- As of January 1, 2012, the state uses an administrative services organization model in which an entity is contracted to administer the Medicaid program and coordinate services, though claims are submitted to the Department of Social Services on a fee-for-service basis. There were a total of 578,620 child and adult beneficiaries enrolled in Connecticut’s Medicaid program as of July 2011.
- Behavioral health services have been provided through an administrative services organization model since 2006. Dental services also are provided through a separate administrative services organization model.
Regulations in Connecticut define medical necessity for Medicaid enrollees to mean:
“…those health services required to prevent, identify, diagnose, treat, rehabilitate or ameliorate an individual’s medical condition, including mental illness, or its effects, in order to attain or maintain the individual’s achievable health and independent functioning provided such services are:
(1) Consistent with generally-accepted standards of medical practice (….)
(2) clinically appropriate in terms of type, frequency, timing, site, extent and duration and considered effective for the individual’s illness, injury or disease;
(3) not primarily for the convenience of the individual, the individual’s health care provider or other health care providers;
(4) not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the individual’s illness, injury or disease; and
(5) based on an assessment of the individual and his or her medical condition.”
They also establish that:
“The Commissioner of Social Services shall provide Early and Periodic Screening, Diagnostic and Treatment program services, as required and defined as of December 31, 2005, by 42 USC 1396a(a)(43), 42 USC 1396d(r) and 42 USC 1396d(a)(4)(B) and applicable federal regulations, to all persons who are under the age of twenty-one and otherwise eligible for medical assistance under this section.”
|Initiatives to Improve Access
Behavioral Health: An Enhanced Care Clinics system for behavioral health has enhanced access to behavioral health services for Medicaid-enrolled children. Connecticut Behavioral Health Partnership (CTBHP), a Medicaid behavioral health carve-out plan that serves approximately 260,000 children and youth, launched a quality improvement initiative aimed to improve access and reduce waiting times for behavioral health services for children entering the child welfare system in and around Bridgeport and Waterbury.
The quality improvement objectives were to:
Oral health: The Connecticut Dental Health Partnership has established specific standards for access, including waiting time limitations for emergency cases, urgent cases, and preventative and non-urgent care. The Partnership also requests that dental providers use an answering machine or answering service to field calls from Medicaid beneficiaries during hours in which staff are not available. Dental providers must also be reachable in case of emergency.
|Reporting & Data Collection||
Utilization data: Under the administrative services organization structure, services are provided on a fee-for-service basis and all claims go through the state’s Medicaid Management Information System.
Reporting: Connecticut Voices for Children conducts independent performance monitoring of care delivered to Medicaid children under a contract between the Department of Social Services and the Hartford Foundation for Public Giving. Voices for Children analyzes that data collected by DSS and issues reports on a range of topics, including utilization of well-child, emergency room, and dental care.
Connecticut’s External Quality Review Organization, Mercer Government Human Services, collects measures for well-child visits (3, 4, 5, and 6 years of life) and developmental screening (9, 18, and 24 month).
Coordinated behavioral health service delivery: Since 2005, the DSS has partnered with the Department of Children and Families (and subsequently the Department of Mental Health and Addiction Services, as well) to integrate public behavioral health services for children and families under the Connecticut Behavioral Health Partnership (CTBHP), the Behavioral Health Partnership Oversight Council oversees ongoing implementation of the CBHP. The Oversight Council is comprised of stakeholders representing policy, provider, and patients. The participating departments have contracted with ValueOptions to serve as the administrative services organization for behavioral health, authorizing and managing behavioral health services for all Medicaid participants.
Screening services: Connecticut’s Medicaid program reimburses pediatricians for developmental and mental health screenings. The state uses both the 96110 and 96111 codes (developmental testing with interpretation and report, limited and extended, respectively) to support developmental screens. The state also added CPT code 99420, “Administration and interpretation of health risk assessment instrument,” to its Medicaid fee schedule as of January 1, 2012. This allows primary care physicians to be paid for mental health screenings separately from the well-child visit reimbursement; these screenings can be billed in conjunction with a well-child visit.
For more information about behavioral health services for children in enrolled in Medicaid in Connecticut, see "Behavioral Health in the Medicaid Benefit for Children and Adolescents: Connecticut."
|Support to Providers and Families||
Support to Providers:
Two websites offer relevant resources to Medicaid-participating providers:
Support to Families:
The state operates a HUSKY Health website that contains information for Medicaid beneficiaries. This includes a searchable provider directory, welcome letters and a Medicaid benefit overview, and health education materials (including educational videos). CHN began piloting a member portal in the spring of 2012. This tool gives members access to member-specific information, including notifications about upcoming or missed well-child visits.
The ASO has a call center that allows members to call in to talk about services they need. If necessary, the call center representative can help the member to make an appointment with a provider.
Connecticut Voices for Children convenes a “Covering Connecticut Kids and Families” group three to four a times a year. The meetings provide both a forum for discussion of issues important to Medicaid and an opportunity for stakeholders to provide feedback to the Department of Social Services.
In 2012, Connecticut introduced a patient-centered medical home (PCMH) initiative within their redesigned HUSKY Health program. Under this initiative, Connecticut Medicaid is providing new payment incentives to practices and clinics that demonstrate a higher standard of person-centered medical care. In order to receive enhanced payments for medical home services, providers must be an active licensed physician, nurse practitioner or physician’s assistant specializing in general internal medicine, geriatrics, family medicine or general pediatrics that functions as a primary care provider for a set panel of patients.
Connecticut requires that participating medical homes meets and receives NCQA medical home recognition standards. In addition, Connecticut mandates that medical home practices must:
The Connecticut Dental Health Partnership, an administrative services organization, manages Medicaid oral health care services on behalf of the Connecticut Department of Social Services. The Partnership’s website contains various informing materials for enrollees and dental providers, including summaries of dental benefits and provider newsletters/communications.
The Partnership has a statewide Care Coordination and Outreach unit consisting of seven Dental Health Care Specialists. Dental providers refer patients to the Care Coordination unit when the patient has significant barriers to receiving dental services, such as medical, behavioral, logistical or cultural barriers (including language and transportation difficulties). Dental Health Care Specialists also:
A July 2013 report on utilization of dental services for Medicaid-enrolled children and their parents in Connecticut examined changes to utilization since dental benefits were carved out in 2008. The report found that the number of very young children under 3 who received any care in 2011 was nearly 42 percent (up from 21 percent in 2008) and the percent with preventive care was 37 percent, up from under 14 percent in 2008. It also found that the number and percent of children 3 to 19 with preventive care increased in Medicaid and the Children’s Health Insurance Program, to 69% and 73% respectively.