Connecticut Department of Social Services Prospectus: Health Care Contracting Opportunities Charter Oak – HUSKY A – HUSKY ...
Prospectus - Table of Contents <ul><li>Section   Page </li></ul><ul><li>Introduction   4 </li></ul><ul><li>Purpose   5 </l...
“ My goal is to make sure that every adult and child in Connecticut has access to health insurance.”   Governor M. Jodi Re...
Introduction: DSS to Release RFP in November 2007 <ul><li>Connecticut Department of Social Services (DSS) anticipates rele...
1. PURPOSE
Purpose: Competitively Procure Health Care Contracts July 1, 2008 <ul><li>Section 23 of Public Act 07-02 (June Special Ses...
2. OPPORTUNITY
Opportunity: Combined HUSKY/Charter Oak Procurement <ul><li>A combined procurement for HUSKY and Charter Oak will cover an...
3.  HUSKY A HUSKY B/HUSKY PLUS
DSS Health Care Programs: HUSKY Plan <ul><li>HUSKY A — Comprehensive health care coverage serving  low-income children, pa...
4. CHARTER OAK HEALTH PLAN
DSS Health Care Programs: Charter Oak Health Plan <ul><li>Charter Oak is designed to provide an affordable health insuranc...
Charter Oak: FPL Table and Projected Enrollment Total Cost of Monthly Premium     32,800  SFY11 Average 21,400  SFY10 Aver...
5. PROCUREMENT
Procurement: Combined to Balance Risk and Simplify Administration <ul><li>DSS will release a Request for Proposals for the...
6. TIMELINE
Timeline: HUSKY/Charter Oak Procurement <ul><li>Release of Prospectus October 2007 </li></ul><ul><li>Release of RFP Novemb...
7. PROCESS
Process: Soliciting Feedback and Partnering <ul><li>DSS is soliciting feedback and interest from qualified carriers and ma...
Process: Soliciting Feedback <ul><li>Simultaneous with this prospectus, the Department is finalizing the RFP for the combi...
8. RATE SETTING
Rate Setting Methodology:  HUSKY A & HUSKY B <ul><li>Rates required to be Actuarially Sound per CMS Requirements </li></ul...
Rate Setting Methodology Changes: Under Consideration  HUSKY A & HUSKY B <ul><li>January 1, 2008 </li></ul><ul><ul><li>Mat...
Rate Setting Methodology: Charter Oak <ul><li>Rates will be Actuarially Sound and able to meet CMS Requirements </li></ul>...
Rate Setting Methodology: Charter Oak <ul><li>Incentives/Sanctions – DSS is considering placing funds at-risk for contract...
HUSKY A  Actuarially-sound  Fiscal Year 2005 – 2007  Capitation Rates  *FY05 and the First Half of FY06 include capitation...
9. PROGRAM DESIGN
Program Design: HUSKY A <ul><li>Geographic Area </li></ul><ul><ul><li>Statewide Status: Approved </li></ul></ul><ul><li>Pr...
Program Design: HUSKY B <ul><li>Geographic Area </li></ul><ul><ul><li>Statewide Status: Approved </li></ul></ul><ul><li>Pr...
Program Design: Charter Oak <ul><li>Geographic Area </li></ul><ul><ul><li>Statewide Status: Anticipated Carriers will offe...
Program Design: HUSKY Benefits Coordination <ul><li>Benefit Design Carve-out:  Specialty   Behavioral Health </li></ul><ul...
Program Design: HUSKY Benefits Coordination (cont.) <ul><li>Benefit Design Carve-out:  Dental </li></ul><ul><ul><li>Effect...
Program Design: Charter Oak Benefits Coordination <ul><li>Charter Oak will follow DSS’s successful track record in benefit...
Program Design: How Benefits Coordination Will Work for HUSKY and Charter Oak Specialty Behavioral Health <ul><li>Benefit ...
Program Design: How Benefits Coordination Will Work for HUSKY Dental <ul><li>Benefit Design Carve-out:  Dental (HUSKY Only...
Program Design: How Benefits Coordination Will Work for HUSKY and Charter Oak Pharmacy <ul><li>Benefit Design Carve-out: P...
10. TARGET POPULATION
Target Population: HUSKY and Charter Oak Member Enrollment Procedures <ul><li>The State, or its designee, determines eligi...
Target Population: Recent HUSKY A Eligibility Changes <ul><li>Eligibility Expansions </li></ul><ul><ul><li>July 1, 2007: <...
