State health policymakers are eagerly waiting to see if Congress’ omnibus budget bill released this week will attempt to stabilize Affordable Care Act (ACA) insurance markets by reinstating ACA’s cost-sharing reduction (CSR) payments. An early proposal by US Sen. Lamar Alexander would fund the cost-sharing subsidies, which reduce a family’s out-of-pocket health care costs, retroactively from 2017 through 2021.
While this is a potential solution to how the federal government can subsidize health insurance for some consumers who purchase insurance through ACA markets, data collected by the National Academy for State Health Policy (NASHP) illustrates the complex interplay between marketplace subsidies and consumer decisions that states face.
States and insurers demonstrated incredible dexterity in quickly redesigning insurance plans in response to the Administration’s late-in-the-game decision to end CSR payments in October 2017. The result was that consumers faced new confusion as insurance plans were revamped and repriced in 2018, resulting in major enrollment shifts both off and within health insurance marketplaces. Below, NASHP presents 2018 enrollment data collected by state-based marketplaces (SBMs), which closely manage their own exchanges, highlight how state actions to address the loss of CSR funding influenced market decisions in 2018. Key findings indicate:
- Decreased enrollment in marketplace silver plans, especially among consumers who no longer had access to CSR subsidies and who did not qualify for tax credits;
- Enrollment growth in marketplace bronze plans;
- Mixed enrollment growth or declines in gold plans; and
- Mixed growth, and some declines in the total number of subsidized enrollees in the marketplaces.
The findings do not provide a complete picture of what has occurred in markets nationwide, as the data represent only 10 states and do not include complete information about off-marketplace enrollment patterns or full consideration of other factors that may have influenced enrollment during the 2018 enrollment period, including shortened enrollment periods and other factors influencing premium costs. However, they provide a glimpse into how states’ markets reacted to federal policy shifts and the serious ramifications of CSR changes wrought by Washington on consumer purchasing behaviors.
Under the CSR program, insurers are required by federal law to cover certain out-of-pocket expenses (e.g., deductibles, copayments, coinsurance) for enrollees with incomes below 250 percent of the federal poverty level (FPL). CSRs are only available through silver-level health plans purchased on the state or federal health insurance marketplaces. Typically, silver-level plans have an actuarial value (AV) of 70 percent, meaning that the plan must cover in aggregate at least 70 percent of the health care costs received under the plan. CSRs change the AV of plans by varying amounts depending on the income of the qualifying consumer (see Table 1).
|Table 1. Qualifying for CSRs|
|To qualify for the ACA’s CSR program, consumers must purchase silver-level health plans and have incomes between 100 to 250 percent of FPL, which in 2018 ranged from $16,642 to $30,150 for individuals and from $33,948 to $61,500 for a family of four.|
|CSR-Eligible Plan||Standard Silver||Silver 73||Silver 87||Silver 94|
|Income||Any||200-250% FPL||150-200% FPL||100-150% FPL|
The ACA designed the CSR program so that insurers would be reimbursed for expenditures incurred under the program, and would be paid back whatever costs were charged to ensure that consumers who received services were only paying out-of-pocket expenses in line with the AV of their CSR-eligible health plan.
Questions about the exact language of the CSR law spurred litigation over whether it was legal for the government to issue reimbursements without an explicit appropriation for the program. Pending the outcome of this litigation, the Administration stopped issuing CSR reimbursements.
Response to Elimination of Federal CSR Reimbursements
After the Administration stopped CSR payments last October, most state regulators directed their insurance carriers to adjust their 2018 premium rates to account for CSR losses. Not responding to the issue would have left insurers exposed to the lost federal funding, possibly resulting in insurers opting to not participate in markets. As CSR payments most directly affected silver-level plans sold on the marketplaces, most states and carriers opted to load premium increases onto silver-level plans offered through their insurance marketplaces. The Congressional Budget Office (CBO) estimated that silver plan premiums increased by 10 percent on average in 2018 in response to elimination of CSR funding. Among the states that operate their own marketplaces, only three did not load the increases onto their silver plans. These included:
- Colorado, which advised its insurers to distribute premium increases across all metal levels to mitigate the effect on silver-level plans;
- Vermont, which similarly distributed premium increases across all metal levels due to uncertainty over the effects of the changes on its uniquely-merged individual and small group markets; and
- Washington, D.C., which calculated that elimination of the CSR payments would have minimal effect on its market due to low enrollment of CSR-eligible individuals.
