connecticut department of social services michael p. starkowski, commissioner april 8, 2008...

ConnecticutDepartment of Social ServicesMichael P. Starkowski, CommissionerApril 8, 2008Addressing Connecticuts Uninsured(Charter Oak and HUSKY)

revised 4/10/2008

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)Charter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Index

Target Population CT Demographics of Uninsured National Perspectives Charter OakProcurementProgram DesignSubsidy ScalesBenefitsNetworkRate SettingKey Numbers & Websites

Charter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Target Population:Sources of Health Insurance CoverageWhile most Connecticut residents continue to have health insurance coverage, the uninsured increased slightly from 5.8% to 6.4% from 2004 to 2006.Employer based insurance increased from 64% to 66.5% from 2004 to 2006HUSKY & Charter Oak are aimed at the 6.4% in state who are uninsured.Source: Results of the Office of Health Care Access 2004 and 2006 Household Surveyhttp://www.ct.gov/ohca/lib/ohca/publications/2007/household06_databook_1-31_version.pdfCharter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Target Population:Connecticut Population BreakdownSource: Results of the Office of Health Care Access 2006 Household Surveyhttp://www.ct.gov/ohca/lib/ohca/publications/2007/household06_databook_1-31_version.pdfSources: CT Office of Health Care Access 2006 Household Survey and population figures from U.S. Census Bureau March 2005 Current Population Survey1 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.Charter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Uninsured and all CT ResidentsRacial/ Ethnic Proportions2006Charter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Chart4

0.7610.2020.038

0.5570.3480.095

0.4660.3420.193

0.60490.27980.1152

0.70242734160.23335104820.0642216102

Source: CT Office of Health Care Access 2006 Household Survey

Coverage for race/ethnic groups, 2006

Private

Public

Uninsured

Percent of race/ethnicity

9%

Chart3

0.450.1110.340.104

0.7580.0940.10190.0456

Race of uninsured and all CT residents, 2006

Sources: CT Office of Health Care Access 2006 Household Survey and U.S. Census Bureau

White

Black

Hispanic

Other


Chart2

0.8720.642

0.7480.379

0.6150.443

0.640.56

Characteristics related to coverage by race, 2006

Sources: CT Office of Health Care Access 2006 Household Survey and U.S. Census Bureau 2006 Annual Social and Economic Supplement

Non-Hispanic White

Minority

Percent of racial identity

Chart1

0.880.8

0.980.95

0.970.86

0.90.67


Percent of insured minorites and non-Hispanic whites at same income level or work status, 2006

Federal Poverty Level

Work status

Non-Hispanic White

Minority


coverage

PrivatePublicUninsured

White76%20%4%

Black56%35%10%(changed to 9% manually on chart above b/c shortens bar otherwise)

Hispanic47%34%19%

Other60%28%12%

Statewide70%23%6%


White198277052535497957260608176%20%4%

Black145163907732461126054756%35%9%

Hispanic1853811363317680839852047%34%19%

Other121309563402321720086660%28%12%

Total2434623808798222593346601470%23%6%

uninsured

%

UninsuredAll CT Residents

White45%76%

Black11%9%

Hispanic34%10%

Other10%5%

Population

White97,9572,627,239

Black24,611325,805

Hispanic76,808353,187

Other23,217158,050

222,5933,466,014

Xteristics of Uninsured

Access to employment based coverage (age

Coverage by Racial/ Ethnic Proportion 2006Charter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Chart4

0.7610.2020.038

0.5570.3480.095

0.4660.3420.193

0.60490.27980.1152

0.70242734160.23335104820.0642216102



Private

Public

Uninsured


9%

Chart3

0.450.1110.340.104

0.7580.0940.10190.0456



White

Black

Hispanic

Other


Chart2

0.8720.642

0.7480.379

0.6150.443

0.640.56



Non-Hispanic White

Minority


Chart1

0.880.8

0.980.95

0.970.86

0.90.67




Work status

Non-Hispanic White

Minority


coverage


White76%20%4%


Hispanic47%34%19%

Other60%28%12%

Statewide70%23%6%


White198277052535497957260608176%20%4%

Black145163907732461126054756%35%9%

Hispanic1853811363317680839852047%34%19%

Other121309563402321720086660%28%12%

Total2434623808798222593346601470%23%6%

uninsured

%


White45%76%

Black11%9%

Hispanic34%10%

Other10%5%

Population

White97,9572,627,239

Black24,611325,805

Hispanic76,808353,187

Other23,217158,050

222,5933,466,014



Coverage by Racial/ Ethnic Proportion2006Charter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Chart4

