Medical Assistance Program Oversight Council June 14, 2013

1. Medical Assistance Program Oversight CouncilJune 14, 2013

2. Today’s Agenda • Overview of Medicaid-related results of legislative session • Budget • Coverage groups • Covered services • Terms of participation • Related notes • Enrollment report 2

3. Overview of Legislative Results: Budget 3 Connecticut is one of only a few states that has historically "gross appropriated“ its Medicaid program - the state budget has accounted for both the federal and state shares of spending as state expenditures toward our constitutional spending cap Under this budget this will change and only the state share will count toward the spending cap.  This is the "net appropriation" method

4. Overview of Legislative Results: Budget (cont.) 4 Medicaid is net appropriated (this does not include federal share) at $2,409,314,923 (SFY'14) and $2,289,569,579 (SFY'15) HUSKY B is funded at $30,460,000 (SFY'14) and $30,540,000 (SFY'15)

5. Today’s Agenda • Overview of Medicaid-related results of legislative session • Budget • Coverage groups • Covered services • Terms of participation • Related notes • Enrollment report 5

6. Overview of Legislative Results: Coverage Groups 6 • HB6705 (the human services implementer) provides the following: • Section 102 requires DSS to submit a plan for coverage of the new “Medicaid Coverage for the Lowest Income Populations” group • the new coverage group will include the current Low Income Adult (LIA, HUSKY D) beneficiaries plus the individuals who will become eligible under Medicaid income eligibility expansion effective January 1, 2014

7. Overview of Legislative Results: Coverage Groups (cont.) 7 • Sections 103 and 158 repeal the current LIA coverage (note: this will be replaced by the new group described immediately above) • See also Sections 67 and 68 of HB6704 (the budget)

8. Overview of Legislative Results: Coverage Groups (cont.) Effective January 1, 2014, Connecticut will expand income eligibility for the existing Low-Income Adult (LIA, HUSKY D) Medicaid coverage group to 133% of FPL (effectively, 138% given the income disregard that will be utilized).  In 2013, this translates into the following income eligibility limits: 8

9. Overview of Legislative Results: Coverage Groups (cont.) 9 • To qualify for the new group, people will need to meet the above income limits, and also: • be at least age 19 or under age 65 • not be pregnant • be ineligible for other specific coverage under Medicaid, Medicare and or CHIP • be a Connecticut resident • be a U.S. citizen or qualified alien (legally in the U.S. for at least five years unless under age 21 or pregnant)

10. Overview of Legislative Results: Coverage Groups (cont.) 10 This is anticipated to increase participation in the LIA group by 50,000 – 55,000 over and above the current enrollment of almost 89,500 people. 

11. Overview of Legislative Results: Coverage Groups (cont.) 11 • To determine income eligibility for the new coverage group, effective January 1, 2014, DSS will as required by federal law use Modified Adjusted Gross Income (MAGI) methodology • The two most important features of MAGI are the following: • MAGI will eliminate current income disregards and deductions and instead utilize a standard 5% income disregard

12. Overview of Legislative Results: Coverage Groups (cont.) 12 (cont.): • MAGI will use tax-based household composition rules to describe families as: • tax filers (e.g. filing taxes jointly, as a married couple filing separately, or as a single person); and • dependent children

13. Overview of Legislative Results: Coverage Groups (cont.) 13 A final note about coverage groups: adults with incomes in excess of 133% of FPL who qualify for Medicaid under HUSKY A will continue to participate in Medicaid.

14. Today’s Agenda • Overview of Medicaid-related results of legislative session • Budget • Coverage groups • Covered services • Terms of participation • Related notes • Enrollment report 14

15. Overview of Legislative Results: Covered Services 15 • HB6705 (the human services implementer) provides the following: • Section 80 (effective 7/1/13): • eliminates the requirement that DSS establish a reimbursement rate for foreign language interpretation – this will instead be done through the CHN-CT contract; and • restores the $250,000 state-funded chiropractic coverage for adults

16. Overview of Legislative Results: Covered Services 16 • HB6705 (the human services implementer) provides the following: • Section 85 (effective from passage) permits DSS to expand the categories of DME (beyond wheelchairs) for which reused parts and components shall be utilized, whenever practicable

17. Overview of Legislative Results: Covered Services 17 • HB6705 (the human services implementer) provides the following: • Section 111 (effective 7/1/13) requires DSS to implement a pilot medication therapy management program in New Haven with the CT Pharmacists Association and a community health center • Section 112 (effective 7/1/13)eliminates the previously enacted authority for stretcher vans

18. Today’s Agenda • Overview of Medicaid-related results of legislative session • Budget • Coverage groups • Covered services • Terms of participation • Related notes • Enrollment report 18

19. Overview of Legislative Results: Terms of Participation 19 • HB6705 (the human services implementer) provides the following: • Section 76(e) (effective 7/1/13)requires DSS, to the extent permitted by federal law, to require Medicaid beneficiaries who use emergency departments for non-emergent care to make co-payments