CSR Loading Had Differing Impacts on Subsidized and Non-subsidized Consumers
Silver-loaded premiums shifted the affordability and value of plans offered through marketplaces, distorting costs and participation in the markets. For consumers who were eligible for premium tax credits to subsidize their coverage (82 percent of marketplace consumers in 2017), some coverage options became even more affordable. This is because the tax credit is calculated based on the second-lowest-cost silver plan available to a consumer. As a result, as silver premium costs increased in response to CSR elimination, so did the total amount of tax credit a qualifying consumer could receive. This increase in tax credits — combined with more marginal increases in premiums for bronze- and gold-level plans than for silver plans — meant that both bronze and gold plans became more affordable for these consumers. Availability of these more affordable plans may have attributed to the enrollment increases seen in some states’ marketplaces.
While the silver-loading strategy served the important purpose of insulating lower-income consumers from CSR losses, it resulted in increases costs for consumers who were ineligible for tax credits. The increased premiums escalated affordability concerns and forced many of these consumers to seek cheaper options, either by enrolling in lower-value bronze plans or by disenrolling from marketplace coverage entirely. These changes had important repercussions for both consumers and insurers participating in the markets.
- Distorted market competition and enrollment. CSR payment elimination had disproportionate effects on marketplace insurers as they adjusted premium rates differently based on the proportion of CSR-eligible consumers enrolled in their plans. Insurers with a greater proportion of CSR-eligible individuals increased premiums by a higher amount than those with fewer CSR-eligible enrollees. In California, for example, CSR-induced premium rate increases ranged from 8 percent to as much as 27 percent. This lead to a distortion of premium prices between insurers and generated shifts in market share as consumers switched to insurers whose plans had smaller premium growth.
- Increased consumer susceptibility to out-of-pocket spending. The lower-cost bronze plans, which offer less coverage, enticed more consumers to purchase them. While this lowered consumers’ annual spending on premiums, the lower AV of bronze plans means that these consumers are at greater risk of higher out-of-pocket spending. This is especially true for consumers who were once CSR-eligible but switched from silver to bronze plans without considering the resulting out-of-pocket costs.
- Complete disenrollment from individual market coverage. While the total impact of CSR changes on enrollment cannot be known without additional data about off-marketplace enrollment, it is highly probable that premium increases and confusion over the changes in premium costs spurred some non-subsidized consumers to drop insurance coverage altogether. These drops in coverage led to altered market risk pools and premium increases.
Consumers Shifted Purchasing Patterns in 2018
While it is not possible to determine the absolute effect of CSR elimination on consumers’ behavior, initial data collected by the 10 SBM states indicate that state and insurer decisions to silver-load influenced consumers’ choices in 2018. Key patterns that emerged include:
- Disenrollment in silver-level health plans, especially among unsubsidized consumers: While the majority of consumers from these states continued to select silver-level health plans, there was an almost a universal drop in the proportion of enrollees selecting silver-level plans (exceptions include Colorado and Vermont, which did not silver-load, and Minnesota, whose Basic Health Program for consumers earning up to 200 percent FPL offset the effect of CSR losses.) As expected, shifts away from silver plan selections were more common among individuals who did not receive tax credits.
- Growth in enrollment in bronze plans: There was almost universal growth across all states in the proportion of enrollees who selected bronze plans, with the exception of Minnesota and Vermont, which only saw marginal reduction in bronze plan selections.
- Varied growth or disenrollment in gold plans: Changes in gold selections vary across states, from Colorado where the proportion of gold enrollments dropped by nearly one-third to Maryland where gold enrollments increased nearly four-fold.
Different trends in enrollment among subsidized and unsubsidized consumers in these states indicate that CSR policies did not by themselves drive shifts in enrollment. It is also likely that the total effect of the CSR issue varied greatly across all states, depending on several factors including:
- The proportion of unsubsidized marketplace consumers in the state — especially those enrolled in silver plans who were most susceptible to silver-loaded premiums; and
- Baseline premium prices of bronze or gold alternatives for consumers seeking to shift away from silver plans.
