Clinical Advisory Committee on Health and Emerging Technology (CACHET)

1. Clinical Advisory Committee on Health and Emerging Technology (CACHET) Department of Health Services August 5, 2010

2. Agenda Part I – CACHET Updates Part II – BadgerCare Plus Basic Updates Part III – Core Plan Update: Renewals Part IV – Core Plan Update: Member Overview Part V – Budget Status Part VI – Proposed Recommendation

3. Part I CACHET Updates

4. Status of March Recommendations Add Compassionate Care Catastrophic Benefit for Basic Plan Members Approved by CMS July 2010. Limit Chiropractic Visits to 10 per year Submitted to CMS May 2010, awaiting approval. Limit Physical, Occupational, and Speech Therapy Visits Submitted to CMS May 2010, awaiting approval. Implement Aggregate Cap of 21 Visits per year for office-based Mental Health and Substance Abuse Services or Physical Health Services Submitted to CMS May 2010, awaiting approval. We will be discussing this benefit later during this presentation.

5. Status of March Recommendations (cont.) • Increase Physician Visit Co-Pay to $5 and Establish Office-Based Mental health and Substance Abuse Visits Co-Pay to $5 Submitted to CMS May 2010, awaiting approval. • Increase Drug Co-Pay to $5 for Generic and $10 for Brand Name Prescriptions with a monthly Maximum of $30 per Member, per Pharmacy Submitted to CMS May 2010, awaiting approval.

6. Part II BadgerCare Plus Basic Updates

7. BadgerCare Plus Basic Plan: Enrollment Update 2,500 enrolled so far. 1,700 in July cohort; 800 in August. 95% of July enrollees paid August premium. Membership spread all across state. Initial claims affordable within premium. Role of Nurse Case Manager

8. New Policy for BadgerCare Plus Basic Members with Cancer Approved by CMS Basic members with verified diagnosis of cancer may apply for Core and bypass the waitlist. Doctor faxes “Core Medical Bypass Form” to the ESC to begin the process. Option in place now.

9. Enrolling in the BadgerCare Plus Basic Plan

10. For a webcast of training on BC+ Basic Plan please go to: http://dhsmedia.wi.gov/main/Viewer/?peid=014df7386143498db9864150e493ddbe BadgerCare Plus Basic Plan

11. Overview of Basic Members • See BadgerCare Plus Basic Dashboard Report • Findings by BadgerCare Plus Basic Nurse Case Manager

12. Part III Core Plan Update: Renewals

13. As of Friday, July 23: Renewal Applications Submitted : 6,217 Fee Paid/Waived: 97% Awaiting Fee Payment: 3% Application Method: 37% on ACCESS and 63% over the phone As a result of members transitioning off the BC+ Core Plan for various reasons throughout the last year, the starting population of the TCLA group when renewals began was about 10,000 people. Core Plan TCLA Renewals

14. DHS has extended the timeframe in which ALL BC+ Core Plan TCLA members can complete their renewal to September 30,2010. After this time any BC+ Core Plan TCLA members that have not renewed will only have the option to join the waitlist and enroll in the BC+ Basic program if they choose. Upon completion of the renewal, submission of verification, and payment of the fee (unless homeless) their coverage can be opened prospectively. All timelines for submission of verification remain the same. Core Plan TCLA Renewal Effort

15. Update on criteria for qualifying for the Enrollment Trustfund. 1,943 individuals have been assisted by the Trustfund 763 of these applications (roughly 40%) were regular Core Plan applications 1,162 of these applications (roughly 60%) were for TCLA individuals. Milwaukee Health Care Partnership Application Fee Trustfund Criteria

16. Renewal “Leveling Plan” approved by CMS. 3,200 Renewals due July 31. About 2,000 of those have applied for renewal. Total Core enrollment at 56,000. About 58,000 on the Core waitlist. 5,000 Renewals due August 31 Core Plan Renewal Update

17. Part IV Core Plan Update: Member Overview

18. Core Plan Members • Transitional (GAMP) members were enrolled into the Core Plan beginning Jan. 1, 2009 and into HMOs beginning April 2009. • Non-transitioned (non-GAMP) members were enrolled into the Core Plan beginning July 15, 2009 and into HMOs beginning Nov. 1, 2009.