Target Population: HUSKY - Who is eligible? Sources:  FPL Data:  http://aspe.hhs.gov/poverty/07poverty.shtml HUSKY Enrollm...
Average HUSKY Managed Care Enrollment by Calendar Year Source: HUSKY A and B Enrollment Reports *As of October  2007 Year ...
Target Population: Connecticut Counties
HUSKY A Enrollment by County  July 2007 Source: HUSKY A and B Monthly Enrollment Reports
HUSKY A Enrollment by MCO by County July 2007 Source: HUSKY A and B Monthly Enrollment Reports
HUSKY A Enrollment by Age and MCO July 2007 Source: Mercer Encounter Eligibility Records for July 2007
HUSKY A Enrollment by Age and MCO July 2007 Source: Mercer Encounter Eligibility Records for July 2007
HUSKY B Enrollment by MCO July 2007 Source: HUSKY A and B Monthly Enrollment Reports
Target Population: S ources of Health Insurance Coverage Source:  Results of the Office of Health Care Access 2004 and 200...
Target Population: Connecticut  Population Breakdown Source:  Results of the Office of Health Care Access 2006 Household S...
Target Population: Projected Charter Oak Enrollment by County – SFY09 Source: DSS Budget Projections adjusted by County
Target Population: Charter Oak Enrollment Projections Source: DSS Budget Projections, October 2007 *Totals may not add due...
11. BENEFITS
Benefits: HUSKY A Basic Features <ul><li>Deductible </li></ul><ul><ul><li>None </li></ul></ul><ul><li>Co-insurance </li></...
Benefits: HUSKY B Basic Features <ul><li>Deductible </li></ul><ul><ul><li>None </li></ul></ul><ul><li>Co-insurance </li></...
Benefits: Charter Oak Basic Benefit Features <ul><li>Deductible </li></ul><ul><ul><li>Varies by FPL </li></ul></ul><ul><li...
12. NETWORK
Network: Overview <ul><li>DSS is looking for Carriers and Managed Care Organizations that have a strong commitment to educ...
Network:  Current HUSKY A and B Participating Managed Care Organizations <ul><li>Anthem Blue Cross and Blue Shield of Conn...
Network: Recent HUSKY Program Changes <ul><li>Legislature Appropriated Substantial Additional Funds to Increase the Above ...
13. BECOMING A CONNECTICUT MCO
Options for Becoming a  Connecticut MCO <ul><li>Apply to the Connecticut Department of Insurance for the Appropriate Licen...
Connecticut MCOs <ul><li>Aetna Health, Inc. </li></ul><ul><li>Anthem Health Plans, Inc. </li></ul><ul><li>CIGNA Health Car...
Connecticut Indemnity MCOs <ul><li>Aetna Health, Inc. </li></ul><ul><li>Alta Health and Life Insurance Co. </li></ul><ul><...
14. SAMPLE DSS HEALTH CARE CONTRACTS
DSS Health Care Contracts: HUSKY <ul><li>Sample DSS Contract for HUSKY A </li></ul><ul><ul><li>Available from DSS upon Req...
15. Appendices
Appendix A: General Information Currently Available <ul><li>www.huskyhealth.com </li></ul><ul><li>www.ct.gov/dss/charteroa...
Appendix B: DSS RFP Library – Examples of Technical Information and Data to be available during the RFP Process <ul><li>Sa...
DSS Health Care Contact: <ul><li>If you have any questions about this prospectus or the DSS Health Care contracting opport...
Connecticut is known as a national leader in providing access to affordable health insurance. We hope this prospectus has ...