Investments in education and outreach also affected how consumers responded to CSR-loading in various states. The Massachusetts’ Health Connector, for example, was among several states that took extensive steps to urge its unsubsidized silver-plan enrollees to seek more affordable options either on or outside the marketplace. Connector officials reported that they were successful in moving 82 percent of affected enrollees into new coverage plans. This meant that 18 percent of unsubsidized consumers remained in silver plans, despite its aggressive outreach efforts to inform consumers about the availability of more affordable options.
Outlook for States and Markets Pending Federal Action
While this information provides a snapshot of enrollment patterns in 2018 from 10 states, it indicates that responses to the CSR funding elimination had diverse effects on states’ markets and consumers. Similarly, if CSR funding is reinstated, the effect will reverberate differently across states’ markets and consumers. Significant changes could mean another year of disruption for insurers, who will need to adapt products and rates based on shifting federal policy, and consumers, who may need to once again actively shop around and switch plans next year. The CBO estimates that 500,000 to 1 million consumers would become uninsured from 2020 to 2021 if CSR funding was reinstated. These would mostly impact consumers with incomes between 200 to 400 percent FPL who would no longer would benefit from tax credits, which are larger than CSR subsidies.
While states and insurers rapidly responded to the Administration’s decision to end the CSR program in 2017, an absence of clear policies and continuous last-minute changes will spur unrest in markets. Without sustainable policies to stabilize the individual market, consumers will face higher costs, confusion, and anxiety about whether insurance coverage will be available when they need it.
While CSR funding remains a concern to some states, states are also seeking solutions that could bring immediate stability to markets, such as federal reinsurance funding. Whatever policies are implemented this spring, time is of the essence as state regulators are already in active negotiations with their insurers for 2019 offerings, with rate filings expected in some states as early as May. Ideally, future federal policies will grant states sufficient time and flexibility to respond to policy changes in a manner most appropriate for their markets.
Click here to view a chart comparing marketplace enrollment by metal level in California, Colorado, Connecticut, Idaho, Maryland, Massachusetts, Minnesota, Rhode Island, Vermont and Washington State.
State policymakers increasingly recognize the need to address the social determinants of health — housing, employment, education, and income — to reduce health care costs and improve population health. Educational attainment, for example, provides dividends for overall health. People with higher levels of education generally live longer and experience healthier lives.
The quality of education a student receives impacts educational attainment and overall health. Evidence shows the overrepresentation of certain groups of students in separate classrooms or other settings of poorer quality overwhelmingly affects students of color. Teachers have identified students of color as having disabilities at higher rates than white students, with research documenting racial bias as influencing their decisions to remove students from the classroom. Students removed from mainstream education settings are less likely to make progress, build skills, and/or return to general educational settings. Black and Latino students are more likely to be affected by disproportionality.
|Disproportionality occurs when any racial or ethnic group’s numbers in special education classes or programs are statistically higher than other students.|
States are uniquely positioned to promote the mental health and educational achievement of all children by addressing the mechanisms that underlie racial and ethnic differences in mental disorder onset and persistence, and the causes and consequences of disproportionality in out-of-regular classroom settings, such as resource rooms, separate schools, or separate facilities. Using the resources of a variety of agencies, including public health, Medicaid, mental health, and education, can address disproportionality. Drawing from interviews with state officials conducted in conjunction with Massachusetts General Hospital’s Disparities Research Unit, the National Academy for State Health Policy (NASHP) identified state policy levers and programs, including mental health consultation, data sharing, convening authority, systemic interventions and supports, that states can use to eliminate mental health disparities.
State Levers to Address Disproportionality in Educational Settings
- Mental health consultation programs: Minnesota, Delaware, Colorado, Ohio and Connecticut utilize mental health consultation programs that can support efforts to address disproportionality. Mental health consultation varies across states, but commonly mental health providers support child care professionals and teachers, including Head Start, Part C Early Intervention Program, and child care workers, to improve their ability to identify and ameliorate mental health issues in children. States are also investing in training resources to improve the skills of early childhood mental health clinicians. Mental health consultants are typically funded by Medicaid agencies, education agencies, state general revenue or federal funds, or grants, and may receive cultural awareness training designed to improve their skills while reducing implicit cultural and racial bias. With leadership from the Substance Abuse and Mental Health Services Administration and other federal health and education agencies, states increasingly expect mental health consultants to carry out their consultative and clinical services in ways that help teachers provide supportive learning environments for all children.
