A Snapshot of the DSS Health Care Transformation Agenda for the Continuum of Care Partnership

We are transforming every aspect of how we provide health services to Connecticut residents. 22

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Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April The Definition has not been amended since

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Clear windows of opportunity are available to prevent MEB disorders and related problems before they occur. Risk factors are well established, preventive interventions are available, and the first symptoms typically precede a disorder by 2 to 4 years. And because mental health and physical health problems are interwoven, improvements in mental health will undoubtedly also improve physical health. NIH 2009

We are putting systems in place to help people access services easily and timely. We will be expanding Medicaid eligibility. Our partner Administrative Services Organizations are supporting people in using their medical, behavioral health, and dental benefits well and in connecting with providers. 99

We are investing in primary, preventative care. We are working to integrate medical and behavioral health care. We are enabling people who need long-term services and supports to receive them in the community. 10

Why are we doing this? Medicaid is a major payer of health services and currently serves over 630,000 beneficiaries 4 out of 10 births in Connecticut are to mothers who are Medicaid beneficiaries Under the ACA expansion, Connecticut Medicaid expects to serve approximately an additional 50,000 to 55,000 individuals 11

We are moving to shift from paying for procedures and services, to reimbursing in a way that rewards outcomes: value-based purchasing. 12

Why are we doing this? (cont.) Overall, Medicaid currently serves 631,782 beneficiaries (17.6% of the state population)  437,652 HUSKY A adults and children  13,436 HUSKY B children  97,203 HUSKY C older adults, blind individuals, individuals with disabilities and refugees  93,749 HUSKY D low-income adults age  3,178 limited benefit individuals (includes behavioral health for children served by DCF, tuberculosis services, and family planning services) 13

Why are we doing this? (cont.) 14 Connecticut has: the fourth highest level of health care expenditures at $8,654 per capita, behind only the District of Columbia, Massachusetts, and Alaska [2009 data] the ninth highest level of Medicare costs at $11,086 per enrollee [2009 data] the highest level of Medicaid costs at $7,561 per enrollee [2010 data] [Kaiser State Health Facts]

Why are we doing this? (cont.) 15 Please note the following per capita break-out of Medicaid costs by recipient group: $16,955 Aged $25,393 Disabled $ 3,533 Adult $ 3,339 Children [Kaiser State Health Facts, 2010 data]

Why are we doing this? (cont.) Key health indicators for Connecticut Medicaid beneficiaries, including hospital readmission rates and outcomes related to chronic disease, are in need of improvement The Department is also deeply conscious of other indicators, such as incidence of Adverse Childhood Events (ACEs), that have bearing on coverage of and means of providing services 16

What is our conceptual framework? DSS is motivated and guided by the Centers for Medicare and Medicaid Services (CMS) “Triple Aim”: improving the patient experience of care (including quality and satisfaction) improving the health of the population reducing the per capita cost of health care 17

We are also influenced by a value-based purchasing orientation. The Centers for Medicare and Medicaid Services (CMS) define value-based purchasing as a method that provides for: Linking provider payments to improved performance by health care providers. This form of payment holds health care providers accountable for both the cost and quality of care they provide. It attempts to reduce inappropriate care and to identify and reward the best- performing providers. 18

Improving the Patient Experience Of Care 19 Issues PresentedDSS StrategiesAnticipated Result Individuals face access barriers to gaining coverage for Medicaid services ConneCT MAGI income eligibility Integrated eligibility process with Access Health CT Streamlined eligibility process that optimizes use of public and private sources of payment Individuals have difficulty in connecting with providers ASO primary care attribution process and member support with provider referrals Support for primary care providers (PCMH, EHR, ACA rate increase) DSS will help to increase capacity of primary care network and to connect Medicaid beneficiaries with medical homes and consistent sources of specialty care Individuals struggle to integrate and coordinate their health care ASO predictive modeling and Intensive Care Management (ICM) Duals demonstration Health home initiative Individuals with complex health profiles and/or co- occurring medical and behavioral health conditions will have needed support