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  1. 1. 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
  2. 2. Prospectus - Table of Contents <ul><li>Section Page </li></ul><ul><li>Introduction 4 </li></ul><ul><li>Purpose 5 </li></ul><ul><li>Opportunity 7 </li></ul><ul><li>HUSKY A/B/Plus 9 </li></ul><ul><li>Charter Oak 11 </li></ul><ul><li>Procurement 14 </li></ul><ul><li>Timeline 16 </li></ul><ul><li>Process 18 </li></ul><ul><li>Rate Setting 21 </li></ul><ul><li>Section Page </li></ul><ul><li>Program Design 27 </li></ul><ul><li>Target Population 37 </li></ul><ul><li>Benefits 52 </li></ul><ul><li>Network 56 </li></ul><ul><li>Becoming an MCO 60 </li></ul><ul><li>Sample Contracts 64 </li></ul><ul><li>Appendices 66 </li></ul><ul><li>Websites 67 </li></ul><ul><li>Sample RFP Library 68 </li></ul><ul><li>Contact Info 69 </li></ul>
  3. 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. 4. Introduction: DSS to Release RFP in November 2007 <ul><li>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 </li></ul><ul><li>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 </li></ul>
  5. 5. 1. PURPOSE
  6. 6. Purpose: Competitively Procure Health Care Contracts July 1, 2008 <ul><li>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 </li></ul><ul><ul><li>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 </li></ul></ul><ul><li>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 </li></ul>
  7. 7. 2. OPPORTUNITY
  8. 8. Opportunity: Combined HUSKY/Charter Oak Procurement <ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>
  9. 9. 3. HUSKY A HUSKY B/HUSKY PLUS
  10. 10. DSS Health Care Programs: HUSKY Plan <ul><li>HUSKY A — Comprehensive health care coverage serving low-income children, parents, relative caregivers with incomes up to 185% of FPL </li></ul><ul><ul><li>Includes pregnant women with incomes up to 250% of FPL </li></ul></ul><ul><ul><li>Traditional Medicaid health coverage </li></ul></ul><ul><li>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) </li></ul><ul><li>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 </li></ul>
  11. 11. 4. CHARTER OAK HEALTH PLAN
  12. 12. DSS Health Care Programs: Charter Oak Health Plan <ul><li>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 </li></ul><ul><li>Charter Oak is not Medicaid: benefits will be based on a commercial model, with enforceable deductibles, co-pays, and coinsurance </li></ul><ul><li>For individuals with incomes less than 300% of FPL, premium will be subsidized by the state according to a fixed sliding scale </li></ul>
  13. 13. Charter Oak: FPL Table and Projected Enrollment Total Cost of Monthly Premium     32,800 SFY11 Average 21,400 SFY10 Average 8,700 SFY09 Average     Clients   Total  
  14. 14. 5. PROCUREMENT
  15. 15. Procurement: Combined to Balance Risk and Simplify Administration <ul><li>DSS will release a Request for Proposals for the combined HUSKY A, HUSKY B and Charter Oak programs in November 2007 </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>
  16. 16. 6. TIMELINE
  17. 17. Timeline: HUSKY/Charter Oak Procurement <ul><li>Release of Prospectus October 2007 </li></ul><ul><li>Release of RFP November 2007 </li></ul><ul><li>RFP Bidders’ Conference December 2007 </li></ul><ul><li>RFP Bids Due January 2008 </li></ul><ul><li>RFP Negotiations February 2008 </li></ul><ul><li>RFP Awards March 2008 </li></ul><ul><li>Open Enrollment May 2008 </li></ul><ul><li>Contract Effective Date July 2008 </li></ul>
  18. 18. 7. PROCESS
  19. 19. Process: Soliciting Feedback and Partnering <ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>
  20. 20. Process: Soliciting Feedback <ul><li>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 [email_address] mailbox </li></ul><ul><li>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 </li></ul>
  21. 21. 8. RATE SETTING
  22. 22. Rate Setting Methodology: HUSKY A & HUSKY B <ul><li>Rates required to be Actuarially Sound per CMS Requirements </li></ul><ul><li>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) </li></ul><ul><li>Rates are based on Health Plan Financials and Encounter data, adjusted for: </li></ul><ul><ul><li>Demographics </li></ul></ul><ul><ul><li>Unpaid Claims Liability </li></ul></ul><ul><ul><li>Program Changes </li></ul></ul><ul><ul><li>Trend </li></ul></ul>
  23. 23. Rate Setting Methodology Changes: Under Consideration HUSKY A & HUSKY B <ul><li>January 1, 2008 </li></ul><ul><ul><li>Maternity and newborn kick payments </li></ul></ul><ul><li>Future Rate Years - Changes Under Consideration </li></ul><ul><ul><li>Risk-Adjusted Rates </li></ul></ul><ul><ul><li>Pay-for-Performance Incentives </li></ul></ul><ul><ul><li>Minimum Loss-Ratio Standards </li></ul></ul><ul><ul><li>Quality/Evidence-Based Payment Incentives </li></ul></ul>