- Data usage: State departments of education are required to monitor, report, and address disproportionality based on race and ethnicity as required by the US Department of Education’s Equity in Individual with Disabilities Education Act final regulation effective July, 1, 2018. Some state officials mentioned having a longitudinal data system to track disproportionality would be helpful, and would provide an opportunity for state health and education agencies to collaborate.
- Advisory groups: Colorado, Minnesota, and Delaware benefit from advisory groups that facilitate interagency collaboration that can address disproportionality. In Minnesota, an interagency task force including the Medicaid agency (Department of Human Services), Department of Health, and Department of Education promotes coordinated efforts to achieve equitable, universal early childhood screening and referrals. Minnesota’s task force laid the foundation to include mental health consultation services within its school-linked grants under its early childhood mental health infrastructure grants. Delaware, Connecticut, and Colorado were able to generate statewide attention to disproportionality by addressing school suspensions and expulsions. Connecticut became the first state to prohibit expulsions in publically-funded preschools and has recently instituted policies to ensure accountability.
- Ohio’s Cultural and Linguistic Competency Plan: Ohio’s Department of Mental Health and Addiction Services instituted a statewide Cultural and Linguistic Competency Plan to promote health equity and eliminate disparities. Ohio provides cultural competence and linguistic trainings to state employees that reference the Culturally and Linguistically Appropriate Services Standards. Additionally, the plan highlights incentives for providing culturally-competent services. Culturally-competent services can result in lowered health care costs stemming from a reduced number of medical errors, unnecessary or avoidable treatments, and lower numbers of missed medical visits. They also can support new business and revenue-generating opportunities, improved performance on quality measures, and alignment with Medicare and Medicaid, which have placed priorities on cultural and linguistic competency. The state also developed a business case for achieving health equity cited in its Cultural and Linguistic Competency Plan.
Mental health inequities can result from disproportionality and are systemic. Addressing this issue involves:
- Unraveling policies and practices that negatively impact students of color of all ages; and
- Implementing systemic interventions and supports to identifying and assisting individual children with specific needs.
As demonstrated by numerous states, state health officials can use several mental health policy levers and strategies to improve students’ overall health and success in school.
This blog was supported by the Massachusetts General Hospital Disparities Research Unit.
1. Green, J.G., McLaughlin, K.A., Alegria, M., Bettini, E., Gruber, M.J., Kwong, L., Sampson, N., Zaslavsky, A.M., Xuan, Z., & Kessler, R.C. (unpublished manuscript). Ethnic/racial inequities in educational placement for youth with psychiatric disorders.
Tuesday, July 29, 2014
1:00 – 2:15 pm ET
View Webinar Here
This webinar explores the leap from health system transformation planning to practice by showcasing four leading states that are designing and implementing multi-payer payment reforms. Through a facilitated discussion, state officials discuss policy levers to shift payment systems away from fee-for-service, offer strategies for sustaining stakeholder momentum and commitment, and share perspectives on promising practices for and operational challenges of turning a plan for multi-payer payment reform into reality.
This webinar is the first in a six-webinar series, supported by Kaiser Permanente Community Benefit, highlighting specific policy and technical issues critical to achieving multi-payer payment reform. It is useful for all states contemplating, designing, or implementing multi-payer payment reforms, particularly SIM Round 2 Model Design applicants.
- Moderator: Anne Gauthier, Senior Program Director, NASHP
- Marcela Myers, Director, Pennsylvania Center for Practice Transformation and Innovation, Pennsylvania Department of Health; Pennsylvania SIM Project Director
- Karen Matsuoka, Director, Health Systems and Infrastructure Administration, Maryland Department of Health and Mental Hygiene; SIM Project Director
- Mark Schaefer, Director, Healthcare Innovation, Connecticut’s Office of the Healthcare Advocate; Connecticut SIM Project Director
- Vatsala Kapur Pathy, Founder, Rootstock Solutions; Colorado SIM Project Director
In January 2012, Connecticut introduced a person-centered medical home (PCMH) initiative within their redesigned HUSKY Health program. Under this initiative, Connecticut Medicaid provides 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. Furthermore, primary care must account for 60 percent of the practitioner’s time across all payers.
