connecticut department of social services health care contracting opportunities charter oak –...

ConnecticutDepartment of Social Services

Health Care Contracting OpportunitiesCharter Oak – HUSKY A – HUSKY B

Bidders’ Conference

February 22, 2008

M. Jodi Rell, Governor

Michael P. Starkowski, Commissioner

2Connecticut Department of Social Services

DSS Bidder’s Conference

AGENDA

Introduction Process Questions HUSKY Charter Oak



HUSKYCost Proposal Requirements

Submit eight hardcopies and two electronic copies Includes CRCS forms for each rating category

(7 for HUSKY A, 3 for HUSKY B plus Charter Oak) Supplemental newborn and maternity information for

HUSKY Supporting narrative detailing assumptions for bid

preparation – separate for HUSKY and Charter Oak Schedule 1: Certification statement – applies to both

HUSKY and Charter Oak Schedule 2: HUSKY and Charter Oak administrative

cost detail Schedule 3: HUSKY and Charter Oak supplemental

information on capitated risk arrangements



HUSKY CRCS Sheet

Health Plan Name: [Plan Name]Rating Period: 7/1/2008 to 6/30/2009Rating Group: HUSKY A – TANF less than 1 year oldRating Region: StatewideEstimated Member Months:

Unit DescriptionCopay

AmountUtilization per

1,000 Net Unit Cost1 Rating Period PMPM

01 Physical Health – Inpatient Hospital Days $________ ________ $________ -$ 02 Physical Health – Outpatient Hospital Non-Emergent Visits $________ ________ $________ -$ 03 Outpatient Hospital – Emergency Visits $________ ________ $________ -$ 04 Physician – Primary Care Visits $________ ________ $________ -$ 05 Physician – Specialty Care Visits $________ ________ $________ -$ 06 Emergency Transportation One-way trips $________ ________ $________ -$ 07 Non-Emergency Transportation One-way trips $________ ________ $________ -$ 08 Lab/Radiology Procedures $________ ________ $________ -$ 09 Durable Medical Equipment Services $________ ________ $________ -$ 10 Vision Services $________ ________ $________ -$ 11 Other (Total of a through e) -$ a) ________ $________ -$ b) ________ $________ -$ c) ________ $________ -$ d) ________ $________ -$ e) ________ $________ -$ 12 Total Medical Expenses -$

Less13 Third Party Liability Recovery (enter as a negative value) -$ 14 Reinsurance Recoveries (enter as a negative value) -$

15 Net Medical Expenses -$ 16 Reinsurance Premium -$

% of Premium17 Administration (from Schedule 2)2 0.00% -$ 18 Underwriting Gain 0.00% -$ 19 Risk/Contingency 0.00% -$

20 Total Capitation Rate -$ 21 Medical Loss Ratio #DIV/0!

Notes:

1 Unit Cost should be expressed net of any copay amounts

2 While DSS currently does not have specific MLR requirements included as part of this RFP, DSS reserves the right to include such requirements at a later date to the extend such a

provision is deemed beneficial to the State.

Category of Service



HUSKYProgram Changes

DSS has implemented a number of recent program changes that bidders will need to consider

Change in eligibility for pregnant women Increase in the Medicaid fee schedule for

hospitals, clinics, physicians and vision Implementation of Medicaid floor Carve out of pharmacy and dental services



HUSKY Rate Negotiation Process

Final HUSKY rates are required to be actuarially sound per CMS regulations

Mercer to determine actuarially sound rate ranges prior to bid submissions

Rates submitted outside of the actuarially sound rate range will receive counter “offer rate” from DSS

If necessary, negotiations will be conducted to ensure final rates are within the actuarially sound rate range.