  24. 24. Rate Setting Methodology: Charter Oak <ul><li>Rates will be Actuarially Sound and able to meet CMS Requirements </li></ul><ul><li>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) </li></ul><ul><li>Rates will be based on HUSKY A adults data, adjusted for differences in: </li></ul><ul><ul><li>Demographics </li></ul></ul><ul><ul><li>Plan Design </li></ul></ul><ul><ul><li>Underlying Risk/Acuity </li></ul></ul><ul><ul><li>Reimbursement </li></ul></ul><ul><ul><li>Trend </li></ul></ul>
  25. 25. Rate Setting Methodology: Charter Oak <ul><li>Incentives/Sanctions – DSS is considering placing funds at-risk for contractor performance standards in several areas, including: </li></ul><ul><ul><li>Geographic distribution of key provider types for overall network access requirements </li></ul></ul><ul><ul><li>Availability of scheduled appointments for primary care and specialty physicians for meeting appointment scheduling waiting standards </li></ul></ul><ul><ul><li>Telephonic wait times, call abandonment and resolution rates for member and provider customer service standards </li></ul></ul><ul><ul><li>Claims adjudication times for meeting claims payment timeliness requirements </li></ul></ul>
  26. 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 $ 188.59 $ 179.90 $ 199.03 $ 188.80 Total $ 263.66 $ 252.39 $ 271.60 $ 257.47 40+ F $ 276.01 $ 264.28 $ 283.57 $ 268.50 40+ M $ 249.45 $ 238.59 $ 257.72 $ 244.49 15-39 F $ 142.80 $ 135.94 $ 155.12 $ 147.07 15-39 M $ 110.16 $ 104.28 $ 123.40 $ 117.07 1-14 $ 677.37 $ 650.45 $ 669.59 $ 635.40 <1 FY07** FY06** (Second Half) FY06* (First Half) FY05* Age             HUSKY A Fiscal Year Rates
  27. 27. 9. PROGRAM DESIGN
  28. 28. Program Design: HUSKY A <ul><li>Geographic Area </li></ul><ul><ul><li>Statewide Status: Approved </li></ul></ul><ul><li>Program Structure </li></ul><ul><ul><li>MCO Original Effective Date: July 20, 1995 </li></ul></ul><ul><li>Authority </li></ul><ul><ul><li>1915(b)(1) </li></ul></ul><ul><li>Type of Enrollment </li></ul><ul><ul><li>Managed Care </li></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><li>Excluded HUSKY Populations </li></ul></ul><ul><ul><ul><li>SSI Adults without Medicare, Duals, GA (State only) Refugees, QMB/SLMB, ConnPACE (State funded Rx only), CHC (State funded) </li></ul></ul></ul>
  29. 29. Program Design: HUSKY B <ul><li>Geographic Area </li></ul><ul><ul><li>Statewide Status: Approved </li></ul></ul><ul><li>Program Structure </li></ul><ul><ul><li>MCO Original Effective Date: July 1, 1998 </li></ul></ul><ul><li>Authority </li></ul><ul><ul><li>State Plan under the State Children’s Health Insurance Program (SCHIP) – Title XXI of the Social Security Act </li></ul></ul><ul><li>Type of Enrollment </li></ul><ul><ul><li>Managed Care </li></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><li>Excluded HUSKY Populations </li></ul></ul><ul><ul><ul><li>SSI Adults without Medicare, Duals, GA (State only) Refugees, QMB/SLMB, ConnPACE (State funded Rx only), CHC (State funded) </li></ul></ul></ul>
  30. 30. Program Design: Charter Oak <ul><li>Geographic Area </li></ul><ul><ul><li>Statewide Status: Anticipated Carriers will offer Coverage Statewide </li></ul></ul><ul><li>Program Structure </li></ul><ul><ul><li>State Program*: July 1, 2008 </li></ul></ul><ul><li>Authority </li></ul><ul><ul><li>Section 23 of Public Act 07-02 (June Special Session) </li></ul></ul><ul><li>Type of Enrollment </li></ul><ul><ul><li>Voluntary, Affordable Health Insurance </li></ul></ul><ul><ul><ul><li>Individuals without health insurance for the last six months or those who meet certain qualifying criteria to exempt them from uninsurance requirement </li></ul></ul></ul><ul><ul><li>Excluded Populations </li></ul></ul><ul><ul><ul><li>Individuals currently insured or insured within last six months (exemptions to be determined) </li></ul></ul></ul><ul><ul><ul><li>Individuals eligible but not enrolled in Public Programs (SAGA, HUSKY A and B, etc) </li></ul></ul></ul>* DSS anticipates submitting a waiver to the Connecticut Legislature, and if approved, to CMS for Federal financial participation in portions of Charter Oak
  31. 31. Program Design: HUSKY Benefits Coordination <ul><li>Benefit Design Carve-out: Specialty Behavioral Health </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>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) </li></ul></ul>
  32. 32. Program Design: HUSKY Benefits Coordination (cont.) <ul><li>Benefit Design Carve-out: Dental </li></ul><ul><ul><li>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 </li></ul></ul><ul><li>Benefit Design Carve-out: Pharmacy </li></ul><ul><ul><li>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 </li></ul></ul>