Connecticut is offering additional support to practices that would not currently receive Level 2 or Level 3 NCQA PCMH recognition, a requirement to receive full payment incentives. Under a “Glide Path” option, practices can participate in a three-phase program that requires them to meet specific milestones that prepares the practice to achieve NCQA recognition. Each phase lasts six months, and practices can take extensions totaling an additional six months. Glide Path practices that fail to achieve NCQA Level 2 or Level 3 recognition within 24 months are no longer qualified to participate in the Glide Path program.
The PCMH initiative is one of several Husky Health reforms, which also includes expanded eligibility to the Aged, Blind, and Disabled (ABD) population and low-income adults. HUSKY Health has already been serving low-income families and Children’s Health Insurance Program (CHIP) enrollees. HUSKY Primary Care, Connecticut’s pilot primary care case management (PCCM) program for low-income families, concluded at the start of 2012. Additional information on the medical home initiative can be found in provider bulletins 2011-77 and 2011-84, as well as the provider application.
Also, Connecticut Public Act 09-148 established the SustiNet Health Partnership, which is tasked with designing and implementing a new public health insurance program for residents who are not eligible for Medicare or Medicaid and are not offered employer-based coverage. This law included multiple references to medical homes, including a statutory PCMH advisory committee and a mandate that medical home services be included in the standard benefits package. More information can be found in the advisory committee’s final report and a 2011 Legislative Report.
Furthermore, in 2009, the Connecticut state comptroller included a PCMH pilot component in the State Health Plan re-procurement process. The state has partnered with ProHealth Physicians to provide 35,000 individuals covered under the state employee health program access to NCQA-recognized medical homes.
Federal Support: Connecticut has received a duals demonstration grant from the Centers for Medicare & Medicaid Services (CMS) to “coordinate care across primary, acute, behavioral health and long-term supports and services for dual eligible individuals.”
Last Updated: April 2014
Minutes from the Medicaid Medical Assistance Program Oversight Council show that the following groups provided input during the development of the Connecticut medical home initiative:
The Connecticut Department of Social Services also hosted five public forums for HUSKY Health enrollees across the state.
Furthermore, Connecticut Public Act 09-148 required the SustiNet Health Partnership to include a Patient Centered Medical Home Advisory Committee composed of physicians, nurses, consumer representatives and other selected qualified individuals. The advisory committee is charged with developing proposed regulations for the administration of medical homes serving SustiNet enrollees.
|Defining & Recognizing a Medical Home||
Recognition: Participating medical homes must meet Level 2 or Level 3 NCQA medical home recognition standards (2008 or 2011, depending on time of NCQA application).
Additionally, Connecticut mandates that medical home practices must:
Practices that choose the Glide Path option will participate in a structured program that culminates in NCQA Level 2 or Level 3 recognition. The purpose of this option is to assist practices that would not currently receive Level 2 or Level 3 NCQA PCMH recognition, a requirement to receive full payment incentives. Practices choosing this option progress through three phases:
Phase I: Practices must meet three of the following requirements:
Phase II: Practices must meet three of the following requirements:
Phase III: NCQA Level 2 or Level 3 recognition.
Practices have six months to complete each phase of the program. However, practices may take extensions totaling no more than six additional months. If a practice does not receive NCQA Level 2 or Level 3 recognition within 24 months from the start of their participation, the practice is no longer qualified to participate in the Glide Path.
|Aligning Reimbursement & Purchasing||
Connecticut Medicaid is using a hybrid payment system under the new HUSKY Health program that is dependent upon NCQA recognition and Glide Path status. In total, the new reimbursement model will allow practices to earn up to 125 percent of the estimated medical home costs. For a summary of this reimbursement model, see the state’s PCMH Reimbursement Summary.
NCQA Level 2 or Level 3 practices:
Incentive Payments: Practices in the top tenth percentile for performance will receive 100 percent of the possible incentive payment, and fractions of the incentive payment begin phasing in at the 25th percentile.
Improvement Payments: Practices in the top tenth percentile for improvement will receive 100 percent of the possible improvement payment. Practices with a 5 percent improvement will receive half of the possible improvement payment, and practices with a 10 percent improvement will receive three-quarters.
Connecticut Medicaid plans to pursue alternative payment methods and intends to develop a prospective per member per month (PMPM) methodology for qualified providers by 2014.
