in their health status or conditions occur, they can seek ICM services again; and • They will continue to have access to non-ICM services (such as 24/7 Nurse Line, health reminders, appointment scheduling assistance, community support services, etc.) through the Medical ASO as needed.

12. Services to Providers • Dedicated Provider Relations Representatives • CMAP Provider Recruitment and Retention • Call Center for Providers • Single source for Utilization Management • Provider Forums, Trainings and Presentations • Person-Centered Medical Home Supports • Reporting, including Patient Panels

13. Determining a Primary Care Provider’s Panel: PCP Attribution Under the ASO Model, Members are now linked to a PCP based on their usual source of care. The attribution process is utilized to reflect a Member’s choice of PCP. • MCO Assignment • Process used by the MCOs prior to 2012 • Based on a members zip code and geographic location to a provider • Could be determined by the member’s choice or the MCO’s algorithm for assignment of Members • Member may have never seen the provider • ASO Attribution • Process effective 2012 and going forward • Based on who the member has visited and provider’s billed services • Member may self select a provider or the ASO will attribute based on a member’s claim history • Member had a service with the provider

14. PCMH Practice Supports The Medical ASO provides a variety of supports to assist practices in transforming to a PCMH model of care. Supports include: • Recruiting and enrolling Medicaid practices to participate in the DSS PCMH/ Glide Path program • Providing guidance, resources, toolkits and training materials on national PCMH standards (NCQA and The Joint Commission) and cultural diversity • Providing data to assist in identifying and managing patients with the highest utilization and gaps in care • Evaluating practice performance for ongoing compliance with accreditation standards

15. Questions