  33. 33. Program Design: Charter Oak Benefits Coordination <ul><li>Charter Oak will follow DSS’s successful track record in benefits carve-outs and will carve-out certain services. </li></ul><ul><li>Benefit Design Carve-out: Specialty Behavioral Health </li></ul><ul><ul><li>Charter Oak contractors will not be required to manage or pay claims for specialty behavioral health services </li></ul></ul><ul><li>Benefit Design Carve-out: Pharmacy </li></ul><ul><ul><li>Charter Oak contractors will not be required to manage or pay claims for pharmacy services </li></ul></ul>
  34. 34. Program Design: How Benefits Coordination Will Work for HUSKY and Charter Oak Specialty Behavioral Health <ul><li>Benefit Design Carve-out: Specialty Behavioral Health </li></ul><ul><ul><li>MCOs have monthly coordination of care meetings with ValueOptions </li></ul></ul><ul><ul><li>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) </li></ul></ul><ul><ul><li>MCOs and ASO have worked together on primary care education and initiatives to improve ease of referral from primary care to BH network </li></ul></ul><ul><ul><li>MCOs remain responsible for most BH in primary care settings and all BH non-emergent medical transportation </li></ul></ul>
  35. 35. Program Design: How Benefits Coordination Will Work for HUSKY Dental <ul><li>Benefit Design Carve-out: Dental (HUSKY Only) </li></ul><ul><ul><li>MCOs and ASO will work together on primary care education and initiatives to improve ease of referral from primary care to the dental network </li></ul></ul><ul><ul><li>Pediatricians will be able to receive reimbursement for provision of dental screens and fluoride treatments to children under 3 </li></ul></ul><ul><ul><li>MCOs will retain responsibility for HUSKY A dental non-emergent medical transportation </li></ul></ul>
  36. 36. Program Design: How Benefits Coordination Will Work for HUSKY and Charter Oak Pharmacy <ul><li>Benefit Design Carve-out: Pharmacy (HUSKY and Charter Oak) </li></ul><ul><ul><li>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) </li></ul></ul><ul><ul><li>DSS’s Pharmacy Program Structure: </li></ul></ul><ul><ul><ul><li>Preferred Drug List (PDL), prior authorization </li></ul></ul></ul><ul><ul><ul><li>One Pharmaceutical & Therapeutics (P&T) Committee & Drug Utilization Review (DUR) Board </li></ul></ul></ul>
  37. 37. 10. TARGET POPULATION
  38. 38. Target Population: HUSKY and Charter Oak Member Enrollment Procedures <ul><li>The State, or its designee, determines eligibility for Managed Care Programs </li></ul><ul><li>The State, through a centralized enrollment broker, handles the enrollment, disenrollment and initial selection of the primary care provider (PCP) </li></ul><ul><li>Enrollments and disenrollments are transmitted electronically daily to each MCO </li></ul><ul><li>Enrollment is continuous and members may change plans at any time (membership done on a full-month basis) </li></ul><ul><li>Source: 2007 HUSKY A and HUSKY B Contract </li></ul>Source: http://www.ahcpr.gov/chip/content/benefit_design/state_ben-husky__features.htm
  39. 39. Target Population: Recent HUSKY A Eligibility Changes <ul><li>Eligibility Expansions </li></ul><ul><ul><li>July 1, 2007: </li></ul></ul><ul><ul><ul><li>Increase eligibility criteria for parents and caretaker relatives of children in HUSKY A from 150% FPL to 185% FPL </li></ul></ul></ul><ul><ul><ul><li>HUSKY coverage provided for all uninsured newborns. </li></ul></ul></ul><ul><ul><ul><ul><li>If enrolled in HUSKY B, state coverage of premium costs for first four months of life. </li></ul></ul></ul></ul><ul><ul><li>January 1, 2008: </li></ul></ul><ul><ul><ul><li>Expand HUSKY A eligibility for pregnant women from 185% to 250% FPL </li></ul></ul></ul>
  40. 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. 41. Average HUSKY Managed Care Enrollment by Calendar Year Source: HUSKY A and B Enrollment Reports *As of October 2007 Year Monthly Enrollment
  42. 42. Target Population: Connecticut Counties
  43. 43. HUSKY A Enrollment by County July 2007 Source: HUSKY A and B Monthly Enrollment Reports
  44. 44. HUSKY A Enrollment by MCO by County July 2007 Source: HUSKY A and B Monthly Enrollment Reports
  45. 45. HUSKY A Enrollment by Age and MCO July 2007 Source: Mercer Encounter Eligibility Records for July 2007
  46. 46. HUSKY A Enrollment by Age and MCO July 2007 Source: Mercer Encounter Eligibility Records for July 2007
  47. 47. HUSKY B Enrollment by MCO July 2007 Source: HUSKY A and B Monthly Enrollment Reports
  48. 48. Target Population: S ources 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. 49. Target Population: Connecticut Population Breakdown 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 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.