Glide Path practices:
Connecticut Medicaid and the Community Health Network of Connecticut, the HUSKY Health administrative services organization, are providing the following practice supports:
As part of the incentive and performance improvement payments, Connecticut will track a number of specific pediatric and adult outcome and process measures. These measures include:
Customized CAHPS-PCMH surveys for both the adult and pediatric populations will include questions to evaluate patient experience with medical homes and the Medicaid provider network.
- 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.
(As of April 2013)
At a Glance
- Strong partnership between Connecticut’s Department of Social Services (Medicaid), Department of Mental Health and Addiction Services, and Department of Children and Families works to integrate public behavioral health services
- Primary care providers can receive separate payments for mental health screenings
- Enhanced Care Clinics receive higher reimbursements to provide timely routine and urgent mental health evaluation services, as well as follow-up
Connecticut has made strides to reduce fragmentation in its behavioral health system and advance a system-wide vision that reduces unnecessary admissions to, and lengths of stay in hospitals and residential treatment facilities. A multi-agency partnership—called the Behavioral Health Partnership—that includes the state Department of Social Services (DSS) seeks to create an integrated behavioral services system for enrollees in state health plans (Medicaid and CHIP, which are housed in the DSS). Behavioral health services to Medicaid beneficiaries in Connecticut have been provided through an administrative services organization (ASO) model since 2006. Under this model, an entity (referred to as an ASO) is contracted to administer the behavioral health benefit and coordinate services, though claims are submitted to the Department of Social Services on a fee-for-service basis.
Connecticut created the Behavioral Health Partnership and transitioned to the ASO model as part of an effort to make a more cohesive and focused behavioral health system. The involvement of the Department of Children and Families helped to focus these reforms on children. The state has pointed to a significant drop in hospital discharge delay days for children in the custody of the state who have behavioral health problems as evidence that the partnerships between the state’s Medicaid and child welfare agencies has been successful.
Coordination and Collaboration
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 ASO, authorizing and managing behavioral health services for all Medicaid participants. ValueOptions produces a provider manual for participating behavioral health providers. The state’s fiscal agent, HP Enterprise Services, processes claims for behavioral health services.
State agencies outside the DSS have also coordinated to better meet the behavioral needs of children. Through the RWJF Resources for Recovery program, which concluded in December 2006, Connecticut developed common contract terms and procedures for use by two agencies—the Department of Children and Families and Court Support Services—in the purchase of treatment services for youth called Multisystemic Therapy (an intensive family-and community-based treatment program that focuses on the entire world of chronic and violent juvenile offenders). This reduced the burden on providers and allowed for the monitoring of the quality of services. Multisystemic Therapy is reimbursed by Medicaid for enrollees under age 21 as a Rehabilitative Behavioral Health Service.
Screening, Assessment and Referrals
Children in Connecticut have several avenues through which to access developmental or behavioral health screens under the Medicaid children’s benefit, including in primary care offices, free-standing clinics, and school-based health centers. 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. However, DSS does not require providers to use specific standardized developmental or mental health screening tools and no recommendations are provided other than the list of instruments compiled by the CTBHP (described below).
The CTBHP produces lists of covered services for providers participating in Medicaid. The list for independent or group practitioners (e.g. medical doctors) clarifies that Medicaid and the Children’s Health Insurance Program reimburse for psychological testing, initial psychiatric interview examinations, and interpretation of the results of psychiatric examinations. The CTBHP has compiled a long list of psychological tests to aid practitioners; the list catalogs existing screening and evaluation instruments, as well as classifying each by type (e.g. behavioral rating scale or chemical dependency), the ages for which the instrument is intended, and the expected duration in minutes. Many of these instruments are designed specifically for children.
As discussed below, behavioral health clinics designated as “Enhanced Care Clinics” must have memoranda of understanding with at least two pediatric primary care practices. These memoranda must include provisions for the clinic conducting annual education and training events for primary care providers and their staff related to “prevention, screening, evaluation and family-centered management of behavioral health disorders in primary care.”
The state also encourages the provision of behavioral health screens in other care settings. Medicaid reimburses school-based health centers (SBHCs) for “diagnostic and treatment services involving mental, emotional or behavioral problems and disturbances and dysfunctions, or the diagnosis and treatment of substance abuse.” Although no specific tools are recommended, the Department of Social Services’ SBHC provider manual is clear that mental health evaluations, assessment procedures, and the interpretation of assessment results will be reimbursed by Medicaid. Among a range of mental health services, SBHCs and Federally Qualified Health Centers can bill for Psychiatric Diagnostic Evaluations (CPT 90791) and Psychiatric Diagnostic Evaluations with Medical Services (CPT 90792).