20. Overview of Legislative Results: Terms of Participation (cont.) 20 According to CMS requirements, when co-payments are implemented, hospitals must do the following before providing a non-emergency service to a Medicaid beneficiary: • The hospital must determine: • after an appropriate medical screening, that the individual does not need emergency medical services and

21. Overview of Legislative Results: Terms of Participation (cont.) 21 • that an alternative non-emergency services provider is actually available and accessible in a timely manner to provide the services needed by the individual with the imposition of no or a lesser copayment • The hospital must provide the individual with (a) notice that a copayment may be required before the service is provided; (b) the name and location of an alternative non-emergency services provider (as described above); and (c) a referral to coordinate scheduling of the individual’s treatment by this provider

22. Overview of Legislative Results: Terms of Participation (cont.) 22 • HB6705 (the human services implementer) provides the following: • Section 81 (effective 7/1/13) eliminates the higher rate of reimbursement to independent pharmacies, which was pending CMS approval and had not yet been implemented

23. Overview of Legislative Results: Terms of Participation (cont.) 23 • Section 105 (effective 7/1/13)confirms that coverage decisions made by the behavioral health Administrative Services Organization (Value Options) must be based solely on the statutory definition of medical necessity, but may use clinical management guidelines to inform and guide the authorization

24. Overview of Legislative Results: Terms of Participation (cont.) 24 • HB6705 (the human services implementer) provides the following: • Section 127 (effective 7/1/13) establishes procedural guidelines for prescription drug step therapy • step therapy will require that the patient try and fail on only one prescribed drug on the preferred drug list before another drug can be prescribed and eligible for payment

25. Overview of Legislative Results: Terms of Participation (cont.) 25 • step therapy will not apply to any mental health–related drugs • DSS must provide a clear and convenient process to expeditiously request an override of such restriction

26. Overview of Legislative Results: Terms of Participation (cont.) 26 • DSS must expeditiously grant an override of such restriction whenever the prescribing practitioner demonstrates that: • the preferred treatment required under step therapy has been ineffective in the treatment of the patient's medical condition in the past;

27. Overview of Legislative Results: Terms of Participation (cont.) 27 • the drug regimen required under the step therapy program is expected to be ineffective based on the known relevant physical or mental characteristics of the patient and the known characteristicsofthe drug regimen • the preferred treatment required under the step therapy program will cause or will likely cause an adverse reaction or other physical harm to the patient; or

28. Overview of Legislative Results: Terms of Participation (cont.) 28 • it is in the best interest of the patient to provide the recommended drug regimen based on medical necessity. • the duration of any step therapy program requirement is limited to no more than thirty days, after which time the prescribing practitioner may deem such treatment as clinically ineffective for the patient

29. Overview of Legislative Results: Terms of Participation (cont.) 29 • when the prescribing practitioner deems the treatment to be clinically ineffective, the drug prescribed and recommended by the practitioner must be dispensed and covered under the Medicaid program

30. Today’s Agenda • Overview of Medicaid-related results of legislative session • Budget • Coverage groups • Covered services • Terms of participation • Related notes • Enrollment report 30

31. Overview of Legislative Results: Related Notes 31 • The obstetrics pay-for-performance (P4P) initiative has been funded under the budget as follows: • $300,000 in SFY’14 • $1,200,000 in SFY’15

32. Overview of Legislative Results: Related Notes (cont.) 32 • The proposed obstetrics pay-for-performance program (P4P), is designed to reward obstetrics providers with bonuses for documentation of care resulting in the following outcomes: • timely completion of online OB notification forms • timely first OB visit after confirmation of pregnancy

33. Overview of Legislative Results: Related Notes (cont.) 33 • timely postpartum visit after delivery • full-term, vaginal delivery after spontaneous labor whenever medically possible • appropriate use of 17-alpha hydroxyprogesterone when there is prior history of preterm labor

34. Overview of Legislative Results: Related Notes (cont.) 34 • HB6705 (the human services implementer) provides the following: • Sections 83, 84, 88-90, 94-101, and 155 eliminate reference to ConnPACE – ConnPACE will sunset as of December 31, 2013 • Sections 86-87, 90-93, and 119-120 eliminate reference to Charter Oak – Charter Oak will sunset as of December 31, 2013 as the Access Health CT plans become effective January 1, 2014

35. Overview of Legislative Results: Related Notes 35 • Special Act 13-7 requires the Medical Assistance Program Oversight Council (MAPOC) to study access to Medicaid services • P.A. 13-74 seeks to require the Health Insurance Exchange Board, not later than 3/14/14 and quarterly thereafter, to submit reports to the committees of cognizance on such data points as stratification by income of individuals who purchase HIX plans, gaps in coverage, and individuals who are not initially but subsequently become eligible for Medicaid

36. Overview of Legislative Results: Related Notes 36 Amended language of HB 6610 (pending signature of the Governor) requires that DSS 1) conduct a cost benefit analysis of providing home care as opposed to institutional care to recipients of Medicaid and HUSKY B who are under the age of 18; and 2) make recommendations on other waiver or State Plan amendments that the state may utilize to cover such services)

37. Questions or comments?