  50. 50. Target Population: Projected Charter Oak Enrollment by County – SFY09 Source: DSS Budget Projections adjusted by County
  51. 51. Target Population: Charter Oak Enrollment Projections Source: DSS Budget Projections, October 2007 *Totals may not add due to rounding               32,800 9,000 5,500 4,200 2,100 12,000 SFY 11 Average 21,400 5,900 3,600 2,800 1,300 7,800 SFY 10 Average 8,700 2,400 1,500 1,100 500 3,200 SFY 09 Average               Poverty Level (FPL) Clients*           Federal  Total 300%+ 235-300% 185-235% 150-185% 0-150% % of the
  52. 52. 11. BENEFITS
  53. 53. Benefits: HUSKY A Basic Features <ul><li>Deductible </li></ul><ul><ul><li>None </li></ul></ul><ul><li>Co-insurance </li></ul><ul><ul><li>None </li></ul></ul><ul><li>Premiums </li></ul><ul><li>Co-Pays </li></ul><ul><ul><li>None </li></ul></ul><ul><li>Lifetime Benefit Maximum </li></ul><ul><ul><li>None </li></ul></ul><ul><li>Outpatient Physician Visits </li></ul><ul><li>Preventive Care </li></ul><ul><li>Dental** </li></ul><ul><li>Prescription Drug </li></ul><ul><li>Inpatient Hospital </li></ul><ul><li>Outpatient Surgical Facility </li></ul><ul><li>Ambulance/Transportation </li></ul><ul><li>Home Health and DME </li></ul><ul><li>Vision Care** </li></ul>See Appendix B: Plan Design Summary Table for additional detail **Limits may apply. Note: Mental Health (IP, OP) and Substance Abuse are carved out of the managed care program effective January 1, 2006. See http://www.ct.gov/dss for complete benefit information. Source: 2007 HUSKY A and HUSKY B MCO contract
  54. 54. Benefits: HUSKY B Basic Features <ul><li>Deductible </li></ul><ul><ul><li>None </li></ul></ul><ul><li>Co-insurance </li></ul><ul><ul><li>None </li></ul></ul><ul><li>Co-pay </li></ul><ul><ul><li>$5 per office visit </li></ul></ul><ul><li>Lifetime Benefit Maximum </li></ul><ul><ul><li>None </li></ul></ul><ul><li>Premiums by enrollee (235%-300% FPL) </li></ul><ul><ul><li>$30 per child/$50 family max. </li></ul></ul><ul><li>Preventive Care </li></ul><ul><li>Dental** </li></ul><ul><li>Prescription Drug </li></ul><ul><ul><li>Co-pays apply to HUSKY B only* </li></ul></ul><ul><ul><ul><li>$3 copay — generics </li></ul></ul></ul><ul><ul><ul><li>$6 copay — brand and formularies </li></ul></ul></ul><ul><li>Inpatient Hospital </li></ul><ul><li>Outpatient Surgical Facility </li></ul><ul><li>Ambulance/Transportation </li></ul><ul><li>Home Health and DME </li></ul><ul><li>Vision Care** </li></ul>See Appendix B: Plan Design Summary Table for additional detail *HUSKY B maximum copayments and premiums applicable based on income. **Limits may apply. Note: Mental Health (IP, OP) and Substance Abuse are carved out of the managed care program effective January 1, 2006. See http://www.ct.gov/dss for complete benefit information. Source: 2007 HUSKY A and HUSKY B MCO contract. Maximum combined premium and co-pay total per year, per family; 5% of income
