Medicaid Managed Care Council update

Today’s Medicaid Managed Care Council meeting touched on some new issues and revisited some old ones. There was a strong exchange on the Charter Oak annual $100,000 and lifetime $1 million limits. Sen. Prague talked about a patient who called her office needing treatment for cancer that exceeded the annual cap. He was eventually able to continue his care, but is facing very large bills. She asked if the department is considering allowing people to tap into their lifetime caps when they have reached the annual limit. DSS stated that they are considering several options to address this concern including her idea of accessing the lifetime cap, but most of the options might include an increase in premiums. The conversation then turned to balancing affordable premiums with some relief for people reaching the coverage limits. Options include excluding specialty drugs from the calculation of the cap, links to the state’s high risk pool, reinsurance and placing a lien on the patient’s house. DSS reported that to date, only one person had exceeded the annual cap, but four others had received letters advising them that they had incurred expenses over $50,000. In the letter, DSS urges patients to contact them to see if they are eligible for other programs or resources to pay their bills.
The revenue and expense reports for 2008 generated a great deal of comment. CHN made a profit of $1.6 million; the other HMOs reported losing money. Overall the state paid $207.30 per member per month, including dental and pharmacy costs until they were carved out. DSS defended CHN’s profits at about 2.7% saying that is to be expected. DSS also believes that the program cost more per member during the months the plans were not at risk (the PIHP model) than under capitation, but did not provide numbers to support that assertion. There was a great deal of discussion of the Comptroller’s audit and the $50 million cut from HUSKY HMO rates in the budget that just passed. DSS stated that it is their expectation/goal to recoup that savings from the plans’ rates in the upcoming negotiations, although they do not agree with the Comptroller’s report. However after further discussion, Rep. Villano stated his concern that DSS did not plan to re-bid the contracts and about their “reluctance” to aggressively pursue those savings. DSS noted that they are no longer hiring outside auditors for rate-setting, but are performing those functions in-house and are restructuring their encounter data management system and should have better information on which to base the rates in the future.
DSS also described the prior authorization process for medications, but never got to the update on PCCM.
The PCCM subcommittee meets next week on Wednesday the 16th at 10am in the LOB.
Ellen Andrews