On Saturday, the Connector held its third annual Board retreat.  The full board attended the Andover session, along with about ten Connector staff, a couple of ANF staff, two insurance plan representatives, and me (Lindsey Tucker -ed.).  This year’s retreat was entirely self-run, without an outside facilitator; both the agenda and the presentations were collaborations between staff and board chair, Leslie Kirwan.  In a more relaxed and intimate setting than the regular board meetings, the retreat showed the best of the Connector.  With extra time and plenty of caffeine and calories, staff offered a series of complex presentations, and board members were able to engage in multiple substantive policy conversations – without losing collective humor and mutual respect.  The retreat ran long, cutting short a few discussions and forcing small items off of the agenda, a testament to the enormity of the Connector’s scope and responsibility.  As a professional Connector Watcher, I continue to be impressed by the relationships among board members; the staff’s ability to present obscure data and intricate policy recommendations clarity; and the continued energy and dedication for the program.  I was also pleased and exited to hear discussions on two top ACT!! Coalition issues: CommCare churn and MCC implementation.

The agenda was a mix of updates and broader policy discussions:

Part 1: Introduction and State Finances

1. State Financial Outlook
2. CommCare: CMS Waiver Briefing

Part 2: Commonwealth Care Program

1. CommCare Enrollment Dynamics: A Deeper Dive
   1. Enrollment/Disenrollment Trends
   2. Redetermination Effects
   3. Improving Eligibility and Enrollment Processes
   4. Employer Sponsored Insurance “Buy-In” (passed over due to time)
2. MCO Procurement
   1. MCO Financial Performance
   2. MCO Audit: Preliminary Findings
   3. MCO Procurement Process
   4. Using Predictive Modeling to Set a Risk-Adjusted Capitation Payment
   5. Value-Based Insurance Design (passed over due to time)

Part 3: Managing “Minimum Creditable Coverage” & Appeals

The retreat revealed some new statistics on CommCare member churn, and the impact this is having on MCO efforts to manage care. Click on the more… for all the details.

Part 1: Introduction and State Finances

Secretary Kirwan opened the retreat with reflection on the Connector’s successes.  Her frame for the morning was the dual task of continuing those successes and managing through the current and upcoming difficult times:  “We have risks on one hand, opportunities on the other.”

She then led the group through a state fiscal review.  While the information was mostly not new, the time afforded board members the opportunity to dialogue with the Secretary of Administration and Finance on details of the financial landscape, the Governor’s 9C cuts, and her projections for the winter and spring.  The emphasis was on conservative planning, shared responsibility across the Administration and quasi-public authorities, and how health reform and Commonwealth Care fit into the broader picture.  The board appreciated the lack of direct cuts to health reform (enrollment, eligibility, services, and the Outreach grants are largely intact-thank you!) but also recognized the cuts to providers and the impact they might have on the system.  Medicaid Director Tom Dehner then led the group through a review of the 1115 Medicaid Waiver, currently approved in principle and awaiting finalization.

Part 2: Commonwealth Care Program-Enrollment Dynamics

The focus of the retreat was the Commonwealth Care program.  Melissa Boudreault led board members in an in-depth look at CommCare enrollment dynamics, with enrollment/disenrollment trends and the effects of redetermination:  “Working to strike the correct balance between program integrity and customer service, we want to make sure we are providing insurance to those eligible and continuously improve the ways in which we support our members.”

In an exploration of enrollment and caseload activity, Melissa focused on the time period between February and October 2008.  She presented data, charts and graphs to illustrate what’s happening in the program.  There has been a decrease in caseload each month, particularly in March and April, largely due to redeterminations.  Between February and October, there were 107,000 total additions-85,000 new and 22,000 returning.  In this time, closings totaled 109,000-41,000 from redeterminations and 68,000 from “natural closings.”  Natural closings include changes in family circumstance or job, the finding of an offer of ESI, and failure to pay.  Thus, the net enrollment change in this time was -2,124 or -1.3%.

Digging in further, Melissa looked specifically at the 41,000 members closed during the redetermination process (of a total 71,000 members selected for redetermination during this time).  “Administrative closings” accounted for 76% of the 41,000, when members failed to return their form.  A change in eligibility, such as moving to MassHealth or the Health Safety Net led 19% to leave the program.  Some 4% were terminated due to returned mail (an impressively low number), and 2% were classified as “other” (for example, they moved out of state or passed away).

An important question here is whether those 76% whose eligibility was terminated due to failure to return their forms should actually still be in the program.  Are these people no longer eligible?  Or is there something wrong with the process?  To help answer this, Melissa looked at re-enrollment following the redet closings.  The average number of closed members that re-enroll within 5 months is 22%.  Over 5,000 members (of 41,000 termed) returned to Commonwealth Care within two months, suggesting that they should never have been terminated.  (Those returning in five or six months may be seeing changes in their eligibility status that is appropriately taking them off the program and then bringing them back on.)