0.7610.2020.038

0.5570.3480.095

0.4660.3420.193

0.60490.27980.1152

0.70242734160.23335104820.0642216102



Private

Public

Uninsured


9%

Chart3

0.450.1110.340.104

0.7580.0940.10190.0456



White

Black

Hispanic

Other


Chart2

0.8720.642

0.7480.379

0.6150.443

0.640.56



Non-Hispanic White

Minority


Chart1

0.880.8

0.980.95

0.970.86

0.90.67




Work status

Non-Hispanic White

Minority


coverage


White76%20%4%


Hispanic47%34%19%

Other60%28%12%

Statewide70%23%6%


White198277052535497957260608176%20%4%

Black145163907732461126054756%35%9%

Hispanic1853811363317680839852047%34%19%

Other121309563402321720086660%28%12%

Total2434623808798222593346601470%23%6%

uninsured

%


White45%76%

Black11%9%

Hispanic34%10%

Other10%5%

Population

White97,9572,627,239

Black24,611325,805

Hispanic76,808353,187

Other23,217158,050

222,5933,466,014



Percent of insured minorities and non-Hispanic whites at same income level or work status 2006 Charter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Chart4

0.7610.2020.038

0.5570.3480.095

0.4660.3420.193

0.60490.27980.1152

0.70242734160.23335104820.0642216102



Private

Public

Uninsured


9%

Chart3

0.450.1110.340.104

0.7580.0940.10190.0456



White

Black

Hispanic

Other


Chart2

0.8720.642

0.7480.379

0.6150.443

0.640.56



Non-Hispanic White

Minority


Chart1

0.880.8

0.980.95

0.970.86

0.90.67




Work status

Non-Hispanic White

Minority


coverage


White76%20%4%


Hispanic47%34%19%

Other60%28%12%

Statewide70%23%6%


White198277052535497957260608176%20%4%

Black145163907732461126054756%35%9%

Hispanic1853811363317680839852047%34%19%

Other121309563402321720086660%28%12%

Total2434623808798222593346601470%23%6%

uninsured

%


White45%76%

Black11%9%

Hispanic34%10%

Other10%5%

Population

White97,9572,627,239

Black24,611325,805

Hispanic76,808353,187

Other23,217158,050

222,5933,466,014



Uninsured Income Eligible For Medicaid But Not Enrolled, By AgeCharter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Chart1

0.18112

0.45430

0.064

0.1218

0.1369

0.032

0.011

Percent

Number

Uninsure Eligible for Medicaid But Not Enrolled, By Age

Chart2

0.18112

0.45430

0.064

0.1218

0.1369

0.032

0.011

Percent

Number

Chart3

0.181

0.454

0.06

0.121

0.136

0.03

0.01

Percent

Sheet1

AgePercent

Under Age 6 (12)18.1%

Age 6-18 (30)45.4%

Age 19-24 (4)6.0%

Age 25-34 (8)12.1%

Age 35-44 (9)13.6%

Age 45-54 (2)3.0%

Age 55 + (1)1.0%

Sheet2

Sheet3

Office of Health Care Access 2006 Hispanic Adults Survey

90 % of Hispanic adults believe that having health insurance is very important1/3 of all Hispanic adults consider the Emergency Department to be their regular source of primary care.28 % of Hispanic adults have employment-based coverage.36 % of Hispanic adults are currently uninsured.21 % of working uninsured Hispanic adults are eligible for their employers coverage.16 % of uninsured Hispanic adults could potentially obtain coverage through a family members employer.55 % of uninsured Hispanic adults are not U.S. citizens and therefore may not be eligible for public coverage.


revised 4/10/2008

Office of Health Care Access 2006 Hispanic Adults Survey

Non-citizens were nearly three times as likely to be uninsured as citizens (63 % compared to 22 %).45 % of the uninsured in the Hispanic population are between the ages 18 and 29; 30 % are between ages 30 and 39.62 percent of the uninsured in the Hispanic population are male.1 of every 5 Hispanic adults had problems paying medical bills in the last year.Almost earn less than 150 % and nearly 2/3 earn less than 300% Federal Poverty Level (FPL).Nearly 1 of every 4 Hispanic adults postponed getting medical care because they could not afford it.13 % of Hispanic adults chose not to get needed medical care during the prior year.