  55. 55. Benefits: Charter Oak Basic Benefit Features <ul><li>Deductible </li></ul><ul><ul><li>Varies by FPL </li></ul></ul><ul><li>Co-insurance </li></ul><ul><ul><li>Varies by service </li></ul></ul><ul><li>Out of Pocket Maximum </li></ul><ul><ul><li>Varies by FPL </li></ul></ul><ul><li>Lifetime Benefit Maximum </li></ul><ul><ul><li>$1,000,000 </li></ul></ul><ul><li>Premiums by enrollee </li></ul><ul><ul><li>*Maximum $250/month </li></ul></ul><ul><ul><li>Varies based on income </li></ul></ul><ul><li>Primary Care Physician Visits </li></ul><ul><ul><li>$25 co-pay </li></ul></ul><ul><li>Specialist Physician Visits </li></ul><ul><ul><li>$35 co-pay </li></ul></ul><ul><li>Preventive Care </li></ul><ul><ul><li>No co-pay, 100% covered </li></ul></ul><ul><li>Inpatient Hospital </li></ul><ul><ul><li>20% Co-insurance </li></ul></ul><ul><li>Outpatient Surgical Facility </li></ul><ul><ul><li>20% Co-insurance </li></ul></ul><ul><li>Ambulance/Transportation </li></ul><ul><ul><li>100% Covered in emergencies </li></ul></ul><ul><li>Durable Medical Equipment </li></ul><ul><ul><li>$2,000 Annual Limit </li></ul></ul><ul><li>Behavioral Health Services, Rx services carved-out and provided through DSS </li></ul><ul><li>Dental and Vision Services may be provided as optional riders by MCOs with separate premium assessment </li></ul>See Appendix B: Plan Design Summary Table for additional detail * Includes aggregate cost for medical, behavioral health and Rx carve-out
  56. 56. 12. NETWORK
  57. 57. Network: Overview <ul><li>DSS is looking for Carriers and Managed Care Organizations that have a strong commitment to education and outreach to help members navigate the health care system; and have strong care coordination and disease management capabilities to ensure that when members do access care, they do so in a way that supports the quality of care and successful health outcomes </li></ul><ul><li>All Bidders have an equal opportunity to receive contracts; preference will not be given to existing contractors </li></ul><ul><li>DSS anticipates awarding at least 3 contracts and up to 6 contracts to ensure adequate network coverage </li></ul>
  58. 58. Network: Current HUSKY A and B Participating Managed Care Organizations <ul><li>Anthem Blue Cross and Blue Shield of Connecticut (BlueCare Family Plan) </li></ul><ul><li>Health Net* </li></ul><ul><li>Community Health Network of Connecticut </li></ul><ul><li>WellCare of Connecticut, Inc. (Preferred One) </li></ul>*Not a HUSKY B MCO
  59. 59. Network: Recent HUSKY Program Changes <ul><li>Legislature Appropriated Substantial Additional Funds to Increase the Above Rates for SFY08: </li></ul><ul><ul><li>Physician ($27M) </li></ul></ul><ul><ul><li>Clinics ($10M) </li></ul></ul><ul><ul><li>Dental ($20M) </li></ul></ul><ul><ul><li>Vision ($1M) </li></ul></ul><ul><ul><li>Hospitals ($46M) </li></ul></ul>
  60. 60. 13. BECOMING A CONNECTICUT MCO
  61. 61. Options for Becoming a Connecticut MCO <ul><li>Apply to the Connecticut Department of Insurance for the Appropriate License based on Current Business Structure </li></ul><ul><li>Acquire an Existing MCO Business in Connecticut </li></ul><ul><li>Establish an Entity with which the Commissioner of Social Services has authority to contract under section 23(e) (2), (3) of Public Act 07-02 (June Special Session) (Charter Oak Health Plan)* </li></ul><ul><li>*See also Conn. Gen. Stat. §§17b-266(b) (2), (3), (4) (HUSKY A and HUSKY B) </li></ul>
  62. 62. Connecticut MCOs <ul><li>Aetna Health, Inc. </li></ul><ul><li>Anthem Health Plans, Inc. </li></ul><ul><li>CIGNA Health Care of CT, Inc. </li></ul><ul><li>ConnectiCare Inc. </li></ul><ul><li>Health Net of Connecticut, Inc. </li></ul><ul><li>Oxford Health Plans, Inc. </li></ul>Source: A Comparison of Managed Care Organizations in Connecticut. October 2006. www.state.ct.us/cid/mancare1.pdf Indemnity Managed Care Organization is defined as a licensed HMO insurer that offers a managed care plan in Connecticut