19. Core Plan Demographics By Gender Male 61.6 % Female 38.4 % By Age Group Age 19-34 31.4 % Age 35-44 14.5 % Age 45-64 54.1 %

20. SFY 2010 Amount Paid by Month (All Core Plan Members)

21. SFY 2010 Amount Paid by Month (Non-GAMP Members)

22. SFY 2010 Amount Paid by Month (GAMP Members)

23. SFY 2010 FFS Amount Paid by Claim Type

24. SFY 2010 Top 15 Highest Cost Drugs (All Core Plan Members)

25. SFY 2010 Highest Cost Drugs (All Core Plan Members)

26. SFY 2010 Top 10 Highest Cost Drugs (Non-GAMP)

27. SFY 2010 Top 10 Highest Cost Drugs (GAMP)

28. SFY 2010 Top 15 DRGs, by Utilization

29. SFY 2010 FFS Top 15 DRGs, by Cost

30. New applicants are required to complete a Health Needs Assessment as part of the application process. Applicants are asked if they have any of 9 conditions: Asthma, Cancer, COPD, Depression, Diabetes, Emphysema, Heart Problems, High Blood Pressure, or Stroke In addition, applicants are asked if they: have a problem with alcohol or drug use. have been hospitalized or had other medical care in the past two years for emotional or psychiatric reasons. use tobacco. have a regular doctor and a regular clinic or hospital. Health Needs Assessment (HNA)

31. HNA Reporting of Physical Conditions* *Physical conditions include asthma, cancer, COPD, depression, diabetes, emphysema, heart problems, high blood pressure, and stroke. **Applicant counts only include applicants who have paid the $60 enrollment fee or have had the enrollment fee waived. Based on enrollment as of June 30, 2010 (56,287).

32. HNA Reporting of Physical Health Conditions *Based on the total number of members who reported having ≥1 physical condition (19,578).

33. HNA Reporting of Mental Health Conditions *Applicants answering yes to the question: “Do you feel that you have a problem with your use of alcohol or drugs?” **Applicants answering yes to the question: “In the last two years, have you been hospitalized or had other medical care for emotional or psychiatric reasons?” ***Based on the total number of members who reported having ≥1 physical condition (19,578).

34. HNA Reporting of Prescription Drug Usage *Based on the total number of members who reported having ≥1 physical condition (19,578).

35. Part V Budget Status 35

36. Budget Status The approved 1115(a) waiver requires: The state will be subject to a limit on the amount of Federal Title 19 funding (Federal Medicaid funding) that the State may receive for expenditures subject to the budget neutrality agreement during the demonstration approval period The budget neutrality limit for FFY10 is the state’s FFY10 DSH Allotment. The state is required to provide written notice to CMS at least 90 days prior to instituting an enrollment cap.

37. Budget Status The Department’s goal is to serve an average of 50,000 members on an ongoing basis in the Core Plan. The following table demonstrates how we got to this number.

38. Budget Status: Total Revenues Available

39. Budget Status: Expenditures and Offsets

40. Budget Shortfall: Factors

41. Per Member Per Month Costs,All Core Plan Enrollees • PMPMs represent the combined FFS and MC costs • PMPMs include monthly Drug PMPMs

42. Ongoing Initiative • Identify CLA enrollees who are improperly enrolled and transition them into proper benefit plan. • This group is primarily composed of SSI-eligible and Medicare dual-eligible individuals. • We anticipate that transitioning these members will allow us to meet budget neutrality in FFY 10.

43. Part VI Proposed Recommendation 43

44. Division Recommendation The Division’s recommendation reflects the following priorities: • Maximize the number of individuals that can be served by the program, which is critical given the current economic situation and the significant demand for the program; • Ensure that vital services are available given the needs of the population served; and • Achieve budget neutrality by implementing limitations that have minimal impacts on members. 44

45. Division Recommendation (cont.) • The following slides identify the Division’s recommended benefit plan changes. • These changes would be subject to federal approval. • These changes would be subject to clarification issued by CMS on the impact of national healthcare reform on the Core Plan.

46. Division Recommendation (cont.) To offset plan costs and assist with maintaining budget neutrality: Limit enrollment to 50,000 members This will be achieved through attrition. 46

47. Division Recommendation (cont.) • To provide coverage of outpatient mental health and substance abuse services: • Due to questions and concerns raised by CMS, amend the March CACHET recommendation as follows: • Implement an aggregate cap of 30 visits per year for either office-based mental health and substance abuse services or physical health services

48. Division Recommendation (cont.) • Require Prior Authorization for any visit—either for mental health and substance abuse services or physical health services—after the 30 limit has been reached. Prior Authorization criteria will be set as follows: • Visit is considered a necessity as a life-saving measure • Visit is considered to be more cost-effective than an alternative service • Anticipated implementation of January 1, 2011.

49. Questions?