Bidders’ Library

HUSKY A historical eligibility and encounter data available upon request

Only HUSKY A encounter data available. No encounter data available for HUSKY B

Due to data limitations, encounter data service categories more limited than those requested in CRCS

Bidders encouraged to use own information to supplement data in bidders’ library



Charter Oak Cost Proposal Requirements

Process Submit eight hardcopies and two electronic copies Includes CRCS forms for Base RFP Plan Design and,

if necessary, alternative Plan Design rating category Supporting narrative detailing assumptions for bid

preparation – separate for HUSKY and Charter Oak



Charter Oak Cost Proposal Requirements

Highlights Two-Tier Rate Structure Community Rated with Individual Target Premium of

$250, regardless of age, sex, or geography for individuals with Incomes Above 300% FPL

Ability to Adjust Rates for Individuals with Incomes Below 300% FPL by FPL Band

MCOs not at risk for BH and Rx, but those services included within $250 Target Premium

Note: BH subject to limitations



Charter OakFPL Table and Projected Enrollment

Tot

al C

ost

of M

onth

ly P

rem

ium

Total

Clients

SFY09 Average 8,700

SFY10 Average 21,400

SFY11 Average 32,800

$175

$75

$150

$100

$75

$175

$50

$200

$250

$-

$50

$100

$150

$200

$250

<150% 150-185% 185-235% 235-300% 300%+

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

Charter Oak Plan Monthly Premiums

Monthly DSS Contribution Monthly Client Contribution



Charter OakProgram Design

Geographic Area– Statewide Status: Anticipated Carriers will offer Coverage Statewide

Program Structure– State Program*: July 1, 2008

Authority– Section 23 of Public Act 07-02 (June Special Session)

Type of Enrollment– Voluntary, Affordable Health Insurance

Individuals without health insurance for the last six months or those who meet certain qualifying criteria to exempt them from uninsurance requirement

– Excluded 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 Oak



Charter OakBasic Benefit Features

Deductible– Varies by FPL

Co-insurance– Varies by service

Out of Pocket Maximum– Varies by FPL

Lifetime Benefit Maximum– $1,000,000

Premiums by enrollee– *Maximum $250/month– Varies based on income

Primary Care Physician Visits– $25 co-pay

Specialist Physician Visits– $35 co-pay

Preventive Care– No co-pay, 100% covered

Inpatient Hospital– 10% Co-insurance

Outpatient Surgical Facility– 20% Co-insurance

Ambulance/Transportation– 100% Covered in emergencies

Rx - $7,500 Annual Limit DME - $4,000 Annual Limit Behavioral Health Services, Rx

services carved-out and provided through DSS

Dental and Vision Services may be provided as optional riders by MCOs with separate premium assessment

See Appendix C in RFP: Charter Oak Plan Design Summary Table for additional detail* Includes aggregate cost for medical, behavioral health and Rx carve-out



Charter Oak CRCS Sheet (Top)

Contractor Name: [Plan Name]Rating Period: 7/1/2008 to 6/30/2009Rating Group: Charter Oak Base RFP Plan DesignEstimated Member Months:

A. Average PMPM DevelopmentBase Data centered at mm/dd/yy

Category of ServicePMPM Cost

Trend Co-Pay Ded OOP Max Plan DesignAdj x

(Describe)Adj x

(Describe)Adj x

(Describe)PMPM Cost

Unit DescriptionAnnual Utilization

per 1,000 membersUnit Cost PMPM Cost

01 Physical Health – Inpatient Hospital -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Days - -$ -$ OK

02 Physical Health – Outpatient Hospital Non-Emergent -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Visits - -$ -$ OK

03 Outpatient Hospital – Emergency -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Visits - -$ -$ OK

04 Physician – Primary Care -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Visits - -$ -$ OK

05 Physician – Specialty Care -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Visits - -$ -$ OK

06 Emergency Transportation -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ One-way trips - -$ -$ OK

07 Non-Emergency Transportation (Not covered in Charter Oak) One-way trips

08 Lab/Radiology -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Procedures - -$ -$ OK

09 Durable Medical Equipment -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Services - -$ -$ OK

10 Vision -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Services - -$ -$ OK

11 Other (Total of a through e) -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ - -$ -$ OK

a) -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ - -$ -$ OK

b) -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ - -$ -$ OK

c) -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ - -$ -$ OK

Pharmacy (Carved out, MCO not a risk) -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Prescriptions - -$ -$ OK