  63. 63. Connecticut Indemnity MCOs <ul><li>Aetna Health, Inc. </li></ul><ul><li>Alta Health and Life Insurance Co. </li></ul><ul><li>American Republic Insurance Co. </li></ul><ul><li>Celtic Insurance Co. </li></ul><ul><li>Cigna HealthCare of CT, Inc. </li></ul><ul><li>ConnectiCare, Inc. </li></ul><ul><li>Oxford Health Insurance, Inc. </li></ul><ul><li>Time Insurance Co. </li></ul><ul><li>Trustmark Insurance Co. </li></ul><ul><li>UniCare Life & Health Insurance Co. </li></ul><ul><li>Union Security Insurance Co. </li></ul>Source: A Comparison of Managed Care Organizations in Connecticut. October 2006. www.state.ct.us/cid/mancare1.pdf Indemnity Managed Care Organization is defined as a licensed non-HMO insurer that offers a managed care plan in Connecticut
  64. 64. 14. SAMPLE DSS HEALTH CARE CONTRACTS
  65. 65. DSS Health Care Contracts: HUSKY <ul><li>Sample DSS Contract for HUSKY A </li></ul><ul><ul><li>Available from DSS upon Request </li></ul></ul><ul><li>Sample DSS Contract for HUSKY B </li></ul><ul><ul><li>Available from DSS upon Request </li></ul></ul>Contracts are subject to change through amendments
  66. 66. 15. Appendices
  67. 67. Appendix A: General Information Currently Available <ul><li>www.huskyhealth.com </li></ul><ul><li>www.ct.gov/dss/charteroak </li></ul><ul><li>www.ct.gov/dss </li></ul><ul><li>www.ctmedicalprogram.com </li></ul><ul><li>www.ctkidslink.org </li></ul><ul><li>http://www.cga.ct.gov/ph/medicaid/default.htm </li></ul><ul><li>www.ctbhp.com </li></ul>
  68. 68. Appendix B: DSS RFP Library – Examples of Technical Information and Data to be available during the RFP Process <ul><li>Sample of Information in RFP Library </li></ul><ul><li>HUSKY A Contract </li></ul><ul><li>HUSKY B Contract </li></ul><ul><li>Enrollment and Passive Billing File specifications, layouts, and data dictionaries </li></ul><ul><li>EQRO Audit Summary Reports </li></ul><ul><li>EPSDT Reports </li></ul><ul><li>Applicable Studies and Reports on HUSKY completed in last two years </li></ul><ul><li>Sample of Data in RFP Library </li></ul><ul><li>Health Plan Encounter Data file extracts with associated specifications, layouts, and data dictionaries </li></ul><ul><li>Summarized HUSKY A/B Enrollment Files </li></ul><ul><li>HUSKY B Utilization Reports </li></ul><ul><li>Additional data as requested by Interested Parties </li></ul>
  69. 69. DSS Health Care Contact: <ul><li>If you have any questions about this prospectus or the DSS Health Care contracting opportunity, direct your written questions to our internet mailbox: </li></ul><ul><li>[email_address] </li></ul><ul><li>Or write to: </li></ul><ul><li>Healthcare Procurement, </li></ul><ul><li>Commissioner’s Office </li></ul><ul><li>Connecticut Department of Social Services </li></ul><ul><li>25 Sigourney Street </li></ul><ul><li>Hartford CT 06106-5033 </li></ul>
  70. 70. Connecticut is known as a national leader in providing access to affordable health insurance. We hope this prospectus has provided you with valuable information regarding the upcoming opportunity to participate in Connecticut healthcare programs. Join us in addressing the health care needs of our Connecticut residents. The RFP will be available on www.ct.gov/dss , click on “Vendors and Contractors”, and on www.das.state.ct.us , click on “Contracting Portal”. Charter Oak Health Plan

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