revised 4/10/2008

DSS Health Care *State Wide Enrollment Hartford

HUSKY A Children 216,731 23,755 Adults 101,03810,989 317,76934,744HUSKY B 16,344 541

FEE for Service 90,082 8,675

SAGA Medical 33,955 5,566

TOTAL 458,150 49,526 *As of 4/1/08 Charter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Uninsured National Perspective:Other States Approaches

State Affordable Insurance InitiativesMaine - Dirigo ProgramMassachusetts Commonwealth Care ProgramNew York - Healthy New York ProgramArizona Health Care GroupCalifornia PAC Advantage


revised 4/10/2008

Uninsured National Perspective:Other States Approaches

Lessons LearnedAffordability is Key to Driving Enrollment and Balancing RiskTrade-Offs Must Be Made to Balance Affordability with CoveragePlan Design Must Be Adjusted to Avoid Adverse SelectionMust Have MCOs/Carriers Willing to Assume Risks Associated with a Start-up ProgramCharter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

HUSKY Charter OakProcurement TimelineRelease of ProspectusOctober 2007Release of RFPJanuary 2008RFP Bidders ConferenceFebruary 2008RFP Bids DueApril 2008RFP NegotiationsMay 2008RFP AwardsMay 2008Open EnrollmentJune 2008Contract Effective DateJuly 2008Charter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

HUSKY Charter Oak Procurement:Combined to Balance Risk and Simplify AdministrationDSS released a Request for Proposals for the combined HUSKY A, HUSKY B and Charter Oak programs on January 3, 2008DSS combined the procurement to allow for continuity of service providers, primary care physicians, etc. When parents in HUSKY A exceed the income eligibility or children age out of HUSKY, Charter oak will be available to them with the same MCOs, same network of providers.DSS combined 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 enrollmentDSS 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


revised 4/10/2008

HUSKY Charter Oak: Procurement:Combined ProcurementA combined procurement for HUSKY and Charter Oak will cover an estimated 350,000 to 400,000 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 contractSuccessful bidders will be required to meet the network, operational, contractual, and financial standards as laid out in the RFP and provide services for both the HUSKY programs, as well as the Charter Oak programAll 350,000 to 400,000 lives will 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 familiesCharter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Program Design:Charter Oak

Geographic AreaStatewide Status: Anticipated Carriers will offer Coverage StatewideProgram StructureState Program*: July 1, 2008AuthoritySection 23 of Public Act 07-02 (June Special Session)Type of EnrollmentVoluntary, Affordable Health Insurance Individuals without health insurance for the last six months or those who meet certain qualifying criteria to exempt them from uninsurance requirementExcluded Populations Individuals currently insured or insured within last six months (exemptions to be determined)Individuals eligible but not enrolled in Public Programs (SAGA, HUSKY A and B, etc)

* DSS anticipates submitting a waiver to the Connecticut Legislature, and if approved, to CMS for Federal financial participation in portions of Charter OakCharter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Charter Oak Program Design:Not MedicaidCharter Oak is not Medicaid: benefits will be based on a commercial model, with enforceable deductibles, co-pays, and coinsuranceCharter 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 monthFor individuals with incomes less than 300% of FPL, premium will be subsidized by the state according to a fixed sliding scaleSliding Scale PremiumsSliding Scale DeductiblesCharter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Charter Oak Program Design:State Subsidy Table and Projected Enrollment

Total Cost of Monthly PremiumCharter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Chart1

17575

150100

75175

50200

300%+250

Monthly DSS Contribution

Monthly Client Contribution

Recipient's Gross Income Range (Given as % of the Federal Poverty Level)

Charter Oak Plan Monthly Premiums

HUSKY - Target Pop

% of the Federal Poverty Level (FPL)ChildrenParents and Caretaker RelativesPregnant Women*Total Enrollment SFY04Total Enrollment SFY05Total Enrollment SFY06

HUSKY A0-185%0-185%0-250%

HUSKY B186-300%--

HUSKY PLUS185% +--

* Eligibity for Parents and Caretaker Relatives expanded from 150% FPL to 185% FPL, effective July 1, 2007