Improving the Health of Populations 20 Issues PresentedDSS StrategiesAnticipated Result A significant percentage of Connecticut residents does not have health insurance Medicaid expansion Integrated eligibility determination with Access Health CT Increased incidence of individuals covered by either Medicaid or an Exchange policy Many Connecticut residents do not regularly use preventative primary care PCMH initiative in partnership with State Employee Health Plan PCMH Increased regular use of primary care; early identification of conditions and improved support for chronic conditions Many health indicators for Medicaid beneficiaries are in need of improvement, and Medicaid has the opportunity to influence other payers Behavioral health screening for children Rewards to Quit incentive- based tobacco cessation initiative Obstetrics and behavioral health P4P initiatives Improvement in key indicators for Medicaid beneficiaries; greater consistency in program design, performance metrics and payment methods among public and private payers

Reducing the Per Capita Cost of Care 21 Issues PresentedDSS StrategiesAnticipated Result Connecticut’s historical experience with managed care did not yield the cost savings that were anticipated Conversion to managed fee- for-service approach using ASOs Administrative fee withhold and performance metrics DSS and OPM will have immediate access to data with which to assess cost trends and align strategies and performance metrics in support of these Connecticut Medicaid’s fee-for-service reimbursement structure promotes volume over value PCMH performance incentives Duals demonstration performance incentives and shared savings Evolution toward value- based reimbursement that relies on performance against established metrics Connecticut Medicaid’s means of paying for hospital care is outmoded and imprecise Conversion of means of making inpatient payments to DRGs and making outpatient payments to APCs DSS will be more equipped to assess the adequacy of hospital payments and will be able to move toward consideration of episode- based approaches

22 Issues PresentedDSS StrategiesAnticipated Result Connecticut expends a high percentage of its Medicaid budget on a small percentage of individuals who require long-term services and supports; historically, this has primarily been in institutional settings Consumers strongly prefer to receive these services at home Strategic Rebalancing Initiative (State Balancing Incentive Payments Program, Money Follows the Person, nursing home diversification funding, workforce analysis, My Place campaign) Duals demonstration payments for care coordination Connecticut will achieve the stated policy goal of making more than half of its expenditures for long-term services and supports at lower cost in home and community-based settings Reducing the Per Capita Cost of Care (cont.)

How does this relate to the work of the Continuum of Care? 23

Questions Posed by Continuum Members Continuum members have posed questions on the following: Eligibility for Connecticut Medicaid services (e.g. juvenile justice involved youth) EPSDT services Connecticut coverage of evidence-based services related to child and family behavioral health 24

First, let’s review some material related to eligibility for Connecticut Medicaid... 25

Eligibility for Connecticut Medicaid Federal rules and the Medicaid State Plan identify eligibility rules Most young people qualify for Medicaid based on their family’s income, but states also must cover “categorically eligible” youth who qualify under Title IV-E of the Social Security Act, including foster care children, adoption assistance children and some children with disabilities 26

Eligibility for Connecticut Medicaid (cont.) Under ACA, beginning in 2014, states also must provide Medicaid coverage to young people up to age 26 who age out of the foster care system, regardless of their income 27

Eligibility for Connecticut Medicaid (cont.) The Continuum is interested in Medicaid eligibility of juvenile justice involved youth Many youth who are not incarcerated do qualify CMS has indicated that Federal Financial Participation (FFP, what we call “match”) is not available for Medicaid services to “inmates” who reside in “public institutions” 28

Eligibility for Connecticut Medicaid (cont.) CMS guidance provides the following definitions:  “inmate” is defined as an individual who is “serving time for a criminal offense or confined involuntarily in State of Federal prisons, jails, detention facilities, or other penal facilities”  “public institutions” are defined as “under the responsibility of a governmental unit, or over which a governmental unit exercises administrative control” 29