In a 2012 policy transmittal, CMAP announced that independent practice licensed or certified behavioral health practitioners could provide behavioral health assessment and treatment services to individuals under age 21 who are covered under Connecticut’s HUSKY C and HUSKY D programs (Medicaid for the aged, blind, and disabled population and Medicaid for low-income adults, respectively).
Around the time that the state switched behavioral health Medicaid benefits to an ASO model, Medicaid also began to address outpatient behavioral health access issues in the state. The state did this by creating a new designation for select behavioral health service providers: Enhanced Care Clinics (ECCs). Clinics receiving this designation receive higher reimbursements for all routine outpatient services—on average, 25 percent above the standard fee schedule—for guaranteeing timely emergent access.
Enhanced Care Clinics are expected to provide enhanced care across five domains of service, originally listed in Appendix A of the Request for Applications to participate as an ECC: access, coordination of care, members services and supports, quality of care, and cultural competence. The ECCs must offer not only routine and urgent mental health evaluation services, they must have the capability for follow-up. ECCs are required to have the capability to see clients with emergent needs within two hours, clients with urgent needs within two days, and clients with routine needs within two weeks. Other requirements for ECCs include that they use evidence-based practices in behavioral health and that they coordinate care with primary care providers.
A 2008 policy transmittal from the Department of Social Services notified ECCs of new requirements that they develop formal relationships with primary care practices in order to retain their designation as ECCs. The document established that “Each ECC that serves children or adolescents must enter into an MOU with two or more pediatric primary care practices.” The memoranda of understanding were required to include several elements, including: protocols for referrals of primary care patients to the ECC; protocols for the referral of ECC patients to the patient’s primary care provider; communication guidelines; and education and training around “prevention, screening, evaluation and family-centered management of behavioral health disorders in primary care.” A recent evaluation of Connecticut’s outpatient mental health system for children prepared for the Department of Children and Families found that the ECC system has “significantly reduced the length of time from referral to intake” for children.
ValueOptions, the ASO managing the Medicaid behavioral health benefit, also provides intensive care management for high-needs children with behavioral health issues, including those with a history of unsuccessful connections to care. Intensive care managers connect Medicaid-enrolled children to care and are responsible for follow-up to ensure that the child stays connected to services. Children who need wraparound services may be referred by intensive case managers to Community Collaboratives for care coordination that are supported by the state’s Department of Children and Families to serve children with serious emotional disturbances who need intensive coordination of an array of services. Case management services can also be provided by community based providers. In such circumstances, case management is billed using a T1016 code (“Case management, each 15 minutes”), unless they are part of an approved curriculum-based home service model.
The authors wish to thank the many state officials and stakeholders who contributed to and reviewed the information in this document.
This document was prepared by NASHP for the Centers for Medicare & Medicaid Services (CMS) under a contract to NORC at the University of Chicago. It does not reflect the views of CMS.
NASHP’s Accountable Care Activity map is a work in progress; state activity pages will be launched in waves throughout Fall 2012.
At this time, we have no information on accountable care activity that meets the following criteria: (1) Medicaid or CHIP agency participation (not necessarily leadership); (2) explicitly intended to advance accountable or integrated care models; and (3) evidence of commitment, such as workgroups, legislation, executive orders, or dedicated staff.
If you have information about accountable care activity in your state, please email firstname.lastname@example.org.
Last updated: October 2012
The Affordable Care Act (ACA) offers states multiple policy levers to improve health status and care for racial and ethnic minority populations through delivery system reforms, public health and community interventions, and insurance coverage, as well as provisions specific to disparities reduction. This report synthesizes the experiences of teams from seven states (Arkansas, Connecticut, Hawaii, Minnesota, New Mexico, Ohio, and Virginia) that participated in a learning collaborative to advance health equity using select ACA and state policy levers. The report also presents opportunities for state and federal collaborations to strengthen these efforts, as well as important lessons for advancing health equity.
An accompanying issue brief provides a high-level summary of the full report.