** Eligibilty for Pregnant Women will expand from 185% FPL to 250% FPL, effective January 1, 2008

Charter Oak Detail

CHARTER OAK Health PLAN WITH 185% EXPANSION UNDER MEDICAIDUpdated 10-03-2007 with the July 1, 2008 start date

& the FPL% Expansion start date of September, 2007

ESTIMATE FOR PREMIUM ASSISTANCE FOR CHARTER OAK HEALTH PLAN

40.0%Enrollment, July 1, 2008 Start Date

ClientState Prem.UninsuredUninsured# Eligible forCOP EligibleCOP AdultsProgam Phase In %Data Summary (per OHCA study)

ContributionAssistanceIndividualsAdultsHUSKY/SAGAAdultsEnrollingUninsuredProrates

1st yr25.0%16,153IndividualsUnknowns

Charter Oak Income Guidelines *as of 4/1/08

revised 4/10/2008

Charter Oak - Benefits:Basic Features

DeductibleVaries based on IncomeCo-insuranceVaries based on IncomeOut of Pocket MaximumVaries based on IncomeLifetime Benefit Maximum$1,000,000Premiums by enrollee*Maximum $250/monthVaries based on incomePrimary Care Physician Visits$25 co-paySpecialist Physician Visits$35 co-pay

Preventive CareNo co-pay, 100% coveredInpatient Hospital10% CoinsuranceOutpatient Surgical Facility20% Co-insuranceAmbulance/Transportation100% Covered in emergenciesDurable Medical Equipment$4,000 Annual LimitBehavioral Health Services, Rx services carved-out and provided through DSSDental and Vision Services may be provided as optional riders by MCOs with separate premium assessment


revised 4/10/2008

Charter Oak-Benefit Structure* Charter Oak - Individuals that have been Uninsured for at Least 6 Mo. Exclusion list will be added. No Asset Test.Charter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Charter Oak-Benefit StructureCharter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Charter Oak-Benefit Structure* Ostomy and Diabetic supplies excluded from cap.Charter Oak4.10.08Revised 4/15/2008

revised 4/10/2008


revised 4/10/2008

Charter Oak-Benefit Structure* Ostomy and Diabetic supplies excluded from cap.Charter Oak4.10.08Revised 4/15/2008

revised 4/10/2008


revised 4/10/2008

Charter Oak-Other Pertinent InformationCharter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Program Design:Charter Oak Benefits CoordinationCharter Oak will follow DSSs successful track record in benefits carve-outs and will carve-out certain services.

Benefit Design Carve-out: Specialty Behavioral HealthCharter Oak contractors will not be required to manage or pay claims for specialty behavioral health services

Benefit Design Carve-out: PharmacyCharter Oak contractors will not be required to manage or pay claims for pharmacy services


revised 4/10/2008

Program Design:How Benefits Coordination Will Work for HUSKY and Charter Oak PharmacyBenefit Design Carve-out: Pharmacy (HUSKY and Charter Oak)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)DSSs Pharmacy Program Structure:Preferred Drug List (PDL), prior authorizationOne Pharmaceutical & Therapeutics (P&T) Committee & Drug Utilization Review (DUR) BoardCharter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Charter Oak - NetworkOverviewDSS is requiring Carriers and Managed Care Organizations to have a strong commitment to education and outreach to help members to 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 outcomesAll Bidders have an equal opportunity to receive contracts; preference will not be given to existing contractorsDSS anticipates awarding 3 contracts.


revised 4/10/2008

Charter Oak Rate Setting:Innovative Opportunities

Incentives/Sanctions DSS is placing funds at-risk for contractor performance standards in several areas, including:Geographic distribution of key provider types for overall network access requirementsAvailability of scheduled appointments for primary care and specialty physicians for meeting appointment scheduling waiting standardsTelephonic wait times, call abandonment and resolution rates for member and provider customer service standardsClaims adjudication times for meeting claims payment timeliness requirementsCharter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Charter Oak - Rate Setting:Basic Rate Setting

Rates will be Actuarially Sound and able to meet CMS Requirements (required to be able to access Federal Financial Participation-FFP)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)Rates will be based on HUSKY A adults data, adjusted for differences in:DemographicsPlan DesignUnderlying Risk/AcuityReimbursementTrendCharter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

Key Numbers & Web Sites Charter Oak4.10.08Revised 4/15/2008

revised 4/10/2008

connecticut department of social services michael p. starkowski, commissioner april 8, 2008...

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