Specialty Behavioral Health (Carved out, MCO not at risk) -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Services - -$ -$ OK

12 B. Total Medical Expenses -$ -$ Less13 Third Party Liability Recovery (enter as a negative value) -$ 14 Reinsurance Recoveries (Not Applicable to Charter Oak) -$

15 Net Medical Expenses -$ 16 Reinsurance Premium (Not Applicable to Charter Oak) -$

% of Premium17 Administration (from Schedule 2) 0.0% -$ 18 Underwriting Gain 0.0% -$ 19 Risk/Contingency 0.0% -$

C. Non-Medical Costs -$ 20 D. Total Capitation Rate (B + C) -$ 21 Medical Loss Ratio 0%

Adjustments (expressed as PMPMs, not %s) SFY09 centered at 01/01/09



Charter Oak CRCS Sheet (Bottom)

12 B. Total Medical Expenses -$ -$ Less13 Third Party Liability Recovery (enter as a negative value) -$ 14 Reinsurance Recoveries (Not Applicable to Charter Oak) -$

15 Net Medical Expenses -$ 16 Reinsurance Premium (Not Applicable to Charter Oak) -$

% of Premium17 Administration (from Schedule 2) 0.0% -$ 18 Underwriting Gain 0.0% -$ 19 Risk/Contingency 0.0% -$

C. Non-Medical Costs -$ 20 D. Total Capitation Rate (B + C) -$ 21 Medical Loss Ratio 0%

E. Age/Sex Factors F. Implied Age/Sex Bid Rates for SFY09 = (BxE)+C G. Projected Enrollment MixIndividual Statewide Individual Statewide Individual

19-29 M - 19-29 M -$ 19-29 M -

19-29 F - 19-29 F -$ 19-29 F -

30-34 M - 30-44 M -$ 30-44 M -

30-34 F - 30-44 F -$ 30-44 F -

35-39 M - 35-39 M -$ 35-39 M -

30-39 F - 30-39 F -$ 30-39 F -

40-44 M - 40-44 M -$ 40-44 M -

40-44 F - 40-44 F -$ 40-44 F -

45-49 M - 45-49 M -$ 45-49 M -

45-49 F - 45-49 F -$ 45-49 F -

50-54 M - 50-54 M -$ 50-54 M -

50-54 F - 50-54 F -$ 50-54 F -

55-59 M - 55-59 M -$ 55-59 M -

55-59 F - 55-59 F -$ 55-59 F -

60+ M - 60+ M -$ 60+ M -

60+ F - 60+ F -$ 60+ F -

Notes:H. Statewide Individual 300% FPL and Above Composite Bid = sumproduct (FxG)

1. Costs are gross and should not include any privately purchased reinsurance -$ TARGET PREMIUM = $2502. Bid does not include costs for additional benefits provided to enrollees (e.g., chiropractic)3. MCO's will input items in blue highlight and other fields will be calculated. I. Statewide Family Size Factor

0.00

J. Statewide Family 300% FPL and Above Composite Bid = sumproduct (HxI)-$

K. Statewide Federal Poverty Level Plan Design Factor (HxK for Individual and JxK for Family)Individual Family

0-150% FPL 0.00 -$ -$ 151-185% FPL 0.00 -$ -$ 186-235% FPL 0.00 -$ -$ 236-300% FPL 0.00 -$ -$ 300% and Above -$ -$



Charter OakRate Negotiation Process

Final Charter Oak rates are required to be actuarially sound per CMS regulations*

srHS to determine actuarially sound rate ranges prior to bid submissions

Rates submitted outside of the actuarially sound rate range will receive counter “offer rate” from DSS

If necessary, negotiations will be conducted to ensure final rates are within the actuarially sound rate range

* DSS anticipates submitting a waiver to the Connecticut Legislature, and if approved, to CMS for Federal financial participation in portions of Charter Oak

connecticut department of social services health care contracting opportunities charter oak –...

Documents

husky bdue

requestonly husky

opportunitiescharter

encounter data available

charter oakschedule

sound rate ranges

data limitations

supplement data