Eligibility for Connecticut Medicaid (cont.) Further, CMS has specified that FFP is:  available for specified groups including, in relevant part, paroled individuals, individuals on probation and individuals on home release except during those times when reporting to a prison for an overnight stay; and  unavailable for specified groups including, in relevant part, inmates voluntarily residing in halfway houses under government control 30

Next let’s look at what Connecticut currently covers... 31

Current Medicaid State Plan-Covered Services Medicaid State Plan: A written plan between a State and the Federal Government that outlines Medicaid eligibility standards, provider requirements, payment methods, and health benefit packages. A Medicaid State Plan is submitted by each State and approved by the Centers for Medicare and Medicaid Services (CMS) 32

Current Medicaid State Plan-Covered Services States must under their State Plans cover identified mandatory services (e.g. inpatient hospital care, FQHC services, physicians’ services) and may elect to cover optional services (e.g. dental, behavioral health, medical transportation) Connecticut covers a broad range of optional services 33

Current Medicaid State Plan-Covered Services For a summary of covered services under HUSKY A (children and parents/relative caregivers), C (older adults and people with disabilities) and D (single childless adults age 19-64), please use this link: ostings/member_benefits/HUSKY_A-C- D_Benefits.pdf 34

Current Medicaid State Plan-Covered Services (cont.) For a summary of covered services for HUSKY B (Children’s Health Insurance Plan/CHIP, uninsured children under age 19), please use this link: ostings/member_benefits/HUSKY_B_Member_Be nefits.pdf 35

Current Medicaid State Plan-Covered Services (cont.) The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid 36

Current Medicaid State Plan-Covered Services (cont.) Under EPSDT, states are required to provide comprehensive services and furnish all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines 37

Current Medicaid State Plan-Covered Services (cont.) EPSDT is made up of the following screening, diagnostic, and treatment services:  Screening Services  Vision Services  Dental Services  Hearing Services  Other Necessary Health Care Services  Diagnostic Services  Treatment 38

Current Medicaid State Plan-Covered Services (cont.) Connecticut Medicaid covers many clinical levels of behavioral health care, a non-exclusive list of which includes:  inpatient hospitalization  psychiatric residential treatment facility  partial hospitalization  intensive outpatient treatment  outpatient treatment 39

Current Medicaid State Plan-Covered Services (cont.) Further, consistent with best practice recommendations for trauma-informed, evidence-based wrap-around services, Connecticut covers the following rehabilitation services:  Multisystemic Therapy  Functional Family Therapy  MultiDimensional Family Therapy 40

Current Medicaid State Plan-Covered Services (cont.) Connecticut also covers Intensive In-Home Child and Adolescent Psychiatric Services (IICAPS) and Extended Day Treatment (EDT) An example of an evidence-based service that Connecticut does not cover is Cognitive Behavioral Therapy (CBT) 41

Recommendations for Expanded Coverage The Department’s Behavioral Health Screening Task Force has made the following recommendations to the Department leadership:  Require, and separately pay, for an annual behavioral (and at younger ages, developmental) screen using a validated screening instrument from age one through 17 years during the annual well- child visit 42

Recommendations for Expanded Coverage (cont.)  Track claims data to ensure that screens are being performed and that proper evaluation and treatment is initiated for those who are identified with behavioral health concerns  Conduct provider outreach program to encourage child health care providers to perform the screening and conduct targeted outreach to those providers who consistently do not conduct screenings 43

Recommendations for Expanded Coverage (cont.)  Collaborate with behavioral health experts and provider organizations to better ensure the needs of those children identified are adequately addressed 44

In conclusion... DSS is utilizing diverse strategies to enable access to services, expand eligibility, connect Medicaid beneficiaries to primary care, enhance utilization of health care services, integrate medical and behavioral health care, enable services and supports in the community, and shift towards paying for value DSS is interested in reviewing need for expansion of the current service array to support children and youth, and their caregivers 45

Questions or comments? 46