This is an area the Connector and Melissa are going to work on.  Proposals for improvement include: sending a CommCare-specific cover letter (for members who don’t recognize or relate to the MassHealth logo); implementing additional forms and technological tools for members to help maintain eligibility; improving initial data collection by asking different questions in different ways; and improving the eligibility process related to ESI.

The current ESI determination process disenrolls the member immediately upon learning that his employer offers coverage; however, over 70% of those individuals end up being eligible for CommCare.  The board engaged in a robust discussion around this last issue and the best way to streamline enrollment and coverage maintenance for those eligible and still remove those applicants or members who are not eligible.  One solution is to change the system to allow the member 30 days to complete the process before they are disenrolled.  This determination process will get easier over time, as the state and HMS (the employer investigation contractor) further develop their list of employers and what coverage is offered to which employees.

Part 2: Commonwealth Care Program-MCO Procurement

Patrick Holland walked the board through the MCOs’ past financial performance as an introduction to this year’s procurement process.  He reviewed the program’s surplus/deficit from CY2007 (through 12/31/07) and the 6-month extension period (through 6/30/08), both across plan types and MCOs.  The state is seeing a surplus from the risk-sharing arrangement with the MCOs in the last contract, and the data will be useful to help the Connector assess risk for this next contract period.

Changing gears, Patrick reviewed the MCO operational audit.  As a result of the RFP process, Navigant Consulting was selected as the audit vendor to look at three components: accuracy of MCO claims payment; care management; and provider network (rates/adequacy).  Concerning claims payment, preliminary results show a 4.5% rate in payment errors.  This percentage is high, but the dollar value of the errors is consistent with industry standards (0.1%, or about $1,000).  These errors were mostly around the collection and application of members co-pays, and they were uniform across the MCOs.  In the category of care management, the audit found that member churn (in and out of CommCare, not movement across the MCOs) significantly impacts the ability of the MCOs to implement disease management.  This elicited a long conversation among board members about care management programs and how to think more globally and collaboratively for improvements.

The final section of Patrick’s presentation was an introduction to this year’s MCO procurement process.  The Connector is thinking about a different type of contract for this year, and the board engaged in a discussion around risk adjustment and what the changed system might look like.  Goals for this year’s contracting model include protecting members from large premium differentials (a key concern of the ACT!! Coalition), rewarding care management, and increasing transparency and simplicity.  Since the board will have to make a final decision on this at the first of their two December meetings, we can expect further discussion and exploration of this topic at the November meeting.

Part 3: Managing “Minimum Creditable Coverage” & Appeals

The final policy topic of the retreat was MCC appeals issues.  Jamie Katz outlined what guidance the staff needs from the board to implement MCC exemptions and appeals, and Bob Carey walked the board through a few examples of appeals that had already come in.  Jamie stressed the need for a consistent system and for maintaining similar exemption standards sponsoring organizations and individuals-i.e., a generous and flexible approach.  At the October meeting, the board came up with some guiding principles for this process: flexibility; consideration of total health benefits package; recognition of individual’s financial situation; reward for good faith efforts to get decent insurance; and consistency.  The questions in front of the board and the staff moving forward is, how close to the MCC regulations does a non-compliant plan have to be in order to receive an exemption, and how does the Connector determine that in the face of potentially hundreds of appeals requests?

Moving forward, the Connector will develop more website and on-line material and tools (similar to the Affordability Tool) to educate and assist people through the appeals process.  Additional guidance might include MCC checklists of necessary insurance features; model policies that meet exemption requirements; and lists of MCC-compliant plans.  As the volume of safe harbor exemptions and MCC appeals grows, Connector staff will develop a regular reporting process for the board, and the goal will be to set out exemptions and appeals by categories.

The timeline for this work is:

• On or before Nov 13: Develop administrative bulletin on actuarial equivalence safe harbor (what are standards and protocols), giving board members a chance to review; develop application forms for plan sponsors, carriers, and individuals to use; begin receiving and reviewing applications.
• November-December 2008: establish safe harbor application process for sponsoring organizations and review applications for 2009.  This will include outreach to employees and taxpayers and materials for the Connector website.
• Jan-July 2009: work with DOR and DOI on coordinating MCC policies and practices.
• Winter-Spring 2010: Process appeals by individuals who raise MCC issues for tax year 2009.

The retreat concluded with a long discussion of real examples of MCC exemption requests.  The examples resonated differently with board members, and the conversation’s conclusion was that the staff needs to create a process for dealing with these examples.  Are there broader, umbrella categories that the majority of these issues could fall under?  The consensus was to start with greater flexibility and get tougher in future years if need be.

The next Connector board meeting is November 13 from 9-11 on the 21^st floor of 1 Ashburton.
Lindsey Tucker